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Breast
Procedures
Surgical Procedures
Sentinel Lymph Node Biopsy
Sentinel Lymph Node Biopsy
Dalliah M. Black, MD, FACS; Katherine McElroy, BA; Henry M. Kuerer, MD, PhD, FACS
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Post Procedure

          TERMINOLOGY

          • Definitions

            • Axillary lymph node dissection (ALND): Removal of level I and II axillary nodes
            • Sentinel lymph node (SLN) biopsy (SLNB): Surgical removal of 1st/primary draining node(s) for staging clinically node-negative breast cancer patients
              • Premise: Breast cancer will spread to 1 or a few sentinel nodes in regional nodal basin before spreading to any other nodes
              • If SLN is negative, 2-5% chance of additional node involvement [= false-negative rate (FNR)]
                • No difference in axillary recurrence rates, no need for ALND
            • Identified by uptake of Tc-99m sulfur colloid ± blue dye ± intraoperative palpation
            • Immunohistochemistry (IHC): Use of antibody to cytokeratin (present in epithelial cells) to identify isolated tumor cells (ITC)
            • Lymphoscintigraphy: Preoperative gamma imaging following injection of Tc-99m sulfur colloid into breast to evaluate lymphatic drainage and SLN location
            • 8th Edition Node Staging
              • pN0: No regional lymph node metastasis or ITCs only
              • pN0(i+): ITCs only with cluster < 0.2 mm
              • pN1: Micrometastasis (> 0.2 mm and < 2.0 mm) or metastasis in 1-3 axillary nodes or metastasis in ipsilateral IM SLN
              • pN2: Metastasis in 4-9 axillary nodes or metastasis in IM node with negative axillary node
              • pN3: Metastasis in 10 or more axillary nodes or in ipsilateral supraclavicular/infraclavicular node
            • Nonsentinel node (NSN): Lymph node not identified by blue dye or Tc-99m sulfur colloid
            • False-negative SLN: NSN with metastasis when SLN negative
            • Targeted axillary dissection (TAD): Localization and excision of known, clipped, metastatic node in addition to 2 SLN [usually after neoadjuvant chemotherapy (NAC)]
            • Clinically suspicious nodes: By physical exam &/or US

          • Location

            • SLN in ipsilateral axillary location in ~ 92-97% of patients
            • Internal mammary node (IMN) and axillary SLN in ~ 14-20%
            • Isolated IMN drainage in 2-8%
              • Isolated IMN metastasis in 1-3% of all patients
            • Isolated contralateral axillary and supraclavicular sentinel node(s) rare

