Negative sentinel node biopsy

What Happens if Sentinel Node Biopsy Is Negative

Recurrence of Melanoma After a Negative Sentinel Node

Sentinel node biopsy - Mayo Clini

  1. to identify regional node-negative patients who would not benefit from a complete nodal dissection. In our opinion, SLNB should be performed on most patients (with acceptable surgical and anesthesia risk) who have melanomas with a Breslow depth ≥ 0.76 mm. Sentinel lymph node biopsy is recommended for most patients with melanomas ≥0.76 mm an
  2. Removing just the sentinel node is called sentinel node biopsy or sentinel node dissection. Sentinel node dissection may be done even if the sentinel node looks normal and shows no signs of cancer on an ultrasound or x-ray. Doctors call this clinically negative
  3. utes to perform. If a lumpectomy is also being performed, an extra 30-45

The sentinel node biopsy allows the examination of one lymph node to first determine if a tumor has spread to the lymph nodes at all. If the sentinel node is negative for tumor cells, it is not necessary to surgically remove additional lymph nodes Introduction. Sentinel node biopsy (SNB) has replaced axillary lymph node dissection (ALND) as the standard method for axilla staging. SNB avoids the complications associated with ALND and allows reliable assessment of nodal status in patients with clinically node-negative breast cancer.1, 2, 3 Initially used to convert locally advanced breast cancers from inoperable to operable,4, 5, 6. Negative Sentinel Node biopsy usually means all axillary lymph nodes in the breast are cancer free. The main advantage of the sentinel node biopsy is that a negative result will, in most cases, spare the breast cancer patient the ordeal of axillary node biopsies and dissections

Introduction: Sentinel node biopsy is the main way to assess lymph node status.If there's cancer in the lymph nodes, sentinel node biopsy will find it over 90 percent of the time [1].. In the past, lymph nodes were assessed using axillary dissection. Now, only some people who have positive sentinel lymph nodes will need an axillary dissection.. A negative sentinel lymph node biopsy indicates a lower risk that the cancer has spread than if the biopsy shows cancer cells. Sentinel node biopsy is performed by cancer surgeons as a staging procedure in some patients with skin cancer Factors that predict melanoma recurrence after a negative sentinel lymph node biopsy (SLNB) are not well-defined. We evaluated melanoma recurrence patterns, factors prognostic for recurrence, and the impact of recurrence on outcomes after a negative SLNB. The Sentinel Lymph Node Working Group database was evaluated from 1996 to 2016 for negative SLNB melanoma patients Negative Sentinel lymph node generally means that other axillary nodes (underarm lymph nodes) are cancer free. The basic concept is that the sentinel lymph node is the first to receive lymphatic drainage or lymph fluid from a malignant tumor that has metastasized (or spread). Therefore, a negative status for the sentinel lymph node can just. A negative result means there are no cancer cells in the sentinel nodes. This means that the melanoma is unlikely to have spread to the other lymph nodes. So you won't usually need any further tests or treatment. A positive result means there are cancer cells in the sentinel nodes

The impact of a negative sentinel lymph node biopsy on

  1. Sentinel lymph node biopsy alone can be used to stage the N 0 neck for the majority of early tumours of the oral cavity and oropharynx Sentinel lymph node pathology did not reflect that of the remaining neck dissection in one of our cases, thus giving us one false negative result. This patient had a large, T 3, floor of mouth tumour
  2. The incidence of axillary recurrence after tumor negative sentinel node biopsy, in the study of Bulte et al. , is 0.6% (3/541). An event occurred in the 11% of patients with a micrometastasis in the sentinel node. This was not significantly different from the patients with a tumour-free sentinel node
  3. Objective: Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection (ALND) as the staging procedure for breast cancer. SLN biopsy causes less morbidity and is more cost effective than complete ALND. Lymphatic mapping and SLN biopsy have a low false-negative rate, but long-term outcomes in large consecutive series of patients are unavailable
  4. But if we took the same 1000 patients and performed sentinel lymph node biopsies on the entire cohort, we would encounter complication rates for sentinel lymph node biopsy with negative nodes, positive nodes, as well as complication rates for those who go on to have complete lymph node dissection - in this case, the total the number of.
  5. ation of the SLN is an important oncological procedure that
  6. In patients with thin melanomas who are clinically node-negative, sentinel lymph node biopsy should be offered to patients with melanomas greater than 0.75 mm in Breslow thickness, according to the results of a recent study published in the Journal of Clinical Oncology

