technetium-tc-99m-sulfur-colloid and iso-sulfan-blue

Techniques for sentinel lymph node injections have varied over the years in both cervical and uterine malignancy lymph node mapping. There remains considerable variation in techniques, particularly for uterine malignancies. This review summarizes some of the techniques that have been published and are currently utilized in sentinel lymph node mapping for cervical and uterine malignancies.

Topics: Female; Humans; Lymph Nodes; Methylene Blue; Neoplasm Staging; Radionuclide Imaging; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Uterine Cervical Neoplasms; Uterine Neoplasms

The axillary nodal status is accepted universally as the most powerful prognostic tool available for early stage breast cancer. The removal of level I and level II lymph nodes at axillary node dissection (ALND) is the most accurate method to assess nodal status, and it is the universal standard; however, it is associated with several adverse long-term sequelae. Lymphatic mapping with sentinel lymph node biopsy has emerged as an effective and safe alternative to the ALND for detecting axillary metastases. This article discusses some lymphatic mapping methodology.

Topics: Breast Neoplasms; Coloring Agents; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Neoplasm Staging; Prognosis; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The goals of the research study were to develop an easily mastered, accurate, minimally invasive technique of sentinel node radiolocalization with biopsy (SNRLB) in the feline model; to compare it with blue-dye mapping techniques; and to test the applicability of sentinel node radiolocalization biopsy in three head and neck tumor types: N0 malignant melanoma, N0 Merkel cell carcinoma, and N0 squamous cell carcinoma.. Prospective consecutive series studies were performed in the feline model and in three head and neck tumor types: N0 malignant melanoma (43 patients), N0 Merkel cell carcinoma (8 patients), and N0 squamous cell carcinoma (20 patients).. The technique of sentinel node radiolocalization with biopsy was analyzed in eight felines and compared with blue-dye mapping. Patterns of sentinel node gamma emissions were recorded. Localization success rates were determined for blue dye and sentinel node with radiolocalization biopsy. In the human studies, all patients had sentinel node radiolocalization biopsy performed in a similar manner. On the morning of surgery, each patient had sentinel node radiolocalization biopsy of the sentinel lymph node performed using an intradermal or peritumoral injection of technetium Tc 99m sulfur colloid. Sentinel nodes were localized on the skin surface using a handheld gamma detector. Gamma count measurements were obtained for the following: 1) the "hot" spot/node in vivo before incision, 2) the hot spot/node in vivo during dissection, 3) the hot spot/node ex vivo, 4) the lymphatic bed after hot spot/node removal, and 5) the background in the operating room. The first draining lymph node(s) was identified, and biopsy of the node was performed. The radioactive sentinel lymph node(s) was submitted separately for routine histopathological evaluation. Preoperative lymphoscintigrams were performed in patients with melanoma and patients with Merkel cell carcinoma. In patients with head and neck squamous cell carcinoma, the relationship between the sentinel node and the remaining lymphatic basin was studied and all patients received complete neck dissections. The accuracy of sentinel node radiolocalization with biopsy, the micrometastatic rate, the false-negative rate, and long-term recurrence rates were reported for each of the head and neck tumor types. In the melanoma study, the success of sentinel node localization was compared for sentinel node radiolocalization biopsy, blue-dye mapping, and lymphoscintigraphy. In the Merkel cell carcinoma study, localization rates were evaluated for sentinel node radiolocalization biopsy and lymphoscintigraphy. In the head and neck squamous cell carcinoma study, the localization rate of sentinel node radiolocalization biopsy and the predictive value of the sentinel node relative to the remaining lymphatic bed were determined. All results were analyzed statistically.. Across the different head and neck tumor types studied, sentinel node radiolocalization biopsy had a success rate approaching 95%. Sentinel node radiolocalization biopsy was more successful than blue-dye mapping or lymphoscintigraphy at identifying the sentinel node, although all three techniques were complementary. There was no instance of a sentinel node-negative patient developing regional lymphatic recurrence. In the head and neck squamous cell carcinoma study, there was no instance in which the sentinel node was negative and the remaining lymphadenectomy specimen was positive.. In head and neck tumors that spread via the lymphatics, it appears that sentinel node radiolocalization biopsy can be performed with a high success rate. This technique has a low false-negative rate and can be performed through a small incision. In head and neck squamous cell carcinoma, the histological appearance of the sentinel node does appear to reflect the regional nodal status of the patient.

Topics: Adult; Aged; Aged, 80 and over; Animals; Carcinoma, Merkel Cell; Carcinoma, Squamous Cell; Cats; Coloring Agents; Female; Head and Neck Neoplasms; Humans; Lymphatic Metastasis; Lymphatic System; Lymphoscintigraphy; Male; Melanoma; Middle Aged; Radiopharmaceuticals; Rosaniline Dyes; Scintillation Counting; Sentinel Lymph Node Biopsy; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid; Time Factors

The advent of sentinel lymph node mapping (SLNM) has had a profound impact on the surgical management of breast cancer and melanoma over the past decade. However, SLNM in gastrointestinal malignancies is still in its infancy. The role of SLNM in gastrointestinal malignancies is to increase staging accuracy and to reduce the understaging associated with standard surgical and pathological techniques. Numerous authors have described the successful use of SLNM in colon, rectal, gastric, esophageal, and anal canal malignancies, with a high degree of accuracy and upstaging by detailed pathological analysis of the sentinel nodes. Over the past 2 years, research and publications related to gastrointestinal lymphatic mapping have dramatically increased worldwide.

