Alternative lymphatic pathway after previous axillary node dissection in recurrent/primary breast cancer

OBJECTIVES: The sentinel lymph node approach has almost become the standard procedure of choice in the management of patients with early breast cancer. The status of sentinel nodes, whether or not pathologically involved by cancer cells, represents those of the axillary nodes with a negative predictive value of almost 100%. If the axillary lymphatic nodal drainage is altered, alternative lymphatic pathways and accordingly sentinel node location will be changed. METHODS: In this article, 4 patients are presented, 3 with recurrent breast cancer who had already undergone lumpectomy, axillary node dissection, and radiotherapy in the past and 1 with primary breast cancer after surgical removal of a malignant melanoma on her back and had axillary node dissection on the same side as the breast cancer. These patients underwent lymphoscintigraphy followed by sentinel node localization using the gamma probe and also blue dye injection during surgery. RESULTS: All patients showed alternate lymphatic pathways, 1 had an ipsilateral internal mammary node and crossed lymphatics to a contralateral axillary node, 2 had intramammary sentinel nodes, and 1 had an internal mammary on the same side. Pathologic examination of the intramammary and contralateral sentinel nodes were negative for metastases. Internal mammary sentinel nodes were not biopsied. CONCLUSION: We feel that sentinel node lymphoscintigraphy should be done even in patients who have altered lymphatic pathways resulting from previous axillary node dissection. It allows identifying and biopsy of the sentinel node at its new unpredicted location.     

Radioguided sentinel lymph node biopsy in breast cancer surgery.

The concept of sentinel lymph node biopsy in breast cancer surgery relates to the fact that the tumor drains in a logical way through the lymphatic system, from the first to upper levels. Therefore, the first lymph node met (the sentinel node) will most likely be the first to be affected by metastasis, and a negative sentinel node makes it highly unlikely that other nodes are affected. Because axillary node dissection does not improve prognosis of patients with breast cancer (being important only to stage the axilla), sentinel lymph node biopsy might replace complete axillary dissection to stage the axilla in clinically N0 patients. Sentinel lymph node biopsy would represent a significant advantage as a minimally invasive procedure, considering that, after surgery, about 70% of patients are found to be free from metastatic disease, yet axillary node dissection can lead to significant morbidity. Furthermore, histologic sampling errors can be reduced if a single (sentinel) node is assessed extensively rather than few histologic sections in a high number of lymph nodes per patient. Although the pattern of lymph drainage from breast cancer can be variable, the mammary gland and the overlying skin can be considered as a biologic unit in which lymphatics tend to follow the vasculature. Therefore, considering that tumor lymphatics are disorganized and relatively ineffective, subdermal and peritumoral injection of small aliquots of radiotracer is preferred to intratumoral administration. (99m)Tc-labeled colloids with most of the particles in the 100- to 200-nm size range would be ideal for radioguided sentinel node biopsy in breast cancer. Lymphoscintigraphy is an essential part of radioguided sentinel lymph node biopsy because images are used to direct the surgeon to the site of the node. The sentinel lymph node should have a significantly higher count than that of background (at least 10:1 intraoperatively). After removal of the sentinel node, the axilla must be reexamined to ensure that all radioactive sites are identified and removed for analysis. The sentinel lymph node should be processed for intraoperative frozen section examination in its entirety, based on conventional histopathology and, when needed, immune staining with anticytokeratin antibody. The success rate of radioguidance in localizing the sentinel lymph node in breast cancer surgery is about 94%--97% in institutions where a high number of procedures are performed and approaches 99% when combined with the vital blue dye technique. At present, there is no definite evidence that negative sentinel lymph node biopsy is invariably correlated with negative axillary status, except perhaps for T1a-b breast cancers, with a size of < or =1 cm. Randomized clinical trials should elucidate the impact of avoiding axillary node dissection on patients with a negative sentinel lymph node on the long-term clinical outcome of patients.     

