乳腺癌前哨淋巴结解剖学定位的临床研究

目的:探讨示踪剂注射部位对乳腺癌前哨淋巴结(sentinel lymph node,SLN)定位的影响。方法:对53例cN0期乳腺癌患者行核素示踪联合染料染色示踪法检测SLN,在原发肿瘤表面的皮下组织内或切除活组织检查残腔肿瘤周围两点注射99m锝(99mTc)标记的硫胶体,将卡纳琳或亚甲蓝分别注射于肿瘤对角线相应部位的皮下组织内(30例)或乳头乳晕下皮下组织内(23例)。SLN活组织检查后再行腋窝淋巴结清除术,标本行常规HE染色组织学检查。结果:53例患者均成功检测出SLN,核素示踪法与蓝染料法的成功率均为96.23%(51/53),联合检测的成功率100%(53/53),共检出SLN103枚,平均每例检出1.94枚,其中50例SLN位于胸大肌外侧缘的外侧组淋巴结(LevelⅠ),1例位于胸小肌后(LevelⅡ),1例同时位于LevelⅠ及LevelⅡ,1例同时位于LevelⅠ及胸骨旁。全部病例蓝染料与核素示踪标识的SLN均为同一枚(或同一组)淋巴结,两者完全吻合;且蓝染料注射于乳头乳晕或肿瘤对角线部位与核素注射于肿瘤周围所标识的SLN也完全一致。结论:SLN可能是乳房整个器官的SLN,而非乳房某个具体部位的SLN,与示踪剂的注射部位无关。     

Ultrasound-guided contrast-enhanced sentinel node biopsy of the head and neck in a porcine model.

OBJECTIVE: To test the feasibility of contrast-enhanced ultrasound (CEUS)-guided sentinel lymph node biopsy (SNB) of the head and neck in a porcine model. STUDY DESIGN AND SETTING: In this prospective, nonrandomized study, methylene blue and Sonazoid were injected into the lateral tongue or floor of mouth (FOM) of four swine. Real-time CEUS was used to identify contrast in the lymphatic channels flowing to the sentinel lymph node (SLN). Endoscopic or open SNB was performed. Neck dissection was then performed, and the residual nodal packet was examined for remaining contrast-enhancing or blue dye-stained nodes. RESULTS: In all eight procedures, the SLN was visualized with ultrasound and blue dye. Seven procedures identified a single SLN, and one identified two SLNs. Subsequent neck dissections revealed no other nodes containing methylene blue or contrast in the nodal specimen or operative bed. CONCLUSION/SIGNIFICANCE: CEUS-guided SNB of the head and neck in swine is feasible, with success comparable to blue dye-guided SNB. This technique may offer several advantages over traditional techniques, and warrants further study.     

Sentinel node biopsy in oral cavity cancer: correlation with PET scan and immunohistochemistry

BACKGROUND: Lymphoscintigraphy and sentinel node biopsy (LS/SNB) is a minimally invasive technique that samples first-echelon lymph nodes to predict the need for more extensive neck dissection. METHODS: We evaluated this technique in 18 oral cavity cancers, stages T1-T3, N0. Patients underwent CT and positron emission tomography (PET) of the neck, followed by LS/SNB, frozen section, immediate selective neck dissection, definitive histology, and immunoperoxidase staining for cytokeratin. Histopathology of the sentinel node was correlated with that of the neck specimen. RESULTS: There were 10 true positives: 6 identified on frozen section; 2 on permanent histology; and 2 only on immunoperoxidase staining. In six, the sentinel node was the only positive node. There were seven true negatives and one false negative. CONCLUSIONS: Gross tumor replacement of lymph node architecture may obstruct and redirect lymphatic flow. Overall LS/SNB holds promise for oral cancer.     

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.     

乳腺癌腔镜前哨淋巴结活检83例临床分析

目的探讨染料法腔镜腋窝前哨淋巴结活检在乳腺癌中的可行性和临床意义。方法应用亚甲蓝染色法对83例Ⅰ、Ⅱ期乳腺癌行腔镜前哨淋巴结活检(ESLNB),然后行腔镜腋窝淋巴结清扫(EALND)。对获取的全部淋巴结行病理检查,评价前哨淋巴结检出率、准确率及假阴性率。结果83例中73例检出前哨淋巴结,检出率87.9%(73/83)。ESLNB准确率97.3%(71/73),灵敏性88.2%(15/17),特异性100.0%(56/56)。结论染料法腔镜腋窝前哨淋巴结活检临床可行,能够对早期乳腺癌进行准确分期,但体重指数高、肿瘤部位在内侧、术前肿瘤切除活检、腔镜技术欠熟练等是影响前哨淋巴结检出的主要因素。     