Clinical outcomes after sentinel lymph node biopsy in

Sentinel lymph node biopsy: What cancer patients should

  1. The sentinel lymph node is the first node where the cancer would be expected to spread, given the flow of the body's lymphatic system. Some cancers spread via the blood and others, like breast cancer and melanoma, typically spread first to lymph nodes. In a procedure called sentinel lymph node biopsy, a surgeon removes the first node that.
  2. imal.. The practice of sentinel lymph node biopsies is beco
  3. Removing just the sentinel node is called sentinel node biopsy or sentinel node dissection. Sentinel node dissection may be done even if the sentinel node looks normal and shows no signs of cancer on an ultrasound or x-ray. Doctors call this clinically negative. Still, a pathologist may find single cancer cells or small groups of cancer cells.
  4. Sentinel lymph node biopsy (SLNB) was first introduced as a technique of axillary nodal staging for breast cancer by Giuliano and Krag in 1993 and 1994 [ 2,3 ]. It has since become the standard of care for axillary staging in clinically node-negative breast cancer [ 4 ]. A properly performed SLNB identifies patients who need further axillary.

Example: The surgeon takes a biopsy of the sentinel axillary node (38525, Biopsy or excision of lymph node[s]; open, deep axillary node[s]). The pathology report indicates that the malignancy has spread, so the surgeon follows up with a lymphadenectomy (for example, 38745, Axillary lymphadenectomy; complete) to remove the affected tissue But if we took the same 1000 patients and performed sentinel lymph node biopsies on the entire cohort, we would encounter complication rates for sentinel lymph node biopsy with negative nodes, positive nodes, as well as complication rates for those who go on to have complete lymph node dissection - in this case, the total the number of. Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection as the routine staging procedure in clinically node-negative breast cancer. False-negative SLN biopsy results in misclassification and may cause undertreatment of the disease

The false negative rate of sentinel lymph node biopsy (SLNB) is 5-10%, and results in improper patient management. The study was to assess the value of ultrasound-suspicious axillary lymph node biopsy (USALNB) in patients with early breast cancer, and to compare SLNB combined with USALNB (SLNB + USALNB) with SLNB alone. From January 2010 to July 2013, 216 patients with early breast cancer were. No sentinel lymph node biopsy will be performed in clinically node-negative triple-negative or HER2-positive breast cancer patients with a radiologic complete response on MRI. Participants will be asked to complete quality of life questionnaires at baseline (prior to surgery), 6 months, 1, 3 and 5 years follow-up

A false negative result of sentinel-node biopsy was defined as regional nodal recurrence in a patient whose sentinel nodes had been found to be tumor-free. The initial sample size, 900 patients. If the sentinel node biopsy is negative, it is more likely that all upstream nodes are negative. If it is positive, it means, there may be other positive lymph nodes upstream. Hence, sentinel node biopsy is useful in order to determine which lymph nodes should be removed. It reduces the risk of complications associated with surgically removing. Results: The sentinel node was identified in 285 (86·9 per cent) of 328 women. The false‐negative rate was 7·9 per cent (eight of 101). Most members of the breast multidisciplinary team would have instituted adjuvant systemic therapy for six false‐negative cases based on clinical features and primary tumour histology Sentinel Node Biopsy provides prognostic data on all depths of melanoma 2 . For example, a patient with pT1b melanoma has 2 options: Option 1 - No SLNBx: This patient's melanoma is now classified as clinical Stage 1B. This patient has a 5-year and 10-year survival of 97% and 93% respectively 3 Sentinel lymph node biopsy is best reserved for breast cancer patients with clinically negative axillary nodes , except perhaps in the setting of clinical trials. However, for those patients with suspicious axillary findings, preoperative ultrasound and fine needle aspiration (FNA) cytology can provide further information on the status of the.

