FDG-PET for axillary lymph node staging in primary breast cancer

Management of the axilla in patients with operable breast cancer is still one of the most controversial areas in clinical oncology. The best procedure to examine the lymph nodes is still standard axillary lymph node dissection; nevertheless, the morbidity associated with this procedure is well known. Based on these considerations, it is important for progress in the treatment of operable breast cancer that strategies are found that permit a less invasive method of axillary sampling which does not impair the patient's quality of life. The technique of sentinel lymph node (SLN) biopsy has recently been proposed for this purpose, with very important results. SLN has now become routine practice in the surgical management of breast cancer, and in many institutions patients with a negative SLN biopsy are spared axillary dissection, while those with a positive SLN biopsy are submitted to axillary node dissection. The good accuracy of SLN biopsy represents a significant advance in the management of primary breast cancer; however, false negative axillary results can occur in a variable percentage of patients, and the contribution of the SLN procedure to the detection of metastases in the internal mammary and supraclavicular lymph nodes is not clear. Among the recently developed imaging modalities, positron emission tomography (PET) with (18)F-fluorodeoxyglucose (FDG) has in particular been applied to the study of lymph node metastases in cancer patients. Several clinical studies have been carried out to evaluate the accuracy of PET in the axillary staging of operable primary breast cancer. These studies have sometimes provided conflicting results, either supporting the possibility of using FDG-PET to select patients who need axillary dissection or questioning whether FDG-PET can accurately assess the axillary status in primary breast cancer. All the limitations and the advantages of FDG-PET are discussed in this paper, by examining the performance of scanner technology and the possible causes of the false negative results. In the experience of the authors, comparing FDG-PET with SLN biopsy in the same series of patients, the results seem to indicate that the lower sensitivity of PET is restricted to micrometastases. Of course, this limitation of PET has to be analysed in relation to the importance of such small axillary metastases for the outcome of patients with breast cancer. The added value offered by PET in breast cancer staging in comparison with intraoperative detection of the sentinel node lies in the fact that FDG-PET is a non-invasive procedure that allows, within a single examination, the biological characterisation of breast cancer and viewing of the entire body.     

Evaluation of axillary status in breast cancer. CT-based determination of sentinel lymph node size

Purpose:
To determine whether the location and size of sentinel lymph nodes (SLN) on CT are predictive of the axillary lymph node status in patients with breast cancer. Material and Methods:
Forty patients with confirmed breast cancer underwent 5-mm CT of both breasts and axillae and the most inferior lymph node in the affected axilla was designated the SLN. Based on CT assessment of the axillary lymph node status, 22 (55%) patients then underwent dye- and gamma probe (DGP)-guided SLN biopsy followed by axillary dissection; 18 (45%) underwent dissection without prior SLN biopsy. The localization and status of the SLN determined on CT and by DGP-guided biopsy were compared. Biopsied and excised nodes were subjected to histopathologic examinations. Results:
All SLN identified on CT were close to the lateral thoracic artery and their localization corresponded well with SLN identified by the DGP-guided method. The positive predictive value of CT diagnosis was 100%. Histopathologic examination of excised nodes confirmed that none of the SLN biopsies was false-negative. Conclusion:
Our CT criteria were highly accurate for identification and diagnostic assessment of SLN and useful for evaluating the axillary status in patients with breast cancer.     

Lymphatic drainage patterns on early versus delayed breast lymphoscintigraphy performed after injection of filtered Tc-99m sulfur colloid in breast cancer patients undergoing sentinel lymph node biopsy

