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New Data on Sentinel-Node Biopsy and Lymphedema
In previous Lymphedema eNews letters I have discussed the emerging evidence that sentinel-node biopsies can accurately predict the lymph node status of a breast cancer patients. The lymph node status of a tumor is critical for several reasons. First, spread to lymh nodes indicated more advanced disease and an increased risk for metastatic spread. Second, lymph nodes involved with tumor can be a reservoir for tumor cells that can grow, spread to other sites and invade the muscles and ribs of the chest. Prev
ious studies had demonstrated that sentinel-node biopsy was similar to axillary dissection in terms of predictive value; however, these studies compared the sentinel-node method to data collected in other studies, many conducted years ago. Since our methods of detection, such as mammography, have improved over the years, a direct comparison to patients treated by current methods was needed to be certain of the value of sentinel node biopsy. A recent paper published by Veronesi et. al in the New England Jou
rnal of Medicine (2003; 349:546-53) addressed this issue.
In this study reported by Veronesi, 516 women were randomly assigned to receive either an axillary dissection or a sentinel-node biopsy. These women had early stage breast cancer. The tumors were 2 centimeters in size or smaller. For the women undergoing sentinel-node biopsy, axillary dissections were performed only for those women with evidence of cancer on the sentinal-node biopsy. In this study, 83 of the 257 (32.3%) women who underwent sentinel-node biopsies were found to have cancer in the sentinel-no
de and these women then underwent axillary dissection to remove the residual cancer. 92 of 259 (35.5%), were found to have involvement of the lymph nodes on axillary dissection. While the number of cancers found was higher among the women undergoing axillary dissection, the numbers are very close and are within the expected error of the study. An important finding of this study was that the number of cases of recurrent cancer in the region of the breast and axilla were similar between the women undergoing
axillary dissection and sentinel-node biopsy. Three women among those who under went axillary dissection subsequently had a local recurrence of breast cancer. Only 1 patient who had a sentinel node biopsy had a local recurrence. These results are very encouraging and clearly demonstrate that the incidence of local recurrence of cancer using the sentinel-node technique is no higher than if a woman had undergone an axillary dissection. In addition, the incidence of metastatic disease was similar between pati
ents undergoing axillary dissection and patients undergoing sentinel-node biopsy.
The authors of the study are to be commended for closely monitoring the patients for signs of lymphedema. In this study the patients had measurements taken of the affected and unaffected arms 6 months and 2 years after the procedure. Measurements were taken at 15 centimeters above the lateral epicondyle (elbow). Six months after the procedure, the women who underwent axillary dissection had significantly more swelling than the women who underwent sentinel node biopsy. 44% of the women with axillary dissect
ion had swelling of less than 1 centimeter compared to the unaffected arm, while only 11% of the women undergoing sentinel-node biopsy had swelling of less than 1 centimeter. Even more striking was the finding that, 6 months after the procedure, 25% of the women who underwent axillary dissection had swelling of more than 1cm. In contrast, less than 1% of the women who underwent sentinel-node biopsy had measurable swelling.
The results of this study are convincing. For patients with small breast cancers, measuring 2 centimeters or less, sentinel-node biopsy appears to be as sensitive as axillary dissection for identifying metastatic cancer. This study clearly demonstrates that the incidence of lymphedema is significantly lower for the women who undergo a sentinel-node biopsy and sentinel-node biopsy should be considered for all patients whose primary tumors are smaller than 2 centimeters. It is important to note, however, tha
t one third of the patients in this study who had a sentinel-node biopsy were found to have cancer in the lymph nodes and subsequently underwent an axillary dissection and as a result are at significant risk for lymphedema. Sentinel-node biopsy is an important step forward in our effort to finally eliminate lymphedema as a complication of the treatment of breast cancer.
Tony Reid MD Ph.D
Once again, this is that time of year that we like to remind people if they have insurance deductibles that renew on January 1st to talk to your health care provider about treatment or garments before the end of the year. Many people have very high deductibles and it is great to get those claims in while it is still covered on the current year.
We would like to also remind you that Peninsula Medical provides insurance verification, at no obligation nor cost. We will verify your coverage for durable medical equipment (DME). We determine the estimated percent of coverage and any deductibles yet to be met, and what is required to obtain DME to help assist your decision should you be contemplating any DME purchase before January 1st. This service is available on line by clicking here or if you would prefer to speak wi
th one of our billing specialists about this service, please call toll free 1-800-293-3362.