UH News

Simple Intervention May Spare Breast Cancer Patients Unnecessary Lymph Node Surgery

Thursday, June 4, 2015

A growing number of women with invasive breast cancer have chemotherapy before surgery, especially those with larger tumors and lymph nodes in the armpit that doctors suspect may be cancerous. Chemotherapy before surgery is known as neoadjuvant therapy.

“This treatment has several advantages, but the most important one is that it can reduce the size of large primary tumors, increasing the chances for a lumpectomy,” says Donna Plecha, MD, Director of Breast Imaging at University Hospitals Seidman Cancer Center.

The success of neoadjuvant therapy, however, poses a new problem. Chemotherapy drugs shrink cancerous lymph nodes so much that they are extremely difficult to detect afterward. They can be hard for a doctor to feel during a physical exam. Plus, they may be difficult to find during a sentinel lymph node biopsy (SLNB) – a common surgical procedure that shows whether breast cancer has spread.

SLNB involves injecting radioactive dye into the breast to identify the lymph node to which cancer cells are most likely to spread first. When a biopsy of the sentinel lymph node is negative for cancer, it suggests that the cancer has not spread to the other lymph nodes and other organs.

Chemotherapy before this test, though, complicates things. “The lymph nodes can shrink down so that they don’t pick up the dye from the SLNB,” says Robert Shenk, MD, a breast surgeon and Medical Director of the Breast Center at UH Seidman Cancer Center.

If the sentinel node isn’t correctly identified, the whole test can be wrong. “Because of this, the standard of care has been to remove all the lymph nodes after neoadjuvant therapy, to be on the safe side,” Dr. Shenk says. “SLNB hasn’t really been the standard for these patients.”

At UH Seidman Cancer Center, breast cancer experts are using a simple innovation to address this issue. When they suspect that a woman’s lymph node may be cancerous, they do a needle biopsy and leave behind a tiny “clip.” If the biopsy is positive for cancer and the woman has chemotherapy before surgery, they make sure they can find the cancerous node again by inserting a tiny wire at the site of the “clip” about an hour before surgery. They use ultrasound images to accurately place the wire. Surgeons then use the wire to find the cancerous node.

Research shows that this approach yields good results. A study of breast cancer patients at UH Seidman Cancer Center found that wire localization improved success in removing cancerous lymph nodes from just under 80 percent (without wire localization) to just over 97 percent (with wire localization). For those women having chemotherapy before surgery, the results were similar. For those undergoing SLNB, successful lymph node removal improved from just under 86 percent (without wire localization) to 100 percent (with wire localization). The team published its results recently in the Annals of Surgical Oncology.

For Drs. Plecha and Shenk, the hope is that this quality improvement will result in more accurate staging of breast cancer patients, and therefore more appropriate treatment. Ultimately, they hope it will also allow more breast cancer patients to be candidates for SLNB after neoadjuvant chemotherapy.

“With some of the newer neoadjuvant chemotherapeutic agents, between 30 and 60 percent of breast cancer patients respond very well,” Dr. Shenk says. “Accurate SLNB with wire localization would result in these patients avoiding removal of all their lymph nodes and the increased risk of lymphedema and other associated morbidities, such as pain, numbness and decreased arm mobility. In simple terms, we may be saving a large group of women from surgeries they don’t need.”

Lymphedema is a swelling in the arm caused by blockage in the lymphatic system. It occurs in about 5 percent of breast cancer patients after a sentinel lymph node biopsy and about 15 percent of women who have all their armpit lymph nodes removed.

Dr. Plecha concurs. “If sentinel lymph node biopsy were more accurate, it could become standard treatment after neoadjuvant therapy,” she says. “When SLNB is accurate, we can be much more targeted with our surgery. Less is better.”

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