Wright_subbed.qxp 26/11/08 02:31 Page 14
suggested that a substantial number of patients undergoing resection for may assume an importance that approaches the role of SLNB in other
CRC could be upstaged by use of the SN technique. malignancies such as melanoma and breast cancer. However, until that time
arrives, SLNB in CRC is best used in the context of prospective clinical trials and
Since the publication of these initial studies, several prospective as an adjunct to, but never in place of, adequate mesenteric resection.
multi-institutional trials have been reported regarding the use of SLNB in
CRC (see Table 2).
Collectively, these reports have highlighted both the Other Applications
promise and the limitations of SN applications in CRC. As SLNB in CRC does Sentinel node techniques have been applied to other gastrointestinal
not result in a more limited or less morbid operative intervention, and only cancers as well. Experience with SLNB in gastric cancer is growing steadily
occasionally alters the intra-operative plan, the real potential benefit to the worldwide, with the greatest expertise rapidly accumulating in Japan, where
technique appears to lie in providing more accurate staging information and the disease is most prevalent.
Multicenter trials are under way in Japan and
better selecting patients for potentially life-saving adjuvant therapy. A elsewhere to fully assess the efficacy and impact of SN identification in
majority of studies indicate that SLNB with increased nodal sectioning and gastric cancer, but early reports demonstrate success in SN identification
assessment of hematoxylin and eosin (H&E)-stained negative nodes with consistent with other gastrointestinal malignancies. There may be a
immunohistochemistry (IHC) and/or reverse transcriptase-polymerase chain particular relevance for this technique in gastric cancer given the complexity
reaction (RT-PCR) techniques results in the upstaging of a substantial of lymphatic drainage from the stomach and the well-described tendency
number of patients who would otherwise be deemed node-negative. for early nodal metastasis to occur well removed from the primary tumor.
However, less clear is the significance of this microscopic nodal disease in Development of a reliable SN technique in esophageal cancer is in the early
terms of both disease-related outcome and selection for adjuvant systemic stages of investigation, but may ultimately prove to be useful in better
therapy. Our group recently reported interim results regarding the selecting patients for attempts at curative en bloc resection.
prognostic impact of micrometastases, and a mean follow-up of 25 months
in 152 CRC patients found no recurrences in patients deemed node- Summary
negative after SLNB by H&E, IHC, and RT-PCR compared with six recurrences SLNB has radically transformed the surgical management of breast cancer
in patients who were tumor-node-positive according to IHC or RT-PCR and malignant melanoma and is now routine in the care of these patients.
Lim et al. found equivalent outcomes in patients with SNs positive This transformation has led to ongoing investigations into the applicability
by IHC only compared with those who were truly node-negative.
of the technique in other solid-organ malignancies, most notably CRC.
Although SLNB shows promise in many of these other cancers, its exact role
Additional issues regarding SLNB in CRC patients include the need for remains largely undefined in these other malignancies and is best used in
considerable surgeon experience, a variable false-negative rate with frequently the setting of a clinical trial. ■
aberrant lymphatic anatomy, and the marginal results achieved in patients with
rectal cancer. The precise role of SLNB in the management of CRC is yet to be Acknowledgments
determined. Further evidence is needed to assess the true importance of This review was supported in part by funding from the Carolyn Dirks
metastatic nodal disease that is too small in volume to be detected with Foundation, the Harold J McAlister Charitable Foundation, the family of
conventional histopathological techniques. As collective experience with this Robert Novick, the Weil Family Fund, the Wrather Family Foundation, and
potentially important treatment tool increases, the role of SLNB in early CRC the Fashion Footwear Association of New York Charitable Foundation.
1. Morton DL, Wen DR, Wong JH, et al., Arch Surg, 1992;127:392–9. 17. Balch CM, Soong SJ, Ross MI, et al., Ann Surg Oncol, 31. Cascinelli N, Greco M, Bufalino R, et al., Eur J Clin Oncol,
2. Giuliano AE, Kirgan DM, Guenther JM, Morton DL, Ann Surg, 2000;7:87–97. 1987;23:795–9.
1994;220:391–8. 18. Morton DL, Thompson JF, Cochran AJ, et al., N Engl J Med, 32. Chen SL, Hoehne FM, Giuliano AE,Ann Surg Oncol,
