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Annals of Surgical Oncology
Published in: Annals of Surgical Oncology 10/2017

01-10-2017 | Breast Oncology

Selective Use of Sentinel Lymph Node Surgery in Patients Undergoing Prophylactic Mastectomy Using Intraoperative Pathology

Authors: Brittany L. Murphy, MD, Amy E. Glasgow, MHA, Gary L. Keeney, MD, Elizabeth B. Habermann, PhD, Judy C. Boughey, MD

Published in: Annals of Surgical Oncology | Issue 10/2017

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Abstract

Background

Routine sentinel lymph node (SLN) surgery during prophylactic mastectomy (PM) is unnecessary, because most PMs do not contain cancer. Our institution utilizes intraoperative pathology to guide the surgical decision for resection of SLNs in PM. The purpose of this study was to review the effectiveness of this approach.

Methods

We identified all women aged ≥18 years who underwent bilateral PM (BPM) or contralateral PM (CPM) at our institution from January 2008 to July 2016. We evaluated the frequency of SLN resection and rate of occult breast cancer (DCIS or invasive disease) in the PM. We used the following definitions: over-treatment—SLN surgery in patients without cancer; under-treatment—no SLN surgery in patients with cancer; appropriate treatment—no SLN in patients without cancer or SLN surgery in patients with cancer.

Results

PM was performed on 1900 breasts: 1410 (74.2%) CPMs and 490 (25.8%) BPMs. Cancer was identified in 58 (3.0%) cases (32 invasive disease and 26 DCIS) and concurrent SLN surgery was performed in 44 (75.9%) of those cases. Overall, SLN surgery guided by intraoperative pathology resulted in appropriate treatment of 1787 (94.1%) cases: 1319 (93.5%) CPMs and 468 (95.5%) BPMs, by avoiding SLN in 1743/1842 cases without cancer (94.6%), and performing SLN surgery in 44/58 cases with cancer (75.9%).

