New Cancer Surgery Mode Is Developed : Health: The dye technique may prevent unnecessary removal of lymph glands in breast malignancies. Its application in other procedures is also under study.
A new procedure that could minimize unnecessary surgery for breast cancer patients and help guide their therapy has been developed by surgeons at the John Wayne Cancer Institute in Santa Monica.
The new technique, which involves injection of a blue dye into a tumor before it is surgically removed, makes it easier for surgeons to determine whether the cancer has metastasized--or spread into the lymph glands--Dr. Armando Giuliano and his colleagues report today in the journal Annals of Surgery.
If the dye-mapping procedure shows that cancer has not spread, the patient is spared the painful removal of her lymph glands, speeding her recovery and reducing costs, Giuliano said.
“This is a very worthy piece of research . . . that has the potential of simplifying the surgical treatment of this disease,” said Dr. Bernard Gardner of the University of Medicine and Dentistry of New Jersey.
“If his (Giuliano’s) preliminary work holds up, it may allow us to be much more selective in who undergoes that particular part of the operative procedure,” added Dr. Walter Laurence, a surgical oncologist at the Medical College of Virginia. “I think the early results look very promising.”
The technique is already the subject of an international study examining its use against melanoma, the most deadly form of skin cancer, and Giuliani is planning a similar trial against breast cancer, he said. He and his colleagues are also studying the potential for using the technique with other types of cancer.
Breast cancer is the leading form of cancer in women, striking an estimated 182,000 each year and killing 46,000, according to the American Cancer Society. Experts predict that one woman out of every nine will develop breast cancer at some point in their lives.
The standard treatment for breast cancer is the surgical removal of either the tumor itself or the entire affected breast. Surgeons also routinely remove all of the 25 to 30 lymph glands that are associated with the affected breast and inspect them for signs of spread. If metastasis has occurred, the patient generally receives chemotherapy, radiation or both.
Removal of the lymph glands does not generally provoke life-threatening complications, Giuliano said, but it can be uncomfortable and irritating. Typical problems include potential nerve injury, a swollen arm and limited arm motion, all of which can impede recovery from the breast surgery itself.
The lymph glands are also part of the body’s immune system, and their removal produces a small impairment of immunity, he added.
Ideally, then, recovery of the patient is most rapid if lymph gland removal can be avoided, but leaving behind lymph glands with cancer cells in them can be fatal. Giuliano’s approach, originally developed by his colleague Dr. Donald L. Morton, is to find the single lymph gland that is most likely to contain a cancer cell--what he terms a “sentinel” gland.
That approach is possible because individual lymph glands in a region are strung together like a series of lakes connected by rivers. Each lake is fed by its own tributary system, and anything that enters a lake through its tributaries is then spread to other lakes through the larger waterways.
In the same fashion, each lymph node is fed by its own “tributaries”--tiny, almost invisible axilla that drain a specific region of tissue. The sentinel gland is the particular lymph gland whose axilla drain the region where the tumor is located. Unfortunately, the sentinel gland cannot be identified by sight.
Morton reasoned that if he injected a dye into the tumor, it would quickly show up in the sentinel gland. “It’s so simple that everyone asks, ‘Why didn’t somebody think of it a long time ago?’ ” Giuliano said.
In the current procedure, the researchers inject 3 to 5 milliliters of a dark blue dye into the tumor itself, or, if it has already been removed, into the tissue at the site. Within five minutes, the dye travels to the sentinel lymph gland. The surgeons then dissect the tissue at the site to follow the axilla and locate and remove the sentinel gland. Theoretically, then, if the sentinel gland contains no cancer cells, the remaining glands would be left intact. If it does contain tumor cells, all glands would be removed.
In today’s paper, the team reports on the examination of 174 women who were undergoing conventional breast cancer surgery and who had all their glands removed. In 114 of them, doctors were able to identify the sentinel gland before the glands were removed. In 109 of those 114 cases, the presence or absence of tumor cells in the sentinel gland correctly showed whether the cancer had metastasized.
Giuliano pointed out that all of the mistakes occurred early in the study while the researchers were developing the procedure. “There’s a very real learning curve,” he said.
He and his colleagues are currently organizing a large-scale trial of the technique to determine its reliability. If the procedure is validated there, he concluded, surgeons would have a valuable tool to determine whether a women would have to suffer the pain and inconvenience of having her lymph nodes removed along with her breast.
