The role of nodal staging in breast cancer. Past, present and future

The axillary nodal status is accepted as the most powerful prognostic tool available for early stage breast cancer. In the past radical removal of level I and level II lymph nodes at axillary node dissection (ALND) has been the most accurate method to assess nodal status, and it is the universal standard; however, it is associated with several adverse long-term sequelae. New diagnostic technologies have helped to individualize diagnostic evaluation and therapy of breast cancer thus improving efficacy and minimizing morbidity of treatment. Lymphatic mapping with sentinel lymph node biopsy has emerged as an effective and safe alternative to the ALND for detecting axillary metastases. Many issues such as indications or technique of performing sentinel node biopsy have been evaluated. Multiple studies now confirm that sentinel lymphadenectomy accurately stages the axilla and is associated with less morbidity than axillary dissection. Blue dye, radiocolloid, or both can be used to identify the sentinel node, and several injection techniques may be used successfully. Sentinel node biopsy is now minimally invasive, highly accurate method of axillary staging, and has replaced routine axillary lymph node dissection as the new standard of care in breast cancer. New technologies for axillary nodal staging include innovative imaging techniques such as single photon emission computerized tomography (SPECT) and modern histopathologic evaluation of sentinel nodes using molecular biologic approaches.     

哨兵淋巴结活检对预测乳腺癌腋窝淋巴结转移的价值

目的 评估哨兵淋巴结（ＳＮ）活检对预测乳腺癌腋窝淋巴结（ＬＮ）转移的价值。方法 本组５２例原发乳腺癌患者,临床及Ｂ超检测腋窝ＬＮ阴性。术中在原发肿瘤周围注射亚甲蓝进行腋窝淋巴结定位和哨兵淋巴结切除（ＳＬＮＤ）,随后行腋窝淋巴结清扫（ＡＬＮＤ）。术中对部分ＳＮ、术后对全部ＬＮ（ＳＮ和非ＳＮ）行常规病理检查。结果 ５２例患者中４６例检测到ＳＮ,成功率为８８．５％;其中４４例（９５．７％）和ＳＮ可以准确     

Improved axillary staging of breast cancer with sentinel lymphadenectomy.

OBJECTIVE: The authors evaluated the effect of intraoperative lymphatic mapping and sentinel lymphadenectomy (SLND) on the axillary staging of patients with carcinoma of the breast. SUMMARY BACKGROUND DATA: The accurate staging of patients with breast cancer is essential to guide management and determine prognosis. The authors previously reported the feasibility and accuracy of SLND in breast carcinoma. Sentinel lymphadenectomy identifies the first ("sentinel") axillary lymph node draining the site of a primary tumor; because this node is the most likely site of axillary metastasis, histopathologic examination of the sentinel node correlates well with examination of the entire axillary contents. The current study compares SLND with standard axillary lymphadenectomy (ALND) for the staging of breast carcinoma. METHODS: The incidence of axillary node metastasis and micrometastasis in SLND and ALND specimens from patients undergoing operative treatment of a primary breast carcinoma was compared prospectively. Multiple sections of each sentinel lymph node in SLND specimens were examined by hematoxylin and eosin (H&E) staining and by immunohistochemical techniques using antibodies to cytokeratin. One or two sections of each nonsentinel lymph node in ALND specimens were examined by routine H&E staining. RESULTS: One hundred thirty-four patients underwent ALND (ALND group), and 162 underwent successful SLND followed by completion ALND (SLND group). Both groups were similar with respect to age (median, 55 and 54 years, respectively), palpable primary tumors (54.5% and 59.3%, respectively), palpable axillary nodes (5.2% and 7.4%, respectively), size of primary tumor (median, 1.5 cm in each group), and total number of axillary lymph nodes examined (median, 19 and 21, respectively). The number of patients with axillary metastasis was 39 (29.1%) in the ALND group and 68 (42.0%) in the SLND group (p < 0.03). Of these, 4 of 39 (10.3%) ALND patients (3.0% of all ALND patients) and 26 of 68 (38.2%) SLND patients (16.0% of all SLND patients) had micrometastasis (< or = 2 mm), a highly significant difference (p < 0.0005) CONCLUSIONS: Sentinel lymphadenectomy with multiple sectioning and immunohistochemical staining of sentinel nodes increases the accuracy of axillary staging in breast cancer and can identify significantly more patients with lymph nodes metastases, especially micrometastases, than can ALND with routine histopathologic processing of lymph nodes.     