          PREPROCEDURE

          • Indications

            • Contraindications

              • Getting Started

                PROCEDURE

                • Patient Position/Location

                  • Procedure Steps

                    • Findings and Reporting

                      • Alternative Procedures/Therapies

                        POST PROCEDURE

                        • Expected Outcome

                          • Things to Do

                            OUTCOMES

                            • Complications

                              Selected References

                              1. Moossdorff M et al: The potential impact of AMAROS on the management of the axilla in patients with clinical T1-2N0 breast cancer undergoing primary total mastectomy. Ann Surg Oncol. 25(9):2612-19, 2018
                              2. Reimer T et al: Is axillary sentinel lymph node biopsy required in patients who undergo primary breast surgery? Breast Care (Basel). 13(5):324-30, 2018
                              3. Yan M et al: Axillary management in breast cancer patients: a comprehensive review of the key trials. Clin Breast Cancer. 18(6):e1251-e1259, 2018
                              4. Giuliano AE et al: Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: the ACOSOG Z0011 (Alliance) Randomized Clinical Trial. JAMA. 318(10):918-26, 2017
                              5. Lyman GH et al: Sentinel lymph node biopsy for patients with early-stage breast cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 35(5):561-4, 2017
                              6. Boughey JC et al: Identification and resection of clipped node decreases the false-negative rate of sentinel lymph node surgery in patients presenting with node-positive breast cancer (T0-T4, N1-N2) who receive neoadjuvant chemotherapy: results from ACOSOG Z1071 (Alliance). Ann Surg. 263(4):802-7, 2016
                              7. Donker M et al: Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol. 15(12):1303-10, 2014
                              8. Boughey JC et al: Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA. 310(14):1455-61, 2013
                              9. Alvarado R et al: The role for sentinel lymph node dissection after neoadjuvant chemotherapy in patients who present with node-positive breast cancer. Ann Surg Oncol. 19(10):3177-84, 2012
                              10. Milgrom S et al: Characteristics and outcomes of sentinel node-positive breast cancer patients after total mastectomy without axillary-specific treatment. Ann Surg Oncol. 19(12):3762-70, 2012
                              11. Mittendorf EA et al: Incorporation of sentinel lymph node metastasis size into a nomogram predicting nonsentinel lymph node involvement in breast cancer patients with a positive sentinel lymph node. Ann Surg. 255(1):109-15, 2012
                              12. Shah C et al: Breast-cancer related lymphedema: a review of procedure-specific incidence rates, clinical assessment AIDS, treatment paradigms, and risk reduction. Breast J. 18(4):357-61, 2012
                              13. Takahashi M et al: Correlation between clinical nodal status and sentinel lymph node biopsy false negative rate after neoadjuvant chemotherapy. World J Surg. 36(12):2847-52, 2012
                              14. Giuliano AE et al: Association of occult metastases in sentinel lymph nodes and bone marrow with survival among women with early-stage invasive breast cancer. JAMA. 306(4):385-93, 2011
                              15. Giuliano AE et al: Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 305(6):569-75, 2011
                              16. Tan VK et al: The feasibility and accuracy of sentinel lymph node biopsy in clinically node-negative patients after neoadjuvant chemotherapy for breast cancer--a systematic review and meta-analysis. J Surg Oncol. 104(1):97-103, 2011
                              17. Krag DN et al: Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol. 11(10):927-33, 2010
                              18. Sharma R et al: Present-day locoregional control in patients with t1 or t2 breast cancer with 0 and 1 to 3 positive lymph nodes after mastectomy without radiotherapy. Ann Surg Oncol. 17(11):2899-908, 2010
                              19. Veronesi U et al: Sentinel lymph node biopsy in breast cancer: ten-year results of a randomized controlled study. Ann Surg. 251(4):595-600, 2010
                              20. Hunt KK et al: Sentinel lymph node surgery after neoadjuvant chemotherapy is accurate and reduces the need for axillary dissection in breast cancer patients. Ann Surg. 250(4):558-66, 2009
                              21. Macdonald SM et al: Chest wall radiotherapy: middle ground for treatment of patients with one to three positive lymph nodes after mastectomy. Int J Radiat Oncol Biol Phys. 75(5):1297-303, 2009
                              22. Bevilacqua JL et al: Doctor, what are my chances of having a positive sentinel node? A validated nomogram for risk estimation. J Clin Oncol. 25(24):3670-9, 2007
                              23. Krag DN et al: Technical outcomes of sentinel-lymph-node resection and conventional axillary-lymph-node dissection in patients with clinically node-negative breast cancer: results from the NSABP B-32 randomised phase III trial. Lancet Oncol. 8(10):881-8, 2007
                              24. Kim T et al: Lymphatic mapping and sentinel lymph node biopsy in early-stage breast carcinoma: a metaanalysis. Cancer. 106(1):4-16, 2006
                              25. Mansel RE et al: Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC Trial. J Natl Cancer Inst. 98(9):599-609, 2006
                              26. Wilke LG et al: Surgical complications associated with sentinel lymph node biopsy: results from a prospective international cooperative group trial. Ann Surg Oncol. 13(4):491-500, 2006
                              27. Lyman GH et al: American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol. 23(30):7703-20, 2005
                              28. Specht MC et al: Predicting nonsentinel node status after positive sentinel lymph biopsy for breast cancer: clinicians versus nomogram. Ann Surg Oncol. 12(8):654-9, 2005
                              29. Truong PT et al: Selecting breast cancer patients with T1-T2 tumors and one to three positive axillary nodes at high postmastectomy locoregional recurrence risk for adjuvant radiotherapy. Int J Radiat Oncol Biol Phys. 61(5):1337-47, 2005
                              30. Balch GC et al: Lymphatic mapping and sentinel lymphadenectomy after preoperative therapy for stage II and III breast cancer. Ann Surg Oncol. 10(6):616-21, 2003
                              Related Anatomy
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                              Related Differential Diagnoses
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                              References
                              Tables

