Retroperitoneal lymph node mapping with intratesticular injected patent blue dye in rats

OBJECTIVES: Endolymphatic injection of several dyes have been previously studied to identify retroperitoneal lymphatic structure in animals and humans with malignant diseases. However, there have been no studies, to our knowledge, that demonstrate the utility of injecting patent blue dye into the testicular parenchyma to detect retroperitoneal lymphoid structure. The aim of this experimental study was to investigate whether intratesticular patent blue dye injection is feasible and is an accurate method for retroperitoneal lymph node mapping in rats. MATERIALS AND METHODS: Twenty male albino Wistar rats were included in the study and divided over two equal groups. The first group underwent patent blue violet (PBV) injection into the spermatic funiculus, while the second group underwent PBV injection into the testicular parenchyma. After the injection, the color changes in the retroperitoneal lymphatic structures and the urinary bladder were anticipated. The time interval between the injection and the staining of lymphatic structures and urinary bladder was measured for each intervention. Blue stained retroperitoneal nodal tissues were dissected and removed. These nodal tissues were examined histologically. RESULTS: After PBV injection, intense staining of the ipsilateral spermatic cord lymphatics was seen and anticipated color changes in the retroperitoneal lymphatic structures and urinary bladder were evaluated visually. Both application routes of dye resulted in the same distribution of retroperitoneal lymph nodes in the same time frame. All retroperitoneal nodular tissues removed were noted histologically to be lymph nodes and were found to be consistent with the ipsilateral lumbar lymph and the ipsilateral suprarenal lymph nodes according to the staining order in both groups. No toxic effects were observed histologically. There were no statistically significant differences in the time intervals between the two groups. CONCLUSIONS: We demonstrated that both funicular and intratesticular injections of patent blue dye are feasible and accurate methods for retroperitoneal lymph node mapping in rats. This shows that intralymphatic dye injection is not absolutely necessary to detect retroperitoneal lymphatic structures and may have applications beyond testis cancer.     

Case report: the danger of postchemotherapy laparoscopic retroperitoneal lymph node dissection for nonseminomatous testicular carcinoma

Laparoscopic retroperitoneal lymph node dissection (RPLND) is a feasible, minimally invasive procedure for the treatment of testicular cancer patients who require surgery to address the retroperitoneal lymph nodes. We report a case of retroperitoneal recurrent disease including a port-site metastasis secondary to laparoscopic RPLND.     

Detection of Sentinel Node in Gastric Cancer Surgery by Indocyanine Green Fluorescence Imaging: Comparison with Infrared Imaging

Background Secure methods for clinical detection of the sentinel node (SN) are in great demand to avoid unnecessary resection. This was a clinical exploration/feasibility study of a novel detection system for SN biopsy using indocyanine green (ICG) fluorescence imaging in gastric cancer surgery. Methods SN biopsy using ICG dye was performed in three patients who had gastric cancer. ICG fluorescence images were obtained using a detection system comprising a charge-coupled device (CCD) camera with a cut filter as the detector and light emitting diodes (LED) as the light source. The nodes were also examined simultaneously by an infrared (IR) imaging videoscope. Results Immediately after intraoperative ICG injection, the fluorescence imaging system allowed easy visualization of the lymphatic vessels draining from the primary gastric tumor toward the lymph nodes and tracing of the moving injected dye. Some lymph vessels and nodes were hardly recognized by ICG green color or IR imaging. The ICG fluorescence system also allowed visualization of the lymph node when ICG was injected the day before surgery, similar to the radio-guided method. Conclusions Detection of SNs in gastric cancer surgery using the ICG fluorescence imaging system is a promising novel technique and may perhaps prove useful for laparoscopic surgery.     