Sentinel Lymph Node Biopsy in Triple Negative Breast

The false-negative rate is the proportion of negative sentinel nodes found at biopsy in a patient who actually has positive axillary lymph nodes. The false-negative rate is extremely important because a patient with a false-negative result may have been understaged and possibly undermanaged Increases with longer follow-u My sentinel node biopsy was done at the same time as mastectomy. You are asleep the entire time. They sent the results to the lab while I was under. Since all the tissue samples proved to be negative for cancer, the surgeon was able to do only a simple mastectomy on that side, rather than the modified radical. Hope all goes well for you. The false-negative rate for sentinel lymph node biopsy is about 5%. Whether or not the presence of positive staining for epithelial antigens by immunhistochemistry predicts for a higher likelihood. During a sentinel node biopsy, the surgeon removes a small sample of lymph nodes and sends it to a lab so it can be tested for breast cancer cells. In early-stage breast cancer, treatment recommendations depend on whether your lymph nodes are negative or positive for metastases (spreading cancer)

Sentinel node biopsy is usually done at the same time as breast surgery (lumpectomy or mastectomy) but sometimes it may be performed as a separate procedure. Jane O'Brien feels that it is often preferable, for example, to perform the sentinel node biopsy as a separate procedure before mastectomy when immediate reconstruction is desired False-negative SLNB can result in The results of sentinel lymph node biopsy (SLNB) can be useful for staging and deciding on adjuvant treatment for patients with head and neck melanoma. False-Negative Sentinel Lymph Node Biopsy in Head and Neck Melanoma - Matthew W. Miller, John T. Vetto, Marcus M. Monroe, Roshanthi Weerasinghe, Peter E. Use of sentinel node biopsy in patients with cervix cancer was developed to avoid a complete pelvic lymphadenectomy and its associated sequelae. As discussed below, evidence suggests that sentinel node biopsy is a feasible method of lymph node assessment with a high detection rate and low false-negative rate. [10, 11

Clinically Node-Negative Breast Cancer: Sentinel Node

A proportion of patients develop recurrence following a tumour-negative sentinel lymph node biopsy (SLNB). This study aimed to explore whether melanoma patients with BRAF or NRAS mutant tumours. Rokutanda N, Horiguchi J, Koibuchi Y, et al. Isolated retromammary lymph node metastasis of breast cancer without axillary lymph node involvement: a case report with a false-negative sentinel lymph node biopsy. Breast Cancer 2009; 16: 162-5. 4. Ikomi F, Yokoyama Y, Ogiwara N et al. Recanalization of the collecting lymphatics in rabbit hind leg Veronesi, U. et al. Sentinel-node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph-nodes. Lancet 349 (9069), 1864-1867 (1997). CAS PubMed Google Schola Sentinel-node biopsy revealed very small areas of cancer in the lymph nodes in 16% of patients. These patients had an average of 1.4 involved lymph nodes. Patients with a positive sentinel-node biopsy had worse five-year survival than patients with a negative sentinel-node biopsy (72% vs. 90%)

Sentinel Lymph Node Biopsy for Melanoma: Indications and

Sentinel lymph node biopsy (SLNB) is considered the main tool for nodal staging in melanoma patients without clinical disease.1, 2, 3 Patients with a positive SLNB are considered as stage III, and this is important for prognosis as shown in the survival curves of the 8th edition of the American Joint Committee on Cancer staging system. 2 In this scenario, complete lymph node dissection and. The probability of nodal positivity after neoadjuvant chemotherapy was less than 3 per cent in patients with TNBC or HER2-positive disease who achieved a breast rCR on MRI. These patients could be included in trials investigating the omission of sentinel node biopsy after neoadjuvant chemotherapy This percentage is high enough to cause concern, and may represent a limiting factor for the sentinel-node biopsy procedure. A patient whose sentinel node is negative in frozen section but is positive on histology will require a further operation to clear the axillary, which is likely to increase her distress Sentinel lymph node biopsy is the standard method of evaluating and staging the axilla in the patients with early stage of the breast cancer. The aim of this study is to evaluate the axillary recurrence rate in patients with negative sentinel node biopsy.From 2006 to 2010, all the patients with a negative sentinel lymph node in their pathologic results were introduced in the study

