Tigerlily Blog

Recently, I shared some finding from The San Antonio Breast Cancer Symposium.  This week, I will continue to share some of the knowledge gained at the conference.  The San Antonio Breast Cancer Symposium (SABCS)was held December 12th to 16th in San Antonio, Texas.  This world renknowned conference is attended by scientists, researchers and advocates from countries around the world.  One of the important discussions centered around whether or not to remove lymph nodes should be removed and tested after a woman has been diagnosed with breast cancer.  The following is an article from the symposium’s newsletter.

To Remove or Not to Remove: Scientists Report on Signs That May Guide Lymph Node Decisions

By Laura Beil
A tumor's size, degree of vascular infiltration, and other distinctions may help predict whether lymph nodes need to be removed and tested, which can provide a roadmap for surgery, scientists reported at SABCS. The research is part of an effort to further refine a practice that has become increasingly accepted over the past decade, yet remains wrought with uncertainties.

Doctors examine lymph nodes after a diagnosis to try to gauge whether cancer has spread. Renegade cells will usually jump to the nearest lymph nodes - in breast cancer these are under the arm — before setting up outposts in other parts of the body. But the lymph nodes can't be studied as long as they remain inside the body.

There was a time when doctors removed many nodes, but lately surgeons have tried to focus on testing only the sentinel nodes — those few nodes that first drain from the tumor.

The theory seems straightforward, but the practice has raised difficult issues. Among them: If cancer cells are found in the sentinel nodes, how many more lymph nodes should be removed? If the sentinel node contains only tiny malignancies, should more nodes be examined? How should doctors interpret positive sentinel nodes that contain just a little bit of cancer?

"The whole problem is, where do you make the cutoff?" says Thomas Julian, MD, of Allegheny General Hospital/Drexel University College of Medicine. Given the complexity, it is perhaps not so surprising that studies have found that one of the biggest predictors of the accuracy of sentinel node biopsy is a surgeon's own experience and the type of procedure used.

To women with breast cancer, these are questions that can profoundly affect quality of life after cancer. With fewer lymph nodes to drain into, fluid can build up painfully in the arm, a condition called lymphedema. Studies have suggested even sentinel node biopsy, which involves the removal of just a few nodes, can cause complications.

Dr. Julian, in the NSABP B-32 sentinel node trial, has found certain hallmarks that appear to predict a higher likelihood that cancer has spread beyond the sentinel lymph nodes, which would raise the need for axillary dissection (or the removal of even more nodes).

His study involved more than 1,300 women who had cancer cells in their sentinel nodes. He and his colleagues found that the larger the tumor, or the presence of tumor cells in lymphatic and vascular spaces, the higher the likelihood cancer had spread.

Also, a higher number of positive sentinel nodes increased the odds that the cancer had spread beyond the sentinel nodes. For example, if a woman had five sentinel nodes, and three contained cancer cells, the disease was more likely to have spread. But if only one of five sentinel nodes contained cancer cells, the odds were lower.

Doctors are also trying to refine the techniques for examining the nodes themselves. Current procedure for studying lymph nodes is called "H&E" staining, and it is one of the most common ways of examining tissues. The stain gives color to individual cells, allowing a pathologist to see the cancer. While this is proven practice, it only allows for examination of a fraction of the node, requires the judgment of an expert, and takes a day or two to get results. Because of this delay, a positive test means a second surgery is needed to remove the nodes.

But methods are getting more sophisticated, allowing doctors to catch cancer cells they might otherwise have missed.

For example, Peter Blumencranz, MD, of Morton Plant Mease Healthcare in Clearwater, Florida, described at the meeting a technique that can analyze half the node and be performed by a technician in less than 40 minutes. The tissue is ground and examined by a machine that will detect the presence of genetic material that appears in malignant cells but not normal ones. (This method, called GeneSearch Breast Lymph Node Assay, received approval by the Food and Drug Administration in July.)

In a study of more than 300 patients described at SABCS Saturday morning, Dr. Blumencranz and his colleagues compared the results of the automated method against the eyes of a pathologist. The genetic screening proved to be more sensitive; when cancer was present, the assay detected it 92 percent of the time, compared with 82 percent of the time under human examination.

A second automated approach described during the meeting also examined the node's genetic material. In a small study, the machine also detected nodes with cancer that the H&E approach missed.

"This will replace the current pathology," predicted Peter Beitsch, MD, of the Dallas Surgical Group, who was involved in both studies.

But while new assays may make the scrutiny of sentinel nodes faster and easier, will their heightened ability to pick up wisps of cancer make any difference? Doctors are increasingly picking up traces of cancer, called "micrometastases." But no one is certain whether these cancer cells signal that the malignancy has actually spread, which would call for the removal of even more nodes and perhaps change the course of treatment.

To try to answer this question, Nora Hansen, MD, described a study of about 800 patients at the John Wayne Cancer Institute in Santa Monica, California. The patients were divided into four groups based on node involvement, which ranged from none to bonafide metastases, which is a deposit larger than 2 millimeters. After eight years, more than 80 percent of those who had the most amount of node involvement at diagnosis were still alive, compared with 95 percent of the other three groups — including those with micrometastases.

"It is unclear whether or not it affects disease-free or overall survival," said Dr. Hansen at the meeting. Further studies are trying to answer the question.

Most physicians predict that sentinel node biopsy is here to stay, but acknowledge that the practice is as yet imperfect. Only with more refinement, they say, will the lymph nodes be the best possible sentinels they can.

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