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  In this article
 »  Abstract
 »  Introduction
 »  What is Sentinel...
 »  Anatomy and Phys...
 »  Technical aspect...
 »  Accuracy of Sent...
 »  Tumor Size and SLNB
 »  SLNB after Neoad...
 »  SLNB for Multice...
 »  Inaccuracy of Fr...
 »  Safety, Contrain...
 »  Conclusions
 »  References
 »  Article Tables

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Year : 2003  |  Volume : 40  |  Issue : 2  |  Page : 60-6

Sentinel lymph node biopsy in the management of breast cancer.

Division of Nuclear Medicine, Department of Radiology, Hospital of the University of Pennsylvania, 110 Donner Bldg. 3400 Spruce Street, Philadelphia, PA, 19104, USA

Correspondence Address:
Rakesh Kumar
Division of Nuclear Medicine, Department of Radiology, Hospital of the University of Pennsylvania, 110 Donner Bldg. 3400 Spruce Street, Philadelphia, PA, 19104
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Source of Support: None, Conflict of Interest: None

PMID: 14716120

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 » Abstract 

Sentinel node localization is the second most important development in this century after conservative lumpectomy for the treatment of early breast cancer. The sentinel node mapping is a new multidisciplinary approach for staging of axilla in an accurate and less morbid way as compared to axillary node dissection. Sentinel lymph node biopsy in patients with breast cancer has been adopted rapidly into clinical practice. The accuracy of sentinel lymph node biopsy is more than 95%, when performed meticulously (by an experienced multidisciplinary team) with proper patient selection. Sentinel lymph node biopsy is most widely used for both palpable and non-palpable T1 and T2 tumors. Recent studies show application of sentinel lymph node technique in patients with locally advanced breast cancer and after neoadjuvant chemotherapy. Therefore, sentinel lymph node biopsy technique has application in developing countries and other countries where screening for breast cancer is not common and most patients present relatively in advanced stage of the disease. Several aspects of the sentinel lymph node biopsy including technique, case selection, pathologic analysis and accuracy with supportive important studies published in the literature will be discussed in this review.

Keywords: Sentinel node biopsy, Breast cancer, Blue dye, Radio colloid, Neoadjuvant chemotherapy.

How to cite this article:
Kumar R, Bozkurt M F, Zhuang H, Alavi A. Sentinel lymph node biopsy in the management of breast cancer. Indian J Cancer 2003;40:60

How to cite this URL:
Kumar R, Bozkurt M F, Zhuang H, Alavi A. Sentinel lymph node biopsy in the management of breast cancer. Indian J Cancer [serial online] 2003 [cited 2022 Dec 7];40:60. Available from:

 » Introduction Top

Breast cancer is the most common cancer in the United States and is the second commonest cancer in India in women.[1] Approximately 1 in 9 women will have breast cancer during her lifetime. Breast cancer is the commonest cause of deaths due to cancer in females through out the world.[2] The incidence of breast cancer is increasing. This increase in incidence may be due to increased detection by regular screening and self-examination.

Staging is very important for the management of all cancer patients and breast cancer is not an exception. Staging of axilla in breast cancer is the single most important prognostic factor for selection of appropriate adjuvant therapy, locoregional recurrence and long-term survival. Exact staging of axillary lymph nodes can be obtained in 2 ways, directly by axillary lymph node dissection (ALND) or indirectly by sentinel node biopsy (SLNB). The ALND is drastic and associated with debilitating complications of the ipsilateral arm like lymphedema, seroma, parasthesia etc. Whereas, sentinel node biopsy is less drastic and devoid of above mentioned complications.[3],[4],[5] The evidences from recent studies that showed benefits from neoadjuvant therapy regardless of axillary lymph node involvement also challenge ALND.[6],[7]

For adopting SLNB technique, it is well-recognized accepted fact that a multidisciplinary team, which includes surgery, nuclear medicine and surgical pathology departments, is required to work in a close cooperation. Each of these disciplines plays a crucial role in achieving success, and the surgeon cannot embark upon a successful SLNB program without cooperation from other disciplines.

 » What is Sentinel Lymph Node? Top

The first lymph node in the lymphatic basin draining the primary tumor is called the sentinel lymph node (SLN). When it is identified, removed and biopsied, it reflects the histological characteristics of the rest of the nodes in the basin. It is well-understood phenomenon that metastases to lymph node are not a random phenomenon and can be determined by identifying the lymph flow from tumor to primary lymph draining node. If there is lymphatic spread of cancer it should involve the sentinel node first and then the other nodes. In case of breast cancer, most of the times SLN node exists in axillary lymph nodes of central group of level I, level II or Level III. The incidence of sentinel lymph node in internal mammary lymph nodes is less than 5% and internal mammary nodes alone harboring metastases are very rare.[8]

The concept of 'sentinel lymph node' was first described by Cabanas in 1977 in patients with carcinoma of penis.[9] Sentinel lymphdectomy in 22 breast cancer patients using Tc99m-sulphur colloid and gamma probe was first described in 1993 by Krag et al.[10] Giuliano et al in 1994 published the first study in breast cancer patients using blue dye method.[11] After that, a large number of studies have been published in the literature on different aspects of this technique.

