Video-assisted breast surgery can sample the second and third sentinel nodes to omit axillary node dissection for sentinel-node-positive patients

Abstract

The preservation of the axillary node (AN) has become standard therapy for early breast cancer patients with a metastasis-positive sentinel node (SN). However, about half of the patients with metastasis in the SN have no metastasis in the other AN. Late-phase three-dimensional computed tomographic lymphography (3D-CT LG) of the breast can show the axillary lymphatic architecture from the SN into the venous angle. These nodes are classified into five groups. For the sake of aesthetics, video-assisted breast surgery (VABS) was used to sample the second and third nodes shown by 3D-CT LG. For marking the SN on the skin, 3D-CT LG was performed the day before the surgery. Iopamiron 300 (2 ml) was injected subcutaneously. A 16-channel multidetector-row helical CT image was reconstructed to produce a 3D image of the lymph ducts and nodes. A biopsy of the SN was performed by the dye-staining method using Visiport-aided endoscopy for VABS. Stained nodes were located by following the dye in the lymph ducts on a video monitor. For SN-metastasis-positive patients, standard AN dissection was performed under video assistance. Since July 2002, the authors have performed SN biopsy for 186 patients as well as 3D-CT LG and VABS SN biopsy for 146 patients. Five chained-node groups were shown. Even in the multiple SN case, the lymph ducts were converging into the second node. The second and third nodes beyond the SN were detected and sampled in 82 patients (56.2%) by VABS assisted with 3D-CT LG. Sentinel node metastasis (n = 40) involved SN metastasis alone in 21 cases (52.5%) and SN, second-node, and third-node metastasis in eight cases. A reviewed lymphoid path by 3D-CT LG confirmed that metastasis occurred in order of lymph flow. The use of 3D-CT LG-guided VABS SN biopsy of the second and third nodes will predict SN metastasis alone and help to obviate the need for dissection of more nodes.