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SELECTIVE AXILLARY DISSECTION IN CARCINOMA BR EAST Dr.Anil Haripriya Assistant Professor General Surgery

Tumour size and axillary lymph node status are the most important prognostic factors in potentially curable carcinoma of the breast. Physical examination, radiologic imaging of the axilla or prognostic models based on primary tumour characteristics cannot accurately predict the occurrence of axillary metastases1-2. Hence axillary lymph node dissection is an important staging procedure in the surgical treatment of breast cancer. National Institute of Health Consensus recommended a level I and II axillary lymph node dissection for staging and regional control of breast cancer 3 . To minimize the short and long term morbidity associated with axillary lymph node dissection, some investigators have proposed a limited axillary dissection 4 . This procedure has less morbidity but misses 24% to 42% of axillary metastases (5-6). Selective axillary dissection means that one should be able to select the patients with breast cancer for total axillary dissection from the ones that don’t need total axillary clearance. This means that if the axilla is involved, it should be completely cleared of all nodal tissues as both the number and level of involved nodes have important prognostic value. Similarly if the axillary nodes are not involved they should be left untouched to avoid

the morbidity of total axillary dissection. There is general agreement that total lymphadenectomy is indicated in patients with clinical suspicious nodes or pathologically proved metastases to the regional lymph nodes. A major controversy exists regarding the utility of this procedure for patients with clinical stage I (CS- I) disease because most of these patients are without nodal metastases and therefore can derive no benefit from regional lymph adenectomy. % of cases where axillary nodes were involved. T1 Tumours 11.3% positive cases T2 Tumours 28.3% T3 Tumours 42.8% Since breast cancer is being detected at early stage due to screening procedures the chances of axillary nodes being free of cancer are high and hence the need for selection of axillary dissection. Selection is possible if we can prove that a single axillary node (Sentinel node) initially receives malignant cells from a breast carcinoma and that an uninvolved sentinel node reliably forecasts a disease free axilla.

This concept of sentinel node biopsy in carcinoma breast is not new. Oliver cope referred to the Delphian node in 1963 as the lymph node that will “fortell the nature of a disease process” affecting a nearby organ. That the predicting value of the first level node is considerable was shown by Veronesi etall7 in a study of 539 patients with carcinoma of the breast treated with total axillary dissection and with positive axillary nodes. Only in 1.5% of the cases the first level was skipped by metastases and in 0.4% of cases both first and second levels were missed. They also showed that axillary lymph node metastases occur in an orderly fashion and that predictive value of first level is considerable i.e. when first level nodes are clear chances of 2nd and 3rd level involvement is rare. When first level lymph nodes are involved, chances of metastases being present at higher levels is high. Of the first level nodes – if one can detect the first or the lymph node nearest the site of primary carcinoma (called sentinel lymph node) its pathological status can be reliably used to selectively dissect or not to dissect the whole axilla. The validity of this concept was first demonstrated for melanoma over 10 years ago by Morton & colleagues8. Patent blue V dye was injected close

to the primary lesion and the blue stained sentinel node was later found by dissection. Various dyes have been tested to optimise the kinetics both in terms of take up and transport and retention by the first node to receive that lymph. Blue dyes have been used to identify the sentinel node in breast cancer, either alone or in conjunction with other radioactive materials. In 1996, John J. Albertini et al9 carried out a study to identify the sentinel lymph node by intra operative lymphatic mapping using a combination of a vital blue dye and filtered technitium – labelled sulfur colloid. The sentinel lymph node was identified and removed followed by a definitive cancer operation and complete axillary dissection. Their results indicated that SLN was successfully identified in 92% of patients using the two lymphatic mapping procedures. 32% were found to have metastatic disease and SLN was tested positive in all 32% of patients. Turner etall10 from Joyce Eisenberg Keefer Breast Centre, at Santa Monica, California used 3 to 5 ml. of 1% isosulfan blue vital dye into the breast parenchyma surrounding the primary tumor. Sentinel node was recognised in the axillae, removed and then level I & II were also