 » Anatomy and Physiology of Lymphatic System of Breast Top

Since the breast is originally an ectodermal tissue, its lymphatic drainage mostly parallels lymph flow of the overlying skin. Lymphatic flow from the skin finds its way to the diffuse subcutaneous plexus between the skin and the superficial fascia. Each lobule of the breast tissue has an extensive lymphatic plexus, that are merged to form Sappey's subareolar plexus. Sappey's subareolar plexus and deep fascial plexus are in connection with each other through fibrous strands traversing the breast tissue. Most part of the breast tissue and the overlying skin can be accepted as a single unit sharing a common lymphatic pathway draining to axillary lymph nodes, because of the common embryologic origin. But there are some exceptional breast areas such as lateral portion of the breast tissue draining to the lymph nodes of the pectoral group and the medial portion that drains to the internal mammarian lymph nodes.[12] In general, most of the lymph of the breast tissue drains to the axillary nodes, whereas approximately 3% drains to internal mammarian lymph nodes and parasternal nodes and very small portion of lymph drains to posterior intercostal nodes.[13] The drainage pattern of lymphatics in breast tissue plays an important role in choosing different radiocolloid injection techniques.

 » Technical aspects of Sentinel Node Biopsy Top

The sentinel lymph node can be identified by a number of ways. SLNB is a robust procedure as satisfactory results are obtained despite significant variations in the methodology. Some centers use blue dye only, others use radiocolloid (Tc99-sulphur colloid) only but most of the center use combination of two for detection of SLNB. All three methods had reliable results in experienced hands. Though theoretically SLN should be one node, in practice there is often more than one node in the axilla which is positive by either blue dye method or radiocolloid method and they all are labeled as SLN. Since most of the time, there is more than one sentinel lymph node as demonstrated by multi-institutional study of 1436 patients, false negative rates fall from 14.3% to 4.3% if multiple nodes were removed instead of single node.[14] McMasters et al also obtained similar results in a large multicentric trial.[15] Therefore, combination technique appears to be more accurate than radiocolloid or blue dye alone. Many authors demonstrated best results with combination techniques proving that this hypothesis is true. Of 39 studies, using radioisotopes (16 studies) or blue dye (11 studies) or a combination of both (12 studies) identified SLN in 92%, 81% and 93% respectively, while false negative rates were 7%, 9% and 5% respectively.[16] All these studies showed that there is higher identification of SLN and lower false negative rate of SLNB for combined method. In a recent study, we also demonstrated higher success rate of SLN identification with combined method than that of radiocolloid or blue dye method alone.[17]

Based on our experience and the published data in the literature, we suggest that combined radiocolloid and blue dye method yields the best result of SLN identification and less false negative cases.

Injection Techniques

Different injection techniques are applied for injection of radiotracer and blue dye in patients with primary breast lesion for SLNB. Initial studies of SLNB involved the multiple peritumoral or intratumoral injection of lymphatic markers because of following reasons; firstly, lymphatic drainage of the skin of the breast and glandular tissue were thought to be significantly different, secondly, the injection distant from tumor may not represent true sentinel lymph node.[18],[19] However, many recent studies used intradermal (ID), subdermal (SD) and subareolar (SA) injection techniques.[20],[21],[22] By simultaneous PT injection of blue dye and ID or SD or SA injection of radiocolloid on the same patient and finding the same SLN as hot and blue they demonstrated that these alternate injection sites also detect the SLN correctly. Several authors demonstrated that visualisation of axillary lymph nodes by ID or SA injection is faster than with PT injection.[22],[23],[24],[25]

On the basis of current literature and our own experience, we feel that single SA or ID/SD injection will map SLN as multiple (4-6 sites) peritumoral injection in majority of patients. SA or ID/SD injections are also much simpler.

Pre-op Lymphoscintigraphy for localization of SLN

Lymphatic mapping demonstrates the draining lymph node of primary breast cancer. Lymph node image acquisition and localization is done with the help of gamma camera after injection of radiotracer. The biggest advantage of pre-operative lymphoscintigraphy is identification of unexpected drainage route especially non-axillary lymph nodes which can be seen in up to 20% patients.[26],[27],[28] The other advantages include determining the exact number of sentinel nodes and distinguishing first from second-tier nodes. Surgeons at the Netherlands Cancer Institute have stated that the lymphoscintigram can act "as a road map in a strange city".[29] However, many researchers feel that pre-operative lymphoscintigraphy does not improve the detection rate of SLN.[27],[28] McMasters et al in their non-randomized multi-institutional study failed to demonstrate any advantage of pre-operative lymphoscintigraphy in 588 patients.[15] In 85% patients in whom SLN was not seen on lymphoscintigraphy initially, it was found intraoperatively.

