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Family Medicine (Expert Forum)
sentinel node Biopsy used during lumpectomy
Answered by
J.M. Keyes, MD - Family Medicine
Gainesville - FL
Questions in the Family Medicine forum are answered by Dr. J.M. Keyes. Topics covered include general health issues, adolescence, babies, child health, eating disorders, fitness, immunizations and vaccines, infectious diseases, medical tests and procedures, and senior health.
sentinel node Biopsy used during lumpectomy
by l0410z, Jun 25, 2009 08:38AM
My wife has IDC the size is about 6mm. She is going in for a lumpectomy with a sentnel node biopsy. We are choosing between two very competent Oncological Surgeons. doing this either 22 or 35 years. Both use Sentinel Node Biopsy to determine if it reached the Lymph node. One uses with the radioactive shot and the blue dye, one uses only the blue dye. On blue dye along, I have read accuracy is anywhere from 82% to 95% (with a competent surgeon). I have read using both is 98% accurate. The Doctor who does the blue dye says the accuracy is both 90%. A third doctor told us radioactive alone, blue dye alone or a combo are all used. She does both. The Dr who uses only the blue dye said his expierence (35 years) is what makes him comforable in using this. I do not want to go crazy but there is a big difference between 82% and 98%. I know the key is identifying the sentinel node. Can someone help sort this out.
Doctor's Answer
by J.M. Keyes, MD, Jun 25, 2009 06:55PM
, Jun 25, 2009 06:55PMTo: l0410z
Hi there,
I am sorry to hear about your wife's diagnosis. I am glad to hear that it was caught early.
It sounds like you have done a lot of research on this topic. I am a family physician, and thus, your surgeons are going to be much more up to date and experienced in this topic than I am, but I can give you my 2 cents for what it is worth. I spent some time researching this question, and as you have pointed out, most studies indicate that the combination of blue dye and radioactive tracing are more successful at identifying the sentinel node.
Your surgeons both have a great deal of experience, which is wonderful. I think you should also take into consideration who seems to be most up to date on the latest research, as well as who you and your wife have a better relationship with.
I think there is no right or wrong answer here, but if it were me with breast cancer, I think I would want the combination of the two methods, because from what I have read there is a better chance of identifying the sentinel node with this method.
I will add a few references here which you may have already read, but in case you haven't come across them:
From an Article Authored by Kathleen M Diehl, MD and Alfred E. Chang, MD
Division of Surgical Oncology, University of Michigan Comprehensive Cancer Center
Sentinel Lymph Node Biopsy:
A sentinel lymph node biopsy is a new technique. This was developed as a test to determine if breast cancer has spread to the lymph ducts or lymph nodes in the axilla without having to do a traditional axillary lymph node dissection. Experience has shown us that the lymph ducts of the breast usually drain to one lymph node first, before draining through the rest of the lymph nodes underneath the arm. That first lymph node is called the sentinel lymph node. That is the lymph node that helps sound the warning that the cancer has spread. Lymph node mapping helps identify that lymph node, and a sentinel lymph node biopsy removes only that lymph node. The sentinel lymph node is identified in one of two ways, either by a weak radioactive dye (technetium-labeled sulfur colloid) that can be measured by a hand held probe, or by a blue dye (isosulfan blue) that stains the lymph tissue a bright blue so it can be seen. Most breast cancer surgeons use a combination of both dyes. This procedure is new. The “best” way to administer the dye, which dye to use, and the benefits and risks of the procedure in various situations is still being studied. A traditional axillary lymph node dissection is the “tried and true” method, and is still considered the “gold standard”.