dissected. Sentinel nodes were examined by H&E and I.H.C. (Immuno histochemistry). Where sentinel nodes were free by H&E and I.C.H. all nonsentinel nodes were examined by I.H.C. only one sentinel node negative patient was positive by I.H.C. from non sentinel nodal mass. In addition 14.3% of sentinel nodes that were negative by H&E stain were tested positive with I.H.C. Umberto Veronesi etall11 from European Institute of Oncology in 163 women with operable breast cancer injected microcolloidal particles of human serum albumin labelled with technitium– 99m. This tracer was injected subdermally close to the tumor site on the day before surgery and scintigraphic images of breast and axille were taken at 10,30 mins. and 3 hrs. later. A mark was placed over the site where radioactive node existed. A small Ɣ- ray detector probe was used at surgery to locate the sentinel node and made possible its removal through a small separate axillary incision. Complete axillary dissection was then carried out. The results show that they could accurately predict axillary lymph node status in 97.5% of the patients in whom sentinel node was identified. In 38% of the cases with metastatic axillary nodes, the sentinel node, was the only positive node

Hence from the ongoing studies · It is possible to dissect sentinel nodes with the help of vital blue dyes and or lympho scintigraphy. There are advantages and disadvantages of vital dyes and lympohscintigraphy. Vital blue dye can be injected few minutes before surgery while lympohscintigraphy must be carried out at least 2 hours before surgery. Disadvantage of dye method is that axillary tissue must be dissected blindly until the blue node is located and this can be few cms. away from the skin incision. The advantage of hand held probe is that it locates the node and indicates exactly where the skin incision should be made and guides the dissection, which is quite successful. ·Sentinel node is a reliable good predictor of the axillary nodal status. ·Frozen section facilities and multiple sectioning of sentinel node is a must, if second operation is to be avoided. · Immunohistochemistry and PCR enhances the detection of micrometastatis. Micrometastatis is also a prognostic factor as of today. · Extensive microcalcification or multifocality is a contraindication to the injection method because in such cases sentinel nodes may be falsely

negative. · Another advantage of sentinel node dissection is its use in Neo adjuvant therapy in Carcinoma breast. ·It provides the pathologists only 1-2 nodes to perform a more detailed and focussed examination and possibly PCR analysis, serial sectioning for immunohistochemical staining. There is a word of caution. Before sentinel node biopsy is adopted routinely in breast cancer management, the outcome of several clinical trials that are presently comparing survival in patients staged by this new approach with that of patients receiving traditional axillary management should be awaited. There is also a learning curve in dissecting sentinel node and hence for the first few cases both sentinel lymph nodes and complete axillary clearance be carried out in individual hands and reliability tested. References 1. Hellman S. Natural history of small breast cancers. J.Clin Oncol 1994; 12:2229-2234. 2. Rosen PP, Groshen S, Saigo PE, et al. A long-term follow-up study of survival in stage I (T1N0M0) and Stage II (T1N1M0) breast carcinoma. J.Clin Oncol 1989; 7:355-366. 3. NIH Consensus Development Conference. Treatment of early stage breast cancer. J. Natl Cancer Inst. 1992; 11:1-5 4. Steele RJC, Forrest APM, Gibson T, et al. The efficacy of lower axillary sampling in obtaining lymph node status in breast cancer a controlled randomized trail. Br. J.Surg 1985;

72:368-369. 5. Kissin MW, Thompson EM, Price AB, et al. The inadequacy of axillary sampling in breast cancer, Lancet 1982; 1:1210-1212. 6. Moffat FL, Senofsky GM, Davis K. et al. Axillary node dissection for early breast cancer; some is good, but all is better. J.Surg Oncol 1992; 51:8-13. 7. Veronesi U, Rilke F, Luini A, Sacchini V, Galimberti V, Campa T et al. Distribution of axillary node metastases by level of invasion. An analysis of 539 cases. Cancer 1987; 59:682-7. 8. Morton DL, Wen DR, Wong JH, Economou JS, Cagle LA, Storm FK et al. Technical details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg 1992; 127:392-9. 9. Albertini JJ, Lyman GH, Cox C, Yeatman T, Balducci L, Ku N et al. Lymphatic mapping and sentinel node biopsy in the patient with breast cancer. JAMA 1996;276:1818-22. 10. Turner RR, Ollila DW, Krasne DL, Giuliano AE. Histopathologic validation of the sentinel lymph node hypothesis for breast carcinoma Ann Surg 1997;226:271-8. 11. Veronesi U, Paganelli G, Galimberti V, Viale G, Zurrida S, Bedoni M et al. Sentinel- node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph- nodes. Lancet 1997; 349:1864-7.

S E L E C T I V E A X I L L A R Y D I S S E C T I O N I N

by Anil Haripriya

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