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Title: Lymphatic mapping and the axilla in primary breast cancer
Author: Lambah, P. A.
Awarding Body: University of Edinburgh
Current Institution: University of Edinburgh
Date of Award: 2003
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Assessment of axillary lymph node status in breast cancer is a collaborative exercise between surgeons and pathologists that continues to provoke debate. A positive result for lymph node metastases is the primary determinant for subsequent therapy decisions. At present wide variation exists in the surgical approach to the axilla ranging from a complete level III clearance of all axillary nodes to no treatment in some centres. The technique of sentinel node biopsy has recently been suggested as a less invasive method of staging the axilla sparing the morbidity associated with an axillary clearance. Despite existing guidelines for the histological processing and reporting of lymph nodes in the UK, practices continue to demonstrate considerable variation within and out with these guidelines. New ways of staining lymph nodes, such as immunohistochemistry are reported to improve on the sensitivity of conventional haematoxylin and eosin in the detection of lymph node metastases but are not considered standard practice in most pathology laboratories. The optimal surgical and histopathological management of the axilla needs clarifying to allow correct selection of patients for adjuvant treatments. The chapters of this thesis present the results of a group of related studies examining existing and new methods of surgical and histopathological assessment of axillary lymph nodes in breast cancer patients. The long-term results of randomised trials of 866 patients comparing a level III axillary node clearance to a non-targeted four-node axillary sample reveal no difference in long-term survival between the two procedures after a median follow up of 8.2 years. Axillary recurrence appears to be more frequent following an axillary node sample than after an axillary clearance. A two-phase, randomised Multicentre trial (the ALMANAC trial) is currently aiming to validate the role of sentinel node biopsy in breast cancer patients in the United Kingdom. The early results of 153 patients recruited into the ALMANAC trial by Edinburgh Breast Unit suggest that sentinel node biopsy is an accurate and reliable method of staging the axilla in T1-2 node-negative breast cancer with minimal morbidity. Accurate intraoperative assessment of sampled lymph nodes allows a surgeon to decide whether or not to proceed immediately to a full axillary clearance in nodepositive patients without the need for a second operation. Imprint cytology is reported to improve upon frozen section histology in the intraoperative detection of lymph node metastases. Imprint cytology of 238 freshly examined lymph nodes from 53 patients with and without immunohistochemistry suggests the technique is at least as accurate as frozen section histology and can be useful in the intraoperative assessment of axillary lymph nodes. The prognostic significance of occult lymph node metastases (or micrometastases) is uncertain. Lymph nodes from 26 node-negative patients who developed axillary recurrence and from 26 patients who developed no axillary recurrence found no clinical significance for axillary lymph node micrometastases after examination by immunohistochemistry.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (M.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available