Sentinel lymph node biopsy in breast cancer: results of intradermal periareolar tracer injection and follow-up of sentinel lymph node-negative patients

Several methods are in use for identification of the sentinel lymph node (SLN) in breast cancer. We set up the hypothesis that intradermal (i.d.) infra-areolar injection of technetium-99m in combination with i.d. injection of patent blue dye lateral to the areola can identify the same lymph node as peritumoral injection, regardless of the location of the tumour. Each of 50 patients with breast cancer (group I) received an i.d. injection of technetium-99m 1cm caudal to the areola. After induction, blue dye was injected intradermally 1cm lateral to the areola. These patients underwent axillary dissection regardless of their lymph node status. The SLN was identified in 96% of these patients. One of them had axillary lymph node metastases even though the SLN was negative (6%). Further 82 patients (group II) underwent SLN identification and removal without further axillary dissection. The duration of mean follow-up for these patients was 28 months (16-39 months). One patient developed axillary recurrence (1%) 24 months after the initial operation. Intradermal periareolar tracer injection is an accurate method of locating the sentinel node. Long-term follow-up of patients who had negative sentinel nodes and did not undergo axillary dissection revealed a low axillary recurrence rate.     

A New Radiocolloid for Sentinel Node Detection in Breast Cancer

Background:The optimal radioactive tracer and technique for sentinel lymph node localization in breast cancer is yet to be determined. The dilemma of small particle size with dispersion to second echelon nodes versus failure of migration of larger radiocolloids needs to be resolved. A new radiocolloid preparation with particle size under 0.1 micron was developed with excellent primary/post lymphatic entrapment ratio.Objective:To assess the feasibility of a new ^99mTc radiocolloid cysteine-rhenium colloid in sentinel lymph node (SLN) localization for breast cancer.Methods:Forty-seven patients with newly diagnosed T1 or T2 breast cancer underwent injection of ^99mTc-labeled cysteine-rhenium colloid followed by lymphoscintigraphy. Same day SLN biopsy with patent blue dye and intraoperative gamma probe to identify SLNs were performed.Results:SLN mapping and intraoperative localization were successful in 46/47 (98%) of patients. The blue dye radioactive tracer concordance was 94%. There was one false-negative in a patient with a nonpalpable tumor that underwent ultrasound-guided peritumoral radiocolloid injection.Conclusions:^99mTc-cysteine-rhenium colloid is highly effective in identifying SLNs. It has the advantage of smaller particle size than sulfur colloid with easier lymphatic migration. It has a more neutral pH with less pain on injection and does not require filtration, thereby minimizing radiation exposure to technologists.Presented at the 53rd Annual Meeting of the Society of Surgical Oncology, New Orleans, Louisiana, March 16–19, 2000     

新型示踪剂99mTc-利妥昔用于原发性乳腺癌前哨淋巴结活检的初步研究

目的 探讨新型示踪剂^99mTc-利妥昔用于原发性乳腺癌前哨淋巴结活检（SLNB）的可行性和效果。方法 采用^99mTc-利妥昔配合染料专利蓝对85例原发性乳腺癌进行前哨淋巴结活检,并对前哨淋巴结（SLN）进行常规病理检查和以细胞角蛋白19为标志物的免疫组化检查,以确定有无SLN转移。结果^99mTc-利妥昔联合专利蓝检测SLN,检测成功率为96％（82／85）。SLN转移阳性30例（37％,30／82）,其中24例（80％,24／30）常规病理检查为转移阳性,6例（20％,6／30）为免疫组化检出的微转移。30例SLN有转移患者中,12例同时存在其他腋下淋巴结转移,18例为惟一转移淋巴结。1例SLN转移假阴性。灵敏度为97％（30／31）,特异度为100％（51／51）,准确度为99％（81／82）,假阴性率为3％（1／30）,阴性预测值为98％（51／52）,阳性预测值为100％（31／31）。内乳淋巴结显像11例,活检病理检查均为转移阴性。结论 ^99mTc-利妥昔可使SLN显像持久,有利于SLNB的时间选择;^99mTc-利妥昔联合专利蓝行SLNB的准确率、敏感度较高。     

