title: Re-emphasizing the concept of adequacy of intraoperative assessment of the axillary sentinel lymph nodes for identifying nodal positivity during breast cancer surgery.
abstract: BACKGROUND
  Although sentinel lymph node (SLN) biopsy is a standard of care for the evaluation of the axillary lymph nodes during breast cancer surgery, a substantial degree of variation exists among individual surgeons as to what represents an adequate assessment. The aim of the current study was to assess when metastatic disease was first identified within consecutively harvested SLN candidates for invasive breast cancers demonstrating a positive SLN.
  
  
  METHODS
  We retrospectively analyzed a series of 400 breast cancers from a recently published prospective randomized clinical trial. A combined radiocolloid and blue dye technique was used. All potential SLN candidates, containing counts of at least 10% of the hottest SLN and/or containing blue dye, were harvested and were consecutively numbered in the order of the decreasing level of counts (with the hottest SLN representing SLN #1).
  
  
  RESULTS
  Among 371 invasive breast cancers, a SLN was identified within 353 cases (95%). Mean number of SLNs identified was 2.5 (range, 1 to 9), with a single SLN identified in 104 (29%) cases, two identified in 110 (31%), three identified in 73 (21%), four identified in 35 (10%), five identified in 16 (5%), and six or more identified in 15 (4%). A positive SLN was found in 104 (29%) cases. SLN #1 was the first positive SLN in 86 (83%). SLN #2 was the first positive SLN in 15 (14%). SLN #3, SLN #4, and SLN #5 were the first positive SLN in one case (1%) each. A positive SLN was found in 18% (19/104) of cases when a single SLN was identified, as compared to in 34% (85/249) when two or more SLNs were identified (P = 0.003).
  
  
  CONCLUSIONS
  The accurate and optimal assessment of the axilla during breast cancer surgery requires persistence and diligence for attempting to identify all potential SLN candidates in order to avoid failing to recognize a positive SLN. The scenario in which only a single negative SLN candidate is intraoperatively identified is one that should raise some concern to the operating surgeon.
authors.affiliation: Section of Surgical Oncology of the Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio 43210, USA. stephen.povoski@osumc.edu
authors.forename: Stephen P
authors.initials: SP
authors.lastname: Povoski
authors.forename: Donn C
authors.initials: DC
authors.lastname: Young
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Walker
authors.forename: William E
authors.initials: WE
authors.lastname: Carson
authors.forename: Lisa D
authors.initials: LD
authors.lastname: Yee
authors.forename: Doreen M
authors.initials: DM
authors.lastname: Agnese
authors.forename: William B
authors.initials: WB
authors.lastname: Farrar
mesh_terms: D000368:Aged; D000704:Analysis of Variance; D001365:Axilla; D001943:Breast Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D015331:Cohort Studies; D004396:Coloring Agents; D018572:Disease-Free Survival; D005260:Female; D005629:Frozen Sections; D006801:Humans; D007430:Intraoperative Care; D016015:Logistic Models; D008198:Lymph Nodes / Q000473:pathology*; D008408:Mastectomy / Q000379:methods; D008875:Middle Aged; D015999:Multivariate Analysis; D009361:Neoplasm Invasiveness / Q000473:pathology*; D009367:Neoplasm Staging; D011336:Probability; D011379:Prognosis; D019275:Radiopharmaceuticals; D012189:Retrospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D021701:Sentinel Lymph Node Biopsy / Q000592:standards* / Q000639:trends; D016019:Survival Analysis; D016896:Treatment Outcome
chemical_list: D004396:Coloring Agents; D019275:Radiopharmaceuticals