Localization of SLN during Surgery

SLN biopsy is usually a straightforward and simple operation. Usually 5 to 10 minutes before the procedure on the breast (excision or mastectomy), 1-2 ml blue dye is injected intraparenchymally at four to six sites around the breast lump or skin-overlying tumor. A gentle massage is given for 10-15 minutes to facilitate the drainage of blue dye to lymph nodes. Isotope counts are taken from the axilla and the injection site in the breast using a hand-held gamma probe with audible guidance system. At the time of surgery, blue lymphatic tract is followed till blue node is identified. Gamma probe is used during surgery to localize isotope positive sentinel lymph nodes. All lymph nodes having counts > 10 times of background count ('hot') are considered as sentinel lymph nodes irrespective of the status of blue dye. As well as all blue dye positive nodes ('blue') are also considered as sentinel node irrespective of radioactive counts. All 'hot' and 'blue' sentinel nodes should be sent for frozen section, H&E staining as well as for immunohistological (Cytokeratin) staining for detection of micro-metastasis.

Learning Curves

Learning curves are well known in SLNB training of surgeons.[30],[32] It takes longer time and more cases are needed for identification of SLN and to achieve reasonable accuracy using blue dye alone than combined blue dye and radiocolloid method.[32],[33] Cox et al, described results amongst 700 cases operated on by 5 surgeons using combined blue dye and radiocolloid.[30] They described a rapid decrease in failure in identification of SLN after first 20 cases. The overall learning curves indicated that 23 and 53 cases were required by 5 surgeons to achieve 90 and 95% accuracy respectively. Similarly, in a large multi-institutional study of 2148 patients, McMasters demonstrated that individual surgeon needs to perform at least 20 SLNB with accompanying complete axillary dissection before the surgeon is likely to reach an acceptable level of identification and accuracy.[33]

 » Accuracy of Sentinel Lymph Node Biopsy Top

Sentinel lymph node biopsy can replace axillary dissection for staging and diagnosis in T1 and T2 breast cancer after appropriate and adequate training of surgeons and management team. These were highlights of Philadelphia consensus conference on the role of sentinel node biopsy in breast cancer in 2001.[34] Fraile et al conducted a meta analysis of 18 studies on 2500 SLNB plus axillary dissection for assessment of accuracy of SLNB.[35] They reported a sensitivity ranging from 83% to 100% and concluded that SLNB is a safe substitute of axillary node dissection. Most of the studies reported > 95% identification of sentinel lymph node in appropriately selected patients.[3],[15],[36],[37] The false negative rates of SLNB are <5% and these numbers are comparable to the failure to detect a metastatic focus in nodes recovered from axillary dissection.

 » Tumor Size and SLNB Top

Till recently, tumor size more than T2 was considered as a contraindication. Therefore, most of the studies undertaken included patients having T1 and T2 tumors, though, it is well known fact that incidence of axillary lymph node metastases increases with tumor size.[38] But axillary dissection can be avoided in patients who have negative SLNB in patients with larger tumors. Two recent studies showed that there is no significant difference in identification of SLN and false negative rate in T3 tumors when compared to T1 tumors.[39],[40] Therefore, tumor size should not preclude the use of SLNB in those patients who otherwise are candidates for the procedure. Bedrosian et al concluded that SLN biopsy for patients with large breast tumors is technically feasible and highly accurate. SLN biopsy should be considered for the staging of clinically negative axilla in patients scheduled to receive neoadjuvant chemotherapy.[41] Therefore, SLNB is not a contraindication in patients with larger breast malignant tumors and clinically negative axillary lymph nodes.

 » SLNB after Neoadjuvant Therapy Top

The patients with large primary breast tumors are considered poor candidates for breast conservation therapy; however, recent success of chemotherapy has allowed lumpectomy. Besides, SLNB has emerged as a possible alternative to axillary node dissection in patients with operable breast cancer, this procedure is also emerging as a possible alternative in patients who have received prior neoadjuvant chemotherapy. Therefore, it is important to know how safe it is to perform SLNB in these patients. Initial smaller, single-institution series with the SLNB have shown significant variability in the identification rates and false negative rates up to 33% resulting in inconsistent conclusions regarding the appropriateness of this technique in this group of patients.[42],[43],[44],[45],[46] Subsequent larger, multicenter series have shown that the identification rates and false negative rates with sentinel node biopsy after neoadjuvant chemotherapy is similar to those when sentinel node biopsy is performed after breast cancer diagnosis[47],[48],[49],[50],[51],[52],[53],[54],[55],[56] [Table - 1].