Subareolar Subcutaneous Injection of Blue Dye versus Peritumoral Injection of Technetium-labeled Human Albumin to Identify Sentinel Lymph Nodes in Breast Cancer Patients

Lymphatic mapping in breast cancer patients is a widely used technique for axillary staging, though the optimal technique is not yet established. The purpose of this study was to show that subareolar and subcutaneous injection of blue dye drains to the same sentinel lymph node (SLN) in the axillary basin as does peritumoral injection of technetium (Tc)-labeled albumin. Two injection methods were compared in 154 consecutive patients with newly diagnosed pT1 or pT2 breast cancers (tumor size 5–45 mm). The diagnosis of invasive breast cancer was confirmed by core needle biopsy. Peritumoral injection of 40 to 60 MBq ⁹⁹Tc-labeled colloidal albumin was performed 18 to 20 hours prior to surgery. In addition, 2 ml of blue dye was injected subcutaneously into the subareolar plexus of the same patients exactly 5 minutes prior to incision and dissection of the SLNs. The blue and hot SLNs were identified by searching for the blue lymphatic vessel and the blue lymph node and by counting the radioactivity with a gamma probe. The correlation between the blue nodes and the hot nodes was examined. Altogether, 154 patients were enrolled in the study. Three patients had bilateral breast cancer, and a total of 157 sentinel lymph node biopsies (SLNBs) were performed. The SLNs could be identified in 155 of the 157 SLNBs (98.7%), and the hot node clearly corresponded to the blue node in 151 of the 155 SLNBs (97.4%). Neither a hot node nor a blue node could be identified in 2 of the 157 SLNBs (1.3%). No concordance between the blue node and the hot node could be achieved in 4 of the 155 SLNBs (2.6%). Injection of blue dye into the subareolar lymphatic plexus shows excellent correlation with peritumoral injection of technetium-labeled albumin concerning the identification of SLNs. Our results support the hypothesis that the lymphatic drainage of the breast parenchyma and the subareolar plexus leads to the same sentinel lymph node. It is a rapid, reliable method for identifying SLNs in breast cancer patients. It is easy to perform, especially in nonpalpable tumors, and it does not disturb surgery by discoloring peritumoral tissue.     

Subareolar injection is a better technique for sentinel lymph node biopsy

BACKGROUND: Numerous techniques and materials show accuracy in localizing the sentinel lymph node (SLN). We hypothesized that subareolar injection of material would localize the SLN as effectively as peritumoral injection. METHODS: Thirty-eight patients were injected with technetium-99 sulfur colloid either peritumorally or subareolarly in addition to the injection of blue dye around the tumor. Radioactive SLNs were localized using a hand-held gamma probe. RESULTS: Nineteen patients were included in each of the two groups, peritumoral and subareolar. SLNs were found in all patients injected subareolarly and in 18 of 19 injected peritumorally. The false-negative rate was 20% for peritumoral injection and 0% for subareolar injection. CONCLUSION: The results suggest that subareolar injection was as accurate, if not more accurate, than peritumoral injection for localizing the SLN. This technique is simpler than peritumoral injection and does not require injection under image guidance for nonpalpable lesions.     