Nerve-sparing retroperitoneal lymph node dissection for stage IIA testicular embryonal carcinoma: a case report]

A 32-year-old man who had left testicular embryonal carcinoma with low volume left para-aortic lymph node swelling was treated initially with 3 courses of cisplatin-based combination chemotherapy. Pathological findings of the primary lesion revealed no yolk sac element and no elevation of serum alpha fetoprotein (alpha-FP) and beta-human chorionic gonadotropin (beta-HCG) levels even before the left orchiectomy. Therefore, the retroperitoneal lymph node dissection (RPLND) was performed despite marked shrinkage of the enlarged nodes. The L1-3 lumber splanchnic nerves from the right sympathetic truncus were detected in the intra-aortocaval region to prevent impairment of ejaculatory function and the lymph nodes in the area were removed one by one between the preserved neurofibers. On the other hand, the left para-aortic lymphatic tissue which included enlarged nodes was dissected in en bloc manner. The pre-aortic lymphatic tissue caudally to the inferior mesenteric artery was preserved not to be touched. The patient ejaculated normally 3 weeks after the RPLND. Treatment of stage IIA disease with chemotherapy first might be helpful in performing RPLND, if necessary, with keeping both ejaculatory function and radicality.     

Laparoscopic RPLND for clinical stage I nonseminomatous germ cell testicular cancer: current status

The purpose of the study was to update the current status of laparoscopic retroperitoneal lymph node dissection in the treatment of clinical Stage I nonseminomatous germ cell testicular cancer. A literature search was conducted to evaluate laparoscopic retroperitoneal lymph node dissection (RPLND) in comparison to other modalities of treatment. All treatment modalities are effective in treating clinical Stage I nonseminomatous germ cell tumors. Morbidity is the major issue that may guide treatment decisions. Laparoscopic RPLND, in its therapeutic form, may replicate open RPLND with a minimally invasive approach. Laparoscopic RPLND is an effective alternative to traditional treatment options.     

Carbon dye as an adjunct to isosulfan blue dye for sentinel lymph node dissection.

BACKGROUND: The success of intraoperative lymphatic mapping depends on accurate identification of the sentinel node. We hypothesized that a carbon particle suspension would allow histopathologic confirmation of the sentinel lymph node through deposition of carbon within that node. METHODS: An animal model was used to compare the lymphatic mapping accuracy of carbon dye with that of isosulfan blue dye, the standard agent for intraoperative visualization of the sentinel lymph node. Twenty-two rats underwent lymphatic mapping in each distal lower extremity with various combinations of carbon dye and isosulfan blue dye. All stained (blue or black) nodes in the inguinal drainage basin were removed for pathologic analysis, including carbon particle analysis. A meticulous search identified all nonstained (nonsentinel) nodes in the same basin. These nonsentinel nodes were examined for carbon particles by light microscopy. Dermal diffusion of mapping agents at the injection site was also recorded. Animals were then observed for 28 days to assess the toxicity of mapping agents. RESULTS: Although isosulfan blue dye and full-strength carbon dye each stained all sentinel nodes, the latter obscured histologic detail. The combination of 2.5% carbon dye, 7.5% saline solution, and 90% isosulfan blue dye also stained all sentinel nodes; carbon particles were seen on light microscopy in all 13 stained nodes and did not interfere with histologic evaluation. No unstained node contained carbon particles, although the number of nonsentinel nodes was small. Carbon dye exhibited significantly less intradermal diffusion than isosulfan blue dye, but the carbon left a permanent mark on the skin. No toxicity or side effect associated with the use of carbon dye was observed. CONCLUSION: Carbon dye allows histopathologic confirmation of sentinel lymph nodes identified by isosulfan blue dye.     

Laparoscopic retroperitoneal lymph node dissection in the extremely obese patient: technical insight into access and port placement.

PURPOSE: We report on laparoscopic retroperitoneal lymph node dissection (RPLND) in a morbidly obese patient to discuss the associated technical steps for satisfactory completion of staging lymphadenectomy. METHODS: A laparoscopic RPLND was performed using a modified template on the left side. Initially, 4 ports were placed with the patient in the supine position. Three were placed 3 cm to the left of midline and one in the anterior axillary line, at the level of the umbilicus. During the operation, successful bowel retraction necessitated placement of 2 additional ports in the anterior axillary line (just above the pelvis and off the tip of the 12th rib). Using these 6 trocar sites, the dissection was completed, and 44 lymph nodes were obtained. RESULTS: Laparoscopic retroperitoneal lymph node dissection was accomplished in an extremely obese patient with acceptable morbidity by using prudent modification of standard techniques. CONCLUSION: If access and port placement limitations are overcome, the benefits of laparoscopy in the obese are clear. This report serves as a signpost that laparoscopic retroperitoneal lymph node dissection for testes cancer can also be accomplished using modification of standard techniques.     

