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Lymph Node Cancer Treatment

The lymphatic system comprises the spleen, thymus gland, lymph nodes, and lymphatic vessels or channels. In addition to containing important cells of the immune system, this highly-organized system is one of the body's complex filtration systems and is responsible for removing blood-bound contaminants (eg, bacteria, cancer cells) from the lymphatic fluid before returning it to the venous circulation by way of the lymphatic vessels or channels.(1)

Groups of lymph nodes that collect extracellular drainage from a specific area of the body are known as nodal basins. For example, lymphatic fluid from the breast primarily drains into the axillary nodal basin (ie, 80% to 85%), and some fluid drains into the internal mammary drainage area.(2) By definition, within a specific nodal basin, the sentinel lymph nodes are the first to receive lymphatic drainage from tumors (Figure 1).(3)

[Figure 1 ILLUSTRATION OMITTED]

Of all cancers, breast cancer is the second leading cause of death for all women and the leading cause of death for women ages 40 to 55.(4) In 1999, 175,000 new cases of breast cancer were reported, 43,300 of which were diagnosed in situ (ie, noninvasively).(5) Currently, the stage of the disease determines breast cancer treatment. Stage one consists of a primary cancerous lesion under 2 cm in diameter, with no lymph node involvement. Stage two involves a cancerous lesion 2 cm to 5 cm in diameter, but differs from stage one in that cancer cells also are present in axillary lymph nodes.(6) Treatment for both stages consists of lumpectomy or mastectomy and a radical axillary node dissection. In stage one, the radical node dissection primarily is used as a general diagnostic and prognostic indicator. In stage two, the cancer-involved tissue must be removed to prohibit further spread of the disease. In both cases, treatment is extensive, physically and psychologically traumatic for the patient, and may cause debilitating postoperative complications.

A sentinel lymph node dissection, however, is highly selective, precise, and can minimize the stage one patient's trauma by providing treatment options based on specific lymph node findings. If, for example, the sentinel lymph node dissection yields a negative finding, the stage one patient can completely avoid radical lymph node dissection.(7) A positive sentinel lymph node finding in stage one changes the diagnosis and reclassifies the patient as stage two due to cancer involvement outside the primary lesion. The patient then undergoes a radical axillary node dissection.(8) In stage two, sentinel lymph node dissection is a powerful diagnostic means by which pathologic information precisely defines the extent of the metastases and helps confirm the emergent need for subsequent radical lymph node dissection.

NUCLEAR MEDICINE

Lymphatic mapping provides surgeons and pathologists a means to precisely and thoroughly examine sentinel lymph nodes likely to contain micrometastatic disease from primary lesions. Currently, surgeons use two methods to identify sentinel lymph nodes. The first method, known as tagging, requires the injection of a radioisotope that, upon the application of a gamma probe, provides the surgeon an audible map of the lymph nodes and vessels under investigation. The other method uses a blue contrast dye (ie, isosulfan blue 1%) that, when injected into the tumor, creates a visual map of the lymphatic structures by staining them. These methods can be used together or individually (Figure 2).(9) It is not required that radioactive precautions be used with the patient or when handling the patient's body fluids.(10)

[Figure 2 ILLUSTRATION OMITTED]

Administration of the radioisotope may take place in the nuclear medicine department. It also can be done in the OR, but requires equipment that is too large for most OR suites. Additionally, the injection can take up to two hours, and no anesthesia is required for the procedure. For these reasons, it is cost-effective to administer the radioisotope in an area other than the OR.

When the radioisotope injection is performed, the patient's primary tumor site receives a 0.1 to 0.2 mL injection of technetium (ie, the sulfur colloid H2S technetium) to identify the primary tumor. This injection also identifies the lymphatic basins, nodal areas, and respective lymph draining sites that are considered to be at risk for metastases. In addition, the injection also is used to estimate the number of sentinel lymph nodes present, fix their location in relation to other nodes in the lymphatic basin, and determine which lymphatic channels are involved." Lymphatic basins with the highest radioisotope concentrations receive a preliminary skin-surface mark for the surgeon's convenience. The skin marks generally are made with a skin scribe and appear as simple dots or marks that include letters (eg, LAT for a lateral marking) to ensure the marks do not become transferred to another skin surface before surgery. Conventional practice defines a node as "hot" when it emits 10 times the amount of normal background radiation. A patient may have one or more marks representing "hot" nodes.

PREOPERATIVE CARE

After the injection of the radioisotope is completed, the patient usually is transported directly to the surgical holding area. The circulating nurse completes a preoperative nursing assessment. The patient verifies the procedure and signs the surgical consent form. The circulating nurse removes the patient's jewelry, visual aids (eg, contact lenses), and prosthetic devices (eg, dentures) and confirms NPO status. Allergies, especially a hypersensitivity to IV dyes, are noted. Pain levels are assessed, and explanations of postoperative pain scales are given. The circulating nurse answers any questions the patient and his or her family members may have.

