The sentinel lymph node is the hypothetical first lymph node or group of nodes reached by metastasizing cancer cells from a primary tumor.
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The spread of some forms of cancer usually follows an orderly progression, spreading first to regional lymph nodes, then the next echelon of lymph nodes, and so on, since the flow of lymph is directional. In layperson language, some cancers spread in a predictable fashion from where the cancer started. In these cases, if the cancer spreads it will spread first to lymph nodes (lymph glands) close to the tumor before it spreads to other parts of the body. The concept of sentinel lymph node surgery is to see if the cancer has spread to the very first lymph node (called the "sentinel lymph node"). If the sentinel lymph node does not contain cancer, then there is a high likelihood that the cancer has not spread to any other area of the body.
The concept of the sentinel lymph node is important because of the advent of the sentinel lymph node biopsy technique, also known as a sentinel node procedure. This technique is used in the staging of certain types of cancer to see if they have spread to any lymph nodes, since lymph node metastasis is one of the most important prognostic signs. It can also guide the surgeon to the appropriate therapy.[1]
To perform a sentinel lymph node biopsy, the physician performs a lymphoscintigraphy, wherein a low-activity radioactive substance is injected near the tumor. The injected substance, Filtered Sulfur Colloid, is tagged with the radionuclide Technetium-99m. The injection protocols differ by doctor but the most common is a 500 μCi dose divided among 5 tuberculin syringes with 1/2 inch, 24 gauge needles. The sulphur colloid is slightly acidic and causes minor stinging. A gentle massage of the injection sites spreads the sulphur colloid, relieving the pain and speeding up the lymph uptake. Scintigraphic imaging is usually started within 5 minutes of injection and the node appears from 5 min to 1 hour. This is usually done several hours before the actual biopsy. About 15 minutes before the biopsy the physician injects a blue dye in the same manner. Then, during the biopsy, the physician visually inspects the lymph nodes for staining and uses a Gamma Probe or a Geiger counter to assess which lymph nodes have taken up the radionuclide. One or several nodes may take up the dye and radioactive tracer, and these nodes are designated the sentinel lymph nodes. The surgeon then removes these lymph nodes and sends them to a pathologist for rapid examination under a microscope to look for the presence of cancer.
A frozen section procedure is commonly employed (which takes less than 20 minutes), so if neoplasia is detected in the lymph node a further lymph node dissection may be performed. With malignant melanoma, many pathologists eschew frozen sections for more accurate "permanent" specimen preparation due to the increased instances of false-negative with melanocytic staining.
There are various advantages to the sentinel node procedure. First and foremost, it decreases unnecessary lymph node dissections where this is not necessary, thereby reducing the risk of lymphedema, a common complication of this procedure. Increased attention on the node(s) identified to most likely contain metastasis is also more likely to detect micro-metastasis and result in staging and treatment changes. The main uses are in breast cancer and malignant melanoma surgery, although it has been used in other tumor types (colon cancer) with a degree of success.[2]
However, the technique is not without drawbacks, particularly when used for melanoma patients. This technique only has therapeutic value in patients with positive nodes.[3] Failure to detect cancer cells in the sentinel node can lead to a false negative result - there may still be cancerous cells in the lymph node basin. In addition, there is no compelling evidence that patients who have a full lymph node dissection as a result of a positive sentinel lymph node result have improved survival compared to those who do not have a full dissection until later in their disease, when the lymph nodes can be felt by a physician. Such patients may be having an unnecessary full dissection, with the attendant risk of lymphedema.[4]
The technique of Sentinel node Radiolocalization was co-founded by James C. Alex, MD, FACS and David N. Krag MD (University of Vermont Medical Center) and they were the first ones to pioneer this technique for the use of Cutaneous Melanoma, Breast Cancer, Head and Neck Cancer and Merkel Cell Carcinoma. Confirmative trials followed soon after.[5] Studies were also conducted at the Moffitt Cancer Center with Charles Cox, MD, Douglas Reintgen, MD and James Norman, MD.
6. Alex JC, Krag DN. Gamma-Probe-Guided Localizaton of Lymph Nodes, Surg Onc 1993, 2: 137-44.
7. Alex JC, Weaver DL, Fairbanks JT, Rankin BS, Krag DN. Gamma-Probe-Guided Lymph Node Localization in Malignant Melanoma, Surg Onc 1993; 2: 303-308.
8, Krag DN, Weaver DL, Alex JC, Fairbanks JT. Surgical Resection and Radio-localization of the Sentinel Node in Breast Cancer Using a Gamma Probe. Surg Onc 1993; 2: 335-340.
9. Krag DN, Meijer SJ, Weaver DL, Loggie BW, Harlow SP, Tanabe KK, Laughlin EH, Alex JC. Minimal Access Surgery for Staging Malignant Melanoma. Arch Surg 1995; 130: 654-658.
10. Alex JC and Krag DN. Gamma Probe Guided Resection of Radiolabeled Lymph Nodes. Surg Onc Clin N Am 1996; 5 (1): 33-41.
11. Alex JC, Krag DN, Meijer S, Weaver DL, Loggie. Sentinel Node Radio-Localization in Head and Neck Melanoma. Arch Otolaryngol Head Neck Surg 1998; 124: 135-140.
12. Alex JC. The Application of Sentinel Node Radiolocalization to Solid Tumors of the Head and Neck – a Ten Year Experience. Laryngoscope, 2004; 114: 2-19.
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