Single-photon emission computed tomography/computed tomographyfor sentinel node mapping in breast cancer

Accurate lymph node staging is essential for the prognosis and treatment in patients with cancer. The sentinel lymph node is the first node to which lymphatic drainage and metastasis from the primary tumor occurs. In malignant melanoma and breast cancer, the sentinel lymph node detection and biopsy already have been implemented into clinical practice. Currently, 2 techniques are used to identify the sentinel lymph nodes: technetium-99m-labeled colloid and blue dye. After peritumoral injection, the material migrates through the lymphatics to the first lymph nodes draining the tumor. The precise anatomic localization of the sentinel lymph nodes is important for minimal invasive surgery and to avoid incomplete removal of the sentinel lymph nodes. All sentinel lymph nodes should be resected to achieve a complete nodal staging. In the inguinal or low-axillary nodal stations, planar scintigraphic images mostly are adequate for the localization of the sentinel lymph nodes. However, in the regions of the head and neck, the chest, and the pelvis, an imaging method for the more precise anatomic localization of the sentinel lymph nodes preoperatively is highly desired. Recently, integrated single-photon emission computed tomography and computed tomography (SPECT/CT) scanners have become available. Initial reports suggest that integrated SPECT/CT might have an additional value in sentinel lymph node scintigraphy in head and neck tumors and tumors draining to the pelvic lymph nodes. We evaluated the clinical use of integrated SPECT/CT in the identification of the sentinel lymph nodes in patients with operable breast cancer. In our experience, localization and identification of sentinel lymph nodes was more accurate by integrated SPECT/CT imaging in comparison with planar images and SPECT images, respectively. In this report, the experiences of sentinel lymph node imaging with SPECT/CT are summarized.     

淋巴显像及术中γ探测定位活检乳腺癌前哨淋巴结

目的：探讨淋巴显像及术中γ探测定位活组织检查乳腺癌前硝淋巴结的临床价值。方法：术前在乳腺肿瘤表面正中皮内注射37－74MBq ^99Tcm-大分子右旋糖酐（Dx)，用淋巴显像和术中γ探测定位乳腺癌 前硝淋巴结，术中切除前 淋巴结，而后行腑窝淋巴结清扫术，两标本连同切除的乳腺肿物同时送病理检查，分析和前哨淋巴结转移与腋窝淋巴结的关系。结果：31例均行淋巴显像和术中γ探测定位乳腺癌前哨淋巴结患者中，检出率为100％，有3例前哨淋巴结病理检查呈假阴性，假阴性率为25％，结论：术中γ探测是乳腺癌前哨淋巴结定位最可靠的手段。以乳腺 癌前哨淋巴结活组织检查取代常规腑窝淋巴结清扫术尚需进一步研究。     

Preliminary study of real-time three-dimensional contrast-enhanced ultrasound of sentinel lymph nodes in breast cancer

To investigate the clinical value of real-time three-dimensional contrast-enhanced ultrasound (3D-CEUS) in the detection of sentinel lymph nodes (SLNs) and drainage lymphatics in breast cancer patients. The prospective study was performed in women with pathology-confirmed T1/2 breast cancer between June 2016 and December 2017 who underwent sentinel lymph node biopsy and 3D-CEUS. The number, size, location, enhancement pattern of SLNs, and the lymphatic drainage patterns were reviewed. The routes, location of SLNs, and lymph channels (LCs) on the surface were marked. All patients underwent blue dye–guided sentinel lymph node biopsy (SLNB) finally. According to the postoperative pathology findings and the blue dye staining of the lymphatic drainage routes, there are six patterns of lymphatic drainage routes and the coincidence rate of the 3D-CEUS was 97.4%; the sensitivity, specificity, positive predictive value, negative predictive value, the LN detection rate, and the correct diagnosis rate of the 3D-CEUS were 75%, 93.0%, 81.8%, 89.9%, 95.3%, and 87.7%, respectively. 3D-CEUS is a new feasible and useful approach to detect the SLNs and LCs. 3D-CEUS can accurately localize the LCs and SLNs and estimate the presence of metastatic lymph nodes. • The three-dimensional contrast-enhanced ultrasound can detect the sentinel lymph nodes. • The three-dimensional contrast-enhanced ultrasound can show the stereo direction of sentinel lymph nodes and lymph drainage routes. • The three-dimensional contrast-enhanced ultrasound can accurately localize the LCs and SLNs and estimate the presence of metastatic lymph nodes.     

