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How I do it—biopsy of axillary and internal mammary sentinel node for complete nodal staging in male breast cancer
EJSO 2002; 28: 557±559 doi:10.1053/ejso.2002.1290, available online at http://www.idealibrary.com on
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How I do itÐbiopsy of axillary and internal mammary sentinel node for complete nodal staging in male breast cancer R. Gennari*², B. Ballardini² and A. Costa² *European Institute of Oncology, Milan and ²The S. Maugeri Foundation, Pavia, Italy
Key words: male breast cancer; sentinel node biopsy; internal mammary chain; lymphoscintigraphy.
INTRODUCTION Breast cancer in men is a rare disease, accounting for less than 1% of all cases of breast carcinoma and with an incidence of 1 in 100 000 men. Each year about 1000 cases are diagnosed in the USA, resulting in roughly 300 deaths annually. The median age of diagnosis of 55 years in men is 10 years older than that of women. Because of its rarity male breast cancer has not been studied as extensively as carcinoma of the female breast, even through recent studies reported that male breast cancer is similar to its female counterpart.1 Standard surgical treatment consists of radical mastectomy, with subsequent possible lymphoedema and numbness of the scar associated with axillary dissection. Recent advances in the management of female breast cancer seem to suggest that a careful examination of the sentinel node may obviate the need for axillary dissection.2 We recently introduced in our clinical practice axillary sentinel node biopsy (SNB) in male breast cancer patients3 as well as, if present, the biopsy of sentinel node of the internal mammary chain (IMC). Here we describe our technique for complete nodal staging, that give us a major new opportunity to stratify male patients with breast cancer for appropriate surgery as well as giving valuable prognostic informations.
TECHNIQUE Human serum albumin containing 5±10 MBq of 99mTclabelled colloid particles ranging between 100±1000 nm Correspondence to: R. Gennari, MD, European Institute of Oncology, Via Ripamonti, 435 20141 Milan, Italy. Tel.: 39 0382 592.271; Fax: 39 0382 592.076; E-mail: [email protected] 0748±7983/02/$35.00
in diameter (Amersham Sorin, Saluggia, Italy) are injected around the tumor, in volumes ranging from 0.2±0.3 ml. Front and lateral view planar scintigraphy images of the breast, axilla, and the internal mammary area are obtained with a gamma camera (Star Camm 4000, GE Medical System) The lymphatic basins at risk are identified and the location of the highest radioisotope uptake is marked on the skin to facilitate intraoperative identification of the sentinel node.
Axillary sentinel node biopsy Under general anesthesia, after standard surgical preparation, access to SN is obtained through the mastectomy incision. The SN is approached by a blunt dissection with special attention to haemostasis. The subcutaneous tissue is explored in search of the SN and the radioactivity is constantly assessed with the gammadetecting probe (Neo2000 GDS, Neoprobe Corp., Dublin, OH, USA). Once the SN is identified and excised, the hand-held gamma-probe is used to search the resection bed to make sure that there are no residual areas of high radioactivity. We recommend handling with care the SN to avoid coagulation and/or disruption of the capsule, where micrometastases are more frequently found. It is important to angle the probe in all directions to ensure that there is no residual SN. The area is explored further if the count in the resection bed remains high. The SN is evaluated histologically with a new and more extensive intraoperative frozen section.4
Internal mammary sentinel node biopsy Using the same incision the pectoral major muscle is exposed directly over the desired interspace. The muscle #
2002 Elsevier Science Ltd. All rights reserved.
558
Figure 1 Sentinel node biopsy of the internal mammary chain. A short strip of the intercostal muscle is removed, exposing the internal mammary artery (A) and the internal mammary vein (B) surrounded by fat tissue containing the sentinel node (C).
fibers are then separated to expose the posterior intercostal space. The external and internal intercostal muscles are divided transversally from the sternal border. In this procedure, particular care must be taken to avoid injury to the inferior parietal pleura. The artery, usually found 10±15 mm from the lateral sternal border, and the vein are covered by fibrous fatty tissue (Fig. 1). This tissue is separated and the small vessels carefully coagulated. Two vessel loops are used to encircle the vein and the artery, preventing major bleeding in the case of accidental transection. If it does occur, prompt disarticulation of the rib is used to control the bleeding. Then, the area is explored in search of radioactivity that is constantly assessed with the gamma-detecting probe. Once identified, the SN should be handled with care to avoid coagulation and/or lesion of the capsule, where micrometastases are more frequently found. After removing the SN, the area is usually irrigated and checked for bubbles, to confirm the integrity of the pleura. The pectoral muscle is then repaired using absorbable suture.