Lymphatic mapping techniques and sentinel lymph node biopsy in breast cancer

The axillary nodal status is accepted universally as the most powerful prognostic tool available for early stage breast cancer. The removal of level I and level II lymph nodes at axillary node dissection (ALND) is the most accurate method to assess nodal status, and it is the universal standard; however, it is associated with several adverse long-term sequelae. Lymphatic mapping with sentinel lymph node biopsy has emerged as an effective and safe alternative to the ALND for detecting axillary metastases. This article discusses some lymphatic mapping methodology.     

Lymphatic invasion, tumor size, and age are independent predictors of axillary lymph node metastases in women with T1 breast cancers

OBJECTIVE: To identify characteristics of the primary tumor highly associated with lymph node metastases. SUMMARY BACKGROUND DATA: Recent enthusiasm for limiting axillary lymph node dissection (ALND) in women with breast cancer may increase the likelihood that nodal metastases will be missed. Identification of characteristics of primary tumors predictive of lymph node metastases may prompt a more extensive surgical and pathologic search for metastases in patients with negative sentinel lymph nodes or limited ALND. METHODS: The authors studied 850 consecutive patients who underwent ALND for T1 breast cancer. Age, tumor size, histopathologic diagnosis, tumor differentiation, presence of lymphatic invasion, and estrogen and progesterone receptor results were studied prospectively. Stepwise logistic regression was used to identify variables independently associated with axillary lymph node metastases. RESULTS: Lymphatic invasion, tumor size, and age were independently associated with lymph node metastases. Fifty-one percent of the 181 patients with lymphatic invasion had axillary lymph node metastases, compared with 19% of the 669 patients without lymphatic invasion. Thirty-five percent of the 470 patients with tumors >1 cm had nodal involvement compared with 13% of the 380 patients with smaller cancers. Thirty-seven percent of the 63 women younger than age 40 had lymph node involvement compared with 25% of the 787 women older than age 40. Significant correlations were noted between lymphatic invasion and patient age and between lymphatic invasion and tumor size. The proportion of tumors with lymphatic invasion decreased progressively with increasing age and increased with increasing tumor size. CONCLUSIONS: Axillary lymph node metastases are most significantly related to lymphatic invasion in the primary tumor, followed, in order of significance, by tumor size and patient age. Axillary nodal metastases should be suspected in the presence of lymphatic invasion of large tumors in young patients.     

An axillary recurrence of breast cancer following a negative sentinel lymph node biopsy

Abstract: In many parts of the United States, lymphatic mapping and sentinel lymph node biopsy has almost replaced axillary lymph node dissection (ALND) as the axillary staging procedure of choice for small, clinically node-negative breast cancers. However, the long-term outcome of patients undergoing a sentinel lymph node biopsy as the only axillary procedure in patients with tumor-free sentinel nodes remains to be determined. We present the first reported case of axillary recurrence in a patient with breast cancer following a tumor-negative sentinel lymph node biopsy. Whether sentinel lymph node biopsy can replace ALND in the management of patients with early breast cancer remains to be answered.     

The role of selective sentinel lymph node dissection in breast cancer

Axillary nodal status continues to be the most statistically significant predictor of survival for patients with breast cancer. Although still providing regional control of axillary disease, axillary dissection is more important as a staging and prognostic tool. Trials are currently underway to investigate the possibility of replacing the current standard treatment of breast cancer, axillary lymph node dissection, with the less invasive lymphatic mapping and sentinel lymph node biopsy. This issue and the technical aspects of sentinel lymph node mapping for breast cancer are discussed in detail in this article.     

Multicentre study of ultrasonographically guided axillary node biopsy in patients with breast cancer

BACKGROUND: Axillary lymph node dissection is still performed as a staging procedure since lymph node status is the most important prognostic factor in patients with breast cancer. Sentinel node biopsy may replace routine axillary lymphadenectomy, especially in patients with small breast cancers. This study investigated whether ultrasonographically guided fine-needle aspiration cytology (FNAC) of the axillary lymph nodes in clinically node-negative patients was an accurate staging procedure to select patients for sentinel node biopsy. METHODS: One hundred and eighty-five consecutive patients were included. All had axillary ultrasonography and detected nodes were categorized according to their dimensions and echo patterns. Ultrasonographically guided FNAC was carried out if technically possible. These results were compared with the results of the sentinel node biopsy and subsequent axillary dissection. RESULTS: In 116 patients no lymph nodes were detected by ultrasonographic imaging. Of 69 patients with visible nodes, 31 had malignant cells on FNAC. There were no false-positive results. Some 87 of 185 patients had axillary metastases on definitive histological examination. Ultrasonography was sensitive in patients with extensive nodal involvement. Failure of the examination was caused by problems learning the method, difficulty in puncturing small lymph nodes and sampling error. CONCLUSION: In patients without palpable axillary nodes, a sentinel node biopsy could be avoided in 17 per cent since ultrasonography combined with FNAC had already diagnosed axillary metastases. The method is particularly valuable in larger breast cancers.     

