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Consensus Statement on Guidelines for Performance of Sentinel
Lymphadenectomy for Breast Cancer
Original statement released November 1998;
First revision released August 2000. Second Revision approved
and released by the Board of Directors on November 1, 2002. Third
Revision approved and released by the Board of Directors on October
19, 2003.
Sentinel lymphadenectomy (SL) is a minimally
invasive staging procedure for patients with breast cancer. SL,
when performed in lieu of axillary dissection, is associated with
potentially less morbidity and enhanced staging .
Multiple studies from single-institution and
multi-center trials have validated the accuracy of SL when performed
by experienced surgeons and SL is rapidly becoming the standard
of practice. However, the degree of experience required to reliably
and accurately perform the procedure, although becoming better
understood, remains undefined.
In regard to SL for breast cancer, the American
Society of Breast Surgeons has updated and revised our prior statement.
As of November 2002, the American Society of Breast Surgeons acknowledges
the following:
- Indications and Contraindications:
In the following situations the published data are neither
extensive nor supportive and SL should be performed as part
of a research protocol or in conjunction with a full node
dissection: the presence of suspicious palpable axillary lymph
nodes, a history of prior breast radiation therapy, or a history
of either extensive prior breast surgery or axillary surgery.
Patients with invasive multifocal disease or patients receiving
pre-operative chemotherapy represent a group for which data,
although not extensive, thus far supports SL as accurate,
and SL can be considered in the well informed patient. SL
should be considered for patients with DCIS who are undergoing
mastectomy. It is highly recommended that all patients who
are candidates for SL have this procedure discussed as an
option in their surgical management.
- Axillary Management:
Axillary treatment for patients with metastatic disease found
in sentinel nodes is currently under investigation in clinical
trials. For patients not participating in a clinical trial,
a complete level I and II lymph node dissection is recommended.
Because the definition of a positive sentinel node is controversial,
careful clinical judgment is encouraged in cases of micrometastatic
disease.
- Credentialing and Privileging:
The credentialing and privileging of SL, as with any surgical
procedure, are to take place in accordance with the policies
and processes of each local hospital. The accumulated data
from many multi-center trials continues to support the need
to perform 20 cases of SL in combination with axillary dissection,
or to perform 20 SL procedures with mentoring, as being necessary
to minimize the risk of false-negative results. We recommend
this experience be obtained before the surgeon proceeds to
performing sentinel node biopsy on his or her own. The false-negative
rate (i.e. the ratio of the number of false-negative biopsy
results to the number of patients with positive lymph nodes)
is the most important factor regarding accurate sentinel lymph
node staging. Fellows and residents who achieve similar experience
with a credentialed sentinel node surgeon in 20 procedures
of SL should be credentialed. The use of mentoring, proctored
cases and formal training in accredited continuing medical
education courses is thought to reduce the personal case experience
necessary to achieve optimal results, but this effect has
yet to be quantified*.
- Technique:
The node-identification rate has been shown to be higher,
and the false-negative rate lower, when a combination technique
(both technetium sulfur colloid and blue dye) are used.
- Axillary Recurrences:
Surgeons are encouraged to track their
axillary recurrence rate. We also encourage surgeons to report
their experience by contributing to national registries and
by enrolling patients in clinical trials.
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