DISCUSSION Every so often a concept emerges in the management of solid malignancy that is rapidly incorporated into practice or alters our perception of treatment and has the potential to influence treatment algorithms considerably. Sentinel node detection and biopsy is a classic example. We now look upon axillary node dissection
R. GENNARI ET AL. as primarily as a means of controlling the disease locally, while at the same time providing valuable prognostic information which helps us to decide about adjuvant systemic treatment or counseling the patient in other ways. Recent reports have shown that male breast cancer is similar to its female counterpart. This finding supported by molecular biology, 5,6 allowed us to propose similar therapeutic approaches. We recently introduced in our clinical practice sentinel node biopsy in male breast cancer patients,3 because recent studies have shown that sentinel node biopsy can reliably predict the state of the axilla, so that when the sentinel node is clear the entire axilla can be assumed to be clear and axillary dissection can safely be avoided.2 Axillary dissection removes immunocompetent tissue, and may have complications, such as reduced mobility of the arm, numbness, pain, and lymphoedema. We recently suggested in the management of male breast cancer a complete nodal staging. When the IMC SN is present on lymphoscintigraphy, we suggest its biopsy. Even if complete dissection of the IMCs is an aggressive treatment, which does not improve prognosis, their status bears a considerable prognostic significance. 7 In fact, survival seems to be significant worse in patients with both axillary and internal mammary metastatic lymph nodes.7 We believe that in experienced surgeons the IMC SN can be easily found by a hand-held gamma probe, and excised through the same incision for breast surgery. In our series, no major complications occurred. Nevertheless, the surgeon needs particular attention to preserving the IM artery because it is the major resource in the event of coronary reperfusion surgery. Moreover, during the biopsy, in the event that injury involves pneumothorax, suture of the pleura with a fine absorbable suture can be easily performed. We also suggest using additional collimation to reduce the scattered radiation and background activity. It may be also helpful to excise the primary lesion prior to the SNs in order to remove the strong source of radioactivity from the proximity of the SN. The potential clinical implications of complete nodal staging are far-reaching, and give us a major new opportunity to stratify male patients with breast cancer for appropriate surgery as well as giving valuable prognostic informations. In conclusion, complete nodal staging in male patients with breast cancer seems to be a simple and reliable method for staging, avoiding unnecessary radical treatment of uninvaded lymph nodes, reducing the cost of treatment and the length of hospital stay. We think that this new method is an important step forward in the search for more conservative treatment for men with breast cancer, and for providing a more accurate staging. It remains to see if all these additional informations can lead a better adjuvant treatments and to a better survival.
BIOPSIES FOR COMPLETE NODAL STAGING IN MALE BREAST CANCER
REFERENCES 1. Borgen PI, Wong GY, Vlamis V et al. Current management of male breast cancer, a review of 104 cases. Ann Surg 1994; 215: 451±9. 2. Veronesi U, Paganelli G, Viale G et al. Sentinel node biopsy and axillary dissection in breast cancer: results in a large series. J Natl Cancer Inst 1999; 91: 368±73. 3. Gennari R, Renne G, Travaini L et al. Sentinel node biopsy in male breast cancer: future standard treatment? Eur J Surg 2001; 167: 461±2. 4. Viale G, Bosari S, Mazzoral G et al. Intraoperative examination of axillary sentinel lymph nodes in breast carcinoma patients. Cancer 1999; 85: 2433±8.
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5. Curigliano G, Renne G, Colleoni M et al. Recognizing features which are dissimilar in male and female breast cancer: expression of P21waf1 and P27kip1 using an immunohistochemical assay. (Ann Onc 2002, In press) 6. Anelli A, Anelli TM, Tran KN et al. Mutations of the p53 gene in male breast cancer. Cancer 1995; 75: 2233±8. 7. Veronesi U, Marubini E, Mariani L et al. The dissection of internal mammary nodes does not improve the survival of breast cancer patients. Thirty-year results of a randomized trial. Eur J Cancer 1999; 35: 1320±5. Accepted for publication 19 March 2002
1
How I do itÐbiopsy of axillary and internal mammary sentinel node for complete nodal staging in male breast cancer R. Gennari*², B. Ballardini² and A. Costa² *European Institute of Oncology, Milan and ²The S. Maugeri Foundation, Pavia, Italy
Key words: male breast cancer; sentinel node biopsy; internal mammary chain; lymphoscintigraphy.
