Performing lymph node biopsy earlier

Altering the standard step-by-step procedure that takes women facing a mastectomy from diagnosis to surgery to reconstruction can improve the process and help in determining if immediate reconstruction is the best course of action, according to research from the University of North Carolina, Chapel Hill.

Key to the new approach is the use of sentinel lymph node biopsy (SLNB) performed as an outpatient procedure a week or so prior to mastectomy, rather than doing the SLNB at the same operation as the mastectomy and reconstruction.

SLNB involves the removal of some of the first "sentinel" lymph nodes into which cancerous cells from the breast might drain. Studies have shown SLNB to be an effective way to determine the spread of disease to the lymph nodes under the arm. In current practice using SLNB, the sentinel node is quick-frozen; a pathologist then examines the node under a microscope. This method quickly gives a diagnosis of cancer spread while the surgeon is waiting to complete the procedure. The diagnosis is confirmed a few days after surgery by a more detailed study called a permanent section.

"If the pathologist does not see tumor in the lymph node on frozen section, there is still a chance that tumor may be found in the lymph nodes on final pathology," notes Nancy Klauber-DeMore, assistant professor of surgery. "There can be major consequences for a patient who has undergone immediate breast reconstruction if a metastasis is found on permanent section that was not recognized on frozen section."

There are two issues here. The first is the need for another operation, axillary lymph node dissection, or removal of all the lymph nodes under the armpit. "Axillary lymph node dissection may present increased complications in a patient with a newly reconstructed breast," Klauber-DeMore relates.

The second is that some patients whose lymph nodes prove positive on final pathology may be recommended to undergo post-mastectomy radiation therapy. "And radiation can sometimes have adverse effects on the reconstruction that may lead to poorer cosmetic results, particularly if the reconstruction is with a tissue expander, a breast-shaped prosthetic that helps create a pocket for a breast implant," Klauber-DeMore explains. "That is why it would be optimal to know the final status of the sentinel node before committing the patient to a large operation such as mastectomy and reconstruction.

"Performing a sentinel node biopsy as a staged procedure prior to definitive mastectomy and reconstruction gives the treating physicians more information to guide the patient regarding the best surgical procedure for [her]."

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