Technical aspects of sentinel node lymphoscintigraphy for breast cancer.

OBJECTIVE: A significant morbidity risk is associated with axillary nodal dissections for breast cancer. Many treatment decisions are based on axillary nodal status. Lymphatic mapping and sentinel node biopsy have been investigated to determine if the histology of the sentinel node reflects the remaining lymph node basin. We describe the technical aspects of sentinel node lymphoscintigraphy for breast cancer. METHODS: Ninety-three patients had lymphoscintigraphy for breast cancer. Patients with palpable lesions had 4 concentric injections around the site and lesions requiring localization had injections made through tubing connected to the localizing wire introducer needle. Immediate static images were acquired and the sentinel node was marked for surgery. Marks were reverified using a handheld gamma probe. RESULTS: Lymph nodes were visualized by lymphoscintigraphy in 87% of cases. Time to visualization of lymph nodes ranged from 1-120 min with a mean of 28 min. An average of 1.5 nodes were visualized. The overall success rate for identifying the sentinel node at time of surgery was 85%. CONCLUSION: We conclude that lymphoscintigraphy for breast cancer is a detailed procedure that requires coordination with radiology and surgery teams to ensure proper identification of sentinel lymph nodes.     

Lymphoscintigraphy in breast cancer: the value of breast lymphoscintigraphy in breast sentinel node staging

A 28-year-old woman with an infiltrating ductal carcinoma in the upper outer quadrant of the left breast diagnosed by excisional biopsy underwent lumpectomy, intraoperative lymphatic mapping, and sentinel node dissection. This was followed by an immediate completion axillary node dissection using a hand-held gamma probe and isosulfan blue to map the lymphatics. Preoperative breast lymphoscintigraphy showed drainage into the axilla and an apparent area of radiocolloid accumulation in the inferior hemisphere of the left breast. Because our protocol called only for removal of axillary sentinel nodes, the inferior hemisphere radiocolloid accumulation was not removed. The patient did not complete local regional therapy with breast irradiation and developed a mass in the inferior hemisphere of the left breast, which on biopsy was shown to be metastatic breast cancer in an intramammary lymph node. This case illustrates the potential value of breast lymphoscintograms to identify unusual sites of lymphatic drainage that may prove to be clinically relevant.     

Factors affecting sentinel node localization during preoperative breast lymphoscintigraphy.

Variable success rates for identifying axillary (AX) sentinel nodes in breast cancer patients using preoperative lymphoscintigraphy have been reported. We evaluated the effects of age, weight, breast size, method of biopsy, interval after biopsy, and imaging view on the success of sentinel node identification and on the kinetics of radiopharmaceutical migration. METHODS: Preoperative breast lymphoscintigraphy was performed in consecutive breast cancer patients from February 1998 to December 1998. The ipsilateral shoulder was elevated on a foam wedge and the arm was abducted and elevated overhead. Imaging using this modified oblique view of the axilla (MOVA) started immediately after peritumoral injection of Millipore-filtered 99mTc-sulfur colloid and continued until AX sentinel nodes were identified. Anterior views were obtained after MOVA. AX, internal mammary (IM), and clavicular (CL) basins were monitored in all patients. MOVA was compared with the anterior view for sentinel node identification. Age, weight, breast size, method of biopsy, interval after biopsy, and primary tumor location were evaluated for their effects on sentinel node localization and transit times from injection to arrival at the sentinel nodes. RESULTS: Seventy-six lymphoscintigrams were obtained for 75 patients. AX sentinel nodes were revealed in 75 (99%) cases. IM or CL sentinel nodes were found in 19 (25%) cases and were not related to tumor location; exclusive IM drainage was present in 1 (1%) case. Identification of AX sentinel nodes was equivalent with MOVA and anterior views in 18 (24%) patients, was better with MOVA in 20 (26%) patients, and was accomplished only with MOVA in 38 (50%) patients. Median transit time was 17.5 min (range, 1 min to 18 h) after injection, and larger breast size was associated with increased transit time. No effect of age, weight, biopsy method, interval from biopsy, or tumor location on transit time was found. CONCLUSION: Use of MOVA can improve identification of AX sentinel nodes. Although AX drainage is the predominant pattern, a tumor in any portion of the breast can drain to IM sentinel nodes. Transit time was influenced by breast size. Overall short arrival times with this technique allow sentinel lymph node dissection to be performed on the same day as lymphoscintigraphy.     