Optimally, the surgical procedure should take place two to three hours after the technetium is injected. Before surgery, the circulating nurse should contact the nuclear medicine physician, from whom he or she may gather specific information about the patient's lymphoscintigraphy results. Knowing the number of expected "hot" nodes and their respective locations helps OR staff members prepare the equipment and supplies needed for the procedure. If, for example, a patient presents with multiple nodes, staff members must be ready to drape a wider area into the surgical field and be prepared for the possible need of extra instrumentation. The patient generally can be positioned in a manner to allow for resection of the primary lesion and the sentinel lymph nodes without the need to reposition during the procedure.

In the OR, the scrub person makes necessary preparations for the procedure. He or she prepares and sets up the necessary instrument sets for the anticipated procedure (eg, lumpectomy, mastectomy, selective node dissection) and collects additional supplies and specialty items noted on the surgeon's preference card. In the meantime, the circulating nurse sets up and checks the calibration of the fully charged gamma detector, probe, and cable before bringing the patient into the OR.

Calibration is checked by first taking an ambient background radiation reading. To perform the reading, the nurse holds the probe in the air, makes note of the reading, and applies the probe to a radioactive test source of cobalt 57. The reading must be within 10% of the manufacturer's guidelines. A gamma detector unit that does not conform to these readings must be recalibrated by using detailed instructions provided by the manufacturer. The circulating nurse or another individual trained in the calibration procedure can perform the calibration. It is important not to use a faulty unit.

After checking the calibration of the gamma detector, the nurse should have the supplies needed for the isosulfan blue injection readily available (ie, a 5-mL syringe, a 25-g needle, isosulfan blue). The injection usually is administered in the OR before surgical preparation. Using aseptic technique, either the surgeon or nurse prepares the injection site (ie, usually the site of the primary lesion) with alcohol. The surgeon then injects the dye either subcutaneously or directly into the lesion. After it is injected, the isosulfan blue will be absorbed selectively by the lymphatic structures, dyeing them blue.

Isosulfan blue is contraindicated for individuals with a known hypersensitivity to the dye. Severe anaphylactic reactions have been reported, including

* hypotension,

* tachycardia,

* dysrhythmias,

* cardiac arrest,

* urticaria,

* flushing, and

* respiratory failure.(12)

As with all surgical procedures, the emergency or crash cart is available, stocked with epinephrine, intubation supplies, and IV fluids. During the injection of the dye, it is absolutely essential that the nurse, surgeon, and anesthesia care provider constantly are aware of and apprised of the patient's condition, paying close attention to his or her oxygen saturation levels. Studies have shown that the injection of IV dyes causes significant false drops in oxygen saturation.(13) The dye, after injected, changes the color of the patient's blood and, thereby, causes a lower reading of the patient's oxygen saturation.

After the site has been injected, the circulating nurse prepares the surgical site for surgery, and surgical team members drape the site. When the patient has been draped, the scrub person covers the gamma detector probe and cable using an appropriate sterile drape (eg, video camera drape) and clamps it securely to the field using nonperforming clamps.

INTRAOPERATIVE CARE

The surgeon performs the sentinel lymph node biopsy before excising the primary breast lesion. After making the biopsy incision, the surgeon looks for file presence of blue-dyed lymph nodes and channels. He or she confirms the dyed area and node with file gamma detector (Figure 3). The probe is held in file incision and the tissue is scanned. The surgeon searches for hot spots by reviewing the readings and listening to the Geiger counter. After identifying and removing the sentinel lymph nodes, the surgeon excises the primary breast lesion. Then the surgical sites are checked for hemostasis and closed. The nurse covers the incision site with a gauze bandage (usually a 2 inch x 2 bandage inch is sufficient) and an impervious dressing. Having prepared individual containers for each specimen, the circulating nurse takes each specimen from the sterile field, verifies its name and location with the surgeon, and places it in formalin. These specimens will not be examined as frozen sections, instead, specimens are prepared by receiving a special immunohistochemical staining in the pathology laboratory. The immunohistochemical staining has proven to be a more sensitive test to identify micrometastes than the routine pathology examination.(14)

[Figure 3 ILLUSTRATION OMITTED]

In collecting the specimens, it is important to remember they have been injected with a radioactive colloid and will, therefore, be handled differently. When collected, the circulating nurse labels the specimen containers with radioactive stickers and carefully places them in a special, lead-lined metal container where they remain for 24 hours before being examined by a pathologist. The 24-hour waiting period effectively reduces the radioactive half-life of the specimen by approximately 97%, making it much safer to handle.

