Readily available, rapid diagnostic techniques could eliminate some breast cancer surgeries
For most women, affected lymph nodes can be detected and removed during first surgery
Simple and quick diagnostic techniques used during breast cancer surgery can spare most women from a second surgery to remove affected lymph nodes, according to research from UC Davis Cancer Center. Results from the sentinel lymph node biopsy — the current standard for identifying metastatic disease — can take up to two weeks and lead to a second surgery if results are positive. However, two procedures known as touch prep and frozen section analyses, which are widely available at most hospitals, can take place during the initial breast tumor surgery and detect in the majority of cases whether or not lymph nodes should be removed at the same time. Study results appear in the July 2008 issue of Annals of Surgical Oncology.
"Spread of early stage invasive breast cancer to the regional lymph nodes can be very difficult to detect prior to surgery," said Richard Bold, chief of surgical oncology for UC Davis and senior author of the study. "The current accepted approach is to remove sentinel lymph nodes during surgery and send them for detailed lab analysis to find out if the disease has spread, then remove remaining lymph nodes during another surgery if the test indicates that this is necessary. This study shows techniques available at nearly every hospital that provide results in about four-to-six minutes are accurate for most women who have stage one or two breast cancer and who also have affected lymph nodes."
Bold describes sentinel lymph nodes as "watchers" of the lymphatic system. They are usually the first tissue in which cancer cells appear once the disease has spread from a primary breast tumor. If sentinel nodes are affected, the remaining lymph nodes in the armpit are removed to prevent further spread of the disease.
Touch prep analysis involves dissecting sentinel lymph node tissue, pressing it to a slide, then examining it under a microscope. Frozen section analysis involves quick-freezing the sample before sections are cut and viewed under a microscope. For the current study, results from both techniques were compared to those of detailed biopsies for 118 UC Davis patients with early-stage breast cancer. Of the 21 percent of women whose lymph nodes were tumor-positive, two-thirds of them could be spared a second surgery by using either technique for immediate analysis at the time of the first surgery.
— Richard Bold, senior study author
"A few patients would still need to undergo a second surgery, since the quicker procedures did not detect all micrometastases, which are less than two millimeters of cancer spread in the lymph node," said Kimberly Vanderveen, lead author of the study and a UC Davis resident when the research was conducted. "But our study indicates that the majority of women can be saved from the anxiety of waiting for results, the pain of a second procedure and delays in further cancer treatments. This is especially good news for patients receiving treatment at smaller hospitals, where dedicated breast pathologists and extensive biopsy facilities are not usually available."
Vanderveen initiated the study as part of a UC Davis program sponsored by the National Institutes of Health designed to train up-and-coming physicians in clinical and translational research so they are fully prepared for careers in improving human health. She decided for her study to find out if the different diagnostic techniques of community and larger hospitals led to distinct results and surgical approaches.
"This study shows that community hospitals have the capabilities to deliver good cancer care," said Vanderveen, who is now an endocrine surgery fellow at the Mayo Clinic. "Wherever a woman is receiving her breast cancer surgery, she can — in most instances — not have to go through the difficulties of a second procedure and get on more quickly with her treatment and recovery."
"There is ongoing research to develop new methods of intraoperative analysis of the sentinel lymph node to accurately identify those patients whose breast cancer has spread and avoid any delays in conducting additional surgery," said Bold. "Until those technologies are validated, we feel that either frozen section or touch prep analysis can be universally implemented today regardless of hospital setting."
A copy of Vanderveen and Bold's study can be downloaded at the journal's Web site: www.annalssurgicaloncology.org.
UC Davis Cancer Center is a National Cancer Institute-designated cancer center that cares for 9,000 adults and children with each year from throughout the Central Valley and inland Northern California. The center's Breast Cancer Program provides comprehensive, multidisciplinary services for patients with all stages of breast cancer. Patients receive all of their care in one location, from a team of top academic physicians with expertise in hematology and oncology, surgical oncology, radiation oncology, pathology, plastic and reconstructive surgery, and diagnostic radiology/mammography. These experts work together to develop individualized treatment plans for each patient. For more information, visit www.ucdmc.ucdavis.edu/cancer.