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Safety of sentinel node biopsy in pregnant patients

2005; Elsevier BV; Volume: 16; Issue: 6 Linguagem: Inglês

10.1093/annonc/mdi177

1569-8041

Gil Dubernard, Jean-Rémi Garbay, Roman Rouzier, Suzette Delaloge,

Global Cancer Incidence and Screening

We read with interest the article entitled ‘Safety of sentinel node biopsy in pregnant patients with breast cancer’ by Gentilini et al. [1.Gentilini O. Cremonesi M. Trifiro G. et al.Safety of sentinel node biopsy in pregnant patients with breast cancer.Ann Oncol. 2004; 15: 1348-1351Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar]. The authors sought to determine the safety of sentinel lymph node biopsy (SLN) in pregnant patients with breast cancer. Twenty-six premenopausal non-pregnant patients who were candidates for lymphoscintigraphy underwent peritumoral injection of 99mTc-HSA nanocolloids. Static and whole-body scintigraphic images were acquired. Activity in the bloodstream and activity concentration in the urine was also evaluated. They concluded that lymphoscintigraphy and sentinel node biopsy can be performed safely during pregnancy, since the very low prenatal doses from this diagnostic procedure, when properly performed, do not significantly increase the risk of prenatal death, malformation or mental impairment. Indeed, it had already been concluded during the 2001 Philadelphia Consensus Conference that the sentinel node biopsy technique exposes patients to very low radiation doses and that this should not confer significant risk to pregnant women [2.Schwartz G.F. Hortobagyi G.N. Consensus Conference Committee. Proceedings of the Consensus Conference on Neoadjuvant Chemotherapy in Carcinoma of the Breast, April 26–28, 2003, Philadelphia, PA.Breast J. 2004; 10: 273-294Crossref Scopus (20) Google Scholar]. We believe that, even though this study highlights new elements concerning the safety of sentinel node biopsy during pregnancy, it overestimates the rationale for doing so and does not provide enough elements justifying sentinel node biopsy in pregnant breast cancer patients outside of a clinical trial. We evaluated in our institution's series whether the characteristics of patients diagnosed with breast cancer during pregnancy meet those considered classically compatible with a sentinel lymph node procedure (T1 breast carcinoma without clinical axillary nodal involvement [3.Schwartz G.F. Giuliano A.E. Veronesi U. Proceedings of the Consensus Conference on the Role of Sentinel Lymph Node Biopsy in Carcinoma of the Breast, April 19–22, 2001, Philadelphia, PA.Cancer. 2002; 94: 2542-2551Crossref PubMed Scopus (435) Google Scholar]). Among 44 patients with breast cancer during pregnancy treated in our institution between 1996 and 2004, tumour sizes ranged from 8 to 200 mm (mean 39.8 mm) and only 28% had T1 tumours, as shown in previous reports. Furthermore, 26 patients out of 44 were classified N1 or N2 at the final pathologic examination (59%) [3.Schwartz G.F. Giuliano A.E. Veronesi U. Proceedings of the Consensus Conference on the Role of Sentinel Lymph Node Biopsy in Carcinoma of the Breast, April 19–22, 2001, Philadelphia, PA.Cancer. 2002; 94: 2542-2551Crossref PubMed Scopus (435) Google Scholar]. In the literature series, the same results have been observed: 60% of pregnant patients with breast cancer have a pathological nodal involvement [4.Woo J.C. Yu T. Hurd T.C. Breast cancer in pregnancy a literature review.Arch Surg. 2003; 138 (98 (Discussion p 99)): 91-98Crossref PubMed Scopus (247) Google Scholar]. Furthermore, in our series, 5 of 11 (45%) patients with T1/pT1 confirmed tumours were node-positive. Our data confirm that pregnant breast cancer patients theoretically eligible for SLN are infrequent and that even among these patients, the nodal involvement rate is high. Beside this, another main concern regarding the use of SLN during pregnancy is that breast modifications occurring during pregnancy may modify tracer migration properties. This issue was not discussed by Gentilini et al. [1.Gentilini O. Cremonesi M. Trifiro G. et al.Safety of sentinel node biopsy in pregnant patients with breast cancer.Ann Oncol. 2004; 15: 1348-1351Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar]. Whether lymphatic pathways are altered in pregnancy is unknown. No data are currently available to confirm or disprove this hypothesis. We therefore think that pregnant breast cancer patients should not currently undergo a sentinel node biopsy without axillary dissection outside of a clinical trial.