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Sentinel Node Biopsy in Breast Cancer - Summary
Guideline Title: Sentinel Node Biopsy in Breast Cancer - Summary

(O): Nov 30, 2011 (R)

Date Signed: February 15, 2013
Issuing Authority: Dr. Rod Martin, Clinical Chief, Surgical Program
Adapted From: The Cancer Care Ontario’s “Sentinel Lymph Node Biopsy in Early-Stage Breast Cancer: Guideline Recommendations”, July 2009 (1).

Target Population:
The recommendations are aimed toward patients who have been diagnosed with cancer of the breast and meet the selection criteria for sentinel lymph node biopsy (SLNB).

All patients who have been diagnosed with early-stage cancer of the breast (ie. without clinically or pathologically positive lymph nodes) should be eligible for sentinel lymph node biopsy when they meet the selection criteria for its use. The selection criteria include those patients who have T1 or T2 unifocal tumors that are less than 3 cms in diameter*.

Circumstances where SLNB would not be recommended*:

  • inflammatory or T4 breast cancer
  • prior axillary surgery (unless minimal).

The clinical circumstances for patients with breast cancer where the evidence is inconclusive or inadequate are those with*:

  • T3 or T4 (tumors larger than 3 cm in diameter) tumors
  • internal mammary lymph nodes
  • multifocal tumors
  • before neoadjuvant therapy
  • DCIS treated by lumpectomy**
  • pregnant or breastfeeding women
  • known allergies to blue dye 
  • previously treated breast cancer or non-oncologic axillary surgery on the affected breast** .


Qualifying Statements:

  • In the Cancer Care Ontario (CCO) SLNB 2008 guideline, the evidence review revealed four randomized control trials (RCTs) comparing SLNB to ALND, which reported high SN detection rates from 95.1% to 97.2% and accuracy rates from 94.4% to 97.6% (1). The false-negative rates were low and node-positive rates were similar between ALND and SLNB-alone arms (1-5). The Sentinella-GIVOM non-inferiority trial also revealed only one axillary recurrence in 345 SN-negative patients at 55.6 months of follow-up, and similar disease-free and overall survival rates between the two arms (6). Since the CCO guideline was published, our literature search revealed 3 more RCTs, a meta-analysis, and a 10 year follow-up study of a RCT, which all confirm the equivalency of SLNB to the ALND in early stage breast cancer (7-11). 
  • Preoperative lymphoscintigraphy is the preferred standard of care where available. The combination use of radioisotope and blue dye is preferred though using either alone is acceptable. The combination approach of intradermal, periareolar of colloid injection is preferred by the nuclear medicine program within Eastern Health (12-14). Frequently, gentle massage is used over the injection site to help facilitate the clearance of the radiocolloid (15). The blue dye injection is given in the upper outer quadrant of the areola. If the patient has had a previous surgery (ex. previous breast biopsy) in this area, the injection is always given above the scar to ensure the scar tissue does not interfere with the dispersion of the isotope/dye to the SN(s). The surgeon then uses a hand held detection probe to identify the location of the radioactive SN(s). The Sentinel Lymph Node working group agreed that there is not enough quality evidence to pursue internal mammary node mapping at this time.  
  • During the intraoperative SLNB procedure, the pathologist has to be at the ready and available to receive the SN specimens from the operating room. To allow timely and efficient processing of the specimens, a completed pathology requisition from the surgeon should accompany them. The surgeon should indicate which node is believed to be sentinel. The pathologist will process the SN(s) via frozen section examination as per Eastern Health’s pathology protocol, and communicate the result to the surgeon as promptly as possible (16,17).
These guidelines are a statement of consensus of the Breast Disease Site Group regarding their views of currently accepted approaches to diagnosis and treatment. Any clinician seeking to apply or consult the guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment.

