4 The apical lymph node should be separately identified, if so designated by the surgeon.Įvery lymph node identified should be examined histologically. The axillary contents can be divided into three anatomical levels if the surgeon has marked the specimen appropriately. In the absence of any abnormality one representative block is adequate. If skin is present any abnormal area should be sampled according to the skin protocol. The lymph node or tumour closest to the surgical margin should be so identified and sampled. Where extracapsular extension is apparent or suspected, lines of dissection should extend through adjacent tissues to allow microscopic evaluation of extracapsular invasion. One section of a macroscopically involved node is sufficient. Macroscopically involved lymph nodes may be bisected along the median plane to demonstrate the relationship of tumour to the capsule. Small lymph nodes, 5mm, serially section looking for grossly identifiable deposits. This is usually achieved by manual dissection of fixed tissue with careful examination by inspection and palpation. Specimens received should be examined carefully to maximise lymph node yield. The research was supported through a Patient-Centered Outcomes Research Institute (PCORI) Award. The study is published in the journal JNCI Cancer Spectrum. More is just more, and in this case, more is worse.” Esserman was not involved in the study. “Some surgeons say that sentinel node biopsies are no big deal, but I disagree. All interventions have consequences,” she said. Laura Esserman, professor of surgery and radiology at the University of California-San Francisco and director of their Breast Care Clinic, is a DCIS researcher and said the findings have important implications for women with breast cancer. Wang cautioned that the findings may not be generalizable to young women and that more research is also needed to determine if sentinel lymph node biopsies benefit patients with a high-risk type of DCIS. The women, all between the ages of 67 and 94, were followed for a median of 5.75 years after their initial lumpectomy. Wang’s study compared the health outcomes of 5,957 women who had undergone a lumpectomy to remove DCIS, including 1,992 who had undergone a sentinel lymph node biopsy, with 3,965 women who did not have the biopsy procedure. “This might create a financial incentive for providers to perform these biopsies even for non-invasive conditions.” Also, the sentinel lymph node biopsy is included in the Centers for Medicare & Medicaid merit-based incentive payment system for invasive breast cancer,” Wang said. “Proponents of sentinel lymph node biopsy cite concerns that occult microinvasive disease within the DCIS may not be detected via other methods. So why do so many women undergo sentinel lymph node biopsies? Since DCIS is not invasive, experts do not recommend these biopsies for DCIS patients. Many also have the sentinel node biopsy, which involves removing a few lymph nodes under the arm to determine if the cancer has spread. Women diagnosed with DCIS almost always have surgery (usually a lumpectomy) to remove the DCIS and not the entire breast. If untreated, however, DCIS can develop into an invasive type of breast cancer. Known as a “stage zero” breast cancer, DCIS is not life-threatening because it is non-invasive, meaning the cancer cells do not spread beyond the milk duct. The findings are important because between 17% and 40% of women with DCIS currently undergo sentinel lymph node biopsies, even though experts do not recommend the procedure for DCIS patients, explains Shi-Yi Wang, M.D., a Yale School of Public Health associate professor and the study’s lead author.Īpproximately 25% of all breast cancer patients have DCIS, the earliest form of breast cancer, in which cancer cells invade the milk duct in the breast. However, the researchers found that the procedure increased the patient’s risk for side-effects associated with the biopsy, which include pain, wound infection, and lymphedema, a painful condition that can restrict a woman’s arm movements. Did not decrease the number of additional cancer treatments.Did not decrease the chances of developing invasive breast cancer.Did not reduce the likelihood of dying from breast cancer. The study, believed to be the first to examine the long-term impact of sentinel lymph node biopsies on thousands of older women, found that the procedure: Older women with a very early, non-invasive breast cancer known as ductal carcinoma in situ (DCIS) gain no long-term benefit from undergoing a sentinel lymph node biopsy to see if the cancer has spread, new research by the Yale School of Public Health has found.
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