POSTOPERATIVE CARE

The patient may leave the hospital after the recovery period in the postanesthesia care unit or may stay in the hospital for 23 hours. The patient should be informed that his or her urine may appear blue for several hours, and there is no cause for alarm as the color change is temporary and the result of the preoperative isosulfan blue injection. The patient is instructed that he or she can shower the next day, which can decrease pain by aiding in muscle relaxation.(15) As with any incision site, the dressing must be checked periodically for drainage. In addition, the patient should be instructed to watch for signs and symptoms indicative of postoperative wound infection (eg, redness, tenderness, swelling, purulent drainage) and given emergency contact information for the surgeon's office in the event these symptoms occur. The nurse also informs the patient that evaluation of the specimen can take up to two weeks. At that time, the patient is told if he or she needs to be scheduled for a complete axillary lymph node dissection or if no further treatment is required.

CONCLUSIONS

Lymph node metastasis is an important consideration in both the assessment of breast cancer prognosis and in planning an aggressive, systemic therapy modality. Recent studies indicate that sentinel lymph nodes are not only easily identifiable, but soon will be indispensable in accurately diagnosing microscopic metastatic disease.(16) More importantly, sentinel lymph node biopsy is a very precise and reliable technique currently used to diagnose metastatic lesions.

Patients suffering from metastatic breast disease genuinely benefit by choosing to undergo the less invasive sentinel lymph node dissection procedure. In addition to avoiding longer hospitalization periods, patients minimize the chances of postoperative complications and are subjected to less postoperative pain. In addition, postoperative therapies are tailored to patients' specific medical and surgical needs.

Health care institutions stand to gain from sentinel node dissection procedures and the subsequent individualized care they precipitate. Use of the procedure will move a significant patient population from the traditional, costly inpatient facility to the more efficient, personalized outpatient health care unit.

Although sentinel lymph node dissection is a developing and nascent technique, technical advances suggest the procedure is very promising. One question that has yet to be answered is whether there is a need to examine and remove the sentinel nodes of the internal mammary arteries after metastases has been determined.

In the next few years, the medical community will carefully track the progress of patients who have chosen to undergo sentinel lymph node dissection. Researchers will gather more data on the long-term effectiveness of the technique; they will work to improve existing surgical and medical methodologies; and they will be instrumental in developing new guidelines for the care and treatment of many kinds of cancer.

NOTES

(1.) J W Hole, Jr, "The lymphatic system," in Human Anatomy and Physiology, ninth edition (Dubuque, Iowa: William C. Brown Co Publishers, 1989) 628-646.

(2.) R F Uren et al, "Mammary lymphoscintigraphy in breast cancer," Journal of Nuclear Medicine 36 (October 1995) 1775-1780.

(3.) S P Leong, "The role of sentinel lymph nodes in human solid cancer," Principles & Practice of Oncology Update 12 no 4 (1998) 2.

(4.) "Facts about breast cancer in the USA." Available from http://www .nabco.org/resources/facts/usafacts .html. Accessed 7 August 2000.

(5.) Ibid.

(6.) W Kelley et al, eds, Textbook of Internal Medicine, second ed (Philadelphia: J. B. Lippincott, 1992) 1070.

(7.) Leong, "The role of sentinel lymph nodes in human solid cancer," 8.

(8.) H S Cod:/III, "Sentinel lymph node mapping in breast cancer," Oncology 13 (January 1999) 31.

(9.) C E Cox et al, "Guidelines for sentinel node biopsy and lymphatic mapping of patients with breast cancer," Annals of Surgery 227 (May 1998) 647.

(10.) Department of Health Services, Memo to All Medical Licensees, 11 March 1999, Radiation Safety Advisor), 99-1: Probe-guided radiopharmaceutical localization in the operating room, Department of Health Services, Sacramento, Calif.

(11.) D Reintgen, "Accurate nodal staging of malignant melanoma," Cancer Control 2 (October 1995) 405-414.

(12.) S P Leong et al, "Adverse reactions to isosulfan blue during selective sentinel lymph node dissection in melanoma," Annals of Surgical Ontology 7 (June 2000) 361-366.

(13.) M S Scheller, R J Unger, M J Kelner, "Effects of intravenously administered dyes on pulse oximetry readings," Anesthesiology 65 (November 1986) 550-552.

(14.) A E Giuliano et al, "Improved axillary staging of breast cancer with sentinel lymphadenectomy," Annals of Surgery 222 (September 1995) 398.

(15.) S P Leong, Patient information: Selective Sentinel Lymph Node Dissection (San Francisco: University of California at San Francisco, 1999).

(16.) D Krag, "The sentinel node in breast cancer: A multicenter validation study," New England Journal of Medicine 339 (October 1998) 941-946.

Sandra Wienholz, RN, MSN, is a clinical nurse in the OR at the University (4f California at San Francisco Mt Zion Medical Center.

Susan F. Dean, RN, BSN, CNOR, is an OR nurse coordinator for the sentinel lymph node program at the University of California at San Francisco Mt Zion Medical Center.

The authors thank Stanley P. Leong, MD, William Shapiro, MD, and Eugene Morita, MD, clinical professors at the University of California at San Francisco, for their valuable assistance with this paper.

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