                              Tables

                              KEY FACTS

                              • Terminology

                                • Preprocedure

                                  • Procedure

                                    • Post Procedure

                                      TERMINOLOGY

                                      • Definitions

                                        • Axillary lymph node dissection (ALND): Removal of level I and II axillary nodes
                                        • Sentinel lymph node (SLN) biopsy (SLNB): Surgical removal of 1st/primary draining node(s) for staging clinically node-negative breast cancer patients
                                          • Premise: Breast cancer will spread to 1 or a few sentinel nodes in regional nodal basin before spreading to any other nodes
                                          • If SLN is negative, 2-5% chance of additional node involvement [= false-negative rate (FNR)]
                                            • No difference in axillary recurrence rates, no need for ALND
                                        • Identified by uptake of Tc-99m sulfur colloid ± blue dye ± intraoperative palpation
                                        • Immunohistochemistry (IHC): Use of antibody to cytokeratin (present in epithelial cells) to identify isolated tumor cells (ITC)
                                        • Lymphoscintigraphy: Preoperative gamma imaging following injection of Tc-99m sulfur colloid into breast to evaluate lymphatic drainage and SLN location
                                        • 8th Edition Node Staging
                                          • pN0: No regional lymph node metastasis or ITCs only
                                          • pN0(i+): ITCs only with cluster < 0.2 mm
                                          • pN1: Micrometastasis (> 0.2 mm and < 2.0 mm) or metastasis in 1-3 axillary nodes or metastasis in ipsilateral IM SLN
                                          • pN2: Metastasis in 4-9 axillary nodes or metastasis in IM node with negative axillary node
                                          • pN3: Metastasis in 10 or more axillary nodes or in ipsilateral supraclavicular/infraclavicular node
                                        • Nonsentinel node (NSN): Lymph node not identified by blue dye or Tc-99m sulfur colloid
                                        • False-negative SLN: NSN with metastasis when SLN negative
                                        • Targeted axillary dissection (TAD): Localization and excision of known, clipped, metastatic node in addition to 2 SLN [usually after neoadjuvant chemotherapy (NAC)]
                                        • Clinically suspicious nodes: By physical exam &/or US

                                      • Location

                                        • SLN in ipsilateral axillary location in ~ 92-97% of patients
                                        • Internal mammary node (IMN) and axillary SLN in ~ 14-20%
                                        • Isolated IMN drainage in 2-8%
                                          • Isolated IMN metastasis in 1-3% of all patients
                                        • Isolated contralateral axillary and supraclavicular sentinel node(s) rare