Sentinel Node Concept in Breast Cancer

BACKGROUND/PURPOSE: It seems that there exists a specific lymph node center called sentinel node (SN) which appears to be the primary site of metastases. The sentinel node concept (SNC) is fundamentally based on the orderly progression of tumor cells within the lymphatic system. It is the most important new concept in surgical and radiation oncology. The purpose is to present the biological significance, the diagnostic and clinical basis of the sentinel node concept in breast cancer patients. MATERIAL AND METHODS: Lymphoscintigraphy and gamma probe biopsy is necessary to show predictable lymph flow to the regional sentinel node, to multiple sentinel nodes or unpredictable lymph flow to extra-regional sentinel nodes and for performing sentinel node procedure. The standard protocol for the evaluation of the sentinel node metastases consists of extensive histopathological investigation including step Hematoxylin & Eosin (H&E) stained sections and immunohistochemistry. RESULTS: A high rate of success of the identification of the sentinel node for breast cancer was reported. The presence or absence of metastasis in this node is a very accurate predictor of overall nodal status. The temptation to examine the sentinel node with the greatest possible degree of accuracy highlights one of the major problems related to sentinel node biopsy. The success of the sentinel node procedure depends primarily on the adequate functional capacity necessary for sufficient uptake to ensure the accurate identification. In negative sentinel-node patients a complete axillary lymph node dissection is avoidable. In sentinel-node positive patients and clinically negative patients a postoperative radiotherapy would permit an adequate tumor control. The last 2 procedures permit a low morbidity. In the actual TNM classification it was recently introduced a definition of a "pN0" patient based on sentinel node biopsy. New target volumes are defined for adjuvant radiotherapy or lymphatic basins could be spared from unnecessary irradiation. CONCLUSION: The sentinel node concept seems to revolutionize the treatment of early breast cancer. Biopsy of the sentinel node is a highly accurate, minimally invasive method of staging patients and can substantially reduce the morbidity and costs of treatment by avoiding unnecessary complete axillary lymph node dissection. The procedure may lead to a more justifiable approach to adjuvant therapy strategies with low complication rates. The identification of the individual lymphatic flow pattern would permit the irradiation of the individual locoregional lymphatic basin.     

The role of sentinel node biopsy in breast cancer management: an overview

Regional lymph nodes surgical management is an integral part of breast cancer therapy. One of the most important therapeutic problems is the risk of surgical treatment which is too wide or inadequate due to the lack of correct presurgical information on the conditions of regional lymph nodes. For melanoma the problem was solved combining surgical accuracy with the slightest surgical resection, using sentinel node biopsy. In breast cancer the removal of axillary nodes proved to be unnecessary in more than 50% of cases. The first international studies on the use of sentinel node biopsy in breast carcinoma for the identification of patients who do not need axillary clearance suggest the high accuracy of the technique. Some practical problems still exist, however, and the optimisation of the method is not yet complete. The use of sentinel node biopsy in breast cancer treatment might be able to provide distinctive clinical information, which can improve our knowledge about the disease?'s biological behaviour and about its treatment.     