Conclusions

Use of intraoperative pathology to direct SLN surgery in patients undergoing PM minimizes over-treatment from routine SLN in PM and minimizes under-treatment from avoiding SLN in PM, demonstrating the value of intraoperative pathology in this era of focus on appropriateness of care.
Literature
1.
Mattos D, Gfrerer L, Reish RG, et al. Lifetime costs of prophylactic mastectomies and reconstruction versus surveillance. Plast Reconstr Surg. 2015;136:730e–40e.CrossRefPubMed
2.
Tuttle TM, Habermann EB, Grund EH, Morris TJ, Virnig BA. Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment. J Clin Oncol. 2007;25:5203–09.CrossRefPubMed
3.
de la Pena-Salcedo JA, Soto-Miranda MA, Lopez-Salguero JF. Prophylactic mastectomy: is it worth it? Aesthetic Plast Surg. 2012;36:140–48.CrossRefPubMed
4.
Erdahl LM, Boughey JC, Hoskin TL, Degnim AC, Hieken TJ. Contralateral prophylactic mastectomy: factors predictive of occult malignancy or high-risk lesion and the impact of MRI and genetic testing. Ann Surg Oncol. 2016;23:72–77.CrossRefPubMed
5.
Goldflam K, Hunt KK, Gershenwald JE, et al. Contralateral prophylactic mastectomy. Predictors of significant histologic findings. Cancer. 2004;101:1977–86.PubMed
6.
Yi M, Meric-Bernstam F, Middleton LP, et al. Predictors of contralateral breast cancer in patients with unilateral breast cancer undergoing contralateral prophylactic mastectomy. Cancer. 2009;115:962–71.CrossRefPubMedPubMedCentral
7.
Boughey JC, Khakpour N, Meric-Bernstam F, et al. Selective use of sentinel lymph node surgery during prophylactic mastectomy. Cancer. 2006;107:1440–47.CrossRefPubMed
8.
King TA, Gurevich I, Sakr R, Patil S, Stempel M, Morrow M. Occult malignancy in patients undergoing contralateral prophylactic mastectomy. Ann Surg. 2011;254:2–7.CrossRefPubMed
9.
Ashikaga T, Krag DN, Land SR, et al. Morbidity results from the NSABP B-32 trial comparing sentinel lymph node dissection versus axillary dissection. J Surg Oncol. 2010;102:111–18.CrossRefPubMedPubMedCentral
10.
Ikeda T. Re-sentinel node biopsy after previous breast and axillary surgery. Surg Today. 2014;44:2015–21.CrossRefPubMed
11.
Karam A, Stempel M, Cody HS, 3rd, Port ER. Reoperative sentinel lymph node biopsy after previous mastectomy. J Am Coll Surg. 2008;207:543–48.CrossRefPubMed
12.
Boughey JC, Cormier JN, Xing Y, et al. Decision analysis to assess the efficacy of routine sentinel lymphadenectomy in patients undergoing prophylactic mastectomy. Cancer. 2007;110:2542–50.CrossRefPubMed
13.
Bunting PW, Cyr AE, Gao F, Margenthaler JA. Sentinel lymph node biopsy during prophylactic mastectomy: is there a role? J Surg Oncol. 2014;109:747–50.CrossRefPubMed
14.
Kuwajerwala NK, Dekhne NS, Pentiak PA, et al. Sentinel lymph node biopsy in contralateral prophylactic mastectomy: are we overtreating? Experience at a tertiary care hospital. Clin Breast Cancer. 2013;13:287–91.CrossRefPubMed
15.
Murthy V, Chamberlain RS. Prophylactic mastectomy in patients at high risk: is there a role for sentinel lymph node biopsy? Clin Breast Cancer. 2013;13:180–87.CrossRefPubMed
16.
Nagaraja V, Edirimanne S, Eslick GD. Is sentinel lymph node biopsy necessary in patients undergoing prophylactic mastectomy? A systematic review and meta-analysis. Breast J. 2016;22:158-–65.CrossRefPubMed
17.
Zhou WB, Liu XA, Dai JC, Wang S. Meta-analysis of sentinel lymph node biopsy at the time of prophylactic mastectomy of the breast. Can J Surg. 2011;54:300–06.CrossRefPubMedPubMedCentral
18.
Boughey JC, Attai DJ, Chen SL, et al. Contralateral prophylactic mastectomy consensus statement from the American Society of Breast Surgeons: additional considerations and a framework for shared decision making. Ann Surg Oncol. 2016;23:3106–11.CrossRefPubMedPubMedCentral
19.
Czyszczon IA, Roland L, Sahoo S. Routine prophylactic sentinel lymph node biopsy is not indicated in women undergoing prophylactic mastectomy. J Surg Oncol. 2012;105:650–54.CrossRefPubMed
20.
Soran A, Falk J, Bonaventura M, Keenan D, Ahrendt G, Johnson R. Is routine sentinel lymph node biopsy indicated in women undergoing contralateral prophylactic mastectomy? Magee-Womens Hospital experience. Ann Surg Oncol. 2007;14:646–51.CrossRefPubMed
21.
Nasser SM, Smith SG, Chagpar AB. The role of sentinel node biopsy in women undergoing prophylactic mastectomy. J Surg Res. 2010;164:188–92.CrossRefPubMed
22.
Gebruers N, Verbelen H, De Vrieze T, Coeck D, Tjalma W. Incidence and time path of lymphedema in sentinel node negative breast cancer patients: a systematic review. Arch Phys Med Rehabil. 2015;96:1131–39.CrossRefPubMed
23.
Mansel RE, Fallowfield L, Kissin M, et al. Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC Trial. J Natl Cancer Inst. 2006;98:599–609.CrossRefPubMed
24.
McLaughlin SA, Wright MJ, Morris KT, et al. Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: patient perceptions and precautionary behaviors. J Clin Oncol. 2008;26:5220–26.CrossRefPubMedPubMedCentral
25.
Langer I, Guller U, Berclaz G, et al. Morbidity of sentinel lymph node biopsy (SLN) alone versus SLN and completion axillary lymph node dissection after breast cancer surgery: a prospective Swiss multicenter study on 659 patients. Ann Surg. 2007;245:452–61.CrossRefPubMedPubMedCentral
26.
Lucci A, McCall LM, Beitsch PD, et al. Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group Trial Z0011. J Clin Oncol. 2007;25:3657–63.CrossRefPubMed
27.
Soran A, Ozmen T, McGuire KP, et al. The importance of detection of subclinical lymphedema for the prevention of breast cancer-related clinical lymphedema after axillary lymph node dissection; a prospective observational study. Lymphat Res Biol. 2014;12:289–94.CrossRefPubMed
28.
Burger A, Thurtle D, Owen S, et al. Sentinel lymph node biopsy for risk-reducing mastectomy. Breast J. 2013;19:529–32.CrossRefPubMed
29.
Cant EL, Shivas AA, Forrest AP. Lymph-node biopsy during simple mastectomy. Lancet. 1975;1:995–97.CrossRefPubMed
30.
Williams RN, Jones L, Stotter A. Lymph nodes in the tail of the breast can be missed in standard axillary dissection. Eur J Surg Oncol. 2009;35:271–75.CrossRefPubMed
31.
Intra M, Veronesi P, Mazzarol G, et al. Axillary sentinel lymph node biopsy in patients with pure ductal carcinoma in situ of the breast. Arch Surg. 2003;138:309–13.CrossRefPubMed
32.
NCCN Guidelines Ductal Carcinoma in Situ (DCIS)2016;Version 2.2016.
Metadata
Title
Selective Use of Sentinel Lymph Node Surgery in Patients Undergoing Prophylactic Mastectomy Using Intraoperative Pathology
Authors
Brittany L. Murphy, MD
Amy E. Glasgow, MHA
Gary L. Keeney, MD
Elizabeth B. Habermann, PhD
Judy C. Boughey, MD
Publication date
01-10-2017
Publisher
Springer International Publishing
Published in
Annals of Surgical Oncology / Issue 10/2017
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI
https://doi.org/10.1245/s10434-017-5925-0

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