Editorial: Sentinel Node Biopsy for Breast Cancer: Past, Present, and Future

Autor: Sheldon Feldman, C. Alden Sweatman
Rok vydání: 2012
Předmět:
Zdroj: Annals of Surgical Oncology. 19:3123-3124
ISSN: 1534-4681
1068-9265
DOI: 10.1245/s10434-012-2550-9
Popis: It was 1898 when William Halsted presented his data on radical mastectomy to the American Surgical Association in New Orleans. For almost 70 years following this presentation this disfiguring operation was the mainstay of the treatment of breast cancer. After much debate in the surgical literature, modified radical mastectomy became popular and acceptable and did, of course, include complete axillary lymph node dissection (CALND). When lumpectomy became established as appropriate treatment, CALND continued as a part of that treatment until the 1990 s, when sentinel node identification was described by Morton for stage I cutaneous melanoma and subsequently applied to the treatment of breast cancer by Krag and Giuliano. Large clinical trials including the National Surgical Adjuvant Breast and Bowel Project (NSABP) B32 and the American College of Surgeons Oncology Group (ACOSOG Z0010 studies have firmly established sentinel lymph node biopsy (SLNB) as an accurate method for axillary staging. The technique has been optimized and widely disseminated and now represents the standard of care as part of surgical management of invasive breast cancer. Surgical scientists continue to advance our understanding of the management of the axilla, with indications for CALND progressively diminishing. This trend was prophetically predicted by Blake Cady in 1984 when he stated that ‘‘Lymph node metastases are indicators and not governors of distant metastases.’’ In this issue of the Annals of Surgical Oncology four articles address SNLB. Two address the impact of the recently published ACOSOG Z0011 trial. These two articles document how ACOSOG Z0011 has changed practice patterns in both the members of the American Society of Breast Surgeons which includes both private practitioners and academicians and the surgical faculty at a major cancer referral center, University of Texas MD Anderson Cancer Center. The use of intraoperative frozen section and CALND is decreasing in most practice settings for patients undergoing breast-conservation surgery with low disease burden in the axilla. This trend was also recently reported in this journal by Dr. Weber and colleagues from Memorial Sloan Kettering Cancer Center. Over a 10-year period, intraoperative frozen section reduced from 100 % to 62 %, and if Z0011 selection criteria had been applied 13 % of the patients would have been spared CALND. The third article is a retrospective review of patients cared for by members of the Department of Surgery at Washington University School of Medicine and John Cochran Veterans Hospital in St. Louis, Missouri who either did or did not undergo CALND in the setting of a positive SLN. The median follow-up was 69 and 73 months for CALND and SNL only, respectively. There was no significant difference in breast, nodal or distant recurrence or mortality. Although a smaller dataset than the ACOSG Z0011 trial, the longer follow-up supports avoiding CALND for many sentinel node-positive patients. The final paper addresses sentinel node excision in patients proven to have nodal metastasis prior to neoadjuvant therapy. The authors conclude that, though normalization of axillary ultrasound is associated with a higher pathologic complete response (pCR), there is still a 20.8 % false-negative rate, and for this reason CALND is recommended. The authors do point out that ACSOG Z1071, ‘‘a phase II study of sentinel lymph node surgery and axillary lymph node dissection following neoadjuvant chemotherapy in women with Stage II–III B node positive cancer,’’ has completed accrual and results are expected soon. This much larger study will further clarify the feasibility of avoiding CALND in patients with more advanced disease. It will be of great interest to see if subsets of patients with basal or HER-2/neu phenotypes will have a Society of Surgical Oncology 2012
Databáze: OpenAIRE
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