Multiple sentinel lymph nodes

The issue regarding number of sentinel nodes requiring removal continues to be hotly debated. One might hypothesise that a regional lymphatic basin first drains to a single SLN, but in actual experience surgeons mostly identify more than one SLN regardless of the technique used (9, 11, 28). We found that most patients have multiple SLNs (29). This may reflect migration of dye or isotope from the "true" SLN into secondary echelon nodes, or simply normal anatomic variation in which the lymphatics of a given site drain simultaneously to more than one SLN.

In the ALMANAC study, the false-negative rate was significantly less in patients who had multiple SLNs (three or more) removed than in those with one or two removed (1.1% vs. 10.1% and 8.5%) (29). These results suggest that removal of several SLNs decreases the false-negative rate. That is not to say that more than one SLN must be removed in every patient. Rather, these data suggest that more than one SLN is present in the majority of patients, and that identification of multiple SLNs is important for reducing the false-negative rate.

Although removal of multiple SLNs is important to accurately stage the axilla, indiscriminate removal of inordinate number of axillary nodes is not justified as they may be secondary echelon nodes and may potentially worsen the morbidity of SLNB. Therefore, the surgeon will naturally wonder if it is safe to stop after removing two, three, or four SLNs, assume-ing that any metastasis would be contained in these nodes, or whether one should continue until all blue or hot SLNs have been removed.

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