Moreover, a study addressing the same issue, evaluating safety of lymphatic mapping in pregnant patients, has recently been published [6]. The authors concluded that the risk to the embryo/fetus from breast lymphoscintigraphy with 92.5 MBq (2.5 mCi) of sulfur colloid Tc 99m (which is much higher than the 12 MBq used in our institute) is sufficiently small to validate SNB as an alternative to complete axillary lymph node dissection in pregnant women with breast cancer.
Therefore the real concern of Dubernard and colleagues is unclear to us: A radiation risk to the baby? Under-staging of the patients? In the series of 44 pregnant patients with breast cancer reported by Dubernard, 26 were N1 or N2 at the final pathological examination. In other words, 18 (40%) had node-negative disease.
Even if we accept that pregnant breast cancer patients theoretically eligible for SNB are infrequent and that ... the nodal involvement rate is high, 40% of patients could still avoid axillary dissection, its side-effects, and, most importantly, the risks to the fetus related to the longer surgical and anaesthetic procedures. Thus we disagree with Dubernard and colleagues about the lack of justification for SNB in pregnant breast cancer patients. On the contrary, we believe that our LS technique and SNB may offer an important benefit to pregnant patients. So far, the only obstacle to application of SNB in pregnant patients has been the absence of data regarding the safety of the fetus, and this has now been partially provided by Keleher et al. [6] and Gentilini et al. [7
].
Dubernardand colleagues state twice that pregnant patients should not undergo SLNB outside clinical trials. We would like to remind them that the removal of axillary nodes is not curative but is performed with staging intent. Therefore it is not necessary to wait for the results of a prospective randomized trial in pregnant patients to validate the procedure. How many decades do we have to wait before providing pregnant patients with an alternative option to axillary staging? In our opinion, it might be less ethical to prevent pregnant patients, who have received adequate information, from choosing a staging procedure offering the important advantages given above with the same staging power as axillary clearance and much less morbidity.
1 Nuclear Medicine, 2 Medical Physics and 3 Senology, European Institute of Oncology, Milan, Italy
* Email: direzione.mnu{at}iec.it
References
1. Veronesi U, Paganelli G, Galimberti V et al. Sentinel node biopsy can avoid axillary dissection in breast cancer patients with clinically negative lymph-nodes. Lancet 1997; 349: 18641867.[CrossRef][ISI][Medline]
2. Veronesi U, Paganelli G, Viale G et al. A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer. N Engl J Med 2003; 349: 546553.
3. Trifirò G, Viale G, Gentilini O et al. Sentinel node detection in pre-operative axillary staging. Eur J Nucl Med Mol Imaging 2004; 31(Suppl. 1): S46S55.[CrossRef][ISI][Medline]
4. Mariani G, Moresco L, Viale G et al. Radioguided sentinel lymph node biopsy in breast cancer surgery. J Nucl Med 2001; 42: 11981215.
5. De Cicco C, Cremonesi M, Luini A et al. Lymphoscintigraphy and radioguided biopsy of the sentinel axillary node in breast cancer. J Nucl Med 1998; 39: 20802084.[Abstract]
6. Keleher A, Wendt R III, Delpassand E et al. The safety of lymphatic mapping in pregnant breast cancer patients using Tc-99m sulfur colloid. Breast J 2004; 10: 492495.[CrossRef][Medline]
7. Gentilini O, Cremonesi M, Trifirò G et al. Safety of sentinel node biopsy in pregnant patients with breast cancer. Ann Oncol 2004; 15: 13481351.
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