The axillary lymph node status is the most important predictor of prognosis and aids in breast cancer treatment planning. Patients with breast cancer now frequently undergo sentinel lymph node (SLN) biopsy rather than axillary lymph node dissection to determine the status of the regional lymph nodes. However, the optimal timing of radionuclide injection relative to the timing of SLN biopsy remains controversial. The objective of this study was to compare the lymphatic drainage patterns on lymphoscintigraphy performed at 15 minutes to 4 hours and at 18 to 24 hours after injection of filtered Tc-99m sulfur colloid, and to determine whether, over time, radiocolloid migrates to second-echelon nodes that are not the SLNs. Fifteen women with breast cancer (mean age, 55 years; range, 38-78 years) were scheduled to undergo SLN biopsy after each received an injection of 18.5 MBq (0.5 mCi) filtered Tc-99m sulfur colloid into the breast parenchyma surrounding the tumor or biopsy cavity. Both early (15 minutes to 4 hours after radionuclide injection) and delayed (18-24 hours after radionuclide injection) lymphoscintigraphy was performed in each patient. SLN biopsy was performed, followed by completion axillary lymph node dissection and planned breast surgery. In each patient the patterns of distribution of the radionuclide in the lymph nodes were the same on early and delayed lymphoscintigrams. These findings, that the distributions of radionuclide in lymph nodes are identical on early and delayed images obtained after injection of filtered Tc-99m sulfur colloid, suggest that performing SLN biopsy on the day after injection does not diminish the accuracy of the technique in predicting the potential site of metastasis in the regional lymph nodes in patients undergoing this procedure for breast cancer.     

Use of ultrasound-guided axillary node core biopsy in staging of early breast cancer

The aim of this study was to see how effective ultrasound-guided needle biopsy was at detecting lymph node involvement in patients with early breast cancer. Patients with newly diagnosed invasive breast cancer underwent axillary ultrasound (US) where lymph node size and morphology were noted. A core biopsy (CB) was undertaken of any node greater than 5 mm in longitudinal section. Patients with benign CBs proceeded to sentinel lymph node (SLN) biopsy, whereas those with malignancy underwent axillary lymph node dissection (ALND). US and CB findings were correlated with final surgical histology in all cases. One hundred and thirty-nine patients were examined, of whom 52.5% had lymph node metastases on final histology. One hundred and twenty-one patients (87%) underwent axillary node CB. The overall sensitivity of CB for detecting lymph node metastases was 53.4% (60.3% for macrometastases; 26.7% for micrometastases). The US morphological characteristics most strongly associated with malignancy were absence of a hilum and a cortical thickness greater than 4 mm. However, one third of patients with normal lymph node morphology had nodal metastases, and only 12% of these were diagnosed on CB. CB of axillary lymph nodes can diagnose a substantial number of patients with lymph node metastases, allowing these patients to proceed directly to ALND, avoiding unnecessary SLN biopsy.     

Use of tomographic nuclear medicine procedures, SPECT and pinhole SPECT, with cationic lipophilic radiotracers for the evaluation of axillary lymph node status in breast cancer patients

Scintimammography with the cationic lipophilic (99m)Tc-tetrofosmin and (99m)Tc-methoxyisobutylisonitrile (MIBI) is one of the most widely available non-invasive imaging methods employed in the preoperative evaluation of breast cancer axillary lymph node status, for which, at present, axillary lymph node dissection (ALND) is still considered the method of choice. Comparative studies have demonstrated that single-photon emission computed tomography (SPECT) acquisition significantly improves the sensitivity and accuracy achieved with planar scintimammography, particularly when lymph nodes are non-palpable, small in size and limited in number. Thus, SPECT should be preferred to planar imaging, particularly in those patients without clinical suspicion of axillary metastatic involvement, given its high negative predictive value; however, false negative results have been reported due to the small size of lymph nodes and/or to partial or micrometastatic involvement. SPECT could also find clinical application in combination with radioguided sentinel lymph node (SLN) biopsy, providing additional useful information in selected cases. The performance of SPECT can be improved by using a pinhole collimator (pinhole SPECT), as recently demonstrated in comparative studies, and this method also determines the number of lymph nodes, thus delivering important prognostic information. Moreover, pinhole SPECT, the principal limitation of which (as with imaging methods) lies in its inability to detect micrometastases, has also proved capable of increasing the accuracy of radioguided SLN biopsy. However, only limited data relating to pinhole SPECT are available as yet, and clinical trials are necessary to validate its potential value.     