A critical review of variables affecting the accuracy and false-negative rate of sentinel node biopsy procedures in early breast cancer

Radionuclide sentinel lymph node localization and biopsy is a staging procedure that is being increasingly used to evaluate patients with invasive breast cancer who have clinically normal axillary nodes. The most important prognostic indicator in patients with invasive breast cancer is the axillary node status, which must also be known for correct staging, and influences the selection of adjuvant therapies. The accuracy of sentinel lymph node localization depends on a number of factors, including the injection method, the operating surgeon's experience and the hospital setting. The efficacy of sentinel lymph node mapping can be determined by two measures: the sentinel lymph node identification rate and the false-negative rate. Of these, the false-negative rate is the most important, based on a review of 92 studies. As sentinel lymph node procedures vary widely, nuclear medicine physicians and radiologists must be acquainted with the advantages and disadvantages of the various techniques. In this review, the factors that influence the success of different techniques are examined, and studies which have investigated false-negative rates and/or sentinel lymph node identification rates are summarized.     

Radioguided sentinel lymph node biopsy in malignant cutaneous melanoma.

The procedure of sentinel lymph node biopsy in patients with malignant cutaneous melanoma has evolved from the notion that the tumor drains in a logical way through the lymphatic system, from the first to subsequent levels. As a consequence, the first lymph node encountered (the sentinel node) will most likely be the first affected by metastasis; therefore, a negative sentinel node makes it highly unlikely that other nodes in the same lymphatic basin are affected. Although the long-term therapeutic benefit of the sentinel lymph node biopsy per se has not yet been ascertained, this procedure distinguishes patients without nodal metastases, who can avoid nodal basin dissection with its associated risk of lymphedema, from those with metastatic involvement, who may benefit from additional therapy. Sentinel lymph node biopsy would represent a significant advantage as a minimally invasive procedure, considering that an average of only 20% of melanoma patients with a Breslow thickness between 1.5 and 4 mm harbor metastasis in their sentinel node and are therefore candidates for elective lymph node dissection. Furthermore, histologic sampling errors (amounting to approximately 12% of lymph nodes in the conventional routine) can be reduced if one assesses a single (sentinel) node extensively rather than assessing the standard few histologic sections in a high number of lymph nodes per patient. The cells from which cutaneous melanomas originate are located between the dermis and the epidermis, a zone that drains to the inner lymphatic network in the reticular dermis and, in turn, to larger collecting lymphatics in the subcutis. Therefore, the optimal route for interstitial administration of radiocolloids for lymphoscintigraphy and subsequent radioguided sentinel lymph node biopsy is intradermal or subdermal injection. (99m)Tc-Labeled colloids in various size ranges are equally adequate for radioguided sentinel lymph node biopsy in patients with cutaneous melanoma, depending on local experience and availability. For melanomas along the midline of the head, neck, and trunk, particular consideration should be given to ambiguous lymphatic drainage, which frequently requires interstitial administration virtually all around the tumor or surgical scar from prior excision of the melanoma. Lymphoscintigraphy is an essential part of radioguided sentinel lymph node biopsy because images are used to direct the surgeon to the sites of the nodes. The sentinel lymph node should have a significantly higher count than that of the background (at least 10:1 intraoperatively). After removal of the sentinel node, the surgical bed must be reexamined to ensure that all radioactive sites are identified and removed for analysis. Virtually the entire sentinel lymph node should be processed for histopathology, including both conventional hematoxylin-eosin staining and immune staining with antibodies to the S-100 and HMB-45 antigens. The success rate of radioguidance in localizing the sentinel lymph node in melanoma patients is approximately 98% in institutions that perform a high number of procedures and approaches 99% when combined with the vital blue-dye technique. Growing evidence of the high correlation between a sentinel lymph node biopsy negative for cancer and a negative status for the lymphatic basin-evidence, therefore, of the high prognostic value of sentinel node biopsy-has led to the procedure's being included in the most recent version of the TNM staging system and starting to become the standard of care for patients with cutaneous melanoma.     