Intraoperative identification of esophageal sentinel lymph nodes with near-infrared fluorescence imaging

OBJECTIVE: In esophageal cancer, selective removal of involved lymph nodes could improve survival and limit complications from extended lymphadenectomy. Mapping with vital blue dyes or technetium Tc-99m often fails to identify intrathoracic sentinel lymph nodes. Our purpose was to develop an intraoperative method for identifying sentinel lymph nodes of the esophagus with high-sensitivity near-infrared fluorescence imaging. METHODS: Six Yorkshire pigs underwent thoracotomy and received submucosal, esophageal injection of quantum dots, a novel near-infrared fluorescent lymph tracer designed for retention in sentinel lymph nodes. Six additional pigs underwent thoracotomy and received submucosal esophageal injection of CW800 conjugated to human serum albumin, another novel lymph tracer designed for uptake into distant lymph nodes. Finally, 6 pigs received submucosal injection of the fluorophore-conjugated albumin with an endoscopic needle through an esophagascope. These lymph tracers fluoresce in the near-infrared, permitting visualization of migration to sentinel lymph nodes with a custom intraoperative imaging system. RESULTS: Injection of the near-infrared fluorescent lymph tracers into the esophagus revealed communicating lymph nodes within 5 minutes of injection. In all 6 pigs that received quantum dot injection, only a single sentinel lymph node was identified. Among pigs that received fluorophore-conjugated albumin injection, in 5 of 12 a single sentinel lymph node was revealed, but in 7 of 12 two sentinel lymph nodes were identified. There was no dominant pattern in the appearance of the sentinel lymph nodes either cranial or caudal to the injection site. CONCLUSION: Near-infrared fluorescence imaging of sentinel lymph nodes is a novel and reliable intraoperative technique with the power to assist with identification and resection of esophageal sentinel lymph nodes.     

Effect of lymphatic tumor burden on sentinel lymph node biopsy in breast cancer

Distal obstruction of the lymphatics by tumor and extensive tumor infiltration of the draining lymph nodes may prevent migration of the tracer to the sentinel lymph node (SLN), adversely affecting SLN identification. Rerouting of lymphatic drainage may divert flow to internal mammary nodes and cause an alternative nonsentinel node to become "sentinel," increasing the risk of a false-negative result. A total of 618 breast cancer patients underwent SLN biopsy using 99mTc albumin colloid and patent blue V injected peritumorally. This was followed by standard axillary node clearance in all patients at the same operation. The overall SLN identification and false-negative rates were 96% (593/618) and 7.6% (17/223), respectively. There was no difference in the SLN identification rate and the false-negative rate with increasing axillary tumor burden (as determined by the total number of positive nodes in the axilla). Further detailed analyses are based on the 64 patients from one center (Cardiff) who had at least one positive SLN and proceeded to axillary clearance. A total of 83 positive SLNs were removed from 64 patients. Tumor burden in the positive SLN was assessed by measuring the size of the metastasis and percentage replacement of the SLN by tumor, and by documenting extranodal invasion. Increasing tumor burden in the SLN (as determined by percentage replacement of SLN by tumor and presence of extranodal invasion) was associated with decreased radioisotope uptake (p = 0.005 and p < 0.0001, respectively). There was no correlation between radioisotope uptake and the size of the metastasis in the SLN. There was no correlation between blue dye uptake, internal mammary drainage on lymphoscintiscan, and tumor burden in the positive SLN. In conclusion, increased axillary lymphatic tumor burden is not associated with failure to identify a SLN or false-negative results when both blue dye and radioisotope are used for SLN biopsy. In an individual SLN, the percentage replacement by tumor, but not the absolute size of the metastatic deposit is associated with reduced radioisotope uptake. Extranodal invasion in the SLN is a marker of lymphatic obstruction and is significantly associated with reduced radioisotope uptake. The lymphatic tumor burden does not seem to affect blue dye uptake or internal mammary drainage.     