乳腺癌前哨淋巴结的临床研究

目的　评价乳腺癌前哨淋巴结活检(sentinellymphnodebiopsy ,SLNB)的必要性、可行性、准确性及临床应用价值。方法　利用脂质体 亚甲蓝混合物对本院 2 0 0 1年 6月～ 2 0 0 2年 12月收治的 32例T1～ 2 N0 M0 乳腺癌患者进行SLNB。随后常规行腋窝淋巴结清扫(axillarylymphnodedisescetion,ALND)。将切除的前哨淋巴结 (SLN)和腋窝淋巴结 (ALN)同时送病理检查 ,了解其符合率 ,并评价SLNB在早期乳腺癌中的可行性及临床应用价值。结果　成功确定患者SLN 31例 ,共 5 7枚 ,成功率为 96 .9% (31/ 32 ) ;SLN阳性 9例(2 9.0 % ) ,SLN阴性 2 2例 (70 % ) ;ALN阳性 10例 (31.3% ) ,ALN阴性 2 2例(6 8.8% ) ;SLNB的灵敏度为 90 .0 % ,准确性为 93.8% ,假阴性率为 10 .0 % ,假阳性率为 0。结论　SLNB可以准确地预测乳腺癌患者ALN的组织学特征 ;利用脂质体 亚甲蓝混合物作为显示剂可以提高SLNB的成功率     

Sentinel node identification using microbubbles and contrast-enhanced ultrasonography

Sentinel lymph node (SLN) biopsy has become the recommended method for surgical staging of the axilla in patients with breast cancer. Grey-scale axillary ultrasonography (US) combined with US-guided biopsy is a widely used preoperative staging procedure but has limited sensitivity. US contrast agent "microbubbles", when injected intradermally, have been shown to have the potential to enter the breast lymphatics, travel rapidly to the axilla, and visualize the putative SLNs. This review illustrates the SLN identification technique using intradermal injection of microbubbles and contrast-enhanced US. The injection method, lymphatic visualization techniques, grey-scale and contrast-enhanced US images of the putative SLNs are reviewed and exemplified.     

Breast sentinel lymph node navigation with three-dimensional interstitial multidetector-row computed tomographic lymphography

OBJECTIVE: Three-dimensional multidetector-row computed tomographic lymphography (3D MDCT-LG) with interstitial injection of a widely available nonionic monometric contrast medium iopamidol was used for navigation of breast sentinel lymph node (SLN) biopsy. METHODS: 3D MDCT-LG was obtained after massage of the interstitially injection sites of a total of 4-5 mL undiluted iopamidol at periareolar and peritumoral areas in 68 consecutive patients with early-stage breast cancer, using a 4 detector-row CT scanner. Drainage lymphatic patterns and SLN anatomy were assessed on 3D MDCT-LG images. 3D MDCT-LG-navigated SLN biopsy with combined use of blue dye was followed by backup axillary lymph node dissection to evaluate accuracy of SLN biopsy. RESULTS: The 3D MDCT-LG images clearly localized primary SLNs by visualizing the direct connection between these nodes and their afferent lymphatic vessels on detailed anatomy of the surrounding structures in all patients. Drainage lymphatic pathways on these images were classified into 4 patterns: single route/single SLN (39 cases, 57%), multiple routes/multiple SLNs (10 cases, 15%), single route/multiple SLNs (9 cases, 13%), and multiple routes/single SLN (10 cases, 15%). Under 3D MDCT-LG navigation, SLNs was found at the accurate location in all patients. With backup axillary lymph node dissection, metastasis was found in 14 (20%) patients, and 8 of these patients had metastasis only in the preoperatively identified SLNs. In other 5 positive patients, metastasis was found both in the SLN and non-SLNs. However, micrometastasis eventually was found only in non-SLN in an elderly patient. Overall, the sensitivity, false-negative rate, and accuracy of 3D CT-L-navigated SLN biopsy were 92% (13/14 patients), 7% (1/14 patients), and 98% (67/68 patients), respectively. CONCLUSIONS: Topographic 3D interstitial MDCT-LG can be a widely available and reliable navigator for breast SLN biopsy.     

