Introduction

As lymphatic mapping with sentinel lymph node dissection has become an increasingly popular alternative to complete nodal dissection, more centers have begun to incorporate this technique into routine patient management. Multiple reports have documented the feasibility and accuracy of lymphatic mapping for identifying regional lymph node metastases in patients with melanoma or breast cancer. However, the majority of these reports have been generated at large centers with high patient volumes, allowing a greater training opportunity to those learning this approach. As these reports become more widely disseminated and the validity of the sentinel node hypothesis is accepted, health-care providers in community hospitals will also begin to perform these procedures. Patients themselves are already beginning to request sentinel node biopsy as an alternative to complete nodal dissection. In fact, pressure from better informed and more sophisticated health-care consumers has led many community surgeons to explore the addition of lymphatic mapping to their practices. The transfer of sentinel node technology from the larger tertiary referral centers to the community hospital has many similarities to the dissemination of laparoscopic technology. During the early 1990s, a patient-driven demand for minimally invasive techniques and ''painless and bloodless'' surgery forced surgeons to change long-established approaches to biliary disease. Many surgeons began performing laparoscopic procedures after brief training courses and with little clinical experience. The compli cation rate was notably higher after laparoscopic cholecystectomy than after traditional open procedures. However, this significantly decreased after completion of a well-defined learning phase [1,2].

Lymphatic mapping with sentinel node biopsy is an alternative procedure for staging the regional lymph nodes. Like laparoscopic cholecystectomy, it can be technologically challenging and requires the mastery of new skills during the learning phase. Laparoscopic techniques have been extensively implemented into surgical residency training, and the majority of recent graduates from surgical training programs in this country have performed more laparoscopic than open cholecystectomies. This has not yet become the case for lymphatic mapping, which has just recently begun to be introduced into training programs. Other differences include the multidisciplinary nature of sentinel node technology and the clinical differences between sentinel node dissection and standard nodal clearance. Although the technical feasibility and validity of the new approach have been addressed in patients with melanoma or breast cancer, the clinical implications of selective rather than complete nodal dissection have not yet been fully explored. In addition, because lymphatic mapping is applied to malignant disease, its failure may have a substantially greater impact than failure of a laparoscopic technique used in benign conditions. Achieving the goal of laparoscopic chole-cystectomy is immediately known, as is the failure of the procedure. Achieving the goal of lymphatic mapping is only absolutely known if a completion lymph node dissection is performed, and failure can present as recurrent disease years after the procedure.

Because of the lack of long-term clinical data and the current lack of technique standardization, some investigators have suggested that lymphatic mapping should not be routinely used in a community hospital outside the setting of a clinical trial [3]. Although the new technique should not replace traditional management of patients with melanoma or breast cancer, it can be integrated into the community surgeon's practice under the auspices of a controlled clinical trial. The informed consent process for lymphatic mapping should clearly convey the current deficiencies in available data on this technique. A review of the currently available data as well as considerations on the community application of lymphatic mapping in melanoma and breast cancer follows.

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