3. Bilchik AJ, Giuliano A, Essner R, et al., Cancer J Sci Am, 2006;335:1307–17. 2007;14:3378–84.
1998;4:351–8. 19. Kalady MF, White RR, Johnson JL, et al., Ann Surg, 33. Cox CE, Kiluk JV, Riker AI, et al., J Am Coll Surg, 2008;206:
4. Ross GL, Soutar DS, Gordon Macdonald D, et al., Ann Surg Oncol, 2003;238:528–35. 261–8.
2004;11:690–96. 20. Wong SL, Brady MS, Busam KJ, Coit DG, Ann Surg Oncol, 34. Sabel MS, Schott AF, Kleer GC, et al., Am J Surg, 2003;186:
5. Faries MB, Bleicher RJ, Ye X, et al., Arch Surg, 2004;139:870–76. 2006;13:302–9. 102–5.
6. Saha S, Wiese D, Badin J, et al., Ann Surg Oncol, 2000;7:120–24 21. Ranieri JM, Wagner JD, Wenck S, et al., Ann Surg Oncol, 35. Yen TW, Hunt KK, Ross MI, et al., J Am Coll Surg,
7. Fortner JG, Woodruff J, Schottenfeld D, Ann Surg, 2006;13:927–32. 2005;200:515–26.
1977;186:101–3. 22. Hershko DD, Robb BW, Lowy AM, et al., J Surg Oncol, 36. Cohen AM, Kelsen D, Saltz L, et al., Curr Prob Cancer,
8. Veronesi U, Adamus J, Bandiera DC, et al., Tumori, 2006;93:279–85. 1998;22:5–65.
1980;66:373–96. 23. Wright BE, Scheri RP, Xing Y, et al., Arch Surg, 2008;143:182–9. 37. Tsioulias GJ, Wood TF, Morton DL, et al., Arch Surg,
9. Sim FH, Taylor WF, Ivins JC, et al., Cancer, 1978;41:948–56. 24. Gershenwald JE, Mansfield PF, Lee JE, Ross MI, Ann Surg Oncol, 2000;135:926–32.
10. Veronesi U, Adamus J, Bandiera DC, et al., Cancer, 2000;7:160–65. 38. Bertagnolli M, Miedema B, Redston M, et al., Ann Surg,
1982;49:2420–30. 25. National Cancer Care Network (NCCN) Breast Cancer. 2007/2008 2004;240:624–8.
11. Krag DN, Meijer SJ, Weaver DL, et al., Arch Surg, National Comprehensive Cancer Network, 2008. Available at: 39. Bilchik AJ, DiNome M, Saha S, et al., Arch Surg,
1995;130:654–8. www.nccn.org 2006;141:527–33.
12. Thompson JF, McCarthy WH, Bosch CM, et al., SMelanoma Res, 26. Siegel BM, Mayzel KA, Love SM, Arch Surg, 1990;125:1144–7. 40. Bembenek AE, Rosenburg R, Wagler E, et al., Ann Surg,
1995;5:255–60. 27. Giuliano AE, Jones RC, Brennan M, et al., J Clin Oncol, 2007;245:858–63.
13. Albertini JJ, Cruse CW, Rapaport D, et al., Ann Surg, 1996;223: 1997;15:2345–50. 41. Stojadinovic A, Nissan A, Protic M, et al., Ann Surg,
217–24. 28. Krag D, Weaver D, Ashikaga T, et al., N Engl J Med, 2007;245:846–57.
14. Leong SP, Steinmetz I, Habib FA, et al., Arch Surg, 1998;339:941–6. 42. Lim SJ, Feig BW, Wang H, et al., Ann Surg Oncol, 2008;15:
1997;132:666–72. 29. McMasters KM, Tuttle TM, Carlson DJ, et al., J Clin Oncol, 46–51.
15. Essner R, Bostick PJ, Glass EC, et al., Surgery, 2000;127:26–31. 2000;18:2560–66. 43. Bilchik AJ, Hoon DS, Saha S, et al., Ann Surg, 2007;246:568–75.
16. Balch CM, Soong SJ, Bartolucci AA, et al., Ann Surg, 1996;224: 30. Hsueh EC, Hansen N, Giuliano AE, et al., Cancer J Clin, 44. Hayashi H, Ochiai T, Mori M, et al., J Am Coll Surg, 2003;196:
255–66. 2000;50:279–91. 68–74.
14 US ONCOLOGY