FDG PET positive lymph nodes are highly predictive of metastasis in breast cancer

AIM: To determine whether or not fluorodeoxyglucose positron emission tomography (FDG PET) imaging when positive could obviate the necessity for sentinel lymph node biopsy and for complete axillary node dissection in patients with breast cancer. METHODS: A total of 80 female patients with a histological diagnosis of breast cancer and clinically negative axillary nodes underwent an FDG PET and sentinel lymph node biopsy (SLNB) or total axillary dissection for staging of axilla. Both SLNB and axillary dissection were performed in 72 patients, while eight patients had total axillary dissection without SLN biopsy. RESULTS: Of the 80 patients, 36 had lymph node metastasis on histopathology. SLNB was positive for metastasis in 35 (97%) of 36 patients (29 macrometastasis and seven micrometastasis). In the patient with false negative SLNB, the lymph node was completely replaced by the tumour. The FDG PET was true positive in 16 of 36 patients (sensitivity, 44%). There were two false positive studies with FDG PET, resulting in a specificity of 95%. The positive predictive value and accuracy of FDG PET for the detection of axillary lymph node metastasis were 89% and 72%, respectively. Univariate analysis revealed that higher grade of tumour, increased size and number of axillary lymph nodes were significantly associated with positive FDG PET results for axillary staging. CONCLUSION: FDG PET cannot replace histological staging using SLNB in patients with breast cancer. However, FDG PET has a high specificity and positive predictive value for staging of the axilla in these patients. The patients with higher grade of tumour, larger size and higher number of axillary lymph nodes may be considered for FDG PET scan for axillary staging.     

Scintigraphic visualization of an epigastric sentinel node in recurrent breast cancer after lumpectomy and postoperative radiation therapy

Sentinel node imaging and biopsy have become standard procedures for staging early breast cancer. Positive sentinel lymph node (SLN) biopsy necessitates the need for axillary lymph node dissection (ALND). Failure to visualize a sentinel lymph node in recurrent breast cancer after treatment by surgery, chemotherapy, and high-dose postoperative radiation therapy is almost the case in every patient. The reason for failure to visualize the sentinel node is the fibrosis that follows high-dose radiotherapy and blocks the lymphatics preventing spread of the tumor cells to the lymph nodes. Alternative pathways for the drainage of lymph from the breast are developed in these patients. We have previously reported on the alternative pathways of lymphatics to the contralateral axilla, supraclavicular area, and also reported on the development of intramammary lymph nodes. In this report, we are presenting another alternative pathway of lymphatics to the region of the epigastrium below the lower end of the sternum.     

Breast sentinel lymph node mapping at CT lymphography with iopamidol: preliminary experience

PURPOSE: To evaluate sentinel lymph node (SLN) mapping with interstitial computed tomographic (CT) lymphography with small volumes of iopamidol for direction of SLN biopsy in breast cancer. MATERIALS AND METHODS: Thin-section transverse and three-dimensional CT images that included the breast and axilla were acquired at multi-detector row helical CT in 17 patients with operable breast cancer before subcutaneous injection of 2 mL of undiluted iopamidol into peritumoral and periareolar areas and 1-5 minutes after massage of injection sites. Location and size of SLNs were assessed at CT lymphography and were compared with SLNs at standard axillary lymph node dissection with blue dye staining. RESULTS: CT lymphography allowed localization of SLNs in all patients by means of visualization of a direct connection between an SLN and its afferent lymphatic vessels draining from the injection sites. Afferent vessels were joined and drained into a single axillary SLN, except in four patients with two or three SLNs, including a parasternal one. SLNs did not enhance because of rerouting of lymph flow in four patients. At surgery, SLNs that were stained or not stained with blue dye were easily found with CT lymphographic guidance. Tumoral infiltration was not evident in any resected nodes, except for infiltration in one patient with micrometastasis in SLN alone and infiltration in four patients with massive metastasis in both SLN and distant nodes. CONCLUSION: Because preoperative CT lymphography-guided SLN mapping provides SLN position with detailed lymphatic anatomy, it may be useful for the direction of breast SLN biopsy.     