Sentinel Node Biopsy After Neoadjuvant Chemotherapy: The Pros Terry Mamounas, M.D., M.P.H Associate Professor of Surgery Comparison of False Negative Rates Between SN Multicenter Studies Multicenter SB-2 Trial 11% (13/114) Italian Randomized Trial 9% (8/91) Ann Arundel 13% (25/193). In the second stage, sentinel lymph node biopsy will be spared in the patients with negative preoperative axillary assessment. Masking: None (Open Label) Primary Purpose: Treatment. Official Title: Sentinel Node Biopsy Vs Observation After Axillary PET Examination. Actual Study Start Date : September 4, 2019 Single center and multicenter validation trials of sentinel node biopsy for breast cancer have demonstrated success rates varying from under 70% to 100%, accuracy rates from 95% to 100%, and false-negative (FN) rates from 0% to 19% [].The NSABP B-32 study is a randomized trial comparing SLN biopsy alone versus SLN biopsy plus ALND

Metachronous bilateral triple‑negative breast cancer

Purpose: Sentinel lymph node biopsy (SLNB) is the standard management for clinically node-negative cutaneous melanoma patients. This study aimed to evaluate the role of SLNB in Taiwanese melanoma patients and in particular, patients with acral lentiginous melanoma (ALM) Sentinel Node Biopsy After Neoadjuvant Chemotherapy in Biopsy-Proven Node-Positive Breast Cancer: The SN FNAC Study Jean-Francois Boileau, Brigitte Poirier, Mark Basik, Claire M.B. Holloway, Louis Gaboury, Lucas Sideris, Sarkis Meterissian, Angel Arnaout, Muriel Brackstone, David R. McCready, Stephen E. Karp, Isabelle Trop

Overview of sentinel lymph node biopsy in breast cancer. The status of the axillary lymph nodes is one of the most important prognostic factors in patients with breast cancer. Histologic examination of lymph nodes is the most accurate method for assessing lymph node metastasis; approximately one in four patients with clinically negative lymph. CONCLUSIONS: The sensitivity of sentinel lymph node biopsy was 81.6%, and a regional nodal basin recurrence after negative-sentinel node biopsy means a worse prognosis, compared with patients submitted to complete lymph node dissection after a positive sentinel biopsy. The evidence of higher number of tumor-positive nodes after delayed.

dissection in patients with melanoma and breast cancer [17,18]. Sentinel node for carcinoma of the parotid gland was first described by Dr. Ernest Gould in 1960. Dr. Gould advocated that the sentinel node should be dissected and sent for frozen section and if found to be without malignancy a radical neck dissection could be omitted [19] A large two-center trial on 323 patients by Horenblas et al. evaluating the role of dynamic sentinel node biopsy (DSLNB) in carcinoma penis, showed a low false-negative rate of 7%. Following the publication of this study, various guidelines have included DSLNB as an option in the management of cN0 groins in carcinoma penis The sentinel lymph node is the hypothetical first lymph node or group of nodes draining a cancer. In case of established cancerous dissemination it is postulated that the sentinel lymph node/s is/are the target organs primarily reached by metastasizing cancer cells from the tumor.. The sentinel node procedure is the identification, removal and analysis of the sentinel lymph nodes of a.

A false negative sentinel node is defined as the proportion of cases in whom sentinel node biopsy is reported as negative, but the rest of axillary lymph node(s) harbours cancer cells. Some of these patients will progress to a clinically overt axillary recurrence. The administration of radiotherapy to the breast and axilla, along with. Negative Sentinel Lymph Node Biopsy in Merkel Cell Carcinoma is Associated with a Low Risk of Same-Nodal-Basin Recurrences Travis E. Grotz, Richard W Joseph , Barbara A Pockaj , Robert L. Foote, Clark C. Otley, Sanjay P. Bagaria, Amy L. Weaver, James W Jaku e12604 Background: The safety of the sentinel lymph node biopsy procedure (SLNB) in the surgical management of breast cancer relies upon a false negative rate (FNR) being less than 10%. The accuracy of SLNB in invasive lobular carcinoma (ILC), the second most common type of breast cancer, has not been evaluated. Because of high rates of false negative imaging and the diffuse growth pattern in.

