Sentinel node biopsy and nodal staging

The presence or absence of lymph node metastases has been claimed as the single most important prognostic factor in breast cancer, what may not hold true for the smallest tumors detected through screening, which are often node-negative. Traditionally, this was assessed by the histological examination of the nodal content of the axilla removed during axillary lymph node dissection (ALND). Sentinel lymph node (SLN) biopsy (SLNB), a low morbidity surgical pathological staging procedure has now widely replaced ALND, especially in the earliest stages of the disease, where ALND often yielded a negative nodal status and therefore proved to be an unnecessary overtreatment. SLNB too, often yields negative results, and raises the question whether or not surgical nodal staging is required at all for small screen detected carcinomas. Although it is generally common to perform a completion axillary dissection when an SLN is involved by metastatic disease, further lymph nodes are only seldom affected by the disease. Therefore, the idea of omitting further axillary treatment after the finding of a positive SLN in these patients with generally favorable outcome needs to be seriously considered in order to reduce their morbidity and overtreatment.