Recently, Sabel et al and Schrenk et al demonstrated 100% identification rate of SLN in patients before neo-adjuvant chemotherapy.[57],[58] There were no false negative results in either of studies.

Thus, it appears that the sentinel node concept is also applicable in patients who have undergone neoadjuvant chemotherapy. This observation has the potential to expand the utility of neoadjuvant chemotherapy in patients with operable breast cancer.[59]

 » SLNB for Multicentric Cancer Top

Most of the studies available in the literature have excluded patients who had multicentric breast masses with the assumption that it is difficult to localize true sentinel lymph node or there may be multiple lymph nodes representing different tumor lesions. Only few studies tried to answer the question if SLNB is safe procedure in patients with multicentric breast cancer. Schrenk et al identified SLN in all 19 patients with multicentric breast cancer with no false negative study.[60] In a study of 48 patients with multicentric breast cancer, we identified SLN in 93% patients.[17] There was no false negative result in this series. Fernandez et al had similar experience of identification rate of 98% with no false negative patient.[61]

All these studies evidenced that lymphatic mapping and SLNB is possible in the patients with multicentric and multifocal breast cancer without increased false negative results. However, large studies are required to validate the utility of SLNB in these patients.

 » Inaccuracy of Frozen Section Top

It is well known fact that micrometastases are missed by routine frozen section of lymph nodes. The serial sectioning with H&E staining and immunohistochemistry methods have found additional micrometastases in 7%-33% cases.[62],[63] Therefore, these patients need second operation to perform a complete ALND once micrometastases are detected on more extensive serial section and/or immunohistochemistry (IHC) staining leading to increase in morbidity and financial burden. There is enough data in the literature suggesting that frozen section analysis is not as sensitive as routine pathological assessment of paraffin section and IHC.[62],[64] Intra-operative lymph node involvement can be assessed by imprint cytology.[65],[66] However this technique has variable results and is operator dependent. Further large studies are required to draw further conclusions.

 » Safety, Contraindications and Limitations Top

There are many specific safety issues in SLNB. Allergic reaction to blue dye and radiocolloid are rare but have been reported. Efron et al reported a case anaphylactic shock in response to injection of isosulfan blue for the purpose of localizing the sentinel node and review the medical literature.[67] The urticaria from blue dye may take the form of striking blue colored wheals and should be treated like any other allergic reaction during perioperative situation. Second important safety issue is radiation exposure to patient and staff involved in SLNB. This issue has been undertaken by many authors and it has been demonstrated that risks are negligible and radiation levels are much lower than permissible limits.[67],[68],[69],[70],[71] The radiation risks to the administered doses are much low relative to many other imaging modalities.[68]

The list of specific contraindications is becoming short and short with the experience in SLNB. Krontiras et al reviewed the current data regarding contraindications for the use of sentinel lymph node biopsy and lymphatic mapping.[72] At present, there are very few contraindications, such as the patient with clinically positive axillary lymph nodes. In these patients with clinically positive lymph nodes, radiocolloid and blue dye may be blocked by infiltration of lymphatic channels by tumour and can lead to identification of non-sentinel lymph node as well as the patient may require axillary dissection as a part of the treatment. Locally advanced breast cancer is also considered as one of the contraindications. Although, recent few studies showed that SLNB can be considered if axillary lymph nodes are negative for metastases even in locally advanced disease. Allergies to blue dye or the radiocolloid should also be considered another contraindication to that material although it is very rare. However there is no cross reactivity among two. The risks of blue dye and radio colloid in pregnancy are not known, and considered as a contraindication till data is available.

Prior axillary procedures like augmentation mammoplasty through axillary incision, prior axillary dissection are relative contraindications. However, the important point in this regard is the consideration of intact lymphatic channels between tumor and lymph node. A small data of SLNB after surgery from Port et al study is noteworthy, but more data is required.[73]

 » Conclusions Top

Sentinel lymph node biopsy is an exciting new tool for staging the axilla in an accurate and less morbid way in breast cancer patients. Proof of SLN is well established and has success rate of more than 95% with multidisciplinary team work. The combined method of radiocolloid and blue dye yields best results of sentinel node identification. The eligibility criteria for SLNB are increasing and contraindications are decreasing with experience. It is becoming more apparent that SLNB is appropriate in a variety of settings including properly selected patients undergoing neoadjuvant chemotherapy and those with locally advanced breast cancer. The absolute contraindications are palpable metastatic lymphadenopathy and pregnancy.