Sentinel lymphadenectomy accurately predicts nodal status in T2 breast cancer

Background: Sentinel lymph node biopsy (SLNB) has emerged as a reliable, accurate method of staging the axilla for early breast cancer. Although widely accepted for T1 lesions, its use in larger tumors remains controversial. This study was undertaken to define the role of SLNB for T2 breast cancer.

Study Design: From a prospective breast sentinel lymph node database of 1,627 patients accrued between September 1996 and November 1999, we identified 223 patients with clinical T1-2N0 breast cancer who underwent 224 lymphatic mapping procedures and SLNB followed by a standard axillary lymph node dissection (ALND). Preoperative lymphatic mapping was performed by injection of unfiltered technetium 99 sulfur colloid and isosulfan blue dye. Data about patient and tumor characteristics and the status of the sentinel lymph nodes and the axillary nodes were analyzed. Statistics were performed using Fisher’s exact test.

Results: Two hundred four of 224 sentinel lymph node mapping procedures (91%) were successful. Median tumor size was 2.0 cm (range 0.2 to 4.8 cm). One hundred forty-five of the 204 patients had T1 lesions and 59 patients had T2 lesions. There were 92 pathologically positive axillae, 5 (5%) of which were not evident either by SLNB or by intraoperative clinical examination. The false-negative rate and accuracy were not significantly different between the two groups, but axillary node metastases were observed more frequently with T2 than with T1 tumors (p = 0.005); other factors, including patient age, prior surgical biopsy, upper-outer quadrant tumor location, and tumor lymphovascular invasion were not associated with a higher incidence of false-negative SLNB in either T1 or T2 tumors.

Conclusions: SLNB is as accurate for T2 tumors as it is for T1 tumors. Because no tumor or patient characteristics predict a high false-negative rate, all patients with T1-2N0 breast cancer should be considered candidates for the procedure. Complete clinical examination of the axilla should be undertaken to avoid missing palpable axillary nodal metastases.     

Limitation in gamma probe localization of the sentinel node in breast cancer patients with large excisional biopsy

BACKGROUND: Radiolocalization and selective biopsy of the sentinel node to correctly predict the status of remaining lymph nodes may provide an alternative to axillary dissection in selected breast cancer patients with clinically negative lymph nodes. STUDY DESIGN: In a nonrandomized, multicenter clinical trial, gamma probe localization for lymphatic mapping and sentinel node biopsy along with axillary dissection was performed on 75 patients with invasive breast cancer and clinically negative lymph nodes. The accuracy of the sentinel node biopsy to correctly predict the status of the remaining axillary lymph nodes was established through standard pathologic investigation. RESULTS: A sentinel node was identified in 70 of 75 patients with a technical success rate of 93%. Of these 70 patients, 21 (30%) had axillary nodal metastases identified pathologically. Four of these 21 (19%) had sentinel nodes negative for metastases. All 4 false-negative patients had prior excisional biopsies. The false-negative group had a larger mean maximal biopsy dimension than the true-positive group. Eleven of the 21 patients with axillary metastases had a diagnosis made by core needle biopsy with no false negatives. CONCLUSIONS: The accuracy of the sentinel node biopsy in correctly predicting the status of remaining axillary lymph nodes may be limited in patients with large excision before radiolocalization of the sentinel node. Our findings suggest that excisional biopsy should be avoided prior to lymphatic mapping for sentinel node biopsy.     

