Clinical practice guidelines for the care and treatment of breast cancer: 13. Sentinel lymph node biopsy.

OBJECTIVE: To provide information and recommendations to women with breast cancer and their physicians regarding what is now known about sentinel lymph node (SLN) biopsy. OPTIONS: Axillary dissection; SLN biopsy followed by backup axillary dissection; SLN biopsy. OUTCOMES: Accurate determination of cancer stage, resulting in better-informed therapeutic decisions. EVIDENCE: Systematic review of English-language literature published from January 1991 to December 2000 retrieved primarily from MEDLINE and CANCERLIT. RECOMMENDATIONS: Axillary dissection is the standard of care for the surgical staging of operable breast cancer. If a patient requests or is offered SLN biopsy, the benefits and risks as well as what is and is not known about the procedure should be outlined. Patients should be informed of the number of SLN biopsies performed by the surgeon and the surgeon's success rate with the procedure, as determined by the identification of the SLN and the false-negative rate (the presence of tumour cells in the axillary nodes when the SLN biopsy result is negative). Before surgeons replace axillary dissection by SLN biopsy as the staging procedure at their institution, they should (a) familiarize themselves with the literature on the topic and the techniques needed to perform the procedure, (b) follow a defined protocol for all 3 aspects of the procedure (nuclear medicine, surgery, pathology) and (c) perform backup axillary dissection until an acceptable success rate (as determined by the identification of the SLN and the false-negative rate) is achieved. A surgeon who performs breast cancer surgery infrequently should not perform SLN biopsy. A positive SLN biopsy result or failure to identify an SLN should prompt full axillary dissection. SLN biopsy is contraindicated in women who have clinically palpable nodes, locally advanced breast cancer, multifocal tumours, previous breast surgery or previous irradiation of the breast. Staining of tissue sections with hematoxylin and eosin, and not immunohistochemical analysis for cytokeratin, should determine adjuvant therapy. Participation in randomized clinical trials is encouraged. [A patient version of these guidelines appears in Appendix 1.] VALIDATION: Internal validation within the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer; no external validation.

Clinical practice guidelines for the care and treatment of breast cancer: 11. Lymphedema.

OBJECTIVE: To provide information and recommendations for women and their physicians when making decisions about the management of lymphedema related to breast cancer. OPTIONS: Compression garments, pneumatic compression pumps, massage and physical therapies, other physical therapy modalities, pharmaceutical treatments. OUTCOMES: Symptom control, quality of life, cosmetic results. EVIDENCE: Systematic review of English-language literature retrieved primarily from MEDLINE (1966 to April 2000) and CANCERLIT (1985 to April 2000). Nonsystematic review of breast cancer literature published to October 2000. RECOMMENDATIONS: Pre- and postoperative measurements of both arms are useful in the assessment and diagnosis of lymphedema. Circumferential measurements should be taken at 4 points: the metacarpal-phalangeal joints, the wrists, 10 cm distal to the lateral epicondyles and 15 cm proximal to the lateral epicondyles. Clinicians should elicit symptoms of heaviness, tightness or swelling in the affected arm. A difference of more than 2.0 cm at any of the 4 measurement points may warrant treatment of the lymphedema, provided that tumour involvement of the axilla or brachial plexus, infection and axillary vein thrombosis have been ruled out. Practitioners may want to encourage long-term and consistent use of compression garments by women with lymphedema. One randomized trial has demonstrated a trend in favour of pneumatic compression pumps compared with no treatment. Further randomized trials are required to determine whether pneumatic compression provides additional benefit over compression garments alone. Complex physical therapy, also called complex decongestive physiotherapy, requires further evaluation in randomized trials. In one randomized trial no difference in outcomes was detected between compression garments plus manual lymph drainage versus compression garments alone. Clinical experience supports encouraging patients to consider some practical advice regarding skin care, exercise and body weight. [A patient version of these guidelines appears in Appendix 2.] VALIDATION: An initial draft of this document was developed by a task force sponsored by the BC Cancer Agency. It was updated and revised substantially by a writing committee and then submitted for further review, revision and approval by the Steering Committee for Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. SPONSOR: The steering committee was convened by Health Canada. COMPLETION DATE: October 2000.