Dynamic MR lymphangiography and carbon dye for sentinel lymph node detection: a solution for sentinel lymph node biopsy in mucosal head and neck cancer

BACKGROUND: The practical application of sentinel lymph node biopsy in squamous cell carcinoma of the head and neck is restricted by the time sensitivity of blue dye and lack of spatial resolution and nonspecific node enhancement with radiocolloid. This study evaluates the use of magnetic resonance (MR) lymphangiography and carbon dye labeling to circumvent these limitations. METHODS: Gadomer/carbon dye mixture was injected into the tongue and stifle of adult swine (n = 4). MR lymphatic mapping was followed by intraoperative mapping with isosulfan blue dye. Sentinel lymph node biopsy and completion node dissection were performed 60 minutes after injection in four nodal basins and at 7 days after injection in eight. RESULTS: The technique was successful in all 12 nodal basins. The sentinel lymph nodes were stained black at the time of the immediate and delayed dissections. CONCLUSIONS: MR lymphangiography provides temporal and anatomic localization of the sentinel lymph node with a single investigation. Carbon dye is a sensitive and persistent visual marker of MRI-targeted sentinel lymph nodes.     

Repeat dynamic sentinel node biopsy in locally recurrent penile carcinoma

Study Type – Diagnosis (case series)
Level of Evidence 4

OBJECTIVE

To explore the role of repeat dynamic sentinel‐node biopsy (SNB) in clinically node‐negative patients with locally recurrent penile carcinoma after previous penile surgery and SNB.

PATIENTS AND METHODS

Between 1994 and 2008, 12 patients (4% of the 304 in our prospectively maintained dynamic sentinel node database) with clinically node‐negative groins had a repeat SNB for locally recurrent penile carcinoma after previous penile surgery and SNB. Five of these patients had previously had a unilateral inguinal node dissection for groin metastases. The median disease‐free interval was 18 months. The protocol and technique of primary dynamic SNB and the repeat procedure were similar, including preoperative lymphoscintigraphy and blue‐dye injection. Completion inguinal node dissection was only done if there was an involved sentinel node.

RESULTS

No sentinel nodes were seen on preoperative lymphoscintigraphy in the five groins that had previously been dissected. A sentinel node was visualized on lymphoscintigraphy in the remaining 19 undissected groins. In 15 of these groins (79%) the sentinel node was identified during surgery. Histopathological analysis showed involved sentinel nodes in four groins of three patients. Additional metastatic nodes were found in one completion inguinal lymph node dissection specimen. During a median follow‐up of 32 months after the repeat SNB, one patient developed a groin recurrence 14 months after a tumour‐negative sentinel node procedure.

CONCLUSIONS

Repeat dynamic SNB is feasible in clinically node‐negative patients with locally recurrent penile carcinoma despite previous SNB.     

Size of metastasis in the sentinel node predicts additional nodal involvement in penile carcinoma

PURPOSE: The majority of patients with penile cancer with a tumor positive sentinel node do not benefit from complementary lymph node dissection because of absent additional involved nodes. We analyzed factors that may determine the involvement of additional nodes. MATERIALS AND METHODS: A total of 158 patients with clinically node negative penile carcinoma underwent sentinel node biopsy. Complementary inguinal lymph node dissection was performed when the sentinel node was tumor positive. The size of the sentinel node metastasis was measured and classified as micrometastasis--2 mm or less, or macrometastasis--more than 2 mm. Sentinel and dissection specimen nodes were step-sectioned. Factors were analyzed for their association with additional nodal involvement, including stage, diameter, grade, absence or presence of vascular invasion of the primary tumor, and sentinel node metastasis size. RESULTS: Tumor positive sentinel nodes were found in 46 groins and complementary lymph node dissection was performed. Nine of these 46 groins (20%) contained additional involved lymph nodes. On univariate and multivariate analyses the size of the sentinel node metastasis proved to be the only significant prognostic variable for additional lymph node involvement (each p = 0.02). None of the 15 groins with only micrometastasis in the sentinel node contained additional involved nodes. CONCLUSIONS: In penile carcinoma additional nodal involvement was related to the size of the metastasis in the sentinel node. Sentinel node micrometastasis was not associated with other involved lymph nodes. This finding suggests that these patients can be spared complementary lymph node dissection.     