Sentinel Node Biopsy: Standard of Care

Abstract: Sentinel lymph node biopsy (SLNB) is a less invasive alternative to axillary lymph node dissection (ALND) for staging breast cancer. In appropriate women, this procedure can stage the axilla with less extensive surgery and fewer complications. Sentinel node status is accurate in predicting axillary status based on single institutional experiences and confirmed by large multi‐center trials. Non‐sentinel nodes are involved very rarely if the sentinel node is tumor‐free. SLNB enables intense examination of a single lymph node. However, the use of special stains to detect micrometastases is of uncertain clinical significance and is the subject of large trials. Early follow‐up from the John Wayne Cancer Institute experience demonstrates excellent outcome for patients with either micrometastases or tumor‐free nodes. Results from techniques with either blue dye or radioisotope colloid tracer and injection locations at peri‐areolar, peritumoral, or subcutaneous sites are similar. These findings support the biological concept of a single (or very few) sentinel nodes for the entire breast. The sentinel node is more predictive of axillary status than any other tumor prognostic factor. Axillary lymph node dissection is unlikely to reveal nodal metastases when the sentinel node is tumor‐free, and in such cases there is no reason to perform a completion axillary node dissection. Sentinel node biopsy alone without axillary lymph node dissection should now be the standard of care for most clinically node‐negative women with breast cancer.     

Lymphatic mapping in patients with breast cancer and previous augmentation mammoplasty

Sentinel lymph node biopsy (SLNB) is now an established method of axillary staging in patients with breast cancer. However, the augmented breast poses an interesting challenge to this procedure. We hypothesized that SLNB is feasible in patients with augmented breasts who subsequently develop breast cancer. A retrospective study was performed from 1995 to 2006. Ten patients with augmented breasts underwent breast conservation therapy with SLNB. Sentinel lymph nodes were identified in all 10 patients. Three patients had positive sentinel nodes. Two patients proceeded to axillary lymph node dissection (ALND), and one declined. The subsequent ALND were negative for metastatic cancer. Seven patients had negative sentinel nodes. One patient with a negative sentinel node underwent ALND with all nodes negative for metastasis. Two patients were lost to follow-up. Of the remaining eight patients, the mean duration of follow-up was 71 months. None of these patients had evidence of axillary recurrence or distant metastasis at time of last follow-up. SLNB is a feasible method of axillary node staging in patients who have undergone augmentation mammoplasty who subsequently develop breast cancer. Further studies are needed to better determine the accuracy of lymphatic mapping in this patient population.     

Axillary staging using positron emission tomography in breast cancer patients qualifying for sentinel lymph node biopsy

Axillary lymph node dissection (ALND) is the standard of care for nodal staging of patients with invasive breast cancer. Due to significant somatic and psychological side effects, replacement of ALND with less invasive techniques is desirable. The goal of this study was to evaluate the clinical usefulness of axillary lymph node (ALN) staging by means of positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) in breast cancer patients qualifying for sentinel lymph node biopsy (SLNB). FDG-PET was performed within 1 week before surgery in 24 clinically node-negative breast cancer patients with tumors smaller than 3 cm. Sentinel lymph nodes (SLNs) were identified by preoperative lymphoscintigraphy following peritumoral technetium 99m-labeled colloid albumin injection, and by intraoperative gamma detector and blue dye localization. Following SLNB, a standard ALND was performed. Serial sectioning and immunohistochemistry of the SLN as well as standard histologic examination of the non-SLN was performed. FDG-PET detected all primary breast cancers. Staging of ALNs by PET was accurate in 15 of 24 patients (62.5%), whereas PET staging was false negative in 8 of 10 node-positive patients and false-positive in 1 patient. The sensitivity, specificity, positive predictive value, and negative predictive value of FDG-PET for nodal status was 20%, 93%, 67%, and 62%, respectively. The mean diameter of false-negative ALN metastases was 7.5 mm (range 1-15 mm). Lymph node staging using FDG-PET is not accurate enough in clinically node-negative patients with breast cancer qualifying for SLNB and should not be used for this purpose.     

Sentinel Lymph Node Biopsy Performed After Neoadjuvant Chemotherapy is Accurate in Patients with Documented Node-Positive Breast Cancer at Presentation

