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Recommendations for use of Sentinel node biopsy

Statements of evidence

STATEMENTS LEVEL OF EVIDENCE19 REFERENCE
In women with early (operable) breast cancer with unifocal tumours equal to or less than three centimetres in diameter:
Sentinel node biopsy is a suitable alternative to axillary dissection to determine if cancer cells have spread to the lymph nodes II Milan4,5
ALMANAC6
SNAC I8
NSABP B-329
Cambridge10
GIVOM11,12
Sentinel node biopsy is an accurate method of staging the axilla II Milan4
SNAC I8
NSABP B-329
GIVOM11
Sentinel node biopsy based management is associated with decreased arm morbidity, compared with axillary dissection II Milan4,5
ALMANAC6,7
SNAC I 8
Cambridge10
GIVOM12
There are limited trial results to support recommendations for sentinel node biopsy in women with tumours greater than three centimetres in diameter ALMANAC6
NSABP B-32
(2007)20
Team, training and experience
Three trials 6,8,9,21,22 that required surgeons to be trained and experienced in the sentinel node biopsy technique had lower false-negative rates and higher sensitivity and accuracy than the one trial11 that did not require surgeons to have formal training or experience ALMANAC6
SNAC I8,22
NSABP B-329,21
GIVOM11
Technique
Lymphatic mapping using a combination of radioisotope and blue dye may be associated with a higher rate of sentinel node detection14,15 than blue dye alone and may be associated with improved accuracy13 II Hung14
Meyer-Rochow15
Radovanovic13
Using blue dye alone or radioisotope alone appears to provide good sentinel node detection and accuracy, however trial data for blue dye alone is limited Milan4,5
GIVOM11,12
Peritumoural, periareolar and intradermal injection sites have all been shown to be effective in detecting the sentinel node in the axilla FRANSENODE16 Povovski17
False negative rate
The false negative rate of sentinel node biopsy decreases and morbidity is minimised if up to three sentinel nodes are removed.

The removal of four or more nodes from the axilla does not lower the false negative rate significantly compared with removing up to three nodes
II NSABP B-32
(2007)20
Pathology
Detailed, definitive histological assessment (including immunohistochemistry and serial sectioning) of the sentinel node increases the accuracy in the detection of metastatic disease NBOCC* & ACN23
False-negative rates for intraoperative assessment (cytologic methods or frozen section) are up to 38.5% II NSABP B-329
GIVOM11
Where intraoperative assessment is used, cytologic methods conserve tissue for subsequent detailed histopathological assessment NBOCC* & ACN23
Risk of recurrence
The long term risk of axillary recurrence following sentinel node biopsy is not known

The duration of follow-up in well-designed randomised control trials is currently limited to a maximum of six years and, to date, no increased risk of axillary recurrence has been identified
Milan5
GIVOM11
ALMANAC6
Adverse events
Allergic reactions have been reported with the use of blue dye in sentinel node biopsy, however, these incidences are rare II NSABP B-329
Trials did not report on adverse events relating to the dose of radiation to the patient from the use of radioisotope in sentinel node biopsy Milan4,5
ALMANAC6,7
SNAC I8
NSABP B-329
Cambridge10
GIVOM11,12
Associated risks of radioisotope use in sentinel node biopsy are minimal and within acceptable limits for patients and staff MSAC Review24

* In February 2008, National Breast Cancer Centre (NBCC), incorporating the Ovarian Cancer Program, changed its name to National Breast and Ovarian Cancer Centre (NBOCC). In July 2011, NBOCC amalgamated with Cancer Australia to form a single national agency, Cancer Australia, to provide leadership in cancer control and improve outcomes for Australians affected by cancer.

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