Moore et al. demonstrated that the occurrence of immunohistochemically detected micrometastases in sentinel lymph nodes increases after instrumentation of the tumor site, in an approximately proportionate manner to the degree of manipulation.1 They are correct in attributing this point of view to me, but they are incorrect in their statement that I have ever suggested such phenomena have no clinical significance.1, 2

On the contrary, in my article2 and published letters,3–6 I have consistently expressed exactly the opposite point of view. I have attempted to sound a clarion call of caution with regard to breast carcinoma manipulation, especially as related to breast massage during the sentinel lymph node procedure. It is my concern that such manipulation will lead to an iatrogenic increase in breast carcinoma mortality.

What I stated in my article2 was that current clinical trials by the National Surgical Adjuvant Breast and Bowel Project and the American College of Surgeons will determine future outcome. These clinical trials will determine the importance of sentinel lymph node immunohistochemistry micrometastases (what I refer to as traumets). In the interim, it is my belief that traumets are the root cause of truemets, and that current improvements in the diagnosis of and therapy for breast carcinoma will be overshadowed by the negative impact of iatrogenic phenomenon described by Moore et al.1


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