 » References Top

1.Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, 1999. CA Cancer J Clin 1999;49:8-31.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Wingo PA, Cardinez CJ, Landis SH, Greenlee RT, Ries LA, Anderson RN, et al. Long-term trends in cancer mortality in the United States, 1930-1998. Cancer 2003;97:3133-75.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Veronesi U, Paganelli G, Viale G, Luini A, Zurrida S, Galimberti V, et al. A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer. N Engl J Med 2003;349:546-53.  Back to cited text no. 3    
4.Schrenk P, Rieger R, Shamiyeh A, Wayand W. Morbidity following Sentinel lymph node biopsy versus axillary lymph node dissection for patients with breast carcinoma. Cancer 2000;88:608-14.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Peintinger F, Reitsamer R, Stranzl H, Ralph G. Comparison of quality of life and arm complaints after axillary lymph node dissection vs sentinel lymph node biopsy in breast cancer patients. Br J Cancer 2003;89:648-52.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.B Cady. The need to reexamine axillary lymph node dissection in invasive breast cancer [Editorial]. Cancer 1994;73:505-8.   Back to cited text no. 6    
7.Pandelidis SM, Peters KL, Walusimbi MS, Casady RL, Laux SV, Cavanaugh SH, et al. The role of axillary dissection in mammographically detected carcinoma. J Am Coll Surg 1997;184:341-5.  Back to cited text no. 7  [PUBMED]  
8.Morrow M, Foster RS Jr. Staging of breast cancer: a new rationale for internal mammary node biopsy. Arch Surg 1981;116:748-51.   Back to cited text no. 8  [PUBMED]  
9.Cabanas RM. An approach for the treatment of penile carcinoma. Cancer 1977;39:456-66.  Back to cited text no. 9  [PUBMED]  
10.Krag DN, Weaver DL, Alex JC, Fairbank JT. Surgical resection and radiolocalization of the sentinel lymph node in breast cancer using a gamma probe. Surg Oncol 1993;2:335-9.  Back to cited text no. 10    
11.Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg 1994;220:391-401.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]
12.Osborne MT. Breast development and anatomy. In: Harris JR, Morrow M, Lippman ME, Hellman S, editors. Diseases of the Breast. Cedar Knolls, NJ: Lippincott-Raven Healthcare; 1996. Vol 1. pp. 1-14.  Back to cited text no. 12    
13.Turner-Warwick RT. The lymphatics of the breast. Br J Surg 1959;46:574-82.  Back to cited text no. 13  [PUBMED]  
14.Wong SL, Edwards MJ, Chao C, Tuttle TM, Noyes RD, Carlson DJ, et al. Sentinel lymph node biopsy for breast cancer: impact of the number of sentinel nodes removed on the false-negative rate. J Am Coll Surg 2001;192:684-91.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]
15.McMasters KM, Wong SL, Tuttle TM, Carlson DJ, Brown CM, Dirk Noyes R, et al. Preoperative lymphoscintigraphy for breast cancer does not improve the ability to identify axillary sentinel lymph nodes. Ann Surg 2000;231:724-31.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]
16.Cody HS III. Clinical aspects of sentinel node biopsy. Breast Cancer Res 2001;3:104-8.  Back to cited text no. 16    
17.Kumar R, Jana S, Heiba SI, Dakhel M, Axelrod D, Siegel B, et al. Retrospective analysis of sentinel node localization in multicentric palpable and non-palpable breast cancer. J Nucl Med 2003:44:7-10.  Back to cited text no. 17    
18.Uren RF, Howman-Giles RB, Thompson JF, Malouf D, Ramsey-Stewart G, Niesche FW, et al. Mammary lymphoscintigraphy in breast cancer. J Nucl Med 1995;36:1775-80.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]
19.Uren RF, Thompson JF, Howman-Giles R. Sentinel-lymph node biopsy in breast cancer. Lancet 1998;352:1472-3.  Back to cited text no. 19  [PUBMED]  
20.McMasters KM, Wong SL, Martin RC 2nd, Chao C, Tuttle TM, Noyes RD, et al. Dermal injection of radioactive colloid is superior to peritumoral injection for breast cancer sentinel lymph node biopsy: results of a multi-institutional study. Ann Surg. 2001;233: 676-87.  Back to cited text no. 20    