Sentinel node imaging and biopsy in breast cancer patients.

BACKGROUND: Several techniques have been shown to be accurate in identifying axillary sentinel lymph nodes. The accuracy of subareolar blue dye injection is compared with intraparenchymal radioisotope injection. METHODS: Forty-two consecutive patients with breast cancer were injected with both intraparenchymal technetium-99m and subareolar isosulfan blue dye. After sentinel lymph node identification, an axillary lymph node dissection was performed. RESULTS: The blue dye and the technetium-99m localized to the same axillary nodes even though the injection sites were different. The sensitivity of blue dye in identifying axillary sentinel nodes was 100%. The sensitivity of radioisotope injection in identifying sentinel nodes was 97.6%. CONCLUSIONS: Subareolar blue dye injection is an extremely accurate and cost-effective method of sentinel node identification in breast cancer patients.     

Sentinel node biopsy in breast cancer: validation study and comparison of blue dye alone with triple modality localization

Background: Sentinel node biopsy (SNB) for breast cancer patients is a new technique with the potential to provide an accurate staging of the axillary nodal status while avoiding the morbidity of an axillary dissection. The objective of the present study is to validate the use of sentinel node biopsy in a New Zealand hospital and to compare the ability of patent blue dye (PB) alone with triple modality (TM) (preoperative lymphoscintigraphy, intraoperative gamma probe and intraoperative blue dye) to identify the sentinel node. Methods: A total of 104 patients who had a palpable breast lump that was confirmed to be malignant by radiology and cytology and a clinical diagnosis of stage I or stage II breast cancer, were enrolled for SNB and randomly assigned to triple modality or blue dye alone for the localization of the sentinel node. Axillary dissection was performed after the sentinel node(s) had been removed. Results: There were 63 patients in the PB group and 41 patients in the TM group. Both groups are comparable, with a similar mean age and primary tumour size. A sentinel node was identified in 57 (90%) of the PB group patients and 40 (98%) of the TM group patients. Of these 23 (37%) of the PB group and 23 (56%) in the TM group had axillary nodes positive for malignancy. There was one false negative SNB in the PB group and two false negative results in the TM group. Therefore, the PB group had an accuracy of 98% and a sensitivity of 96% compared to an accuracy of 95% and a sensitivity of 91% for the TM group. Conclusion: The results of the present study validate the use of SNB in suitable breast cancer patients. Identification and the accuracy of the sentinel node localization were similar between the two groups. Therefore, in hospital centres without adequate access to a nuclear medical facility, it would be feasible to conduct SNB using blue dye alone.     

The impact of immunohistochemistry on sentinel node biopsy for primary cutaneous malignant melanoma.

Sentinel node biopsy (SNB) has emerged as an accurate means of identifying nodal disease in patients with malignant melanoma. Superselection of pathological nodes has allowed improved pathological staging of disease. The aim of this study was to look at the impact of immunohistochemistry on pathological staging of sentinel nodes. The first 100 patients undergoing SNB for primary cutaneous malignant melanoma were included in this study. Sentinel node harvesting was performed with the aid of preoperative lymphoscintigraphy and the intraoperative use of both a gamma probe and blue dye. If the sentinel nodes contained tumour on either routine pathology or immunohistochemistry, patients were offered a therapeutic lymph node dissection (TLND). Patients underwent no other treatment to the primary lymph node basin if the sentinel node was free of metastases. In all, 95 patients had at least one node identified, and 25 were staged SNB positive and offered subsequent TLND. We found that 76% (19/25) of SNB positive patients were staged positive on routine pathology, and 24% (6/25) were staged with immunohistochemistry. Immunohistochemistry upstaged disease in 8% of patients (6/76). In all, 21 of the patients staged positive with SNB underwent TLND; 50% (8/16) of the patients staged sentinel node positive with routine pathology showed no further disease in the TLND, compared with 100% (5/5) of the patients staged sentinel node positive with immunohistochemistry only (P<0.05). Three patients have developed recurrence within the nodal basin following a negative SNB. The sensitivity of the procedure is currently 89% (25/28), with a mean follow-up of 24 months. Immunohistochemistry is an essential part of identifying micrometastasis in sentinel nodes, upstaging 8% of patients in our series. Patients with micrometastatic disease may well have a different prognosis from those with occult disease, and careful delineation of these patients is required to determine the prognostic influence of micrometastasis.     