Background The optimal strategy for incorporating lymphatic mapping and sentinel lymph node biopsy into the management of breast cancer patients receiving neoadjuvant chemotherapy remains controversial. Previous studies of sentinel node biopsy performed following neoadjuvant chemotherapy have largely reported on patients whose prechemotherapy, pathologic axillary nodal status was unknown. We report findings using a novel comprehensive approach to axillary management of node-positive-patients receiving neoadjuvant chemotherapy. Methods We evaluated 54 consecutive breast cancer patients with biopsy-proven axillary nodal metastases at the time of diagnosis that underwent lymphatic mapping with nodal biopsy as well as concomitant axillary lymph node dissection after receiving neoadjuvant chemotherapy. All cases were treated at a single comprehensive cancer center between 2001 and 2005. Results The sentinel node identification rate after delivery of neoadjuvant chemotherapy was 98%. Thirty-six patients (66%) had residual axillary metastases (including eight patients that had undergone resection of metastatic sentinel nodes at the time of diagnosis), and in 12 cases (31%) the residual metastatic disease was limited to the sentinel lymph node. The final, post-neoadjuvant chemotherapy sentinel node was falsely negative in three cases (8.6%). The negative final sentinel node accurately identified patients with no residual axillary disease in 17 cases (32%). Conclusions Sentinel lymph node biopsy performed after the delivery of neoadjuvant chemotherapy in patients with documented nodal disease at presentation accurately identified cases that may have been downstaged to node-negative status and can spare this subset of patients (32%) from experiencing the morbidity of an axillary dissection.     

染料法前哨淋巴结活检治疗乳腺癌进展

本旨在复习前哨淋巴结活检术的发展过程和乳腺的淋巴引流解剖，总结染料法前哨淋巴结活检术在乳腺癌诊治中的临床意义。乳腺癌的淋巴转移常常首先到达腋窝前哨淋巴结，染料法前哨淋巴结活检术对腋窝淋巴结是否受累以及是否需行清扫有确切指导作用。当染料法前哨淋巴结活检阴性时，可不必常规行腋窝淋巴结清扫术，由此可避免后带来的并发症和痛苦。     

Axillary dissection after unsuccessful sentinel lymphadenectomy for breast cancer.

Intraoperative lymphatic mapping and sentinel lymphadenectomy (LM/SL) has been demonstrated to provide sensitive axillary staging for breast cancer. LM/SL has a steep learning curve, and factors associated with unsuccessful LM/SL are not well known. Two hundred sixty patients with breast carcinoma and clinically negative axillae underwent injection of about 5 cm3 of isosulfan blue dye (Lymphazurin, US Surgical Corp, Norwalk, CT) into breast tissue surrounding a cancer or biopsy site. After 5 minutes of breast compression, blue-stained lymph nodes were sought. In 47 patients, no blue nodes were detected; a standard axillary dissection was performed. All 47 patients were women with a mean age of 56 years (range, 34-80). Ductal carcinoma was most common (91.5%). Mean tumor size was 1.99 cm. Axillary dissection yielded a mean of 15.8 lymph nodes (range, 6-35). Sixteen patients (34%) had positive lymph nodes (mean, 7.6; median, 6; range, 1-24). Factors associated with LM/SL difficulty include surgeon inexperience, medial hemisphere primary location, extensive axillary metastases, and extranodal invasion. Inability to identify a sentinel node in a clinically negative axilla is a risk factor for extensive axillary tumor burden. Axillary dissection should be performed for patients with unsuccessful LM/SL, particularly those with lateral hemisphere primaries.     

Lymph node mapping and axillary sentinel lymph node biopsy in 243 invasive breast cancers with no palpable nodes. The south Lyon hospital center experience

STUDY AIM: To evaluate the effect of intraoperative lymph node mapping and sentinel lymph node dissection (SLND) on the axillary staging of patients with N0 breast carcinoma. Two techniques were used: blue dye alone (Evans Blue and Patent Blue) and combined technique (blue dye and isotope). METHODS: The incidence of axillary node metastasis in axillary lymph node dissection (ALND) and SLND was compared prospectively. Multiple sections of each SLN were examined by HPS staining and immunohistochemical techniques. Two sections of each non sentinel node in ALND specimens were examined by routine HPS staining. RESULTS: 243 patients underwent ALND after SLN biopsy. The SLN detection rate was 225/243 cases (92.59%): 89.94% with blue dye alone and 100% with the combined technique. The false-negative rate was less than 2%. CONCLUSION: SN biopsy is an accurate staging technique for N0 breast cancer. SLN biopsy with multiple sections and immunohistochemical staining of the SLN can identify significantly more patients with lymph node metastases than ALND with routine HPS staining.     

