December 13, 2016

Sentinel Node Biopsy Guidelines Encourage ‘Less Is More’ Approach

SEATTLE, Wash -- December 13, 2016 -- New recommendations from breast cancer experts on sentinel lymph node biopsy reinforce the most recent “less is more” guidelines for early-stage disease. However, many surgeons still perform full lymph node dissection routinely.

“The new guidelines, first established in 2014, seem to have been embraced within academic centres and larger hospitals and cancer centres, but compliance is still quite variable elsewhere,” said Gary Lyman, Fred Hutchinson Cancer Center, Seattle, Washington.

The new guidelines, published in the December 12 issue of the Journal of Clinical Oncology, echo a more conservative approach first recommended in 2014 where surgeons were advised NOT to automatically harvest all lymph nodes if cancer was found in a sentinel node.

This was a dramatic shift from 2005’s recommendation that surgeons use sentinel node biopsies to stage the cancer and then go on to perform axillary lymph node dissection, removing all lymph nodes under the patient’s arm (or arms) if any disease was found in the sentinel node.

“In smaller hospitals, particularly in rural areas, many women are still being told they need a full axillary dissection,” said Dr. Lyman. “There are economic issues, geographic issues, and education issues for both clinicians and patients.”

Now surgeons are advised to forego routine axillary lymph node dissection in most women with no evidence of cancer on sentinel node biopsy or if cancer is found in only 1 to 2 sentinel nodes. As a result, the majority of women receiving lumpectomy and whole breast radiation can also forego a full lymph node dissection. This is important because axillary lymph node dissection can have a dramatic effect on patients’ quality of life, leading to lymphedema, infections, reduced range of motion, and other painful and costly side effects.

“There are cautions,” said Dr. Lyman. “The sentinel node biopsy has to be well-conducted, the tumour should not be greater than 5 centimetres in size, and there should be no other major risk factors. However, approximately two thirds of women meet these criteria. Full removal is always an option, and some women want to have all of the lymph nodes taken out. But given the down side of the full axillary dissection in terms of quality of life and possible complications, many women who have a lower risk say, ‘I want to avoid those problems.’”

“If a woman has only one or two sentinel lymph nodes that are cancerous and if the tumour is not too big and not too aggressive, there’s no value in doing a complete lymph node dissection,” he added.

SOURCE: Fred Hutchinson Cancer Research Center

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