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Recommendations to individuals should be based on their risks without sentinel node biopsy, the absolute benefits and harms of the procedure, and their preference. These factors should be discussed with the woman. Recommendations should also take account of any uncertainties about the long-term effects of sentinel node biopsy.
| RECOMMENDATIONS | LEVEL OF EVIDENCE19 | REFERENCE |
|---|---|---|
| In women with early (operable) breast cancer: | ||
|
Sentinel node biopsy should be offered as a suitable alternative to axillary dissection for women with:
Sentinel node biopsy is not recommended for women with clinically or pathologically positive nodes There are no randomised trial results to support the use of sentinel node biopsy in:
|
II | Milan4,5 ALMANAC6 SNAC I8 NSABP B-329 Cambridge10 GIVOM11,12 |
|
Information about procedures should be discussed with the patient. The patient should be adequately prepared for the procedure For sentinel node biopsy this includes:
|
I | NBCC* & NCCI25 |
|
If the sentinel node is identified at the time of sentinel node biopsy:
If the sentinel node is not identified at the time of sentinel node biopsy:
|
II | Milan4,5 |
| Team, training and experience | ||
|
The outcome of women with breast cancer is better if they are treated by a clinician who has access to the full range of treatment options in a multidisciplinary care setting The team for performing sentinel node biopsy should comprise a surgeon, nuclear physician (where nuclear medicine facilities are available), pathologist, anaesthetist and appropriate nursing support throughout and following the procedure Ongoing data collection and audit of sentinel node biopsy performance by the team should be conducted |
III | NBCC1 * |
|
The surgeon performing sentinel node biopsy should be appropriately trained and experienced in the sentinel node biopsy techniques and have evidence of successful identification of sentinel node(s) The Australian SNAC I22 protocol states the surgeon performing sentinel node biopsy should have completed sentinel node biopsy in at least 20 consecutive cases with a greater than 90% success rate in locating the sentinel node(s) |
Milan4,5 ALMANAC6 SNAC I8 NSABP B-329 |
|
| Technique | ||
| Where possible, lymphatic mapping with pre-operative lymphoscintigraphy in combination with intraoperative use of the gamma probe and blue dye should be used to locate the sentinel node(s) | II | Radovanovic13 Hung14 Meyer-Rochow15 |
|
Where combination technique is not available or suitable, use of blue dye or radioisotope alone is an appropriate option Blue dye alone could be used where no nuclear facilities are available; however, the individual surgeon’s sentinel node biopsy technique and results should be audited |
II | Radovanovic13 Meyer-Rochow15 Hung14 Milan4,5 GIVOM11,12 |
Trial results do not indicate that any site of injection (peritumoural, periareolar or intradermal) is superior in detecting the sentinel node(s) in the axilla |
FRANSENODE16 Povovski17 |
|
All identified sentinel nodes should be excised, including non-axillary sentinel nodes, if they can be accessed and excised without increased morbidity |
SNAC I22 | |
| False negative rates | ||
|
To reduce false-negative rates, surgeons should aim to remove all identified sentinel and/or clinically suspicious nodes at the time of surgery However, removal of four or more nodes from the axilla can increase risk of morbidity, and does not lower the false negative rate significantly compared with removing up to three nodes |
II | NSABP B-32(2007)20 |
| Pathology | ||
Detailed, definitive histological assessment (including immunohistochemistry and serial sectioning) of the sentinel node is recommended for the detection of metastatic disease |
NBOCC* & ACN23 | |
|
Intraoperative assessment of the sentinel node may be performed, allowing those cases identified as positive for metastatic disease to proceed to immediate axillary dissection as a single procedure Intraoperative assessment should be confirmed with detailed, definitive histological assessment |
II | NSABP B-329 GIVOM11 |
| Adverse events | ||
| Surgeons and anaesthetists should be aware of the possibility of adverse reactions (including allergies) in patients and, in the event of an adverse reaction, agreed protocols should be in place | IV | MSAC24 TGA26 |
| Clinical trials | ||
| When sufficient evidence does not exist to guide definitive recommendations for the use of sentinel node biopsy, if possible, patients should be offered entry into properly conducted clinical trials where indicated and/or appropriate | III | NBCC 1 * |
* In February 2008, National Breast Cancer Centre (NBCC), incorporating the Ovarian Cancer Program, changed its name to National Breast and Ovarian Cancer Centre (NBOCC). In July 2011, NBOCC amalgamated with Cancer Australia to form a single national agency, Cancer Australia, to provide leadership in cancer control and improve outcomes for Australians affected by cancer.
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