Selective intraoperative consultation for the evaluation of sentinel lymph nodes in breast cancer

Routine intraoperative evaluation of sentinel lymph nodes (SLNs) in breast cancer suffers from lack of sensitivity and consumes both time and resources. Failure to perform immediate consultation requires node-positive patients to return for delayed dissection.

We sought to determine whether selective use of intraoperative pathology consultation (IOC), based on the surgeon's clinical suspicion for metastases, would be accurate, avoid unnecessary consultations, and have a similar rate of delayed axillary dissection. We performed a retrospective chart review of two cohorts of clinically node-negative patients with invasive breast cancer undergoing axillary lymph node dissection (ALND). Selective pathology evaluation was performed in the study group and mandatory evaluation in the control group.

The axillary basins of 327 patients undergoing routine IOC were compared with those of 91 patients in whom selective IOCs were requested. Twenty-eight consultations (31%) were obtained in the selective group. Selective consultation changed intraoperative management in 11 of 28 patients (39%) compared to 46 of 327 (14%) in the routine group (P = 0.005). The mean SLN metastasis size was 9.6 mm compared to 1.5 mm in patients in whom consultation was deferred (P = 0.003). The need for delayed ALND (17% vs. 14%) was similar in both groups, and was determined by occult metastases that were not detected by either method.

Selective use of IOC detects the majority of SLN macrometastases, avoids consultation that does not alter intraoperative management, and is not associated with an increased need for delayed ALND.