乳腺癌新辅助化疗后前哨淋巴结活检的初步研究

目的研究乳腺癌新辅助化疗后前哨淋巴结活检（SLNB）的可行性和效果。方法利用新型示踪剂——^99mTc-利妥昔配合专利蓝染料对60例原发性乳腺癌新辅助化疗后病例进行SLNB，并对SLN进行常规病理检查和免疫组织化学检查。SLNB后常规腋窝淋巴结清扫。结果SLN检测成功率95％（57／60）。SLN转移阳性23例（40％），其中18例为常规病理检查转移阳性（78％），5例为免疫组织化学检出的微转移（22％）。23例SLN有转移病例中，9例同时存在其他腋窝淋巴结转移，另外14例为惟一转移淋巴结。1例SLN转移假阴性。灵敏度96％（23／24），准确性98％（56／57），特异度100％（33／33），假阴性率4．3％（1／23），阴性预测值97％（36／37），阳性预测值100％（24／24）。内乳淋巴结显像11例，活检病理检查均为转移阴性。结论同位素示踪剂和蓝染料联合检测方法对原发性乳腺癌新辅助化疗后进行SLNB同样适用，内乳前哨淋巴结活检不应做常规推荐。     

Comparison between periareolar and peritumoral injection of radiotracer for sentinel lymph node biopsy in patients with breast cancer

BACKGROUND: The technique of sentinel lymph node (SLN) biopsy in patients with breast cancer varies among reports, and the optimal method remains to be established, particularly with regard to the site of radiotracer injection. The aim of this study was to compare periareolar and peritumoral injection of radiotracer in detecting SLN in patients with breast cancer. METHODS: Patients with T1-2 breast cancer (n = 155) were enrolled in this study. In phase 1 (n = 62), SLN biopsy was performed by using peritumoral injection of blue dye alone followed by backup axillary lymph node dissection. In phase 2, SLN biopsy was performed by using peritumoral injection of blue dye and peritumoral (group A, n = 41) or periareolar (group B, n = 52) injection of technetium 99m tin colloid. RESULTS: In phase 1, the detection rate of SLN was 81% and the false-negative rate was 5.6%, indicating our skill in SLN biopsy. In phase 2, the success rate of lymphoscintigraphy was significantly (P <.001) higher in group B (90%) than in group A (51%). The mean ex vivo radioactivity of SLN in group B (117 counts per second; range, 5 to 900) was also significantly (P <.05) higher than in group A (51 counts per second; range, 8 to 260). In addition, the detection rate of SLN was significantly (P <.05) higher in group B (100%) than in group A (90%). CONCLUSIONS: Periareolar injection of radiotracer for SLN biopsy is superior to peritumoral injection because of its simplicity, achieving a high success rate in lymphoscintigraphy and SLN detection.     

Sentinel lymph node biopsy in breast cancer: unfiltered radioisotope is superior to filtered

BACKGROUND: The combination of gamma-probe radiolocalization and blue-dye mapping of sentinel lymph nodes (SLNs) has been advocated as the most accurate method for staging the clinically negative axilla in breast cancer patients, but the technical aspects of these procedures are not fully characterized in the literature. In this study, we compared the success of SLN localization in 134 consecutive breast cancer patients using blue dye plus two different preparations of radiocolloid. STUDY DESIGN: A retrospective analysis of a prospectively maintained data base was performed to assess SLN localization in two cohorts of patients. Unfiltered technetium-99m (Tc-99m) sulfur colloid (in 77 patients; group I) was compared with filtered Tc-99m sulfur colloid (in 57 patients; group II). All patients had a peritumoral injection of blue dye and isotope, followed immediately by lymphoscintigraphy to confirm radioactivity at the injection site and to image the SLN. Statistical analysis was performed using the Pearson chi-square test. RESULTS: Unfiltered Tc-99m sulfur colloid was superior to the filtered radiocolloid in localizing the SLN (88% versus 73%; p = 0.03). SLN imaging by lymphoscintigraphy was also more successful in the unfiltered group. Using the combination of blue dye and radiolocalization, SLNs were identified in 94% of patients. CONCLUSIONS: For optimal localization of the SLN in breast cancer patients, surgeons should use the combined technique of blue-dye mapping and gamma-probe localization using unfiltered Tc-99m sulfur colloid.     