INTRODUCTION Breast cancer in men is a rare disease, accounting for less than 1% of all cases of breast carcinoma and with an incidence of 1 in 100 000 men. Each year about 1000 cases are diagnosed in the USA, resulting in roughly 300 deaths annually. The median age of diagnosis of 55 years in men is 10 years older than that of women. Because of its rarity male breast cancer has not been studied as extensively as carcinoma of the female breast, even through recent studies reported that male breast cancer is similar to its female counterpart.1 Standard surgical treatment consists of radical mastectomy, with subsequent possible lymphoedema and numbness of the scar associated with axillary dissection. Recent advances in the management of female breast cancer seem to suggest that a careful examination of the sentinel node may obviate the need for axillary dissection.2 We recently introduced in our clinical practice axillary sentinel node biopsy (SNB) in male breast cancer patients3 as well as, if present, the biopsy of sentinel node of the internal mammary chain (IMC). Here we describe our technique for complete nodal staging, that give us a major new opportunity to stratify male patients with breast cancer for appropriate surgery as well as giving valuable prognostic informations.
TECHNIQUE Human serum albumin containing 5±10 MBq of 99mTclabelled colloid particles ranging between 100±1000 nm Correspondence to: R. Gennari, MD, European Institute of Oncology, Via Ripamonti, 435 20141 Milan, Italy. Tel.: 39 0382 592.271; Fax: 39 0382 592.076; E-mail: [email protected] 0748±7983/02/$35.00
in diameter (Amersham Sorin, Saluggia, Italy) are injected around the tumor, in volumes ranging from 0.2±0.3 ml. Front and lateral view planar scintigraphy images of the breast, axilla, and the internal mammary area are obtained with a gamma camera (Star Camm 4000, GE Medical System) The lymphatic basins at risk are identified and the location of the highest radioisotope uptake is marked on the skin to facilitate intraoperative identification of the sentinel node.
Axillary sentinel node biopsy Under general anesthesia, after standard surgical preparation, access to SN is obtained through the mastectomy incision. The SN is approached by a blunt dissection with special attention to haemostasis. The subcutaneous tissue is explored in search of the SN and the radioactivity is constantly assessed with the gammadetecting probe (Neo2000 GDS, Neoprobe Corp., Dublin, OH, USA). Once the SN is identified and excised, the hand-held gamma-probe is used to search the resection bed to make sure that there are no residual areas of high radioactivity. We recommend handling with care the SN to avoid coagulation and/or disruption of the capsule, where micrometastases are more frequently found. It is important to angle the probe in all directions to ensure that there is no residual SN. The area is explored further if the count in the resection bed remains high. The SN is evaluated histologically with a new and more extensive intraoperative frozen section.4
Internal mammary sentinel node biopsy Using the same incision the pectoral major muscle is exposed directly over the desired interspace. The muscle #
2002 Elsevier Science Ltd. All rights reserved.
558
Figure 1 Sentinel node biopsy of the internal mammary chain. A short strip of the intercostal muscle is removed, exposing the internal mammary artery (A) and the internal mammary vein (B) surrounded by fat tissue containing the sentinel node (C).
fibers are then separated to expose the posterior intercostal space. The external and internal intercostal muscles are divided transversally from the sternal border. In this procedure, particular care must be taken to avoid injury to the inferior parietal pleura. The artery, usually found 10±15 mm from the lateral sternal border, and the vein are covered by fibrous fatty tissue (Fig. 1). This tissue is separated and the small vessels carefully coagulated. Two vessel loops are used to encircle the vein and the artery, preventing major bleeding in the case of accidental transection. If it does occur, prompt disarticulation of the rib is used to control the bleeding. Then, the area is explored in search of radioactivity that is constantly assessed with the gamma-detecting probe. Once identified, the SN should be handled with care to avoid coagulation and/or lesion of the capsule, where micrometastases are more frequently found. After removing the SN, the area is usually irrigated and checked for bubbles, to confirm the integrity of the pleura. The pectoral muscle is then repaired using absorbable suture.
