Foreword
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 accordingly has the potential to
influence
treatment algorithms significantly. Sentinel lymph node
scintigraphy
and biopsy represent a classic example. This method
was
initially introduced for the management of malignant mela-
noma and
rapidly proved to be popular and valuable. It has sub-
sequently
been applied to breast cancer and its popularity has spread
with almost
indecent haste. With increasing experience it is be-
coming
apparent that the technique, whilst of potential value, never-
theless
requires fastidious performance if it is to be effective, and
it must be
assessed carefully. Demonstration of proven efficacy is
necessary if
it is to be incorporated into general surgical practice.
What do we
mean by efficacy in this case? Up until about 30 years
ago surgical
clearance of the axilla was considered essential as a life-
saving
component of the radical management of primary breast
cancer.
Since then, however, we have become more modest in our
objectives.We
now look upon axillary node dissection as primarily a
means of
controlling the disease locally, whilst at the same time
providing
valuable prognostic information to make decisions about
adjuvant
systemic therapy or for counselling the patient in other
ways.As
breast cancer is being diagnosed at earlier and earlier stages,
the
positivity of the axilla after radical clearance has fallen to a level
of about 30
%. This means that up to 70 % of patients with primary
breast
cancer are undergoing unnecessary axillary dissection with its
subsequent
morbidity for no particular return. At the same time,
is adjuvant
chemotherapy being recommended to more and more
patients
with negative axillae, particularly amongst the pre-meno-
pausal
group, in spite of a negative lymph node status. Ideally,
therefore,
we need some procedure that will allow us to avoid un-
necessary
radical treatment of the negative axilla, whilst allowing us
to make
borderline decisions about the role of adjuvant systemic
therapies
amongst patients at the more favourable end of the
spectrum of
prognosis. It is in this area that the sentinel node biopsy
is likely to
prove its worth, but not until it has been subjected to
a large,
pragmatic, randomised controlled trial, comparing un-
selected
axillary node clearance and management dependent on
the outcome
of the sentinel node biopsy. Such a trial has just been