Update on detection of sentinel lymph nodes in patients with breast cancer

Sentinel lymph node biopsy is now the practice of choice for the management of many patients with breast cancer. This was not true in the early 1990s, when the first such procedures were performed and protocols for such were refined often. This was also not true in the first years of the 21st century, when a decade of collective experience and information acquired from numerous clinical investigations dictated additional subtle and not-so-subtle refinements of the procedures. However, it is true today; reports of the latest round of clinical investigations indicate that there are several breast cancer sentinel node procedures that result in successful identification of potential sentinel nodes in nearly all patients who are eligible for such procedures. A significant component of many of these successful sentinel node procedures is a detection and localization protocol that involves radiotracer methodologies, including radiopharmaceutical administration, preoperative nuclear medicine imaging, and intraoperative gamma counting. The present state and roles of nuclear medicine protocols used in breast cancer sentinel lymph node biopsy procedures is reviewed with emphasis on discussion of recent results, unresolved issues, and future considerations. Included are brief reviews of present radiotracer and blue-dye techniques for node localization, including remarks about injection strategies, counting probe technology, and radiation safety. Included also are discussions of on-going investigations of the implications of the presence of micrometastases; of the management value of detection, localization, and excision of extra-axillary nodes such as internal mammary nodes; and of the broad range of recurrence rates presently being reported. Remarks on the present and possible near- and long-term roles for nuclear medicine in the staging of breast cancer patients including comments on positron emission tomography and intraoperative imaging conclude the article.     

MR imaging-guided axillary node biopsy for breast cancer: initial findings

The aim of this study was to evaluate the usefulness and feasibility of preoperative sentinel node needle biopsy of the breast under guidance of open MR imaging, a method that we developed. Nine patients with breast cancer in whom the axillary lymph nodes were not palpable underwent preoperative sentinel node needle biopsy under real-time MR imaging guidance. The sentinel nodes were identified before the biopsy using CT and MR imaging. Diagnostic ability of this method was compared with that of the operative diagnosis. Sentinel nodes were correctly identified in all 9 patients. The MR imaging-guided sentinel node needle biopsy was performed for all of the 9 patients, and, in 7 (77.8%) of the 9, a specimen sufficient for pathologic evaluation was obtained; and in 6, whether malignancy existed was precisely diagnosed. No serious complications were noted. This experience indicates the possibility of a precise diagnosis of whether the sentinel node in breast cancer is benign or malignant without surgery.     

Sentinel lymph node mapping for breast cancer: analysis in a diverse patient group.

PURPOSE: To evaluate sentinel lymph node mapping in patients with breast cancer. MATERIALS AND METHODS: Sixty-two patients with breast cancer scheduled to undergo axillary nodal dissection underwent scintigraphic localization of sentinel lymph nodes with filtered technetium 99m sulfur colloid. At surgery, isosulfan blue was injected. Sentinel nodes were identifiable by blue color and by radioactivity with hand-held gamma probe. Results were analyzed statistically. RESULTS: A sentinel lymph node was identified in 49 patients (79%). Lymph nodes were positive for metastatic disease in 26 patients (42%). The mapping success rate was 78% (n = 21) in the 27 patients with no prior surgery, 78% (n = 18) in the 23 patients with prior surgery, and 86% (n = 12) in the 14 patients with prior chemotherapy. Axillary nodes were positive in 11 (41%) of the 27 patients with no prior intervention, six (26%) of the 23 patients with prior surgery, and 10 (71%) of the 14 patients with prior chemotherapy. There were no false-negative findings in patients without prior intervention. Four patients with positive nodes had false-negative sentinel nodes. CONCLUSION: Sentinel lymph node mapping and biopsy without axillary dissection is appropriate in patients with breast cancer who have not undergone prior intervention. Further study is necessary to ascertain the accuracy of the procedure for patients who have undergone presurgical chemotherapy or previous excisional biopsy.     