Improved Lymphatic Mapping Technique for Breast Cancer

Abstract: Breast sentinel lymph node biopsy is becoming more common. However, the best injection technique is not well established. Currently the gold standard is peritumoral injection. However, for upper outer quadrant tumors there is considerable axillary “shine through” which makes the identification of the radioactive sentinel lymph node difficult. We undertook a study to compare an injection in Sappey's subareolar plexus to the gold standard of peritumoral injection. Between December 1997 and March 1998, 85 patients with breast cancer were enrolled in the study. All patients were injected with 2 cc of normal saline containing 1.0 mCi of unfiltered technetium sulfur colloid in Sappey's subareolar plexus in the clock position of the breast cancer. In the operating room the patients underwent a peritumoral injection of 5 cc of 1% isosulfan blue. All blue and radioactive lymph nodes were identified and removed. The majority of the tumors were in the upper outer quadrant and were diagnosed by core biopsy. Only half of the patients had palpable tumors and approximately 25% had previous upper outer quadrant biopsy incisions. Peritumoral blue dye injection yielded an identification rate of 94%, with 99% of these being blue and radioactive. Three patients had radioactive lymph nodes with no blue lymph nodes identified. One of these patients had a micrometastasis. Injection in Sappey's subareolar plexus in the clock position of the tumor drained to the same sentinel lymph node as peritumoral injection. This injection technique solved the two major problems confronting the wide adoption of sentinel lymph node biopsy for breast cancer staging. First, it eliminates axillary “shine through” which will allow nonspecialist surgeons to more easily identify the radioactive axillary sentinel lymph node. Second, it allows for easier isotope injection by the technician or nuclear medicine physician, by eliminating the need for three-dimensional localization. This new technique should allow the majority of breast cancer patients who are treated by nonspecialist surgeons to be offered this less morbid, more accurate procedure.     

Functional lymphatic anatomy for sentinel node biopsy in breast cancer: echoes from the past and the periareolar blue method

OBJECTIVE: To simplify and improve the technique of axillary sentinel node biopsy, based on a concept of functional lymphatic anatomy of the breast. SUMMARY BACKGROUND DATA: Because of their common origin, the mammary gland and its skin envelope share the same lymph drainage pathways. The breast is essentially a single unit and has a specialized lymphatic system with preferential drainage, through select channels, to designated (sentinel) lymph nodes in the lower axilla. METHODS: These hypotheses were studied by comparing axillary lymph node targeting after intraparenchymal peritumoral radiocolloid (detected by a gamma probe) with the visible staining after an intradermal blue dye injection, either over the primary tumor site (90 procedures) or in the periareolar area (130 procedures). The radioactive content, blue coloring, and histopathology of the individual lymph nodes harvested during each procedure were analyzed. RESULTS: Radiolabeled axillary nodes were identified in 210 procedures, and these were colored blue in 200 cases (94%). The targeting concordance between peritumoral radiocolloid and intradermal blue dye was unrelated to the breast tumor location or the site of dye injection. Radioactive sentinel nodes were not stained blue in 10 procedures (5%), but this mismatching could be explained by technical problems in all cases. In two cases (1%), the (pathologic) sentinel node was blue but had no detectable radiocolloid uptake. CONCLUSIONS: The lessons learned from this study provide a functional concept of the breast lymphatic system and its role in metastasis. Anatomical and clinical investigations from the past strongly support these views, as do recent sentinel node studies. Periareolar blue dye injection appears ideally suited to identify the principal (axillary) metastasis route in early breast cancer. Awareness of the targeting mechanism and inherent technical restrictions remain crucial to the ultimate success of sentinel node biopsy and may prevent disaster.     