DISCUSSION Every so often a concept emerges in the management of solid malignancy that is rapidly incorporated into practice or alters our perception of treatment and has the potential to influence treatment algorithms considerably. Sentinel node detection and biopsy is a classic example. We now look upon axillary node dissection
R. GENNARI ET AL. as primarily as a means of controlling the disease locally, while at the same time providing valuable prognostic information which helps us to decide about adjuvant systemic treatment or counseling the patient in other ways. Recent reports have shown that male breast cancer is similar to its female counterpart. This finding supported by molecular biology, 5,6 allowed us to propose similar therapeutic approaches. We recently introduced in our clinical practice sentinel node biopsy in male breast cancer patients,3 because recent studies have shown that sentinel node biopsy can reliably predict the state of the axilla, so that when the sentinel node is clear the entire axilla can be assumed to be clear and axillary dissection can safely be avoided.2 Axillary dissection removes immunocompetent tissue, and may have complications, such as reduced mobility of the arm, numbness, pain, and lymphoedema. We recently suggested in the management of male breast cancer a complete nodal staging. When the IMC SN is present on lymphoscintigraphy, we suggest its biopsy. Even if complete dissection of the IMCs is an aggressive treatment, which does not improve prognosis, their status bears a considerable prognostic significance. 7 In fact, survival seems to be significant worse in patients with both axillary and internal mammary metastatic lymph nodes.7 We believe that in experienced surgeons the IMC SN can be easily found by a hand-held gamma probe, and excised through the same incision for breast surgery. In our series, no major complications occurred. Nevertheless, the surgeon needs particular attention to preserving the IM artery because it is the major resource in the event of coronary reperfusion surgery. Moreover, during the biopsy, in the event that injury involves pneumothorax, suture of the pleura with a fine absorbable suture can be easily performed. We also suggest using additional collimation to reduce the scattered radiation and background activity. It may be also helpful to excise the primary lesion prior to the SNs in order to remove the strong source of radioactivity from the proximity of the SN. The potential clinical implications of complete nodal staging are far-reaching, and give us a major new opportunity to stratify male patients with breast cancer for appropriate surgery as well as giving valuable prognostic informations. In conclusion, complete nodal staging in male patients with breast cancer seems to be a simple and reliable method for staging, avoiding unnecessary radical treatment of uninvaded lymph nodes, reducing the cost of treatment and the length of hospital stay. We think that this new method is an important step forward in the search for more conservative treatment for men with breast cancer, and for providing a more accurate staging. It remains to see if all these additional informations can lead a better adjuvant treatments and to a better survival.
BIOPSIES FOR COMPLETE NODAL STAGING IN MALE BREAST CANCER
REFERENCES 1. Borgen PI, Wong GY, Vlamis V et al. Current management of male breast cancer, a review of 104 cases. Ann Surg 1994; 215: 451±9. 2. Veronesi U, Paganelli G, Viale G et al. Sentinel node biopsy and axillary dissection in breast cancer: results in a large series. J Natl Cancer Inst 1999; 91: 368±73. 3. Gennari R, Renne G, Travaini L et al. Sentinel node biopsy in male breast cancer: future standard treatment? Eur J Surg 2001; 167: 461±2. 4. Viale G, Bosari S, Mazzoral G et al. Intraoperative examination of axillary sentinel lymph nodes in breast carcinoma patients. Cancer 1999; 85: 2433±8.
559
5. Curigliano G, Renne G, Colleoni M et al. Recognizing features which are dissimilar in male and female breast cancer: expression of P21waf1 and P27kip1 using an immunohistochemical assay. (Ann Onc 2002, In press) 6. Anelli A, Anelli TM, Tran KN et al. Mutations of the p53 gene in male breast cancer. Cancer 1995; 75: 2233±8. 7. Veronesi U, Marubini E, Mariani L et al. The dissection of internal mammary nodes does not improve the survival of breast cancer patients. Thirty-year results of a randomized trial. Eur J Cancer 1999; 35: 1320±5. Accepted for publication 19 March 2002