Sentinel node mapping affects intraoperative pulse oximetric recordings during breast cancer surgery

BACKGROUND: In invasive breast cancer lymphatic mapping with patent blue vital dye (PBV) is used intraoperatively to identify the sentinel lymph nodes: the first axillary node draining the mammary lymphatic basin and first involved by the metastatic growth in breast cancer. Patent blue vital dye spreads to tissues giving a bluish tinge to patients. We have noted the possibility that intraoperative peripheral pulse oximetric (SpO2) values are artificially low when intradermal PBV is used. METHODS: Twenty patients with normal pulmonary function undergoing breast cancer surgery in standardized anesthesia either did or did not receive intradermal PBV sentinel node marking. The radial artery was cannulated for blood-gas-analysis; arterial oxygen tension (PaO2); and arterial oxygen saturation (SaO2). Peripheral oxygen saturation was measured using the light absorption technique. Red and infrared light (660 and 900 nm), used by pulseoxymetry, is partially absorbed when passing through the tissue. The amount of light absorbed is sensed and saturation calculated. The color of the skin was evaluated. RESULTS: Peripheral oxygen saturation decreased only immediately after the injection of PBV, and remained at a significantly lower level (P<0.001) throughout the operation and up to 90 min postoperatively. Arterial oxygen tension and SaO2 values did not decrease after intradermal PBV. Patent blue vital dye made patients' skin more bluish (P<0.001). No changes in SpO2, PaO2 and SaO2 were found in control patients. CONCLUSION: The spectrum of PBV has a peak absorption at 640 nm, thus making the SpO2 values incorrect. Peripheral oxygen saturation values are falsely low and true arterial oxygenation is not impaired when PBV is used during sentinel node mapping.     

Paracolic recurrence: the importance of wide excision of the spermatic cord at retroperitoneal lymph node dissection.

PURPOSE: Four patients who underwent retroperitoneal lymph node dissection elsewhere and subsequently had radiographic evidence of expanding ipsilateral paracolic recurrence were referred to our institution for treatment. We evaluated ipsilateral spermatic cord metastatic involvement at retroperitoneal lymph node dissection and identified the possible etiology of these unusual recurrences. MATERIALS AND METHODS: Between January 1988 and February 1998, 34 of 685 patients who underwent a total of 702 retroperitoneal lymph node dissections had metastatic disease in the spermatic cord specimen. Variables examined in this group of patients included other disease sites, lymphovascular invasion in the primary tumor, histopathological findings of the primary tumor and retroperitoneal disease, clinical and pathological stage, disease side and the specific site of anatomical involvement of metastatic disease within the spermatic cord specimen, that is spermatic vessels and/or surrounding lymphatic tissue. RESULTS: Of these 34 positive spermatic cord specimens 18 were in primary retroperitoneal lymph node dissections and 16 were in post-chemotherapy specimens. Histopathological evaluation in 25 (74%) and 9 (26%) of the 34 primary tumors showed a mixed germ cell pattern and pure embryonal carcinoma, respectively. Similarly 9 of the 34 retroperitoneal lymph node specimens (26%) showed pure embryonal cell carcinoma and the remainder showed mixed histopathological findings. Disease was clinical stage I in 13 cases (38%) and lymphovascular invasion was absent in the primary tumor in 11 (32%). Despite disease in the spermatic cord specimen there was none at the primary landing zone in 2 patients (6%), including 1 in whom the spermatic cord was the only disease site. In 12 positive spermatic cord specimens (35%) disease was identified in the surrounding perivascular and lymphatic tissue without gonadal vessel involvement. CONCLUSIONS: Metastatic disease in the spermatic vessels and/or surrounding lymphatic tissue represents a possible site of recurrence when incompletely excised. The lack of lymphovascular invasion in the primary tumor does not preclude metastatic disease in the spermatic cord specimen. Complete and wide excision of the spermatic cord and surrounding lymphatic tissues at retroperitoneal lymph node dissection is necessary and may prevent paracolic recurrence.     