前哨淋巴结阳性乳腺癌患者腋窝转移危险因素的研究

目的研究前哨淋巴结（sentinellymphnode,SLN）阳性乳腺癌患者腋窝非前哨淋巴结（NSI-N）转移的危险因素,验证纪念斯隆一凯特琳癌症中心（MSKCC）腋窝NSLN转移预测模型评估乳腺癌患者的临床应用价值。方法回顾性地分析军事医学科学院附属医院普外科2000年,11月至2011年3月175例成功行SLN活检且结果阳性、随即行腋窝淋巴结清扫的乳腺癌患者临床病理资料,使用MSKCC预测模型计算每例患者腋窝NSLN转移风险,利用校正曲线和受试者操作特性曲线（ROC）下面积（AUC）评估该模型预测的准确性。结果原发肿瘤大小、肿瘤是否多发、阳性SLN数、阳性SLN转移率、阴性SLN数与腋窝NSLN转移相关,P值分别为0．0018、0．0029、0．0049、0．0007、0．0002。多因素Logistic回归分析发现,原发肿瘤大小、肿瘤是否多发和阳性SI．N数是NSI．N转移的独立危险因素,P值分别为0．0022、0．0160、0．0176。校正曲线显示预测值曲线和真实值曲线趋势相近,MSKCC预测模型被验证的AUC值为0．79。结论对于SLN转移阳性的乳腺癌患者,原发肿瘤越小、肿瘤单发、阳性SLN数越少、阴性SLN数越多、阳性SLN转移率越低,其腋窝NSLN转移可能性越低,可对是否行腋窝淋巴结清扣提供参考。MSKCC预测模型可较准确地预测腋窝NSI．N的转移风险。     

Is imaging the future of axillary staging in breast cancer?

Axillary management in patients with breast cancer has become much less invasive with the introduction of sentinel lymph node biopsy (SLNB). However, over 70 % of SLNBs are negative, questioning the generic use of this invasive procedure. Emerging evidence indicates that breast cancer patients with a low axillary burden of disease do not benefit from axillary lymph node dissection (ALND). Non-invasive techniques such as paramagnetic iron oxide contrast-enhanced magnetic resonance imaging (MRI) may provide genuine alternatives to axillary staging and should be evaluated within clinical trials. Selective axillary surgery could then be offered based on imaging findings and for therapeutic intent. This non-operative approach would reduce morbidity further and facilitate interpretation of follow-up imaging. Key Points ? Modern imaging and biopsy greatly help the axillary staging of breast cancer. ? Superparamagnetic iron oxide (SPIO)-enhanced MRI offers a further advance. ? Sentinel lymph node biopsy may become redundant with SPIO-enhanced MRI. ? Selective therapeutic axillary surgery should be based upon preoperative imaging findings.     

Predicting sentinel lymph node metastasis in breast cancer with lymphoscintigraphy

Objective

Lymphoscintigraphy is an effective method for detecting sentinel lymph nodes (SLNs). However, the rate and degree of SLN detection is not uniform. We quantified SLNs detected with lymphoscintigraphy, and investigated correlations with factors that may influence detection. We then attempted to predict SLN metastasis from lymph node counts, comparing the predictions to subsequent biopsy results.

Methods

We assessed lymph node counts in 100 breast cancer patients in whom a single SLN was detected with a fixed lymphoscintigraphy procedure. We examined correlations between the counts and factors known to influence lymphoscintigraphic SLN detection (age, body mass index, tumor size, and presence or absence of metastasis), and determined reference values (lymph node counts of 10.0, 19.4 and 53.0) which were used to predict SLN metastasis in 100 subsequent patients. The predictions were then compared with the SLN biopsy findings.

Results

SLN counts correlated strongly with the presence or absence of metastasis, with metastasis-positive lymph nodes showing significantly lower counts than negative nodes (p < 0.001). Prediction of SLN metastasis achieved a 100% positive predictive value at a reference value of 10.0, and a 100% negative predictive value at a reference value of 53.0. At a reference value of 19.4, the sensitivity, specificity, and diagnostic accuracy were 77.8, 73.2, and 74.0%, respectively.

Conclusions

The SLN counts detected with lymphoscintigraphy were significantly lower in metastasis-positive lymph nodes than in metastasis-negative lymph nodes. This suggests that prediction of SLN metastasis in breast cancer is possible using lymphoscintigraphy.     