亚甲蓝定位前哨淋巴结在cN0甲状腺乳头状癌的经验与技巧

目的应用亚甲蓝示踪剂定位cN0甲状腺乳头状癌前哨淋巴结,探讨亚甲蓝定位前哨淋巴结的手术经验和技巧。方法应用亚甲蓝作为前哨淋巴结示踪剂,对51例甲状腺乳头状癌患者进行前哨淋巴结活检术,同时常规行颈部功能淋巴结清扫术,统计前哨淋巴结及颈部淋巴结数量,结合术中冰冻及术后石蜡病理,分析前哨淋巴结及颈部淋巴结转移情况及其相关性。结果 51例患者中,共有46例发现蓝染的前哨淋巴结,前哨淋巴结检出率90.2%,阳性率45.7%,阴性率50%,假阴性率4.3%,灵敏度91.3%(21/23),准确度95.7%(44/46)。结论亚甲蓝定位cN0甲状腺乳头状癌前哨淋巴结,对cN0甲状腺乳头状癌颈淋巴转移状态的判断,及手术方式的选择具有指导意义,临床上应严格掌握操作规则并灵活处理。     

Cost/Accuracy Ratio Analysis in Breast Cancer Patients Undergoing Ultrasound-Guided Fine-Needle Aspiration Cytology,Sentinel Node Biopsy,and Frozen Section of Node

We evaluated the effectiveness and the cost of axillary staging in breast cancer patients by ultrasound-guided fine-needle aspiration cytology (US-FNAC), sentinel node biopsy (SNB), and frozen sections of the sentinel node to achieve the target of the highest number of immediate axillary dissections. From January 2003 through October 2005, a total of 404 consecutive eligible breast cancer patients underwent US-FNAC of suspicious axillary lymph nodes. If tumor cells were found, immediate axillary dissection was proposed (33% of node-positive cases). If US or cytology was negative, SNB was performed. Frozen sections of the sentinel node allowed immediate axillary dissection in 31% of node-positive cases. The remaining 36% underwent delayed axillary dissection. We compared our policy with clinical evaluation of the axilla, showing better specificity of US-FNAC, the cost balanced by a 12% reduction of SNBs, and a marked reduction of unnecessary axillary dissections resulting from false-positive clinical staging. Moreover, the comparison between our policy and permanent histology of the sentinel node showed an 8% cost saving, mainly associated with the immediate axillary dissections. US-FNAC of axillary lymph nodes in breast cancer patients reliably predicts the presence of metastases and therefore refers a significant number of patients to the appropriate surgical treatment, avoiding an SNB. As cost saving to the health care system in our study is mainly related to one-step axillary surgery, US-FNAC of axillary lymph nodes and frozen section of the sentinel node generate significant cost saving for patients who have metastatic nodes.     

Video-assisted axillary surgery for cancer: non-randomized comparison with conventional techniques

Endoscopic techniques have been introduced in most of surgical disciplines including surgery for breast cancer. However, there is shortage of evidence-based guidelines and oncological outcome data. We present a controlled trial of endoscopic axillary surgery for breast cancer with mid-term oncologic results. Fifty cases of axilloscopy for sentinel node biopsy, axillary sampling or full axillary dissection were included. Sentinel node biopsy was accomplished with the blue dye technique. Full axillary dissection was performed with a three-port approach with gas insufflation without liposuction. Endoscopic axillary dissection significantly lowered duration of drainage and operative blood loss. Lymph node harvest with endoscopic approach was significantly lower than with open procedure. One case developed axillary recurrence. Endoscopic sentinel node biopsy yielded identification rate of 80%. Current data do not justify the oncological safety of resectional endoscopic procedures. Endoscopically assisted axillary cancer surgery is technically feasible. The technique is valuable to maximize utility of blue dye method for sentinel lymphadenectomy in areas with no access to radio-guided surgery.     

