Assessment of clinical palpation of the axilla as a criterion for performing the sentinel node procedure in breast cancer

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Abstract

Aims

Clinically palpable lymph nodes (LNs) are regarded as a contraindication for performing the sentinel node (SN) procedure. Many studies have shown, however, that clinical assessment of axillary LNs is inaccurate.

This study evaluated the reliability of clinical axillary LN assessment by experts and assessed whether inaccuracy can be related to LN size.

Methods

Three hundred and one consecutive breast cancer patients undergoing either axillary dissection or SN were studied prospectively.

Results

The risk of having metastasis to the LN was 40.4% if the preoperative clinical assessment was “non-palpable LN”, 61.5% if the assessment was “palpable but benign LN” and 84.4% if it was “suspicious LN”.

There were no clinically significant differences in mean size either when the LN was palpable versus non-palpable, or when the LN had metastasis or not.

Conclusions

The clinical assessment of axillary LNs as a criterion for offering the SN procedure is of little value.

Introduction

The sentinel node (SN) procedure is widely accepted as a reliable method for staging the axilla in breast cancer patients. The method is though time consuming and expensive. Since SN is only relevant in patients who have no signs of metastasis to the axillary lymph nodes (LNs), reliable preoperative assessment is becoming increasingly important.

Some standard texts,1 some international research protocols,2 and some national guidelines3, 4 use clinical palpation of the axilla as a criterion for whether the patient should be offered SN or not. That is to say, clinically palpable LNs are regarded as a contraindication for SN while a patient with non-palpable LNs may be offered SN.

However, many studies have shown that clinical assessment of axillary LNs is inaccurate.5, 6

We found it of interest to study two aspects of this problem:

  • 1

    How reliable is clinical axillary LN assessment in the hands of experienced breast surgeons?

  • 2

    Can the inaccuracy of the clinical assessment be related to LN size?

Section snippets

Patients and methods

The Breast Surgery Clinic, Horsholm Hospital, is a centralized breast care unit serving a population of 375,000. It is manned by 5 full-time specialist breast surgeons. The clinic has about 10,000 out-patient visits per year and treats about 350 women with primary breast cancer per year.7

Three hundred and one consecutive patients with newly diagnosed invasive breast cancer undergoing either axillary dissection or SN in the period from 1st June, 2003 to 31st June, 2004 were studied

Results

Of the 223 cases (72.6%) assessed as having non-palpable LNs, metastases were found in 90 cases. The negative predictive value was 59.6%. There were palpable LNs in 84 of 307 axillas (27.4%). In 52 cases (16.9%) the palpable LN was assessed as benign. Of these, 32 had metastases. The negative predictive value was 38.5%. In 32 cases (10.4%) the palpation revealed suspicious LNs. The diagnosis was confirmed in 27 of these cases. The positive predictive value was 84.4%. These differences were

Discussion

Clinical examination of the axilla is notoriously inaccurate.5, 6 This is the case also when the axillary palpation is done by experts. In a study from Memorial Sloan Kettering Cancer Center,5 only 77% of LNs which were highly suspicious at palpation had metastases. Our study confirms that even in the hands of specialist breast surgeons, the examination has little value. When the surgeons considered the axilla to be normal, they were wrong in 44% of cases. They were better at diagnosing

Conclusion

The message of our study is that clinical assessment of axillary LNs as a criterion for offering the SN procedure is of little value. This is the case even in the hands of highly specialized surgeons. We believe that the clinical assessment of the axilla should be supplemented with ultrasound examination and that fine needle aspiration cytology should be added if LNs are considered suspicious at ultrasound examination.

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