Sentinel node biopsy to evaluate the metastatic dissemination of oesophageal adenocarcinoma

BACKGROUND: The aim of this study was to determine the feasibility and accuracy of sentinel lymph node (SLN) biopsy for oesophageal adenocarcinoma. METHODS: Fifty-seven patients with adenocarcinoma of the lower oesophagus (n = 40) or gastric cardia (n = 17) underwent endoscopic peritumoral injection of (99m)Tc-radiolabelled nanocolloid before en bloc resection with extended lymphadenectomy. SLNs were identified during surgery using a handheld gamma probe and the pattern of radioactive uptake was quantified after operation. All 1667 resected lymph nodes were examined immunohistochemically for micrometastases. RESULTS: SLNs were identified in all 57 patients. They contained metastases (n = 32) or micrometastases (n = 3) in 35 of 37 node-positive patients and there were two false-negative studies. The overall accuracy of SLN biopsy was 96 per cent and SLNs were more likely to contain tumour than other lymph nodes (P < 0.001). Tumour-infiltrated nodal stations had a higher proportion of radioactive uptake (P < 0.001). Lower oesophageal tumours had a greater proportion of SLNs (P = 0.018), radioactive uptake (P < 0.001) and malignant nodes (P = 0.004) in the mediastinum than gastric cardia tumours. CONCLUSION: The sentinel node concept is applicable to oesophageal adenocarcinoma and could be used to tailor the extent of lymphadenectomy. There is a close relationship between patterns of radioactive uptake and lymphatic tumour dissemination, which differ for lower oesophageal and gastric cardia tumours.     

前哨淋巴结检测在乳腺癌治疗中的意义

目的评价前哨淋巴结活检术 (sentinellymphnodebiopsy,SLNB)预测腋淋巴结肿瘤转移的准确性及其临床意义。方法使用专利蓝染色法和 /或99mTc标记的硫胶体示踪法对我院收治的81例乳腺癌患者进行前哨淋巴结活检。两种方法联合检测 3例前哨淋巴结 (sentinellymphnode ,SLN)均阴性者未行腋淋巴结清扫术。结果 81例患者SLN总检出率为 96 3% (78/81) ,总准确率为97 5 % ,总假阴性率 9 7%。 5 3例单纯染色法检出率为 92 5 % ,准确率 94 2 % ,假阴性率 15 8% ;2 8例99mTc示踪法和 /或染色法联合检测结果分别为 10 0 % ,10 0 %和 0。结论SLNB能够准确预测腋窝淋巴结的转移状况。两种方法联合检测为最佳。术前化疗对假阴性率可能有影响。     

直视下吲哚菁绿荧光显影在乳腺癌前哨淋巴结活检中的应用

目的探讨直视下吲哚菁绿荧光显影在乳腺癌腋窝前哨淋巴结活检中的应用。方法入组34例术前考虑临床腋窝淋巴结阴性的乳腺癌患者。全麻成功后,常规消毒铺巾后,使用2 ml注射器及22 G针头,于患侧乳腺外上象限近乳晕皮下组织内注入1%亚甲蓝1~2 ml。亚甲蓝注射10~15 min后,将吲哚菁绿1 ml(1 mg/ml),注射至乳晕边缘3点、6点、9点和12点位置皮下。使用明德脉管成像仪,行患侧乳腺外上象限区域淋巴管引流实时显像。再用科大在研直视下荧光脉管显影仪行患侧乳腺外上象限区域淋巴管引流实时显像。术中荧光显影及亚甲蓝蓝染的淋巴结均予以切除,均行石蜡切片病理学检查。结果明德显像仪淋巴管显影率为97.06%(33/34),科大在研直视下显影仪淋巴管显影率97.06%(33/34)。34例可见明显荧光浓聚,33例可见明显蓝染淋巴结,1例未见蓝染淋巴结,但术中可见荧光显影。在平均淋巴结检出数量上,科大在研直视下荧光脉管显影仪为(3.090±1.602)个,明德系统为(3.060±1.613)个,亚甲蓝染色为(3.020±1.527)个,三组间两两比较差异无统计学意义(P>0.05)。结论科大在研直视下荧光脉管成像仪的淋巴结显影效果与明德成像仪相似,且能降低手术操作的繁琐程度,有望减少手术时间,为精准外科治疗提供一个更便捷的手术导航系统。     

Touch Imprint Cytology Evaluation of Sentinel Lymph Node in Breast Cancer

Background  

Most centers use lymphoscintiscan for identification of a sentinel lymph node (SLN) and frozen section for its evaluation. The aim of the present study was to assess the accuracy of peritumoral methylene blue dye injection for SLN identification and the technique of touch imprint cytology (TIC) for its evaluation.     