Sentinel lymph node identification in breast cancer patients

PURPOSE: To evaluate the predictive value of sentinel lymph node biopsy versus axillary node dissection on lymph node status in patients with T1-T2 breast cancer. MATERIAL AND METHODS: Twenty-nine patients with T1 and 12 with T2 breast carcinoma and clinically N0 axillary lymph nodes, underwent lymphoscintigraphy following the administration of 99mTc-human albumin nanocolloids. The tracer was injected subdermally, over the tumor mass, in the 34 patients with palpable lesions and peritumorally (n=3) or intratumorally (n=4), under stereotactic or ultrasound guidance, in the 7 patients with non-palpable lesions. Anterior and lateral planar images were acquired 15 min after the injection of the tracer and repeated every 30 min up to 3 hr until identification of sentinel lymph node. At the end of the scintigraphic study, sentinel node skin projection was marked using a dermographic pen. Eighteen hours after lymphoscintigraphy, sentinel lymph node was identified and removed during surgery by hand-held gamma probe, then, the remaining axillary lymph nodes were dissected. All surgical specimens underwent histologic examination. Sentinel lymph nodes free of metastasis at histology, underwent additional examination with immunohistochemistry using monoclonal antibodies against cytokeratin and EMA to search for micrometastases. RESULTS: Sentinel lymph node was identified in the 34 patients injected subdermally and in the 3 patients injected peritumorally, while it remained undetected in the 4 patients injected intratumorally except for one case in which it was isolated by radioguided surgery but not scintigraphically. Sentinel nodes resulted free of metastases both at histology and immunohistochemistry in 32 cases and metastatic in 6. In the 32 patients with non-metastatic sentinel lymph nodes the other axillary nodes were also free of metastases. Among the 6 metastatic sentinel lymph nodes, in 3 cases they were the only metastatic nodes of the axilla while in the other 3 cases metastases were spread to other axillary nodes. CONCLUSIONS: In agreement with previous studies, our results showed that sentinel lymph node radioguided biopsy is a simple and reliable method for predicting axillary lymph nodes status and for avoiding axillary dissection in early breast cancer patients with sentinel node free of metastases.     

Sentinel node biopsy in male breast cancer

OBJECTIVE: Male breast cancer is a rare disease and axillary status is the most important prognostic indicator. Lymphoscintigraphy associated with gamma-probe guided surgery has been proved to reliably detect sentinel nodes in female patients with breast cancer. This study evaluates the feasibility of the surgical identification of sentinel node by using lymphoscintigraphy and a gamma-detecting probe in male patients, in order to select subjects who would be suitable for complete axillary lymphadenectomy. METHODS: Colloid human albumin labelled with 99Tc was administered to 18 male patients with breast cancer and clinically negative axillary lymph nodes. Lymphoscintigraphy was performed the day before surgery. An intraoperative gamma-detecting probe was used to identify sentinel nodes during surgery. RESULTS: Lymphoscintigraphy and biopsy of the sentinel node were successful in all cases. A total of 20 sentinel nodes were removed. Pathological examinations showed 11 infiltrating ductal carcinomas, two intraductal carcinomas and five intracystic papillary carcinomas. Six patients (33%) had positive sentinel node (micrometastases were found in three patients). These patients underwent axillary dissection; in five of them (83%) the sentinel node was the only positive node. Twelve patients (67%) showed negative sentinel nodes; in all of them no further surgical treatments were planned. CONCLUSIONS: As in women, lymphoscintigraphy and sentinel node biopsy under the guidance of a gamma-detecting probe proved to be an easy method for the detection of sentinel nodes in male breast carcinoma. In male patients with early stage cancer, sentinel node biopsy might represent the standard surgical procedure in order to avoid unnecessary morbidity after surgery, preserving accurate staging of the disease in the axilla.     

