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Intraoperative assessment of axillary lymph nodes in patients with breast cancer

BMJ 2014; 349 doi: (Published 25 November 2014) Cite this as: BMJ 2014;349:g6803
  1. J Michael Dixon, professor of surgery1,
  2. Emiel Rutgers, clinical director2,
  3. Kelly K Hunt, professor of surgical oncology3
  1. 1Edinburgh Breast Unit, Western General Hospital, Edinburgh, UK
  2. 2Netherlands Cancer Institute, Amsterdam, Netherlands
  3. 3University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
  1. Correspondence to: K K Hunt

Time to abandon?

The main advantage of intraoperative assessment of axillary lymph nodes in patients having surgery for breast cancer is that metastatic disease can be diagnosed and removed in a single operation. However, there are several disadvantages that have cast doubt on its use. These include concerns about its accuracy and the uncertainty that all patients with diseased sentinel nodes need additional treatment.

Accuracy questioned

Several methods have been used for intraoperative assessment of axillary nodes, including frozen section analysis, touch preparation cytology, and one step nucleic acid amplification. The National Institute for Health and Care Excellence (NICE) approved one step nucleic acid amplification in 2011, and it is the most widely used axillary staging method in the United Kingdom.1

A recent meta-analysis has raised doubts about the ability of one step nucleic acid amplification to accurately determine the extent of axillary node involvement.2 The method is based on the measurement of messenger RNA for cytokeratin 19, expression levels of which vary between and within cancers, with copy numbers ranging from 4700 to 140 000 copies per microlitre. The meta-analysis concluded that the wide range of copy numbers in a fixed tumour volume …

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