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Reply
David E Rivadeneira, MD
New York, NY
We appreciate and thank Dr Bland for his kind and insightful
comments. We agree that a substantial number of patients with
small invasive breast cancers, tumors <1cm, are at
risk of axillary nodal metastases. This has previously been reported
by Dr Bland and the group at Brown University, in which they
showed a 16% incidence of nodal involvement in patients with
T1a and T1b tumors, and is recently supported by our study in
which 18% of patients with small invasive tumors were found to
have axillary nodal disease. In addition, both groups identified
by multivariate analysis similar predictive factors for nodal
metastases, including patient age, tumor size, and tumor grade.
We are also convinced that these predictive factors should
be considered in selecting appropriate management of the axilla
in this group of patients. Given the significant incidence of
axillary nodal metastases even in those patients identified with
favorable parameters, 8.7% incidence in our study and 7% reported
by the Brown University Study, we concur with Dr Bland regarding
the use of "highly selective" sentinel node biopsy
in an attempt to identify nodal disease in patients with small
invasive cancers.
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