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Overview of breast cancer staging and surgical treatment options

March 1, 2008|Cleveland Clinic Journal of Medicine
Clarisa Hammer, DO;Alicia Fanning, MD;Joseph Crowe, MD
Author and Disclosure Information

Clarisa Hammer, DO
Department of General Surgery, Cleveland Clinic, Cleveland, OH

Alicia Fanning, MD
Department of General Surgery, Cleveland Clinic, Cleveland, OH

Joseph Crowe, MD
Department of General Surgery, Cleveland Clinic, Cleveland, OH

Correspondence: Alicia Fanning, MD, Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue, A10, Cleveland, OH 44195; fannina@ccf.org

All authors reported that they have no commercial affiliations or financial interests that pose a potential conflict of interest with this article.

ABSTRACT

Following diagnosis of breast cancer, patients undergo assessment for local and systemic treatment. Establishing a relationship and communication with the patient is critical to this assessment, as are history-taking, clinical breast examination, review of imaging studies, and interactive discussion with the patient of treatment options and possible breast reconstruction. Some type of surgical therapy is indicated in virtually all women with breast cancer, generally as the first part of a multicomponent treatment plan. The main goal of surgical therapy is to remove the cancer and accurately define the stage of disease. Surgical options broadly consist of breast conservation therapy, generally followed by radiation therapy, or mastectomy. The surgical procedure also includes assessment of regional lymph nodes for metastasis, either by axillary lymph node dissection or by the less-invasive sentinel lymph node biopsy, for the purpose of cancer staging and guiding adjuvant therapy.

Sentinel node biopsy: A less-invasive alternative

Axillary lymph node dissection has been called into question over the last 15 years due to its invasiveness and the potential morbidity associated with it (including lymphedema and paresthesias). As a result, sen­tinel lymph node biopsy, a minimally invasive technique for identifying axillary metastasis, was developed to avoid the need for (and risk of complications from) axillary lymph node dissection in patients who have a low probability of axillary metastasis.

Figure 5. Sentinel lymph node biopsy involves intraoperative injection of vital blue dye and/or radionuclide near the areola, after which the axillary nodes are inspected for uptake of the dye or radionuclide to identify the sentinel node.
The concept of the sentinel node is based on two basic principles: (1) there is an orderly and predictable pattern of lymphatic drainage to a respective nodal basin, and (2) the first lymph node functions as an effective filter for tumor cells.12 The technique of mapping the sentinel node in breast cancer patients was developed in the early 1990s and has since been studied, refined, and validated. The technique is performed intraoperatively with periareolar injection of vital blue dye, technetium-labeled sulfur colloid, or a combination of the two (Figure 5). The axillary lymph nodes are then inspected for staining and/or the radioactive tracer, and any node that has taken up the dye or tracer is designated as a sentinel lymph node and removed (Figure 6). Generally, the sentinel node is sent for intraoperative frozen section examination to determine the presence or absence of metastasis. If the sentinel lymph node biopsy is positive for metastasis, then axillary lymph node dissection is warranted; if it is negative, no additional axillary surgery is needed.
Figure 6. Removal of a sentinel lymph node after uptake of vital blue dye.
Reprinted from Contemporary Surgery (Pawlik TM, Gershenwald JE. Sentinel lymph node biopsy for melanoma. Contemp Surg 2005; 61:175–182.) with permission of Dowden Health Media.
Figure 6. Removal of a sentinel lymph node after uptake of vital blue dye. Arrows point to the afferent lymphatic vessel that drains to the lymph node.
If this mapping procedure fails to clearly identify a sentinel node, then a complete axillary lymph node dissection is performed. Reasons for failed mapping include technical issues as well as anatomic ones.13 Performing sentinel lymph node biopsies clearly involves a learning curve, and the sensitivity and specificity of these biopsies do vary among surgeons, correlating with the surgeons’ technical experience.14 Disruption of the breast lymphatics from prior breast surgery can reduce the sensitivity of a sentinel lymph node biopsy. Similarly, the presence of a hematoma or seroma from a prior biopsy can impede sentinel node detection. Tumor location can also be a factor in detecting a sentinel node, especially for tumors located in the inner quadrants of the breast, as they may drain to the internal mammary nodes.

Overall, however, it is now accepted that intraoperative lymph node mapping with sentinel lymphadenectomy is an effective and minimally invasive alternative to axillary lymph node dissection for identifying nodes containing metastases.

CONCLUSIONS

Decisions surrounding the choice of breast surgery procedure must be individualized to the patient and her desires and based on comprehensive patient evaluation and thorough patient counseling. Optimal results for the patient—oncologically, psychologically, and in terms of cosmetic outcomes—require consultation and collaboration among general surgeons, medical oncologists, genetic counselors, radiation oncologists, radiologists, and plastic surgeons to clarify the risks and benefits of various intervention options. Striving for this multidisciplinary collaboration will promote optimal patient management and the most favorable clinical outcomes.

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