Sentinel node biopsy for breast cancer: is it already a standard of care? A survey of current practice in an Italian region.

BACKGROUND: Although sentinel node biopsy (SNB) is becoming the standard approach for axillary staging in patients with small breast cancer, criteria for patient selection and some technical aspects of the procedure have yet to be clearly defined. The aim of the present survey was therefore to investigate the way in which SNB is used by general surgeons working in the Veneto region, Italy. METHODS: A 29-item questionnaire regarding various aspects of SNB practice was mailed to surgeons in charge of breast surgery in all the 56 surgical centres of the region. RESULTS: The rate of response to the questionnaire was 82.1% (n = 46); 69.6% (n = 32) of the respondents routinely perform SNB in their clinical practice. Most of the interviewed surgeons (93.5%) expressed the belief that the acceptable false negative rate should be < or =5%. However, among the surgeons who perform SNB, only 34.4% performed more than 20 SNB during the learning phase. Indications are limited to tumours of < or =1 cm by 31.2% (n = 10) of respondents, < or =2 cm by 46.9% (n = 15) and < or =3 cm by 21.9% (n = 7). Almost all respondents (93.7%) agreed that a clinically positive axilla is a contraindication to SNB, while opinions differed widely concerning other potential contraindications. In most of the centres considered, SN identification is undertaken on the day before surgery using a subdermal injection of 30-50 MBq of 99mTc-albumin-nanocolloid followed by lymphoscintigraphy. CONCLUSIONS: SNB is currently performed in the majority of hospitals in the Veneto region. However, the training phase and criteria used for patient selection differ from centre to centre. Certified training courses and shared guidelines are therefore highly desirable.

Subareolar injection for sentinel lymph node location in breast cancer.

AIM: Several different injection techniques are currently used for sentinel node (SN) identification in patients with breast cancer. Some studies suggest that the subareolar plexus drains lymph from the whole breast to the same axillary SN. In order to test this hypothesis, we ascertained whether subareolar blue dye injection and subdermal radioisotope injection close to the tumour identify the same axillary nodes. METHODS: One day prior to surgery, 50 patients with breast cancer underwent subdermal injection of 30-40MBq of 99m-Tc colloidal albumin (Nanocoll) at the site of the cutaneous projection of the tumour. Ten minutes before surgery, each patient received a subareolar injection of 2-3cc of patent blue. All axillary radioactive nodes and blue-stained nodes were excised and a histologic examination was made. RESULTS: Radioisotope marked the SNs in 47/50 (94%) cases, and the blue dye in 43/50 cases (86%). In three cases, SNs were not identified with either method. Of the 43 cases in which both the tracers reached the axilla, in 40 (93%) the SN was hot and blue-stained, while in 3 cases the two tracers identified different nodes. CONCLUSIONS: Our findings suggest that subareolar injection and subdermal injection elsewhere in the breast usually identify the same SN. Subareolar injection appears to be particularly valuable in patients with multicentric or deep non-palpable breast tumours.