Results of Preoperative Lymphoscintigraphy for Breast Cancer Are Predictive of Identification of Axillary Sentinel Lymph Nodes

The aim of this study was to identify the variables associated with successful peroperative sentinel lymph node (SLN) localization. We studied 201 patients with T1, T2, N0 invasive breast cancer who underwent a SLN procedure from 1999 to 2003. Of these 201 patients, 55 underwent peritumoral and 146 underwent periareolar radioisotope injection before the blue dye injection. All patients were operated on by breast conservative surgery and axillary dissection after SLN biopsy. Age, weight, menopausal status, previous biopsy, localization of the tumor, results of lymphoscintigraphy, site of radiotracer injection, tumor size, tumor grade, experience of surgeons, and the number of invaded axillary nodes were analyzed to determine whether they had any significant correlation with successful identification of SLN. Variables found to have a statistically significant influence on the SLN identification rate and on preoperative lymphoscintigraphy identification were introduced into a univariate and multivariate logistic regression model. In multivariate analysis, successful lymphoscintigraphy (P < 0.0001) and the absence of metastatic axillary nodes (P < 0.005) were associated with successful identification of SLNs. The peritumoral injection of radiotracer (P < 0.001), patient age > 60 years (P < 0.003), and localization of the tumor in the upper outer quadrant (P < 0.004) were associated with failure of lymphoscintigraphic visualization of SLN. The technique of SLN detection thus appears to be better for patients with low risk of invaded axillary lymph nodes.     

Sentinel node mapping during laparoscopic distal gastrectomy for gastric cancer

Background The goal of this study was to evaluate the feasibility and accuracy of sentinel node (SN) mapping with endoscopic submucosal blue dye injection during laparoscopic distal gastrectomy for gastric cancer. Methods Thirty-four patients affected by gastric adenocarcinoma without gross clinical serosal invasion and distant metastasis were prospectively enrolled. At the start of the surgery, 2 ml of 2% patent blue was endoscopically injected into the submucosal layer at four points around the site of the primary tumor. Sentinel nodes were defined as nodes that were stained by the blue dye within 5–10 min after the dye injection. After identification and removal of sentinel lymph nodes, each patient underwent laparoscopic distal gastrectomy with D1 (n = 2) or D2 (n = 32) lymphadenectomy. Results Of the 34 patients, 14 had positive nodules (41%). SNs were detectable as blue nodes in 27 (80%) of 34 patients. The mean number of dissected lymph nodes per patient was 31 ± 10 (range = 16–64) and the mean number of blue nodes was 1.5 (range = 1–4). Only five (sensitivity 36%) of 14 N(+) patients had at least one metastatic lymph node among the SNs identified. In these 14 patients the sentinel node was traced in 12 cases. Sentinel node status diagnosed the lymph node status with 74% accuracy. In early gastric cancer (n = 18), three patients had lymph node metastasis. These early gastric cancer patients with nodal metastases had at least one metastatic lymph node among the SNs identified (sensitivity 100%). Conclusions Blue dye SN mapping during laparoscopic distal gastrectomy seems to be a feasible and accurate diagnostic tool for detecting lymph node metastasis in patients with early-stage gastric cancer in which the accuracy of the method was 100%. However, in more advanced gastric cancer the results are not satisfactory. Validation of this method requires further studies on technical issues, including selection of the tracers.     

