Lymph node diagnosis

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Lymph node involvement remains the most powerful individual prognostic factor in breast cancer. Conventional axillary staging is either by axillary node clearance or some form of sampling. BASO data show that around one-third of surgeons in the UK are sampling and two-thirds performing some type of clearance. The exact definition of clearance is not well defined and surgeons have different techniques. Evidence does suggest that, although lymph node sampling is qualitatively similar to clearance, the morbidity is little different, if the sample nodes prove positive and treatment is completed by radiotherapy to the breast and axilla. In view of these facts there is now enormous current interest in the technique of sentinel node biopsy, which aims to remove the first level (draining node - a so-called sentinel node). The technique, which is best performed by a combination of radioisotope and blue dye, has been shown to detect a lymph node about 95% of the time and the false negativity varies from an average of 5% up to 30%. Current trials are taking place in the USA, Europe and the UK, looking at sentinel node biopsy in the breast cancer setting. The British trial, ALMANAC, is just completing the audit phase where each surgeon carries out 40 sentinel nodes biopsies, followed by a full axillary clearance or sampling. This has shown an acceptably low false-negative rate and the main randomised portion of the trial is just beginning. This will compare sentinel node biopsy alone against conventional axillary treatment.