Late pelvic recurrence of nonseminomatous testicular carcinoma after negative retroperitoneal lymph node dissection

We report a case of pathologic Stage I teratoma recurring in the pelvis as embryonal carcinoma 12 years after radical orchiectomy and bilateral retroperitoneal lymph node dissection (RPLND). The patient received three cycles of chemotherapy (cisplatin, etoposide, bleomycin) followed by complete surgical excision of the pelvic mass. Successful treatment of these rare late recurrences usually requires chemotherapy and complete surgical excision. Pelvic relapse may potentially result from incomplete iliac node resection at the time of RPLND, altered lymphatic drainage from an incompletely resected spermatic cord, or a second primary extragonadal tumor focus. Our case emphasizes the importance of meticulous surgical technique during RPLND and the necessity for follow-up beyond 5 years in patients with testicular cancer.     

Two cycles of cisplatin-based chemotherapy for low-volume retroperitoneal stage II nonseminomatous germ cell tumours

OBJECTIVE: To evaluate the oncological efficacy of reducing cisplatin-based chemotherapy to two cycles in patients with low-volume retroperitoneal stage II nonseminomatous germ cell tumours (NSGCTs). PATIENTS AND METHODS: From October 1988 until January 2004, two cycles of cisplatin-based chemotherapy were administered in 59 patients with low-volume retroperitoneal clinical stage II NSGCT (retroperitoneal mass of <5 cm in diameter). Regardless of remission detected on computed tomography, 6 weeks after chemotherapy the patients had a retroperitoneal lymph node dissection (RPLND) to assess residual active tumour or mature teratoma (open modified bilateral RPLND until 1992, then laparoscopic unilateral template RPLND). RESULTS: The chemotherapy was effective, as no active tumour was found in any of RPLND specimens. Mature teratoma was present in lymphatic tissue in 23 of 59 patients (39%). In one patient there was a pulmonary recurrence, successfully treated with cisplatin-based salvage chemotherapy. One patient died from an accident but with no evidence of tumour, and 56 patients remained free of disease at a mean follow-up of 98.6 months. No patient died from disease. All patients had antegrade ejaculation after laparoscopic RPLND, as did 89% after open RPLND. CONCLUSION: In this pilot study, the oncological efficacy of two cycles of cisplatin-based chemotherapy was favourable, but this approach still cannot be recommended as a standard treatment for patients with low-volume retroperitoneal stage II disease. RPLND after chemotherapy has diagnostic (detecting active tumour) and therapeutic (removing mature teratoma) value and can be done laparoscopically. Based on the present results a prospective randomized trial seems reasonable.     

Laparoscopic retroperitoneal lymph node dissection for nonseminomatous testicular carcinoma

Retroperitoneal lymph node dissection (RPLND) is still the most sensitive and specific method for the detection of lymph node metastases in stage I nonseminomatous testicular carcinoma. In stage II disease, residual malignant tumor and mature teratoma can be removed. Acceptance of this operation, however, has decreased due to the morbidity caused by the open approach. To reduce this morbidity, and to improve the acceptance of RPLND, laparoscopy has been introduced. Clinical data with long-term follow-up are now available which demonstrate the technical feasibility of laparoscopic RPLND. Studies comparing laparoscopy and open surgery show advantages for the laparoscopic approach in terms of reduced blood loss, intraoperative complications and operative time. Mainly minor complications, such as chylous ascites or lymphocele formation, are observed. The conversion rate to open surgery, mainly due to intraoperative bleeding, is acceptable at less than 10%. As in open surgery, antegrade ejaculation can be preserved successfully. RPLND has also been shown to provide adequate oncological results. In stage I disease, lymph node metastasis is found in 25–41% of cases. Patients with histologically proven retroperitoneal tumor receive adjuvant chemotherapy whereas individuals without evidence of retroperitoneal disease do not require additional treatment. Follow-up controls in both groups, without local recurrence, demonstrate the excellent diagnostic accuracy of this procedure. Meanwhile laparoscopic RPLND has also been introduced successfully in the management of stage II disease. Small volume residual tumors can be removed with an acceptable complication rate. However, this operation is technically demanding and should be performed only at institutions with considerable laparoscopic experience. In conclusion, laparoscopic RPLND is a safe method for low-stage germ cell tumors with minimal invasiveness and excellent clinical results. Thus laparoscopy might contribute to a better acceptance of RPLND.     