Advantages:
The advantages to the sentinel lymph node procedure are many. There is no need to stay overnight in the hospital. There is no need for a drain, or physical therapy exercises. Your recuperation from the procedure is faster. You are typically doing your regular activities within a few days, and the incision is well healed within a few weeks. A sentinel lymph node biopsy can lead to a more accurate assessment of whether the cancer has spread to the lymph nodes. In a traditional axillary dissection, the pathologist receives at least 10 lymph nodes or more; there is no way of telling which one is the sentinel lymph node. So the pathologist makes one cut in each lymph node and looks for cancer. When the pathologist receives only one, or a few, lymph nodes from a sentinel lymph node procedure, he or she can make many cuts through that lymph node to look for cancer. A negative sentinel lymph node(s) indicates a >95% chance that the remaining lymph nodes in the axilla are also cancer free. Therefore, there is no need to undergo a full axillary lymph node dissection, or to risk the long term complications and side effects from an axillary dissection.
What to Expect:
If you decide to undergo the procedure, the morning of your operation, you will go see a nuclear medicine specialist who is a physician specifically trained in injecting the radioactive dye used for the procedure. The injections are done into the area of the breast where the tumor is, and/or around the nipple areolar complex of the breast. You will then return to the nuclear medicine department a few hours later, and pictures will be taken which show the pathways the dye takes as it leaves the breast. (See Figure 3) This will help guide your surgeon in identifying the sentinel lymph node. Then you will proceed to the operating room. At the beginning of the operation, your surgeon will inject the blue dye. The surgeon then makes an incision underneath your arm in the area of the axillary lymph tissue. A hand-held sterile probe measures areas that have the radioactive dye. (See Figure 4) The lymph nodes that have taken up the radioactive dye, or are stained with the blue dye, are removed. Usually one to three nodes are removed. These nodes are sent to the pathologist, who then looks at them under a microscope to see if the sentinel node contains cancer. Your incision is closed, and there is no need for a drain. There is no need for physical therapy exercises. Unless you are having another operation done which requires that you stay overnight, you can go home from the hospital that day. The sentinel lymph node biopsy can be done in combination with a lumpectomy, or a mastectomy. The procedure is successful in >90% of those patients whom we think are good candidates for the procedure. If the procedure is unsuccessful in identifying the sentinel node, a full axillary dissection is done.
Also, a couple of articles:
Derossis AM, Fey J, Yeung H, Yeh SD, Heerdt AS, Petrek J, VanZee KJ, Montgomery LL, Borgen PI, Cody HS., III A trend analysis of the relative value of blue dye and isotope localization in 2,000 consecutive cases of sentinel node biopsy for breast cancer. J Am Coll Surg. 2001;193:473–478. doi: 10.1016/S1072-7515(01)01038-9. [PubMed]
Hung WK, Chan CM, Ying M, Chong SF, Mak KL, Yip AW. Randomized clinical trial comparing blue dye with combined dye and isotope for sentinel lymph node biopsy in breast cancer. Br J Surg. 2005;92:1494–1497. doi: 10.1002/bjs.5211. [PubMed]
Best of luck with this decision, and with your wife's treatment.
JMK MD
I am sorry to hear about your wife's diagnosis. I am glad to hear that it was caught early.
It sounds like you have done a lot of research on this topic. I am a family physician, and thus, your surgeons are going to be much more up to date and experienced in this topic than I am, but I can give you my 2 cents for what it is worth. I spent some time researching this question, and as you have pointed out, most studies indicate that the combination of blue dye and radioactive tracing are more successful at identifying the sentinel node.
Your surgeons both have a great deal of experience, which is wonderful. I think you should also take into consideration who seems to be most up to date on the latest research, as well as who you and your wife have a better relationship with.
I think there is no right or wrong answer here, but if it were me with breast cancer, I think I would want the combination of the two methods, because from what I have read there is a better chance of identifying the sentinel node with this method.