21.Pelosi E, Baiocco C, Ala A, Gay E, Bello M, Varetto T, et al, Lymphatic mapping in early stage breast cancer: comparison between periareolar and subdermal injection. Nucl Med Commun 2003;24: 519-23.  Back to cited text no. 21    
22.Celliers L, Mann GB. Alternative sites of injection for sentinel lymph node biopsy in breast cancer. ANZ J Surg 2003;73:600-4.  Back to cited text no. 22  [PUBMED]  [FULLTEXT]
23.Kern KA, Rosenberg RJ. Preoperative lymphoscintigraphy during lymphatic mapping for breast cancer: improved sentinel node imaging using subareolar injection of technetium 99m sulfur colloid. J Am Coll Surg 2000;191:479-89.  Back to cited text no. 23  [PUBMED]  [FULLTEXT]
24.Linehan DC, Hill AD, Tran KN, Yeung H, Yeh SD, Borgen PI, et al. Sentinel lymph node biopsy in breast cancer: unfiltered radioisotope is superior to filtered. J Am Coll Surg 1999;188:377-81.  Back to cited text no. 24  [PUBMED]  [FULLTEXT]
25.De Cicco C, Cremonesi M, Luini A, Bartolomei M, Grana C, Prisco G, et al. Lymphoscintigraphy and radioguided biopsy of the sentinel axillary node in breast cancer. J Nucl Med 1998;39:2080-84.  Back to cited text no. 25    
26.Krag D, Weaver D, Ashikaga T, Moffat F, Klimberg VS, Shriver C, et al. The sentinel node in breast cancer-a multicenter validation study. N Engl J Med 1998;33:941-6.  Back to cited text no. 26    
27.Victorzon M, Hamalainen E, Svartback M, Lantto A. Extra-axillary sentinel node biopsy in breast cancer staging-is it necessary? Eur J Surg Oncol 2003;29:604-6.   Back to cited text no. 27  [PUBMED]  [FULLTEXT]
28.Upponi SS, McIntosh SA, Wishart GC, Balan KK, Purushotham AD. Sentinel lymph node biopsy in breast cancer-is lymphoscintigraphy really necessary? Eur J Surg Oncol 2002;28:479-80.  Back to cited text no. 28  [PUBMED]  
29.Rutgers EO, Nieweg OE. How to do it: the Netherlands Cancer Institute approach. In: Cody HS III, editor. Sentinel node biopsy. London, England: Martin Dunitz; 2002. pp. 245-9.  Back to cited text no. 29    
30.Cox CE, Bass SS, Boulware D, Ku NK, Berman C, Reintgen DS. Implementation of new surgical technology: outcome measures for lymphatic mapping of breast carcinoma. Ann Surg Oncol 1999;6:553-61.   Back to cited text no. 30  [PUBMED]  [FULLTEXT]
31.Morrow M, Rademaker AW, Bethke KP, Talamonti MS, Dawes LG, Clauson J, et al. Learning sentinel node biopsy: results of a prospective randomized trial of two techniques. Surgery 1999;126: 714-20.   Back to cited text no. 31  [PUBMED]  [FULLTEXT]
32.Cody HS 3rd, Hill AD, Tran KN, Brennan MF, Borgen PI. Credentialing for breast lymphatic mapping: how many cases are enough? Ann Surg 1999;229:723-6.  Back to cited text no. 32  [PUBMED]  [FULLTEXT]
33.McMasters KM, Wong SL, Chao C, Woo C, Tuttle TM, Noyes RD, et al. Defining the optimal surgeon experience for breast cancer sentinel lymph node biopsy: a model for implementation of new surgical techniques. Ann Surg 2001;234:292-9.  Back to cited text no. 33  [PUBMED]  [FULLTEXT]
34.Schwartz GF, Giuliano AE, Veronesi U. Consensus Conference Committee. Proceedings of the consensus conference on the role of sentinel lymph node biopsy in carcinoma of the breast, April 19-22, 2001, Philadelphia, Pennsylvania. Cancer 2002;94:2542-51.  Back to cited text no. 34    
35.Fraile M, Rull M, Julian FJ, Fuste F, Barnadas A, Llatjos M, et al. Sentinel node biopsy as a practical alternative to axillary lymph node dissection in breast cancer patients: an approach to its validity. Ann Oncol 2000;11:701-5.  Back to cited text no. 35    
36.Shivers S, Cox C, Leight G, Beauchamp D, Blumencranz P, Ross M, et al. Final results of the Department of Defense multicenter breast lymphatic mapping trial. Ann Surg Oncol 2002;9:248-55.  Back to cited text no. 36  [PUBMED]  [FULLTEXT]
37.Tafra L, Lannin DR, Swanson MS, Van Eyk JJ, Verbanac KM, Chua AN, et al. Multicenter trial of sentinel node biopsy for breast cancer using both technetium sulfur colloid and isosulfan blue dye. Ann Surg 2001;233:51-9.  Back to cited text no. 37  [PUBMED]  [FULLTEXT]
