Intended for healthcare professionals

Rapid response to:

Practice Guidelines

Diagnosis and treatment of advanced breast cancer: summary of NICE guidance

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b509 (Published 25 February 2009) Cite this as: BMJ 2009;338:b509

Rapid Response:

Management of Patients with Isolated Tumour Cells in Sentinel Lymph Nodes

The authors of the NICE guidelines for the diagnosis of the treatment
of early breast cancer, including locally advanced disease, are to be
congratulated for summarising evidence based best practice so clearly1.

There is one point upon which we strongly disagree. The guidelines
state that when sentinel lymph nodes contain isolated tumour cells (ITCs)
no further surgery should be recommended. In our opinion this advice is
based on a misunderstanding of the significance of ITCs. It is vital to
distinguish between the prognostic significance of ITCs and axillary
nodes, and the significance of ITCs in sentinel lymph nodes as a marker
for non sentinel lymph node macro metastasis.

The evidence clearly supports the guideline suggestion that when
axillary nodes contain ITCs only, patients should be treated as node
negative. However up to 15% of patients with ITCs in the sentinel lymph
node have other non sentinel node macro metastasis, as reported in several
published series2-6. In these patients recommendations about adjuvant
chemotherapy are likely to change.

In our view it would be negligent not to discuss the potential
adverse effects of a 14% – 15% false negative rate in this small group of
patients, and they should be assessed individually to decide with them
whether further axillary surgery would be in their best interest. We are
sorry that repeated communications with NICE on this subject were both
ignored and unacknowledged, and suggest this guide line should be urgently
amended.

References

1. Adrian Harnett, James Smallwood, Victoria Titshall, Andrew
Champion, on behalf of the Guideline Development Group. Diagnosis and
treatment of early breast cancer, including locally advanced disease –
summary of NICE guidance BMJ 2009;338:b438

2. Van Rijk MC, Peterse JL, Nieweg OE, Oldenburh HS, Rutgers EJ, Kroon BB.
Additional axillary metastases and stage migration in breast cancer
patients with micrometastases in submicrometastases in sentinel lymph
nodes. Cancer 2006 Aug 1;107(3):467-71.

3. Van Deurzen CH, van Hillegersberg R, Hobbelink MG, Seldenrijk CA,
Koelemij R, Van Diest PJ. Predictive value of tumour load in breast
cancer sentinel lymph nodes for second echelon lymph node metastases.
Cell Oncol. 2007;29(6):497-505

4. Ganaraj A, Kuhn JA, Jones RC, Grant MD, Andrews VR, Knox SM, Netto GJ,
Altrabulsi B, Livingston SA, McCarthy TM. Predictors for nonsentinel node
involvement in breast cancer patients with micrometastases in the sentinel
lymph node. proc (Bayl Univ Med Cent) 2003 Jan;16(1):3-6

5. Dabbs DJ, Fung M, Landsittel D, McManus K, Johnson R. Sentinel lymph
node micrometastasis as a predictor of axillary tumour burden. Breast
Journal 2004 Mar-Apr;10(2):101-5

6. Giuseppe Viale, MD, Eugenio Maiorano, MD, Giancarlo Pruneri, MD, Mauro
G. Mastropasqua, MD, Stefano Valentini, MD, Viviana Galimberti, MD,
Stefano Zurrida, MD, Patrick Maisonneuve, Eng, Giovanni Paganelli, MD, and
Giovanni Mazzarol, MD. Predicting the Risk for Additional Axillary
Metastases in Patients With Breast Carcinoma and Positive Sentinel Lymph
Node Biopsy. Annals of Surgery Volume 241, Number 2, February 2005

Competing interests:
None declared

Competing interests: No competing interests

17 March 2009
Peter A Jones
Consultant Breast Surgeon
Sue Jones
Peggy Wood Breast Care Centre, Maidstone Hospital, Maidstone, Kent, ME16 9QQ