I will add a few references here which you may have already read, but in case you haven't come across them:
From an Article Authored by Kathleen M Diehl, MD and Alfred E. Chang, MD
Division of Surgical Oncology, University of Michigan Comprehensive Cancer Center
Sentinel Lymph Node Biopsy:
A sentinel lymph node biopsy is a new technique. This was developed as a test to determine if breast cancer has spread to the lymph ducts or lymph nodes in the axilla without having to do a traditional axillary lymph node dissection. Experience has shown us that the lymph ducts of the breast usually drain to one lymph node first, before draining through the rest of the lymph nodes underneath the arm. That first lymph node is called the sentinel lymph node. That is the lymph node that helps sound the warning that the cancer has spread. Lymph node mapping helps identify that lymph node, and a sentinel lymph node biopsy removes only that lymph node. The sentinel lymph node is identified in one of two ways, either by a weak radioactive dye (technetium-labeled sulfur colloid) that can be measured by a hand held probe, or by a blue dye (isosulfan blue) that stains the lymph tissue a bright blue so it can be seen. Most breast cancer surgeons use a combination of both dyes. This procedure is new. The “best” way to administer the dye, which dye to use, and the benefits and risks of the procedure in various situations is still being studied. A traditional axillary lymph node dissection is the “tried and true” method, and is still considered the “gold standard”.
Advantages:
The advantages to the sentinel lymph node procedure are many. There is no need to stay overnight in the hospital. There is no need for a drain, or physical therapy exercises. Your recuperation from the procedure is faster. You are typically doing your regular activities within a few days, and the incision is well healed within a few weeks. A sentinel lymph node biopsy can lead to a more accurate assessment of whether the cancer has spread to the lymph nodes. In a traditional axillary dissection, the pathologist receives at least 10 lymph nodes or more; there is no way of telling which one is the sentinel lymph node. So the pathologist makes one cut in each lymph node and looks for cancer. When the pathologist receives only one, or a few, lymph nodes from a sentinel lymph node procedure, he or she can make many cuts through that lymph node to look for cancer. A negative sentinel lymph node(s) indicates a >95% chance that the remaining lymph nodes in the axilla are also cancer free. Therefore, there is no need to undergo a full axillary lymph node dissection, or to risk the long term complications and side effects from an axillary dissection.
What to Expect:
If you decide to undergo the procedure, the morning of your operation, you will go see a nuclear medicine specialist who is a physician specifically trained in injecting the radioactive dye used for the procedure. The injections are done into the area of the breast where the tumor is, and/or around the nipple areolar complex of the breast. You will then return to the nuclear medicine department a few hours later, and pictures will be taken which show the pathways the dye takes as it leaves the breast. (See Figure 3) This will help guide your surgeon in identifying the sentinel lymph node. Then you will proceed to the operating room. At the beginning of the operation, your surgeon will inject the blue dye. The surgeon then makes an incision underneath your arm in the area of the axillary lymph tissue. A hand-held sterile probe measures areas that have the radioactive dye. (See Figure 4) The lymph nodes that have taken up the radioactive dye, or are stained with the blue dye, are removed. Usually one to three nodes are removed. These nodes are sent to the pathologist, who then looks at them under a microscope to see if the sentinel node contains cancer. Your incision is closed, and there is no need for a drain. There is no need for physical therapy exercises. Unless you are having another operation done which requires that you stay overnight, you can go home from the hospital that day. The sentinel lymph node biopsy can be done in combination with a lumpectomy, or a mastectomy. The procedure is successful in >90% of those patients whom we think are good candidates for the procedure. If the procedure is unsuccessful in identifying the sentinel node, a full axillary dissection is done.
Also, a couple of articles:
Derossis AM, Fey J, Yeung H, Yeh SD, Heerdt AS, Petrek J, VanZee KJ, Montgomery LL, Borgen PI, Cody HS., III A trend analysis of the relative value of blue dye and isotope localization in 2,000 consecutive cases of sentinel node biopsy for breast cancer. J Am Coll Surg. 2001;193:473–478. doi: 10.1016/S1072-7515(01)01038-9. [PubMed]
Hung WK, Chan CM, Ying M, Chong SF, Mak KL, Yip AW. Randomized clinical trial comparing blue dye with combined dye and isotope for sentinel lymph node biopsy in breast cancer. Br J Surg. 2005;92:1494–1497. doi: 10.1002/bjs.5211. [PubMed]
Best of luck with this decision, and with your wife's treatment.
JMK MD
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