Radioguided localisation of non-palpable breast lesions and simultaneous sentinel lymph node mapping

The authors report their experience with a new strategy for radioguided breast surgery that combines radioguided occult lesion localisation (ROLL) and sentinel lymph node (SLN) mapping. The study population comprised 38 women with non-palpable breast lesions suspicious for breast cancer (BI-RADS 4-5). On the day before surgery, 0.2 ml solution containing particles of dextran labelled with approximately 15 MBq of technetium-99m was injected under stereotaxic guidance by mammography. All patients underwent open surgical biopsy guided by gamma probe, radiographic control of the surgical specimen and frozen section analysis. The rate of confirmation of lesion removal was 100% and the rate of simultaneous SLN mapping was 97.3% (37/38). Eleven cases of infiltrating carcinoma and eight of ductal carcinoma in situ (DCIS) were diagnosed intraoperatively. In the first eight invasive lesions, the SLN was biopsied and complete axillary lymph node dissection was performed; in the three other invasive lesions and in two aggressive cases of DCIS, only the SLN was dissected. The intraoperative results of SLN analysis and the definitive histopathological examinations of the SLN were always negative. It is concluded that ROLL and SLN can be employed simultaneously when dextran is used as a tracer; this technique allows frozen section diagnosis and intra-operative node analysis, and has many advantages over the conventional two-step procedure.     

Magnetic resonance imaging for axillary staging in patients with breast cancer

Purpose

To determine the utility of MRI for assessing axillary lymph node status in patients with breast cancer.

Materials and Methods

A consecutive series of patients who underwent breast MR before surgical management of breast cancer with axillary sampling between 2005 and 2007 were identified. MRs were evaluated for the number of nodes, contrast kinetics, nodal area, and number of nodes with no fatty hilum. Data were analyzed in the context of final breast pathology, sentinel lymph node status, and axillary nodal status. Correlations were analyzed using Kendall's τ‐b test. Reported P values are one‐sided.

Results

Fifty‐six females (median = 58 years) were studied. Sentinel lymph nodes (SLN) were positive in 15/56 patients (27%). All SLN + patients (n = 15) had completion axillary dissection. Extent of nodal disease was 1 (n = 3), 2 (n = 4), >2 (n = 8). Presence of any axillary lymph node with no fatty hilum and the number of nodes with no fatty hilum on MR significantly correlated with pathologic node positivity (P = 0.04); while kinetics, node number, and node size did not correlate.

Conclusion

Breast MR may be useful in the assessment of axillary nodes in patients with breast cancer. J. Magn. Reson. Imaging 2009. © 2009 Wiley‐Liss, Inc.     

Sentinel lymph node biopsy in pregnant patients with breast cancer

Purpose

Sentinel lymph node biopsy (SLNB) is currently not recommended in pregnant patients with breast cancer due to radiation concerns.

Methods

Twelve pregnant patients with breast cancer received low-dose (10 MBq on average) lymphoscintigraphy using ^99mTc human serum albumin nanocolloids.

Results

The sentinel lymph node (SLN) was identified in all patients. Of the 12 patients, 10 had pathologically negative SLN. One patient had micrometastasis in one of four SLN. One patient had metastasis in the SLN and underwent axillary clearance. From the 12 pregnancies, 11 healthy babies were born with no malformations and normal weight. One baby, whose mother underwent lymphatic mapping during the 26th week of gestation, was operated on at the age of 3 months for a ventricular septal defect and at 43 months was in good health. This malformation was suspected at the morphological US examination during week 21, well before lymphoscintigraphy, and was confirmed a posteriori by a different observer based on videotaped material. No overt axillary recurrence appeared in the patients with negative SLNs after a median follow-up of 32 months.

Conclusion

Our experience supports the safety of SLNB in pregnant patients with breast cancer, when performed with a low-dose lymphoscintigraphic technique.     

