1) In your centre, is the Sentinel Node Biopsy (SNB) technique currently used rather than Axillary Lymph Node Dissection (ALND) in clinical practice?

No

Yes

2)If not, what is the main reason?

There are insufficient data in the literatureto justify its use in the daily practice

Nuclear Medicine Department not available

Gamma probe for radio-guided surgery not available

We have not yet completed the learning curve


Other reasons (specify)

3) Is your centre taking part in any multicentric clinical trial on SNB?

No

Yes

4)Do you believe there is currently enough scientific evidence to justify the use of SNB in clinical practice?

Yes

Yes, but precise indications and its limitations are still unclear

No, but due to patient demand, we perform SNB in selected cases.

Absolutely not

5)Do you believe that mass-media propaganda in favour of SNB has in some way lead to its use in the clinical practice?

No

Yes

6)Have you had any experience of patients specifically requesting SNB and refusing, a priori, elective ALND, even after being illustrated the possible risks of the technique?

No

Rarely

Sometimes

Frequently

7)Although the advantages of this technique (less aggressive and with fewer side effects) are well known, what percentage of false negative rate would you consider acceptable?

 0%

 <5%

 5-10%

 10-15%

 >15%

8)
When did you start to investigate the SNB technique?

Before 1997

1997

1998

1999

2000

2001

2002

2003

9)When did you start to use the SNB instead of ALND in your clinical practice?

Before 1997

1997

1998

1999

2000

2001

2002

2003

10)How many cases of SNB followed by the standard ALND procedure did you perform during your learning phase?

 <10

 10-20

 20-30

 >30

11)With time, have you extended the indications of the SNB technique?

No

Slightly

A great deal

12)In which of the following cases do you usually utilise the SNB technique?

Tumours < 1 cm

Tumours < 2 cm

Tumours < 3 cm

Any size

13) Which of the following do you consider a contraindication to SNB?

Multi-centric tumours (multiple foci >2-3 cm apart)

Retroareolar tumours

Non-palpable tumours

Previously biopsied tumours

Previous quadrantectomy (without axillary surgery) in the upper outer quadrant

Previous axillary incision (i.e. for breast implant operation)

Clinically positive axilla

14) Do you perform SNB in cases of ductal carcinoma in situ?

Never

Only if >2 cm

Always

15)Do you perform SNB in patients who have undergone neoadjuvant chemotherapy?

Never

Sometimes

Always

16)What is your usual approach in cases of micrometasasis in the sentinel lymph node?

Always axillary dissection

Axillary dissection with some exceptions

Axillary dissection only in some cases

No further axillary surgery

17)Do you perform frozen section examination of the sentinel lymph node?

usually yes

never

It varies from case to case

18)Do you use local anaesthesia for SNB?

Never

Sometimes

Often

19) Which of the following procedures do you mainly follow in cases of small palpable tumours?

Primary tumour and SN biopsy under local anaesthesia, wait for definitive histology and then perform radical treatment of the breast associated with delayed ALND in cases of positive sentinel node

Perform radical treatment of the primary tumour and SNB, wait for SN definitive histology and then, if necessary, perform a delayed ALND

Perform frozen section examination of the SN and immediate radical breast surgery associated with ALND if sentinel node is positive

20)What SN localisation technique do you use?

Blue dye injection alone

Radio-tracer (99mTc-albumin nanocolloid)

Both the above in association

21)Which site do you usually use for tracer injection in cases of palpable tumour?

Subdermal / intradermal in the tumour area

Deep peritumoural injection

Subareolar

Intratumoural

Fill in this area only if you use radioisotope for sentinel node identification

22)How often do you perform a preoperative lymphoscintigraphy?

Always

Occasionally

Never

23)When is the tracer injected?

The day before surgery

The same day of surgery

It varies from case to case

24)What dose of radioisotope is usually injected?

<30 MBq

30-50 MBq

>50 MBq

25)What type of gamma probe is used?

……………………………………………………………….

26)Which “hot” lymph nodes do you usually remove?

Only the hottest

All nodes with similar radioactivity levels

All nodes with radioactive counts higher than 10% of those measured in the hottest node

All nodes with a radioactivity level greater than that of background activity.

27)Do you also look for radioactive emission along the internal mammary chain during surgery?

Never

Only if highlighted at lymphoscintigraphy

Always

28)If a significant radioactive emission is observed along the internal mammary chain, do you perform internal node(s) biopsy?

Always

Only if no axillary sentinel nodes are found

Never

29)Which site do you usually use for tracer injection in cases of non-palpable tumours?

We never perform SNB in non-palpable tumours

Subdermally in the cutaneous projection of the tumour

Deep in the peritumoural area

In the subareolar area