Not performing a sentinel node biopsy may avoid potential morbidity and should be reevaluated for patients 70 years of age or older with clinically negative nodes. Patients were unlikely to have treatment recommendations changed based on a sentinel node biopsy, and adjuvant therapy was less likely to be administered, regardless of nodal status Retrospective review of 520 melanoma patients with a negative sentinel lymph node biopsy showed an overall recurrence rate of 16%, with median follow-up of 61 months. For recurrences in the sampled nodal basin, the false-negative rate was 4%

(PDF) Sentinel Lymph Node Biopsy for Melanoma: Indications

Sentinel Lymph Node Biopsy. A Publication of OakLeaf Medical Network, Inc, March 2000. This year, sentinel node biopsy has been added as a new procedure performed at the Oak Leaf Surgery Center. This procedure is done for melanoma and breast cancer, and to this date has not been performed elsewhere in the Chippewa Valley Sentinel Node Biopsy and a question. Is it possible to have negative sentinel nodes but positive lymph nodes? Also if you have positive sentinel nodes and they say they took two layers of lymph nodes does anyone know what that means? I have gotten two different pieces of communication one from the surgeon through my mom and a co worker (I didn.

Breast Cancer Cells in Sentinel Lymph Node Don't Affect

Neoprobe Sentinel Node Biopsy. Sentinel node biopsy is vital to the discovery and tracking of lymph node cancers. The Neoprobe for sentinel biopsy is widely considered among the best. However, Intramedical Imaging's Node Seeker 2000 promises twice the power with a more intuitive interface A 'positive' sentinel node biopsy finding, means that malignant cells are present in the sentinel lymph node. But, sentinel lymph node biopsies, when negative, indicate that the axillary nodes are cancer free. So, medics consider a negative sentinel node biopsy result to be about 95% accurate

Pathology Outlines - Axillary lymph nodes

the results from biopsy were negative and the patients underwent primary surgical treatment. In a single case, in all 21 patients with positive SN no node was detected during standard preoperative ultra - sound evaluation. In all the other cases, normal LN with Table 1. The number of positive sentinel node biopsie In 2006, a meta-analysis of nearly 1300 patients undergoing sentinel lymph node biopsy after neoadjuvant chemotherapy reported a false-negative rate of 12%, 5 and a 2012 presentation of the ACOSOG. Sentinel node biopsy is a technique that has evolved over recent years and it is now the usual way to assess the lymph nodes in women with early breast cancer. It aims to avoid some of the side effects of axillary clearance by removing fewer glands. Removing only the sentinel or 'guardian' nodes lessens the likelihood of complications and. False-Negative Sentinel Node Biopsy False-Negative Sentinel Node Biopsy Nieweg, Omgo 2009-06-12 00:00:00 Ann Surg Oncol (2009) 16:2089-2091 DOI 10.1245/s10434-009-0540-3 EDITORIAL Omgo E. Nieweg, MD, PhD Department of Surgery, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands The concept of the orderly progression of lymph node lymph node dissection. Sentinel lymph node biopsy (SLNB) should be offered to all patients with a clinically negative nodal basin and a primary melanoma greater than 1 mm in depth. As noted, evaluation of the nodal basins via elective lymph node dissection (ELND) was most commonly limited to melanoma with a depth of 1-4 mm. Biopsy of the sentinel node carries a lower.

Sentinel Lymph Node Biopsy: Pain & Procedure Recovery Tim

A nomogram to identify high-risk melanoma patients with a negative sentinel node biopsy [published online November 2, 2018]. J Am Acad Dermatol. doi: 10.1016/j.jaad.2018.10.060. Measures of ulceration, Breslow thickness, and microsatellitosis in the primary melanoma after a negative sentinel node biopsy (SNB) are predictive of recurrence risk. Sentinel Lymph Node Biopsy. The efforts of breast surgeons and the positive results of clinical trials led to the development and adoption of another procedure, known as sentinel lymph node biopsy. The sentinel lymph node (or nodes) is/ are the first lymph node(s) to which a breast cancer will travel as it spreads Sentinel node biopsy should not be performed in women who have early-stage breast cancer with large or locally advanced invasive breast cancers (tumor size T3/T4). For patients with a negative. An important purpose of the study of 1313 patients with melanoma was to determine the ability of sentinel node biopsy to identify involved lymph node basins. The false-negative rate was found to be 14.4%; this high rate was obtained despite a meticulous technique and a comprehensive quality control program. 1 High false-negative rates have been. Sentinel lymph node biopsy has become an accepted method of staging breast cancer in many institutions, validated by false-negative rates of 5% or less with completion axillary dissection. 12,16-18 Before introducing the technique into clinical practice at the Mayo Clinic, a training protocol was conducted. Using only isosulfan blue dye, SLNs.

