title: What to Do with Non-visualized Sentinel Nodes? A Dutch Nationwide Survey Study.
abstract: BACKGROUND
  International guidelines differ regarding their recommendations on axillary treatment of patients with non-visualized sentinel lymph nodes (non-vSLN). Therefore, we distributed a survey among Dutch oncological surgeons to determine their routine practice and opinion regarding axillary treatment in case of a non-vSLN, with the emphasis on whether these practices and opinions have changed since publication of the Z0011 trial.
  
  
  METHODS
  A Dutch nationwide survey containing 10 questions regarding clinical routine during the sentinel node procedure and axillary treatment of non-vSLN patients was distributed among 510 oncological surgeons.
  
  
  RESULTS
  The survey was completed by 122 (24%) oncological surgeons, of whom 116 (95%) were registered as specialized breast surgeons. These surgeons had, on average, 13 years of experience. The majority of respondents used both lymphoscintigraphy and Patent Blue during the sentinel node procedure, and 39% estimated the prevalence of a non-vSLN to be 1-2%. Most surgeons are currently more reserved when considering whether to perform an axillary lymph node dissection (ALND) than prior to publication of the Z0011 trial (15 vs. 80%, respectively). Sixty percent base their decision on various clinicopathological characteristics. Twenty-three respondents (20%) opted for an alternative axillary treatment.
  
  
  CONCLUSIONS
  This study shows that, in daily practice, most specialized breast surgeons think that a non-vSLN is rare. If so, most currently opt not to perform an ALND, whereas a small proportion consider an alternative axillary treatment. These decisions differ than in the period prior to the Z0011 trial. More research is needed to provide optimal treatment recommendations in case of a non-vSLN.
authors.affiliation: Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands. n.verheuvel@mmc.nl.
authors.forename: Nicole C
authors.initials: NC
authors.lastname: Verheuvel
authors.affiliation: Department of Medical Oncology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, The Netherlands.|Department of Epidemiology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, The Netherlands.|Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.
authors.forename: Adri C
authors.initials: AC
authors.lastname: Voogd
authors.affiliation: Department of Medical Oncology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, The Netherlands.
authors.forename: Vivianne C G
authors.initials: VCG
authors.lastname: Tjan-Heijnen
authors.affiliation: Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands.|Department of Medical Oncology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, The Netherlands.
authors.forename: Rudi M H
authors.initials: RMH
authors.lastname: Roumen
mesh_terms: D001365:Axilla; D001943:Breast Neoplasms / Q000473:pathology* / Q000601:surgery; D005260:Female; D006801:Humans; D008197:Lymph Node Excision; D010818:Practice Patterns, Physicians' / Q000592:standards*; D011379:Prognosis; D000071036:Sentinel Lymph Node / Q000473:pathology* / Q000601:surgery; D021701:Sentinel Lymph Node Biopsy; D066231:Surgeons; D011795:Surveys and Questionnaires