Sequential dermal-peritumoral radiocolloid injection for sentinel node biopsy for breast cancer: the University of Florida experience

Although sentinel lymph node (SLN) biopsy is rapidly becoming the standard of care for small breast cancers the optimal radiocolloid injection technique remains controversial. We report our experience with sequential dermal-peritumoral radiocolloid injection that takes advantage of both techniques. One hundred eighteen patients with clinical stage T(is), T1, T2 and N0 breast cancer underwent SLN biopsy at the University of Florida. Twelve to 18 hours before surgery patients received either an injection of 0.5 to 1.0 mCi 50:50 filtered:unfiltered technetium sulfur colloid into the dermis overlying the tumor and/or a peritumoral injection of a 3 to 4-mCi of radiocolloid 30 minutes later. Dynamic lymphoscintigraphy was performed and the topographical location of all imaged lymph nodes was marked on the skin. The next morning the surgeon utilized a hand-held gamma probe to remove all SLN(s) defined as any lymph node with radioactive counts 10 per cent or more of the ex vivo counts of the most radioactive SLN [internal mammary (IM) nodes were not removed]. The SLN identification rate was 98.5 per cent (3 IM nodes) for dermal injection (d.), 83.3 per cent (1 IM node) for peritumoral injection (p.), and 100 per cent (14 IM nodes) for sequential dermal-peritumoral injection (d.p.) (p < 0.05 DP versus D). Sequential d.p. 50:50 filtered:unfiltered technetium sulfur colloid injection results in a rapid, high SLN identification rate that persists until surgery the next morning. Delineation of nonaxillary SLNs may lead to more accurate breast cancer staging and may also influence the delivery of IM node radiation.     

Dermal injection of radioactive colloid is superior to peritumoral injection for breast cancer sentinel lymph node biopsy: results of a multiinstitutional study

OBJECTIVE: To determine the optimal radioactive colloid injection technique for sentinel lymph node (SLN) biopsy for breast cancer. SUMMARY BACKGROUND DATA: The optimal radioactive colloid injection technique for breast cancer SLN biopsy has not yet been defined. Peritumoral injection of radioactive colloid has been used in most studies. Although dermal injection of radioactive colloid has been proposed, no published data exist to establish the false-negative rate associated with this technique. METHODS: The University of Louisville Breast Cancer Sentinel Lymph Node Study is a multiinstitutional study involving 229 surgeons. Patients with clinical stage T1-2, N0 breast cancer were eligible for the study. All patients underwent SLN biopsy, followed by level I/II axillary dissection. Peritumoral, subdermal, or dermal injection of radioactive colloid was performed at the discretion of the operating surgeon. Peritumoral injection of isosulfan blue dye was performed concomitantly in most patients. The SLN identification rates and false-negative rates were compared. The ratios of the transcutaneous and ex vivo radioactive SLN count to the final background count were calculated as a measure of the relative degree of radioactivity of the nodes. One-way analysis of variance and chi-square tests were used for statistical analysis. RESULTS: A total of 2,206 patients were enrolled. Peritumoral, subdermal, or dermal injection of radioactive colloid was performed in 1,074, 297, and 511 patients, respectively. Most of the patients (94%) who underwent radioactive colloid injection also received peritumoral blue dye injection. The SLN identification rate was improved by the use of dermal injection compared with subdermal or peritumoral injection of radioactive colloid. The false-negative rates were 9.5%, 7.8%, and 6.5% (not significant) for peritumoral, subdermal, and dermal injection techniques, respectively. The relative degree of radioactivity of the SLN was five- to sevenfold higher with the dermal injection technique compared with peritumoral injection. CONCLUSIONS: Dermal injection of radioactive colloid significantly improves the SLN identification rate compared with peritumoral or subdermal injection. The false-negative rate is also minimized by the use of dermal injection. Dermal injection also is associated with SLNs that are five- to sevenfold more radioactive than with peritumoral injection, which simplifies SLN localization and may shorten the learning curve.