A novel method for sentinel lymph node mapping using magnetite in patients with non-small cell lung cancer

OBJECTIVE: The detection rate of sentinel lymph nodes in patients with non-small cell lung cancer using isosulfan blue dye is too low for clinical use. Although exposure to radioactivity is reportedly minimal, special procedures are nonetheless required when a radioactive isotope is used as a tracer. Therefore, to eliminate the need for a radioactive tracer and to obtain a better detection rate than is obtained with isosulfan blue dye, we have developed a novel method that employs magnetite as the tracer. The aim of the present study was to test the feasibility of this technique. METHODS: The tracer employed was ferumoxides, a colloidal superparamagnetic iron oxide of nonstoichiometric magnetite. Thirty-eight non-small cell lung cancer patients participated in the study; each received 5 mL of ferumoxides, injected around the tumor intraoperatively. Fifteen minutes after injection, lung resection and lymph node dissection were carried out. The magnetic force within the lymph nodes was measured using a highly sensitive handheld magnetometer ex vivo. All lymph nodes were also subjected to conventional histological analysis. RESULTS: The rate of detection of sentinel lymph nodes was 81.6% (31/38). The accuracy, sensitivity, and false-negative rates were 96.8% (30/31), 85.7% (6/7), and 14.3% (1/7), respectively. CONCLUSION: Intraoperative sentinel lymph node mapping using ferumoxides and a highly sensitive magnetometer is a safe, accurate, and sensitive way to detect sentinel lymph nodes in non-small cell lung cancer patients.     

Preoperative lymphoscintigraphy and dynamic sentinel node biopsy for staging penile cancer: results with pathological correlation

PURPOSE: We assessed the sensitivity of preoperative lymphoscintigraphy and dynamic sentinel node biopsy for staging the inguinal region of patients with penile cancer and no palpable inguinal adenopathy. MATERIALS AND METHODS: The records of 31 patients with invasive penile cancer and nonpalpable (29) or nonsuspicious (2) inguinal lymph nodes were reviewed. Preoperatively lymphoscintigraphy plus dynamic sentinel node biopsy with (99m)technetium labeled sulfur colloid and isosulfan blue dye was performed in 21 patients and dynamic sentinel node biopsy alone with blue dye only was done in 10. All patients underwent superficial lymph node dissection regardless of preoperative lymphoscintigraphy or dynamic sentinel node biopsy findings to establish pathological nodal status. RESULTS: Six of 32 groins that showed drainage on preoperative lymphoscintigraphy had inguinal node metastasis, as did 1 of 10 that was drainage negative. The sensitivity of preoperative lymphoscintigraphy drainage for cancer detection was 86%. Using dynamic sentinel node biopsy with blue dye plus radiotracer 5 sentinel lymph nodes were positive for cancer, although 2 false-negative results were obtained. Thus, the sensitivity of dynamic sentinel node biopsy per groin for cancer detection was 71%. CONCLUSIONS: In our experience preoperative lymphoscintigraphy and dynamic sentinel node biopsy as currently performed remain insufficient for detecting occult inguinal disease. Superficial lymph node dissection remains the gold standard for detecting inguinal microscopic metastasis in select patients.     

Accuracy of sentinel lymph node in papillary thyroid carcinoma.

BACKGROUND: The sentinel lymph node has been used in several tumors. The aim of this study was to analyze the accuracy of the sentinel node in papillary thyroid carcinoma. METHODS: A series of 22 patients with papillary thyroid carcinoma were included. Approximately 0.5 cc of isosulfan blue dye was injected at operation to trace the sentinel node. Lymph node dissection of the ipsilateral central compartment and extensive sampling of the jugular compartment were performed in addition to sentinel node resection. Surgical specimens were stained with hematoxylin-eosin, and negative sentinel nodes were subsequently stained with immunohistochemistry for cytokeratin-7. RESULTS: Mean age was 37 +/- 14 years. Twenty patients were women, and 2 were men. Mean tumor size was 2.5 +/- 1 cm. A sentinel lymph node was found in 20 patients. With use of hematoxylin-eosin, metastases were identified in 12/20 sentinel nodes (60%). Eleven patients with positive sentinel nodes presented additional lymph node metastases: 9 in the central compartment, 1 in the jugular compartment, and 1 in both compartments. Two patients with negative sentinel nodes had lymph node metastases elsewhere. When sentinel nodes were processed by immunohistochemistry, accuracy increased to 100%. CONCLUSIONS: Sentinel node is highly accurate for diagnosing metastases in papillary thyroid carcinoma.     