探测乳腺癌前哨淋巴结的初步应用

目的 评价核素淋巴显像和γ探针定位确定乳腺癌前哨淋巴结（SLN）的价值。方法 28例妇性乳腺癌患者,体检腋窝未扪及肿块。^99Tc^m－右旋糖酐（Dx）37MBq皮下注射,行淋巴显像后用γ探针皮肤定位,并与手术、病理检查结果对照。结果 28例患者中活检的SLN26例,灵敏度为85.7%(6/7例）,特异性100％（19／19例）。结论 核素淋巴显像和γ探针定位是一种简便、安全、易被患者接受的检测SLN的方法,对预测腋窝淋巴结转移有很大帮助。     

Sentinel lymph node identification and sampling in women with early breast cancer using 99m Tc labelled dextran 500 and patent blue V dye

The status of the homolateral axillary lymph nodes is still the most important prognostic factor in early stage breast cancer. The information obtained from the pathological examination of the lymph nodes guides is of critical importance in the decision process regarding the use of postoperative adjuvant therapy. However, lymph node axillary dissection can be followed by significant locoregional morbidity. The sentinel lymph node (SLN) technique was developed as a means of avoiding the full exploration of the axilla and consists in the identification of the first lymph node in the lymphatic drainage system of the breast tumour in the homolateral axilla. It has been demonstrated that the status of the SLN is highly predictive for the presence or absence of tumour involvement in the remaining lymph nodes in the axilla. In this study we evaluated the SLN technique using both 99mTc labelled dextran 500 and patent blue V dye in relation to the classical lymph node resection a series of 56 women with early breast cancer who attended the Breast Unit of the Academic Hospital of the Federal University of Rio Grande do Sul, Brazil. To our knowledge this is the first report in the literature of the utilization of 99mTc dextran 500 for the SLN technique. As there are no similar commercially available dedicated radiopharmaceuticals labelled for use in lymphoscintigraphy studies, we report on an effective method to label dextran 500 with 99mTc which proved to be simple, inexpensive and yielded similar results for SLN identification compared with those given in the literature. The median age of the patients was 57 years (range 32-82 years). Seventeen patients were age 50 years or less, and 39 patients were older than 50 years. The median tumour size was 2.0 cm (range 0.8-7.0 cm). The mapping of the SLN was possible in all cases during the transoperative period by using a hand-guided gamma probe and a blue dye. A median of 2.0 (range 1-5) SLN were excised per patient. The median of axillary lymph nodes excised per patient was 21 (range 10-36). The calculated sensitivity and specificity of the method were 95.6% and 100%, respectively. The negative predictive value and overall accuracy were 97% and 98.2%, respectively. In conclusion, the SLN technique was feasible and produced similar positive results as previously reported in the literature.     

The use of periareolar intradermal Tc-99m tin colloid and peritumoral intraparenchymal isosulfan blue dye injections for determination of the sentinel lymph node

PURPOSE: The purpose of the present study was to evaluate the use of lymphoscintigraphy, blue dye, and gamma probe detection methods for determination of the sentinel lymph node (SLN) using both periareolar intradermal injection of Tc-99m tin colloid and peritumoral intraparenchymal injection of isosulfan blue dye. METHODS: One hundred patients with T1-2 breast cancer and clinically negative nodes were enrolled in the present study. The study was composed of 2 groups. Backup axillary lymph node dissection (ALND) was mandatory in group 1 (20 patients) regardless of their lymph node status. In group 2 (80 patients), complete ALND was performed when intraoperative frozen section analysis of SLN revealed metastases. Otherwise, only SLN biopsy was performed without ALND. One day before surgery, Tc-99m tin colloid was injected at 4 periareolar sites intradermally. Lymphoscintigraphy was performed 1 to 2 hours after injection of the radiocolloid. Twenty minutes before surgery, isosulfan blue dye was injected into parenchyma surrounding the tumor or the biopsy cavity. RESULTS: The detection rates of SLN and false-negative rate of lymphoscintigraphy, blue dye, and gamma probe detection were 85%, 95% 100%, and 0% in group 1, 91%, 87%, and 95% in group 2, respectively. Detection rate by the combination of blue dye and radio tracer was 98%. CONCLUSIONS: According to the results of our study, we conclude that perioareolar intradermal injection of Tc-99m tin colloid combined with peritumoral intraparenchymal injection of blue dye is an accurate and easy method of locating the sentinel node with very high detection rates. It is recommended that the combination of all methods such as lymphoscintigraphy, blue dye, and gamma probe application will increase the success rate of SLN detection in patients with breast cancer.