                                      PREPROCEDURE

                                      • Indications

                                        • Contraindications

                                          • Getting Started

                                            PROCEDURE

                                            • Patient Position/Location

                                              • Procedure Steps

                                                • Findings and Reporting

                                                  • Alternative Procedures/Therapies

                                                    POST PROCEDURE

                                                    • Expected Outcome

                                                      • Things to Do

                                                        OUTCOMES

                                                        • Complications

                                                          Selected References

                                                          1. Moossdorff M et al: The potential impact of AMAROS on the management of the axilla in patients with clinical T1-2N0 breast cancer undergoing primary total mastectomy. Ann Surg Oncol. 25(9):2612-19, 2018
                                                          2. Reimer T et al: Is axillary sentinel lymph node biopsy required in patients who undergo primary breast surgery? Breast Care (Basel). 13(5):324-30, 2018
                                                          3. Yan M et al: Axillary management in breast cancer patients: a comprehensive review of the key trials. Clin Breast Cancer. 18(6):e1251-e1259, 2018
                                                          4. Giuliano AE et al: Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: the ACOSOG Z0011 (Alliance) Randomized Clinical Trial. JAMA. 318(10):918-26, 2017
                                                          5. Lyman GH et al: Sentinel lymph node biopsy for patients with early-stage breast cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 35(5):561-4, 2017
                                                          6. Boughey JC et al: Identification and resection of clipped node decreases the false-negative rate of sentinel lymph node surgery in patients presenting with node-positive breast cancer (T0-T4, N1-N2) who receive neoadjuvant chemotherapy: results from ACOSOG Z1071 (Alliance). Ann Surg. 263(4):802-7, 2016
                                                          7. Donker M et al: Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol. 15(12):1303-10, 2014
                                                          8. Boughey JC et al: Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA. 310(14):1455-61, 2013
                                                          9. Alvarado R et al: The role for sentinel lymph node dissection after neoadjuvant chemotherapy in patients who present with node-positive breast cancer. Ann Surg Oncol. 19(10):3177-84, 2012
                                                          10. Milgrom S et al: Characteristics and outcomes of sentinel node-positive breast cancer patients after total mastectomy without axillary-specific treatment. Ann Surg Oncol. 19(12):3762-70, 2012
                                                          11. Mittendorf EA et al: Incorporation of sentinel lymph node metastasis size into a nomogram predicting nonsentinel lymph node involvement in breast cancer patients with a positive sentinel lymph node. Ann Surg. 255(1):109-15, 2012
                                                          12. Shah C et al: Breast-cancer related lymphedema: a review of procedure-specific incidence rates, clinical assessment AIDS, treatment paradigms, and risk reduction. Breast J. 18(4):357-61, 2012
                                                          13. Takahashi M et al: Correlation between clinical nodal status and sentinel lymph node biopsy false negative rate after neoadjuvant chemotherapy. World J Surg. 36(12):2847-52, 2012
                                                          14. Giuliano AE et al: Association of occult metastases in sentinel lymph nodes and bone marrow with survival among women with early-stage invasive breast cancer. JAMA. 306(4):385-93, 2011
                                                          15. Giuliano AE et al: Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 305(6):569-75, 2011
                                                          16. Tan VK et al: The feasibility and accuracy of sentinel lymph node biopsy in clinically node-negative patients after neoadjuvant chemotherapy for breast cancer--a systematic review and meta-analysis. J Surg Oncol. 104(1):97-103, 2011
                                                          17. Krag DN et al: Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol. 11(10):927-33, 2010
                                                          18. Sharma R et al: Present-day locoregional control in patients with t1 or t2 breast cancer with 0 and 1 to 3 positive lymph nodes after mastectomy without radiotherapy. Ann Surg Oncol. 17(11):2899-908, 2010
                                                          19. Veronesi U et al: Sentinel lymph node biopsy in breast cancer: ten-year results of a randomized controlled study. Ann Surg. 251(4):595-600, 2010
                                                          20. Hunt KK et al: Sentinel lymph node surgery after neoadjuvant chemotherapy is accurate and reduces the need for axillary dissection in breast cancer patients. Ann Surg. 250(4):558-66, 2009
                                                          21. Macdonald SM et al: Chest wall radiotherapy: middle ground for treatment of patients with one to three positive lymph nodes after mastectomy. Int J Radiat Oncol Biol Phys. 75(5):1297-303, 2009
                                                          22. Bevilacqua JL et al: Doctor, what are my chances of having a positive sentinel node? A validated nomogram for risk estimation. J Clin Oncol. 25(24):3670-9, 2007
                                                          23. Krag DN et al: Technical outcomes of sentinel-lymph-node resection and conventional axillary-lymph-node dissection in patients with clinically node-negative breast cancer: results from the NSABP B-32 randomised phase III trial. Lancet Oncol. 8(10):881-8, 2007
                                                          24. Kim T et al: Lymphatic mapping and sentinel lymph node biopsy in early-stage breast carcinoma: a metaanalysis. Cancer. 106(1):4-16, 2006
                                                          25. Mansel RE et al: Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC Trial. J Natl Cancer Inst. 98(9):599-609, 2006
                                                          26. Wilke LG et al: Surgical complications associated with sentinel lymph node biopsy: results from a prospective international cooperative group trial. Ann Surg Oncol. 13(4):491-500, 2006
                                                          27. Lyman GH et al: American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol. 23(30):7703-20, 2005
                                                          28. Specht MC et al: Predicting nonsentinel node status after positive sentinel lymph biopsy for breast cancer: clinicians versus nomogram. Ann Surg Oncol. 12(8):654-9, 2005
                                                          29. Truong PT et al: Selecting breast cancer patients with T1-T2 tumors and one to three positive axillary nodes at high postmastectomy locoregional recurrence risk for adjuvant radiotherapy. Int J Radiat Oncol Biol Phys. 61(5):1337-47, 2005
                                                          30. Balch GC et al: Lymphatic mapping and sentinel lymphadenectomy after preoperative therapy for stage II and III breast cancer. Ann Surg Oncol. 10(6):616-21, 2003