38.Carter C, Allen C, Henson D. Relation of tumor size, lymph node status and survival in 24,740 breast cancer cases. Cancer 1989; 63:181-7.   Back to cited text no. 38    
39.Chung MH, Ye W, Giuliano AE. Role for sentinel lymph node dissection in the management of large (>or=5 cm) invasive breast cancer. Ann Surg Oncol 2001;8:688-92.   Back to cited text no. 39  [PUBMED]  [FULLTEXT]
40.Wong SL, Chao C, Edwards MJ, Tuttle TM, Noyes RD, Carlson DJ, et al. Accuracy of sentinel lymph node biopsy for patients with T2 and T3 breast cancer. Am Surg 2001;67:522-6.  Back to cited text no. 40  [PUBMED]  
41.Bedrosian I, Reynolds C, Mick R, Callans LS, Grant CS, Donohue JH, et al. Accuracy of sentinel lymph node biopsy in patients with large primary breast tumors. Cancer 2000;88:2540-5.  Back to cited text no. 41  [PUBMED]  [FULLTEXT]
42.Breslin TM, Cohen L, Sahin A, Fleming JB, Kuerer HM, Newman LA, et al. Sentinel lymph node biopsy is accurate after neoadjuvant chemotherapy for breast cancer. J Clin Oncol 2000;18:3480-6.  Back to cited text no. 42  [PUBMED]  [FULLTEXT]
43.Nason KS, Anderson BO, Byrd DR, Dunnwald LK, Eary JF, Mankoff DA, et al. Increased false negative sentinel node biopsy rates after preoperative chemotherapy for invasive breast carcinoma. Cancer 2000;89:2187-94.  Back to cited text no. 43  [PUBMED]  [FULLTEXT]
44.Cohen LF, Breslin TM, Kuerer HM, Ross MI, Hunt KK, Sahin AA. Identification and evaluation of axillary sentinel lymph nodes in patients with breast carcinoma treated with neoadjuvant chemotherapy. Am J Surg Pathol 2000;24:1266-72.  Back to cited text no. 44  [PUBMED]  [FULLTEXT]
45.Haid A, Tausch C, Lang A, Lutz J, Fritzsche H, Peschina W, et al. Is sentinel lymph node biopsy reliable and indicated after preoperative chemotherapy in patients with breast carcinoma? Cancer 2001;92:1080-4.  Back to cited text no. 45  [PUBMED]  [FULLTEXT]
46.Fernandez A, Cortes M, Benito E, Azpeitia D, Prieto L, Moreno A, et al. Gamma probe sentinel node localization and biopsy in breast cancer patients treated with a neoadjuvant chemotherapy scheme. Nucl Med Commun 2001;22:361-6.  Back to cited text no. 46  [PUBMED]  [FULLTEXT]
47.Julian TB, Patel N, Dusi D, Olson P, Nathan G, Jasnosz K, et al. Sentinel lymph node biopsy after neoadjuvant chemotherapy for breast cancer. Am J Surg 2001;182:407-10.   Back to cited text no. 47  [PUBMED]  [FULLTEXT]
48.Tafra L, Verbanac KM, Lannin DR. Preoperative chemotherapy and sentinel lymphadenectomy for breast cancer. Am J Surg 2001;182:312-5.  Back to cited text no. 48  [PUBMED]  [FULLTEXT]
49.Stearns V, Ewing CA, Slack R, Penannen MF, Hayes DF, Tsangaris TN. Sentinel lymphadenectomy after neoadjuvant chemotherapy for breast cancer may reliably represent the axilla except for inflammatory breast cancer. Ann Surg Oncol 2002;9:235-42.  Back to cited text no. 49  [PUBMED]  [FULLTEXT]
50.Miller AR, Thomason VE, Yeh IT, Alrahwan A, Sharkey FE, Stauffer J, et al. Analysis of sentinel lymph node mapping with immediate pathologic review in patients receiving preoperative chemotherapy for breast carcinoma. Ann Surg Oncol 2002;9:243-7.  Back to cited text no. 50  [PUBMED]  [FULLTEXT]
51.Mamounas EP, Brown A, Smith R. Accuracy of sentinel node biopsy after neoadjuvant chemotherapy in breast cancer: updated results from NSABP B-27. Proc Am Soc Clin Oncol 2002;21:140.  Back to cited text no. 51    
52.Julian TB, Dusi D, Wolmark N. Sentinel node biopsy after neoadjuvant chemotherapy for breast cancer. Am J Surg 2002;184:315-7.  Back to cited text no. 52  [PUBMED]  [FULLTEXT]
53.Brady EW. Sentinel lymph node mapping following neoadjuvant chemotherapy for breast cancer. Breast J 2002;8:97-100.  Back to cited text no. 53    
54.Piato JR, Barros AC, Pincerato KM, Sampaio AP, Pinotti JA. Sentinel lymph node biopsy in breast cancer after neoadjuvant chemotherapy. A pilot study. Eur J Surg Oncol 2003;29:118-20.  Back to cited text no. 54    
55.Reitsamer R, Peintinger F, Rettenbacher L, Prokop E. Sentinel lymph node biopsy in breast cancer patients after neoadjuvant chemotherapy. J Surg Oncol 2003;84:63-7.  Back to cited text no. 55  [PUBMED]  [FULLTEXT]