Dynamic sentinel node biopsy for penile cancer: reliability of a staging technique

PURPOSE: We determine the value of dynamic sentinel node biopsy for staging squamous cell carcinoma of the penis. MATERIALS AND METHODS: A total of 90 patients with clinically node negative penile cancer were prospectively entered in this study. Preoperative lymphoscintigraphy was performed after intradermal injection of 99mtechnetium nanocolloid around the primary tumor. The sentinel node was intraoperatively identified with the aid of intradermal administered patent blue dye and a gamma ray detection probe. Histopathological examination of sentinel nodes included serial sectioning and immunohistochemical staining. Regional lymph node dissection was performed only if metastasis was found in a sentinel node. Median followup was 36 months (range 5 to 95). RESULTS: Lymphoscintigraphy visualized 217 sentinel nodes in 159 inguinal regions of 88 patients. A total of 208 sentinel nodes were intraoperatively identified in 149 inguinal regions of 88 patients. Sentinel node metastasis was found in 19 inguinal regions of 18 patients. Four of 8 patients with unilateral clinical stage N1 disease had a tumor positive sentinel node on the opposite site. Regional recurrence after excision of a tumor negative sentinel node or after nonvisualization was seen in 5 patients, resulting in a false-negative rate of 22% (5 of 23). The 3-year disease specific survival was 98% and 71% for patients with a tumor negative or tumor positive sentinel node, respectively (p = 0.0018). CONCLUSIONS: Occult lymph node metastases in penile cancer can be detected with a sensitivity of about 80% by dynamic sentinel node biopsy, including preoperative lymphoscintigraphy, vital dye and a gamma ray detection probe.     

The Role of Sentinel Lymph Node Biopsy with Blue Dye Alone in Breast Cancer Patients with Excisional Biopsy

Purpose : Sentinel lymph node biopsy (SLNB) appears to offer an excellent alternative method to routine axillary lymph node dissection for staging patients with breast cancer. The aim of this study is to evaluate the effect of excisional biopsy on identification and false negative rate of sentinel lymph node biopsy with blue dye alone in breast cancer patients with clinically negative axilla.

Material and Methods : From March 1998 to March 2003, 266 consecutive sentinel lymph node biopsies (SLNB) were performed using isosulfan blue dye alone. Patients were divided into two groups. One hundred and four patients (39.1%) had previously undergone an excisional biopsy (Group I); in 162 patients (60.9%), pre-operative diagnosis was obtained by either fine-needle aspiration biopsy (FNAB) or core biopsy (Group II). Following sentinel lymph node biopsy, all patients had axillary lymph node dissection (ALND). Data concerning patients, sentinel lymph nodes and the status of the axilla were collected and compared using Fisher’s exact test. A p value of less than 0.05 was considered statistically significant.

Results : The sentinel lymph node was successfully identified by blue dye in 94.3% (251/266) of patients. Mean lymph nodes removed from the axilla was 19 (range 11–36) and the mean number of sentinel nodes was 2 (range 1–5). The identification and false negative rate were unrelated to size, type or location of the tumour, or a previous surgical biopsy. Conclusions : SLNB with blue dye for evaluation of the axilla is a rapid and accurate technique that provides increased efficacy in the detection of lymphatic metastasis when careful pathologic evaluation with serial sections is performed. The risk-benefit analysis of lymphatic mapping with blue dye provides improvement in staging, with reduced morbidity and hospital stay, and the elimination of general anaesthesia. The technique may also be used safely and accurately in breast cancer patients with excisional biopsy.     

Clinical relevance of multiple sentinel nodes in patients with breast cancer

BACKGROUND: Indiscriminate removal of axillary nodes may not be justified as it may potentially worsen the morbidity of the sentinel lymph node biopsy (SNB) procedure. This study examined the factors associated with removal of multiple sentinel lymph nodes and determined whether there was an upper threshold for the number of sentinel nodes that should be removed. METHODS: A total of 803 patients with breast cancer underwent successful SNB using peritumoral injection of (99m)Tc-labelled albumin colloid and Patent Blue V dye. SNB was followed by standard axillary treatment at the same operation in all patients. RESULTS: The mean number of sentinel nodes removed per procedure was 2.2 (range 1-9). Multiple sentinel nodes (mean 2.9, range 2-9) were found in 501 patients (62.4 per cent). The false-negative rate in patients who had one sentinel node harvested was 10 per cent, compared with 1 per cent in patients who had three or more nodes removed (P = 0.010). Factors associated with finding multiple sentinel nodes were age less than 50 years (P = 0.004), low body mass index (P < 0.001), tumour in the outer half of the breast (P = 0.013), sentinel node visualization on lymphoscintigraphy (P < 0.001) and an interval of 12 h or less between radioisotope injection and SNB (P = 0.014). For 99.6 per cent of node-positive tumours, metastasis was detected within the first four sentinel nodes removed. CONCLUSION: The identification of multiple sentinel nodes, when present, reduced the false-negative rate. These data suggested that removal of more than four nodes was unnecessary.