Consequences of Missed Nodes during Retroperitoneal Lymph Node Dissection and How to Avoid Them

ContextToday, the role of urologic surgery in the management of nonseminomatous germ cell tumours (NSGCT) of the testis is limited to orchiectomy and post-chemotherapy surgery for residual disease. Retroperitoneal lymph node dissection (RPLND) in low stage disease is considered an optional staging procedure and templates have been introduced to avoid the risk of postoperative loss of antegrade ejaculation. Furthermore, patients with positive nodes are given adjuvant chemotherapy.ObjectiveTo determine how best to develop templates that help surgeons to avoid missed nodes at RPLND maintaining antegrade ejaculation.Evidence acquisitionOnly through a thorough understanding of the lymphatic drainage of the testis can we hope to avoid missed nodes during RPLND. This paper looks at the history of research in this area of functional anatomy as well as at the current work on the management of RPLN metastases in nonseminomatous germ cell tumours (NSGCT).Evidence synthesisTemplates that have been constructed to guide open or laparoscopic RPLND are fit for nerve sparing but are not able to avoid occasional missed nodes at RPLND. Critical evaluation of current templates suggests to extent RPLND templates to further zones. The consequence is that more extended templates can compromise antegrade ejaculation, which can be secured by prospective nerve sparing technique. Furthermore, RPLND alone will cure 70% of pathological stage IIA patients.ConclusionsLanding zones for retroperitoneal lymph node metastases are too scattered to design a restricted template that will allow both radical RPLND and an easy nerve-sparing technique to maintain antegrade ejaculation. We also have to bear in mind that chemotherapy is not a panacea for missed or recurrent nodal metastases: radical surgery does have curative potential and prospective nerve-sparing is safer than templates.     

淋巴绘图和前哨淋巴结定位在腹腔镜结肠癌切除术中的应用

目的 探讨淋巴绘图(LM)和前哨淋巴结(SLN)定位分析在腹腔镜结肠癌手术中的应用价值.方法 32例结肠癌患者,术中在纤维电子肠镜辅助下,将0.5～1.0 mL异硫蓝染剂注射在瘤体四周的黏膜下层,随即通过腹腔镜观察,蓝染的SLN清晰可见.结肠采用标准术式切除.所有淋巴结经苏木精-伊红(HE)染色,对每一个SLN进行多点取材,同时进行HE染色及抗细胞角蛋白免疫组织化学(IHC)染色双重病理检查.结果 所有患者在腹腔镜下至少识别1个SLN.94%成功检出SLN,并正确反映了该区域淋巴结的肿瘤状况.8例(25.0%)蓝染的淋巴管系超出了术前预计范围,术中实行了宽系膜切除.4例(12.5%)患者的SLN经HE染色阴性而IHC染色证实存在微转移灶.结论 SLN绘图在腹腔镜结肠癌切除术中,可以指导切除范围;联合应用IHC染色可以提高肿瘤分期,将对患者手术方式的选择和预后评估更加准确.     

睾丸癌腹膜后淋巴结清扫的现状及展望(附光盘)

随着临床分期的不断细化以及多学科诊疗的不断进展,睾丸肿瘤的治愈率可以超过95%。腹膜后淋巴结清扫术(RPLND)是睾丸非精元细胞瘤多模式治疗重要的一部分,对总体治愈率做出了重要贡献。双侧保留神经的RPLND对于肿瘤学控制及功能恢复是适当的选择,腹腔镜和机器人辅助的RPLND都是安全有效的选择。     

Blue Dye Injection in the Arm in Order to Conserve the Lymphatic Drainage of the Arm in Breast Cancer Patients Requiring an Axillary Dissection

Background Despite the widespread use of the sentinel lymph node biopsy technique, many patients with invasive breast cancer still undergo an axillary lymph node dissection and are at risk of arm lymphedema. With the new awareness of lymphatic spread in the axillary nodes, it should be possible to define a new surgical approach between sentinel lymph node biopsy and complete axillary dissection, a procedure preserving specifically lymph nodes in relation to the arm. Methods Twenty-one patients with an operable breast cancer requiring an axillary dissection underwent surgery with an attempt to separate nodes related to the breast from specific nodes related to the arm. After an injection of blue dye in the arm, the surgeon performed the axillary dissection trying to identify blue nodes and ducts in order to preserve lymphatic arm drainage (LAD). If the blue nodes were located in the normal axillary dissection, they were removed separately. Results In 15 of 21 patients (71%), blue nodes in relation with LAD were identified. In 10 (47%) patients, it was possible to dissect the LAD with the preservation lymphatic ducts. In 10 patients, the LAD nodes were removed: none of them contained metastases, despite the fact that the non-LAD axillary nodes contained metastases in 7 of 10 cases. Conclusions Identifying the LAD with blue dye injection in the arm is possible. A subsequent study can now begin to determine if this procedure is safe for patients and able to prevent lymphedema of the arm.     

