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Correspondence and Brief Communications |

The Learning Curve for Sentinel Lymph Node Biopsy in Breast Cancer

Hiram S. Cody III, MD
Arch Surg. 2000;135(5):605. doi:.
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I have read with interest the article by Orr et al1 and agree entirely with their recommendation that surgeons beginning to do sentinel lymph node (SLN) biopsy should perform backup axillary lymph node dissection (ALND) early in their experience. I find their other considerations anything but practical.

Any model is only as good as its assumptions.

  • Their assumption of a 38% failure rate (based on the earliest experiences of Giuliano et al2 and Guenther et al3 when the technique of SLN biopsy was still evolving) ignores more than 30 subsequent studies in which the failure rate of the authors' early experience averaged 10% or less.

  • This same literature reports an overall false-negative rate of about 5%, not 26%, as they assume in their model.

  • They raise the specter of a 3% axillary recurrence rate after negative SLN biopsy without mentioning that this figure is derived from experience with melanoma,4 not breast cancer. No axillary recurrences have yet been reported after negative SLN biopsy for breast cancer; they are certain to occur, but probably at a rate no higher than that observed after conventional ALND, perhaps 1% or less.

  • Finally, and most important, they ignore the limitations of the routine pathologic analysis of ALND specimens in which a single hematoxylin-eosin–stained section is taken from each node. A substantial literature review by Dowlatshahi et al5 demonstrates that serial sectioning and/or immunohistochemical staining of lymph nodes detects missed nodal metastases in 7% to 30% of patients with breast cancer deemed "node negative" after conventional ALND, and that (given a study with adequate size and length of follow-up) these micrometastases are prognostically significant.

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