Contact Information:
For more information on this guideline, please contact:
Dr. Christopher Cox MD FRCSC,
St. John’s, NL
Telephone 709-237-7022.
For the complete guideline on this topic or for access to any of our guidelines, please visit our Cancer Care Program website

*Adapted from the CCO guideline “sentinel node biopsy in early-stage breast cancer” (1).
**In some circumstances, treatment decisions will be made on a case-by-case basis.

Literature Support:
  • George R, Quan ML, et al. Sentinel node biopsy in early-stage breast cancer: Guideline recommendations. Cancer Care Ontario (CCO). July 2009.
  • Zavagno G, De Salvo GL, et al. A randomized clinical trial on sentinel lymph node biopsy versus axillary lymph node dissection in breast cancer: Results of the Sentinella/GIVOM trial. Ann Surg. 2008;247(2):207-213.
  • Zavagno G, Del Bianco P, et al. Clinical impact of false-negative sentinel lymph nodes in breast cancer. Eur J Surg Oncol. 2008;34:620-625.
  • Krag DN, Anderson SJ, et al. Technical outcomes of sentinel-lymph-node resection and conventional axillary-lymph-node dissection in patients with clinically node-negative breast cancer: results from the NSABP B-32 randomised phase III trial. Lancet Oncol. 2007;8:881-888. 
  • Goyal A, Newcombe RG, et al. Factors affecting failed localisation and false-negative rates of sentinel node biopsy in breast cancer – results of the ALMANAC validation phase. Breast Cancer Res Treat. 2006;99:203-208.
  • Del Bianco P, Zavagno G, et al. Morbidity comparison of sentinel lymph node biopsy versus conventional axillary lymph node dissection for breast cancer patients: Results of the sentinella-GIVOM Italian randomised clinical trial. EJSO. 2008;34:508-513.
  • Gill G & SNAC Trial Group. Sentinel-lymph-node-based management or routine axillary clearance? One-year outcomes of sentinel node biopsy versus axillary clearance (SNAC): A randomized controlled surgical trial. Ann Surg Oncol. 2009;16(2):266-275.
  • Canavese G, Catturich A, et al. Sentinel node biopsy compared with complete axillary dissection for staging early breast cancer with clinically negative lymph nodes: results of randomized trial. Ann Oncol. 2009;20(6):1001-1007.
  • Moon HG, Han W, et al. Comparable survival between pN0 breast cancer patients undergoing sentinel node biopsy and extensive axillary dissection: A report from the Korean Breast Cancer Society. J Clin Oncol. 2010;28(10):1692-1699.
  • Kell MR, Burke JP, et al. Outcome of axillary staging in early breast cancer: A meta-analysis. Breast Cancer Res Treat. 2010;120:441-447.
  • Veronesi U, Paganelli G, et al. Sentinel-lymph-node biopsy as a staging procedure in breast cancer: Update of a randomised controlled study. Lancet Oncol. 2006;7(12):983-990.
  • Ellis RL, Seifert PJ, et al. Periareolar injection for localization of sentinel nodes in breast cancer patients. The Breast J. 2004;10(2):94-100.
  • Newman EA & Newman LA. Lymphatic mapping techniques and sentinel lymph node biopsy in breast cancer. Surg Clin N Am. 2007;87:353-364.
  • Mudun A, Sanli Y, et al. Comparison of different injection sites of radionuclide for sentinel lymph node detection in breast cancer. Clin Nucl Med. 2008;33(4):262-267.
  • Buscombe J, Burak ZE, et al. Sentinel node in breast cancer procedural guidelines. Eur J Nucl Mol Imaging. 2007;34:2154-2159.
  • Ali R, Hanly AM, et al. Intraoperative frozen section assessment of sentinel lymph nodes in the operative management of women with symptomatic breast cancer. World J Surg Oncol. 2008;6(69):1-6.
  • Van de Vrande S, Meijer J, et al. The value of intraoperative frozen section examination of sentinel lymph nodes in breast cancer. Eur J Surg Oncol. 2009;35:276-280.


Downloadable Documents:
Sentinel Node Biopsy

Updated Mar 12, 2013