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Contraindications to sentinel lymph
node biopsy
Martine Berliere
GGOLFB
Breast Clinic
Cancer Center
Cliniques Universitaires St Luc
Sentinel lymph node biopsy (SLNB)
 is an evolving, ongoing process
Indications and contraindications can change:
Yesterday’s contraindications may not be
applicable today
SLNB: contraindications
Absolute
contraindications
Relative
Absolute contraindications
Centers electing to perform SLNB for breast cancer must adopt a
multidisciplinary approach, coordinating the efforts of radiology, surgery,
gynecology, oncology, nuclear medicine, pathology and radiotherapy.
 absence of an experienced surgeon + team is an absolute contraindication to
SLNB
WHY?
• Because the surgeon’s experience is the most important factor in sentinel lymph
node identification
• Prior to offering SLNB as a stand-alone procedure, attending surgeons should
have a false-negative rate of less than or equal to 5 % in their last 20 consecutive
cases
Absolute contraindications
Clinically positive axillary lymph nodes (palpable
adenopathy and diagnosis of malignant cells
confirmed by fine needle aspiration)
Why is this a contraindication to SLNB?
The lymphatics leading to these clinically positive
nodes may be blocked and prohibit accurate
mapping, giving to a false-negative result (up to
30 % false-negative rate)
Other advanced breast cancer
conditions
• Clinically positive supraclavicular lymph node(s)
• Locally advanced or inflammatory breast cancer
• (T3 / T4 lesions)
• Metastatic breast cancer
Other conditions
• Adverse or allergic reactions to blue dye (isosulfan
blue) or 99mTC sulphur colloid radionucleotide
• Patients unable to give informed consent for
SLNB
Relative contraindications
Prior axillary surgery
• Prior axillary surgery is considered to be a contraindication
to SNLB because the lymphatics draining the breast are
disrupted and successful axillary mapping is not possible
• Pori reported an identification rate of 75 % after prior
axillary surgery
 More data are required before practice changes are
implemented
Relative contraindications
• Previous breast irradiation
• Previous breast surgery
 need for more data
Small studies on breast implants are
encouraging
Neoadjuvant chemotherapy (NAC)
• Largest report to date: NSABP B27 trial findings
updated by Mamounas
– 420 patients underwent SLNB for axillary staging after
NAC
– 340 of them underwent complete axillary dissection
– identification rate: 85 %
– false-negative rate: 12 %
• Most studies are very small, compared to extensive
multicentric SLNB trials (NSABP B32, …)
Mamounas et al
No. of patients Identification False-negative
rate (%)
rate (%)
340
85
12
Stearns et al
34
85
38 (6)
Miller et al
35
86
0
Montgomery et al
33
88
6
Brady
14
93
0
Julian et al
31
94
0
Breslin et al
51
94
12
Nason et al
15
87
33
NAC: conclusion
• Very small studies
• SLNB after NAC is feasible, but not yet
acceptable outside clinical trials
• Timing could be important; for patients with
clinically negative axillae, SLNB before NAC
seems to be a better alternative (Jones)
Question?
Alterations in lymphatic drainage in patients
with initially clinically positive axillae
undergoing NAC
Ductal carcinoma in situ (DCIS)
• SLNB is not recommended in all cases of DCIS
• DCIS, by definition, has little or no metastatic
potential in the in situ phase
BUT
• Patients with DCIS and
– high-grade lesions
– microinvasion detected by biopsy
– large lesions (> 5 cm) identified by mammography
are at higher risk of invasive carcinoma
Only in these cases is SLNB recommended
Prophylactic mastectomy
(0.1-5 % of all incidental cancers)
King, Goldflam, Cancer 2004
Multicentric disease
• It has been shown that subareolar injection for SLNB is as accurate as
peritumoral injection, indicating that most areas of the breast drain
into the subareolar plexus and then into a lymph node in the axilla
• Two small studies have shown some degree of success with SLNB in the
setting of multicentric disease (Schrenk and Fernandez)
– IR: 97 %
– FNR: 0 %
Although larger studies are required, these preliminary data suggest that
SLNB may be an alternative to axillary lymph node dissection (ALND) in
patients with clinically negative axillae and multicentric disease
Multiple tumors
Study
N
Nodepositive
SLN ID
rate
FN
rate
Layeeque et al
Am J Surg 2003; 186: 730-35
40
63 %
100 %
0%
Tousimis et al
70
J Am Coll Surg 2003; 197: 529-35
54 %
100 %
8%
ALMANAC Trialists Group
EJSO 2004; 30: 475-79
45 %
94.7 %
8.8 %
75
Pregnancy
• Lymphoscintigraphy and SLNB can be performed
safely during pregnancy, since the very low
prenatal doses required for this diagnostic
procedure do not significantly increase the risk of
prenatal death, malformation or mental
impairment (Philadelphia Consensus Conference)
• Lymphazurin: not yet tested in pregnant animals
or humans
• The role of SLNB in pregnant women with early
breast cancer is unknown
• Also unknown is whether lymphatic pathways are
altered in pregnancy
• 60 % of pregnant women with breast cancer have
pathological nodal involvement  pregnant breast
cancer patients theoretically eligible for SLNB are
infrequently encountered
• Not recommended outside clinical trials
Axillary assessment is important upon
diagnosis of breast cancer for prognosis and
adjuvant therapy decisions
It offers some benefit in terms of regional
control and a possible small survival advantage
SLNB has minimal risks compared to ALND
It is an evolving and ongoing process
Take-home message
Contraindications
• Absence of experienced surgeon + team
• Clinically positive nodes
• Locally advanced breast cancer
– T3-T4
– inflammatory
• Metastatic breast cancer
• Allergies
• Previous breast / axillary surgery
• Previous breast radiotherapy
• DCIS / prophylactic surgery
• NAC
• Multicentric disease
• Pregnancy / breastfeeding