Non-visualization of sentinel lymph node in patients with breast cancer

Histological evaluation of the first draining lymph node (sentinel node) in the axilla of patients with breast cancer has dramatically altered the surgical approach to these patients, with sparing of the axilla if no tumour cells are identified. In a fraction of patients imaged after peri-tumoural injection of the breast, there is no visualization of the sentinel node. We retrospectively analysed the status of patients whose nodes were visualized and of patients whose nodes failed to visualize, to define the variables associated with non-visualization of the sentinel node. Seventy-four breast cancer patients were imaged following peri-tumoural injection of filtered 99Tc(m)-sulfur colloid, immediately and up to 5.5 h post-injection. The scintigraphic data were analysed with reference to the patient's age, histology, grade, site and size of tumour, previous diagnostic procedure and time interval to scan, using univariate analysis and a logistic regression model. A sentinel node was visualized in 53 of 74 women (72%). Comparison of patients with non-visualized versus visualized sentinel nodes disclosed no statistically significant univariate relation to age of the patients (P = 0.10), size of tumour (P = 0.46), site (P = 0.26), histology [invasive ductal carcinoma in 16 of 20 (80%) non-visualized cases, and in 43 of 53 (81%) visualized patients], prior excision biopsy (P = 0.36) and time interval to surgery (P = 0.29). Tumour grade was the only significant variable on univariate analysis (P = 0.03), though multivariate analysis showed that none of the independent parameters were statistically significant. In 39 patients with an upper outer quadrant tumour, the location of the sentinel node was not limited to the axilla and even crossed the midline of the breast. Our results show that none of the independent variables is associated with non-visualization of sentinel lymph node on preoperative lymphoscintigraphy of patients with breast cancer, though the tumour grade may have contributed to non-visualization of this node. The non-axillary drainage from upper outer quadrant tumours suggests the routine use of lymphoscintigraphy prior to axillary dissection.     

新型特异性靶向前哨淋巴结示踪剂的研究进展

前哨淋巴结活检术（SLNB）广泛应用于乳腺癌、黑色素瘤等恶性肿瘤,其使用的示踪剂主要有放射性核素示踪剂和活性蓝染料,包括近年应用较多的荧光示踪剂,均为非特异性示踪剂,且存在次级淋巴结显影的问题。以B细胞表面的CD20抗原和巨噬细胞表面的甘露糖受体CD206为靶点的新型特异性靶向前哨淋巴结（SLN）示踪剂,通过放射性核素、荧光或两者共同对其进行标记,与常规示踪剂相比,其具有注射部位快速清除、SLN可快速、高摄取以及较少的远端淋巴结显影等特点,满足理想示踪剂的特性。此外,受体靶向荧光放射性药物可以实现术前放射性核素显像与术中荧光成像,研究应用于前列腺癌、结肠癌等肿瘤的SLN活检。笔者主要对新型特异性靶向SLN示踪剂的研究进展进行综述。     

Sentinel lymph node biopsy after percutaneous diagnosis of nonpalpable breast cancer.

PURPOSE: To determine the technical success rate of sentinel lymph node biopsy in women with nonpalpable infiltrating breast cancer diagnosed by using percutaneous core biopsy and to determine the frequency with which sentinel lymph node biopsy obviated axillary dissection. MATERIALS AND METHODS: Retrospective review revealed 33 women who underwent sentinel node biopsy after percutaneous core biopsy diagnosis of nonpalpable infiltrating breast cancer. Sentinel nodes were identified with radioisotope and blue dye; the procedure was technically successful if sentinel nodes were found at surgery. All sentinel nodes were excised. Axillary dissection was performed if tumor was present in sentinel nodes. RESULTS: Sentinel nodes were found at surgery in 30 women (91%). Sentinel nodes were identified with both radioisotope and blue dye in 22 (73%) of these women, with only radioisotope in six (20%), and with only blue dye in two (7%). Sentinel nodes were found in 12 (80%) of 15 women in the first half of the study versus all 18 (100%) women in the second half (P = .08). Sentinel nodes were free of tumor in 23 (77%) of 30 women. In six (86%) of seven women with tumor in sentinel nodes, the sentinel nodes were the only nodes with tumor. CONCLUSION: Sentinel node biopsy was successful in 30 women (91%) with nonpalpable infiltrating carcinoma diagnosed with percutaneous core biopsy and obviated axillary dissection in 23 women (70%). Using both radioisotope and blue dye may increase the success rate. A learning curve exists, and success improves with experience.