Halsted Revisited: Internal Mammary Sentinel Lymph Node Biopsy in Breast Cancer

OBJECTIVE: To investigate the feasibility of internal mammary sentinel lymph node biopsy as a method to refine and thereby improve nodal staging in breast cancer. SUMMARY BACKGROUND DATA: The internal mammary lymph node status is a major prognostic factor in breast cancer. If positive, prognosis is less favorable. However, staging this regional nodal basin is not performed routinely, thus discarding additional staging information. METHODS: In a consecutive series of 256 patients with primary breast cancer, sentinel node biopsy was performed based on lymphoscintigraphy, intraoperative gamma probe detection, and blue dye mapping using 10 mCi (370 MBq) (99m)Tc-nanocolloid injected peritumorally and 0.5 to 1.0 mL Patent Blue V injected intradermally. During surgery, whenever possible, both axillary and internal mammary sentinel nodes were sampled. RESULTS: Lymphoscintigraphy showed axillary sentinel nodes in 95% (243/256) and additional internal mammary sentinel nodes in 25.3% (65/256). The overall success rate of axillary sentinel node biopsy was 97% (249/256). Sampling the internal mammary basin, based on the results of lymphoscintigraphy, was successful in 63% (41/65). In three patients a small pleural lesion resulted from staging this basin. This technique revealed internal mammary metastases in 26.8% (11/41). In 7.3% (3/41), internal mammary nodes showed metastatic involvement without accompanying axillary metastases. CONCLUSIONS: Internal mammary sentinel node biopsy is feasible without serious additional complications. It improves nodal staging in breast cancer by identifying higher-risk subgroups with internal mammary nodal metastases, which might benefit from altered adjuvant treatment regimens.     

Sentinel lymph node mapping following neoadjuvant chemotherapy for breast cancer

The purpose of this study was to evaluate the feasibility of sentinel lymph node mapping in patients undergoing neoadjuvant chemotherapy for breast carcinoma prior to lumpectomy or mastectomy and sentinel lymph node mapping followed by complete axillary dissection. A retrospective analysis of 14 patients from February 1998 to July 2000 with stage I to stage IIIB breast cancer diagnosed by core biopsy underwent neoadjuvant chemotherapy (doxorubicin/cyclophosphamide) prior to definitive surgery, including lumpectomy or mastectomy and sentinel lymph node mapping, followed by full axillary dissection. Thirteen of 14 patients had successful sentinel lymph node identification (93%), and all 14 underwent full axillary dissection. An average of 2.2 sentinel nodes and a median of 16 axillary lymph nodes (including sentinel nodes) were found per patient. Of the 13 patients in whom a sentinel lymph node was identified, 10 were positive for metastases (77%). Only 4 of the 10 had further axillary metastases (40%). Three patients had negative sentinel lymph nodes shown by hematoxylin and eosin and cytokeratin stainings and had no axillary metastases (0% false negative). The single patient in whom a sentinel lymph node could not be identified had stage IIIA disease with extensive lymphatic tumor emboli. Sentinel lymph node mapping is feasible in neoadjuvant chemotherapy breast cancer patients and can spare a significant number of patients the morbidity of full axillary dissection. Further study to evaluate sentinel lymph node mapping in this patient population is warranted.     

Routine preoperative lymphoscintigraphy is not necessary prior to sentinel node biopsy for breast cancer.

BACKGROUND: This prospective study was performed to ascertain the added benefit of lymphoscintigraphy to a standard method of intraoperative lymphatic mapping and sentinel node biopsy for breast cancer. METHODS: Patients with invasive breast cancer were injected with 99mTc sulfur colloid prior to sentinel node biopsy; preoperative lymphoscintigraphy was then performed in half of the patient population. RESULTS: Sentinel node identification was possible in 45 of 50 patients (90%). All 14 patients (31%) with axillary nodal metastases had at least one histologically positive sentinel node (0% false negative rate). Lymphoscintigraphy revealed sentinel nodes in 17 of the 24 patients (70.8%) imaged. All 17 of these patients had one or more axillary sentinel nodes identified using intraoperative lymphatic mapping. In addition, 5 of 7 patients with a negative preoperative lymphoscintogram had an axillary sentinel lymph node(s) identified intraoperatively. None of the tumors showed drainage to the internal mammary lymph node chain by lymphoscintigraphy despite the fact that there were 5 patients with inner quadrant tumors. There was no significant advantage with respect to sentinel lymph node localization (91.7% versus 88.5%, P = not significant) or false negative rate (0%, both groups, P = not significant) in the group undergoing preoperative lymphoscintigraphy when compared with the patients in whom lymphoscintigraphy was not performed. CONCLUSIONS: Preoperative lymphoscintigraphy adds little additional information to intraoperative lymphatic mapping, and its routine use is not justified.