56.Schwartz GF, Meltzer AJ. Accuracy of axillary sentinel lymph node biopsy following neoadjuvant (induction) chemotherapy for carcinoma of the breast. Breast J 2003;9:374-9.  Back to cited text no. 56  [PUBMED]  [FULLTEXT]
57.Sabel MS, Schott AF, Kleer CG, Merajver S, Cimmino VM, Diehl KM, et al. Sentinel node biopsy prior to neoadjuvant chemotherapy. Am J Surg 2003;186:102-5.  Back to cited text no. 57  [PUBMED]  [FULLTEXT]
58.Schrenk P, Hochreiner G, Fridrik M, Wayand W. Sentinel node biopsy performed before preoperative chemotherapy for axillary lymph node staging in breast cancer. Breast J 2003;9:282-7.  Back to cited text no. 58    
59.Mamounas EP. Sentinel lymph node biopsy after neoadjuvant systemic therapy. Surg Clin North Am 2003;83:931-42.  Back to cited text no. 59  [PUBMED]  
60.Schrenk P, Wayand W. Sentinel-node biopsy in axillary lymph-node staging for patients with multicentric breast cancer. Lancet 2001;357:122.  Back to cited text no. 60  [PUBMED]  [FULLTEXT]
61.Fernandez K, Swanson M, Verbanac K, Tafra L. Is sentinel lymphadenectomy accurate in multifocal and multicentric breast cancer [abstract]. Ann Surg Oncol 2002;9:S16-7.  Back to cited text no. 61    
62.Dowlatshahi K, Fan M, Snider HC, Habib FA. Lymph node micrometastases from breast carcinoma: reviewing the dilemma. Cancer 1997;80:188-97.  Back to cited text no. 62  [PUBMED]  [FULLTEXT]
63.Pargaonkar AS, Beissner RS, Snyder S, Speights VO Jr. Evaluation of immunohistochemistry and multiple-level sectioning in sentinel lymph nodes from patients with breast cancer. Arch Pathol Lab Med 2003;127:701-5.  Back to cited text no. 63    
64.G Cserni. Complete sectioning of axillary sentinel nodes in patients with breast cancer. Analysis of two different step sectioning and immunohistochemistry protocols in 246 patients. J Clin. Pathol 2002;55:926-31.  Back to cited text no. 64    
65.Fisher CJ, Boyle S, Burke M, Price AB. Intraoperative assessment of nodal status in the selection of patients with breast cancer for axillary clearance. Br J Surg 1993;80:457-8.  Back to cited text no. 65  [PUBMED]  
66.Creager AJ, Geisinger KR, Shiver SA, Perrier ND, Shen P, Ann Shaw J, et al. Intraoperative evaluations of sentinel lymph nodes for metastatic breast carcinoma by imprint cytology. Mod Pathol 2002;15:1140-7.  Back to cited text no. 66  [PUBMED]  
67.Efron P, Knudsen E, Hirshorn S, Copeland EM. Anaphylactic reaction to isosulfan blue used for sentinel node biopsy: case report and literature review. Breast J 2002;8:396-9.  Back to cited text no. 67  [PUBMED]  [FULLTEXT]
68.Waddington WA, Keshtgar MR, Taylor I, Lakhani SR, Short MD, Ell PJ. Radiation safety of the sentinel lymph node technique in breast cancer. Eur J Nucl Med 2000;27:377-91.   Back to cited text no. 68  [PUBMED]  [FULLTEXT]
69.Miner TJ, Shriver CD, Flicek PR, Miner FC, Jaques DP, Maniscalco-Theberge ME, et al. Guidelines for the safe use of radioactive materials during localization and resection of the sentinel lymph node. Ann Surg Oncol 1999;6:75-82.  Back to cited text no. 69    
70.Cremonesi M, Ferrari M, Sacco E, Rossi A, De Cicco C, Leonardi L, et al. Radiation protection in radioguided surgery of breast cancer. Nucl Med Commun 1999;20:919-24.  Back to cited text no. 70  [PUBMED]  
71.Eshima D, Fauconnier T, Eshima L, Thornback JR. Radiopharmaceuticals for lymphoscintigraphy: including dosimetry and radiation considerations. Semin Nucl Med 2000;30:25-32.   Back to cited text no. 71  [PUBMED]  
72.Krontiras H, Bland KI. When is sentinel node biopsy for breast cancer contraindicated? Surg Oncol 2003;12:207-10.  Back to cited text no. 72  [PUBMED]  [FULLTEXT]
73.Port ER, Fey J, Gemignani ML, Heerdt AS, Montgomery LL, Petrek JA, et al. Reoperative sentinel lymph node biopsy: a new option for patients with primary or locally recurrent breast carcinoma. J Am Coll Surg 2002;195:167-72.  Back to cited text no. 73  [PUBMED]  [FULLTEXT]


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