Sentinel lymph node biopsy. Axillary lymph node evaluation has been the standard of care in breast cancer treatment. This procedure involves the removal of two levels of lymph nodes from the axilla (armpit) to determine if the cancer has spread locally. This is considered part of the staging of the breast cancer and is routinely done at the. Injection of radiocolloid the day of the biopsy appears to be equivalent to injection the day before, in terms of the false-negative sentinel node rate and the number of sentinel nodes identified . A study by Wondergem et al. of 117 patients who underwent radiocolloid injection and lymphoscintigraphy 1 and 2 h later suggests decreased sentinel. The sensitivity of sentinel lymph node biopsy was 81.6%, and a regional nodal basin recurrence after negative-sentinel node biopsy means a worse prognosis, compared with patients submitted to complete lymph node dissection after a positive sentinel biopsy. The evidence of higher number of tumor-positive nodes after delayed lymphadenectomy in false-negative group compared with tumor-positive.

Assessment of the efficacy and safety of methylene blueRACGP - Melanoma – a management guide for GPsLymphedema and Breast Cancer Surgery - National Cancer

Sentinel node biopsy involves removing the first lymph node (or nodes) in the armpit to which cancer cells are likely to spread from the breast. It's important that sentinel node biopsy is done by a surgeon who is trained and experienced in this method. Sentinel node biopsy is usually done during breast surgery (breast conserving surgery or mastectomy) Sentinel node biopsy results were negative. The patient has remained free of local, regional and distant disease for the follow-up time of 16 months. Conclusion. The rarity of this tumor makes definitive conclusions difficult but SLN biopsy appears to be a useful adjunct in the treatment of these sarcomas Patients who experience a change in axillary lymph node status from positive to negative also are unlikely to be good candidates for SLN biopsy; in the current study, of the 7 patients who had their axillary lymph node status changed from positive to negative by NAC, 2 had false-negative results, and, thus the false-negative rate for those 7. Background With the increased use of neoadjuvant chemotherapy (NAC) in breast cancer, the timing of sentinel lymph node biopsy (SLNB) has become increasingly important. In this study, we aimed to evaluate the feasibility and accuracy of SLNB for initially clinically node-negative breast cancer after NAC by conducting a systematic review and meta-analysis

99mTc-rituximab, a novel specific tracer of sentinel lymphThe SAVE Review: Sonographic Analysis Versus Excision forDoctor's Corner - Santa Barbara Women's Imaging Center

Sentinel lymph node biopsy (SLNB) is a staging tool for patients with clinically node-negative primary cutaneous malignancies and no evidence of distant metastasis. It is used to determine the histologic status of the nodes of the regional nodal basin (s) draining the primary site. If the sentinel node is negative, the rest of the nodes in the. Ann Surg Oncol (2010) 17:579-591 DOI 10.1245/s10434-009-0658-3 ORIGINAL ARTICLE - TRANSLATIONAL RESEARCH AND BIOMARKERS Beyond the False Negative Rate: Development of Quality Indicators for Sentinel Lymph Node Biopsy in Breast Cancer May Lynn Quan, MD, MSc1, Bryan J. Wells, MD1, David McCready, MD, MSc2, Frances C. Wright, MD, MEd1, Novlette Fraser, MA1, and Anna R. Gagliardi, PhD1 1. For example, Chagpar et al used the National Cancer Database to determine the effect of omitting sentinel lymph node biopsy (SNB) in clinically lymph node-negative, hormone-positive invasive breast cancer in patients 70 years of age and older. Of 193,728 patients, 79.8% had regional lymph node surgery and 15% of them were found to have. The surgeon removes the sentinel nodes and sends them to a pathologist. When the surgeon removes sentinel nodes, it doesn't mean there's cancer in the nodes. It just means a pathologist needs to check the nodes for cancer. Findings from a sentinel node biopsy. Lymph node-negative. None of the sentinel nodes contain cancer A bigger question is whether a sentinel lymph node biopsy is adequate. Some institutions do sentinel lymph node biopsies only in very small tumors and prefer, due to the incidence of skip metastasis (where the first or second node is negative and the third node is positive) to do axillary node dissection