Giuliano et al., Ann Surg 1994 — “Lymphatic mapping and sentinel lymphadenectomy for breast cancer.”

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • What they asked?
    • Could intraoperative lymphatic mapping with a blue dye–guided sentinel lymphadenectomy accurately reflect axillary status in breast cancer”
      • Is the SLN a reliable surrogate for the entire basin? PubMed
  • Methods (early feasibility):
    • Design / setting: 
      • Prospective feasibility / accuracy series at John Wayne Cancer Institute
    • Technique: 
      • Vital blue dye injected at the primary site
      • Surgeons traced stained lymphatics to the first (“sentinel”) node, excised it, then performed ALND on all patients to verify accuracy
    • Cohort: 
      • 174 mapping procedures PubMed
  • Key performance results:
    • Identification rate: 
      • 65.5% (SLN found in 114 / 174 procedures):
        • Reflecting the learning curve of this first-in-breast series PubMed
    • Accuracy when SLN identified: 
      • 95.6% (SLN status matched final axillary status in 109 / 114)
      • All false-negatives occurred early:
        • In the last 87 cases:
          • SLN status was 100% predictive PubMed
    • Unique value of the SLN: 
      • In 38% (16 / 42) of clinically node-negative but pathologically node-positive axillae:
        • The sentinel node was the only involved node:
          • Limited disease that a blind sample / low-level dissection might have missed PubMed
    • Anatomic insight: 
      • Among the last 54 mapped cases:
        • 10 had level II-only metastases:
          • Underscoring why targeted mapping can outperform low-level sampling PubMed
  • Why it mattered?
    • Provided the first clinical proof-of-concept in breast cancer that a mapped SLN can accurately stage the axilla with far less surgery:
      • Laying the groundwork for later multicenter validation (Krag 1998) and definitive RCTs (NSABP B-32, ACOSOG Z0011) that enabled omission of routine ALND in properly selected patients PubMed
  • Practical pearls / caveats:
    • Learning curve is real: 
      • Early experience showed lower identification and some false-negatives
      • Performance improved to perfect concordance in later cases
      • Training and standardized technique are crucial PubMed
    • Technique used here was blue dye alone (pre-radioisotope era):
      • Subsequent adoption of radiotracer (± dye) further raised identification and lowered FNR, but the 1994 study established the principle
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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