Laparoscopic and open retroperitoneal lymph-node dissection for clinical stage I nonseminomatous germ-cell testis tumors

BACKGROUND AND PURPOSE: Laparoscopic retroperitoneal lymph node dissection (L-RPLND) has been reported as efficacious for staging of the retroperitoneum in patients with stage I nonseminomatous germ-cell testis tumors (NSGCT). However, reports are limited to a few centers, and this procedure has yet to be widely accepted as an alternative to open retroperitoneal lymph node dissection (O-RPLND). Thus, we compared our contemporary open and laparoscopic experience with RPLND. PATIENTS AND METHODS: A retrospective chart review identified 28 patients who underwent either open (N = 6) or laparoscopic (N = 22) RPLND for clinical stage I NSGCT since 2000. Each patient received the appropriate modified template dissection. Perioperative demographic data, histologic nodal status, and recurrence data were evaluated. The mean follow-up was similar in the two groups. RESULTS: The mean operative time was not significantly different (313 minutes for L-RPLND v 284 minutes for O-RPLND). However, L-RPLND did have a significantly shorter hospitalization (1.2 v 8.5 days). Significantly more lymph nodes were removed with O-LPLND than with L-RPLND (mean 33 v 17). There was a single recurrence outside the modified template after both L-RPLND and O-RPLND and one within-the-template recurrence in the O-RPLND group. CONCLUSIONS: The L-RPLND is associated with less blood loss and a shorter hospital stay than O-RPLND, whereas the lymph-node yield of O-RPLND is greater. However, during the critical early follow-up period, the oncologic effectiveness and morbidity of L-RPLND for clinical stage I NSGCT appears similar to that of O-RPLND.     

Laparoscopic retroperitoneal lymph node dissection for nonseminomatous germ-cell tumors: current status

We review the published literature regarding the technical feasibility, oncologic outcomes, morbidity, and cost-effectiveness of laparoscopic retroperitoneal lymph node dissection (LRPLND). With proof that it is feasible, several centers have become expert in LRPLND and morbidity appears to be less than that of open RPLND. As the technique improves, it is likely that LRPLND will become equally if not more cost-effective than conventional RPLND. However, the oncologic outcomes, while on par with open RPLND series, are difficult to attribute to successful LRPLND alone when nearly all patients with positive lymph nodes received chemotherapy postoperatively. Although uncertainties exist, LRPLND holds much future promise.     

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 Lymph Node Biopsy in Patients with Extramammary Paget''s Disease

BACKGROUND: Patients with invasive extramammary Paget's disease appear to have a risk of regional lymph node metastasis. Despite the poor prognosis for patients with lymph node metastasis, management of extramammary Paget's disease without clinical evidence of involved nodes is controversial. OBJECTIVE: To evaluate the usefulness of sentinel lymph node biopsy, patients with extramammary Paget's disease underwent sentinel lymph node biopsy using preoperative lymphoscintigraphy and intraoperative patent blue dye injection with a handheld gamma-detecting probe. METHODS: Thirteen patients with primary genital extramammary Paget's disease were included in the study. Sentinel nodes identified were excised and examined by hematoxylin and eosin staining. All sentinel lymph nodes were also subjected to immunohistochemical staining for carcinoembryonic antigen, MUC1, cytokeratin 7, and gross cystic disease fluid protein-15. RESULTS: A total of 23 nodes were removed successfully. Tumor cells were detected in 4 nodes from four patients by hematoxylin and eosin staining. No additional lymph nodes were positive by immunohistochemistry. Three of the four sentinel-node-positive patients developed distant metastases. All nine patients without node involvement were free from disease during the follow-up period. CONCLUSION: Sentinel lymph node biopsy was safe and feasible method and may have an important role in the management of extramammary Paget's disease with clinically N0 status. To establish the optimal management of inguinal lymph nodes in extramammary Paget's disease, additional studies in large number of patients are needed.