Topics: Colorectal Neoplasms; Coloring Agents; Congresses as Topic; Drainage; Gastrointestinal Neoplasms; Humans; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Sentinel lymph node (SLN) mapping and biopsy have emerged as the technique of choice for axillary staging of breast cancer. Several methods have been developed to identify SLNs, including peritumoral or intradermal injection of isosulfan blue dye or technetium sulfur colloid (TSC). We hypothesize that intradermal TSC is the optimal mapping technique and can be used alone to identify SLNs.. From March 1997 through January 2001, 180 women with T1 and T2 invasive breast cancer and clinically negative axilla underwent SLN mapping and biopsy. Peritumoral TSC was injected in 74 patients, 62 of whom also received peritumoral blue dye. Intradermal TSC (above tumor) was performed in 94 patients, 76 of whom also received peritumoral blue dye. Technetium-rich nodes were identified intraoperatively using a hand-held gamma probe and blue nodes were identified visually. Hematoxylin- and eosin-stained SLN sections were examined by light microscopy for breast cancer metastases.. Overall, the SLN mapping procedures were successful in 91% of patients. Peritumoral and intradermal TSC were successful in identifying SLNs in 78% and 97% of patients, respectively. Peritumorally injected isosulfan blue was successful in identifying 83% of SLNs. Intradermal TSC was found to be superior to peritumoral TSC and peritumoral blue dye in identifying SLNs (p = 0.00094, chi-squared, and p = 0.020, ANOVA).. SLN mapping by intradermal TSC has a significantly higher success rate than peritumoral TSC or blue dye. There was minimal benefit in identifying additional SLNs with addition of peritumoral blue dye to intradermal TSC. So, SLN mapping and biopsy using intradermal-injected TSC can be used alone to effectively stage the axilla for breast cancer.

Topics: Breast Neoplasms; Coloring Agents; Female; Humans; Injections, Intradermal; Injections, Intralesional; Lymphatic Metastasis; Neoplasm Staging; Radioisotopes; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Topics: Colectomy; Colorectal Neoplasms; Humans; Lymphatic Metastasis; Neoplasm Staging; Radioimmunodetection; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Topics: Axilla; Breast Neoplasms; Coloring Agents; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Neoplasm Staging; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The Clinical test of sentinel nodes (SNs) in uterine cancer began recently, especially endometrial cancer. In relation to cervical cancer, the detection rate of SN ranged anywhere between 15% to 100% and likewise the sensitivity rate varied from 66% to 100%. Due to these inconclusive results, the data cannot be reliably used for clinical study purposes. Meanwhile, it should be noted that endometrial cancer research has just begun. The tracer used for detection can be roughly classified into an isotope method and a dye method. The isotope method shows a better detection rate, but it can supplemented by using together with the dye method. In Japan, the most commonly reported radiopharmaceutical agent is technetium-99m-labeled phytic acid isotope and 1% isosulfan blue as the dye. In conducting cervical cancer studies, there are many reports of utilizing technetium-99m-labeled phytic acid isotope, injected into 4 different areas of the cervix. Regarding research conducted for endometrial cancer, experiments range from direct injection into the uterine body, injections into the cervix, and hysteroscopic injection. Due to ambiguity in the results, additional clinical testing is required to gather more data.

Topics: Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Uterine Neoplasms

Worldwide incidence of malignant melanoma is on the rise. Early detection of this malignancy is key to survival, and in the case of more advanced malignancy, early and effective detection of micrometastatic disease is crucial for staging and therapy. Because melanoma spreads primarily via lymphatic drainage patterns, effective methods for tracing these pathways are of paramount importance. The authors summarize the efficacy of blue dye, gamma probe, and lymphoscintigraphy detection methods, both individually and combined; the "missed disease" (or false-negative) rate; and the clinical discordance between expected and actual location of metastatic disease in head and neck melanoma. A clinical meta-analysis of current studies in head and neck melanoma was used to evaluate clinical data. A success rate of 95% to 100% for detection of sentinel lymph nodes can be achieved when blue dye, gamma probe, and lymphoscintigraphy techniques are combined. This is associated with a false-negative rate of 7.7% to 10.4%. With respect to intermediate-depth melanomas of the head and neck, a significant discordance exists between expected and actual lymphatic drainage patterns. This problem is best addressed using a combination of lymphoscintigraphy, blue dye, and gamma probe localization, which yields a success rate of 95% to 100% for detection of sentinel lymph nodes and a low false-negative rate of 7.7% to 10.4%. In the instance of a failed study, one in which sentinel nodes are not detected by the aforementioned methods, elective node dissection is the treatment modality of choice.

Topics: False Negative Reactions; Head and Neck Neoplasms; Humans; Lymph Nodes; Lymphatic Metastasis; Melanoma; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid

The last decade has seen the development of a minimally invasive technique to identify representative nodes--sentinel nodes--that reflect the tumor status of nodes in the axillary lymphatic basin draining a primary breast carcinoma. Sentinel lymph node dissection (SLND), originally developed as an alternative to elective complete lymph node dissection in patients with primary cutaneous melanoma, has been applied successfully to the management of patients with breast cancer. SLND holds promise as a staging technique to replace formal level I and II axillary lymph node dissection in selected patients with breast carcinoma, thus avoiding an unnecessary procedure that has no role in many patients with tumor-free axillae. Under way are two large randomized trials examining the role of SLND for the management of patients with invasive breast carcinoma. Even when tumor is detected in the sentinel node, a focused examination of this node may indicate whether or not completion axillary lymph node dissection is necessary. However, although SLND has great potential, its successful widespread use requires more stringent definition of the sentinel node and standardized guidelines for lymphatic mapping. Each institution must carefully assess the accuracy and consistency of results obtained by its multidisciplinary SLND team.

Topics: Axilla; Breast Neoplasms; Coloring Agents; False Negative Reactions; Feasibility Studies; Female; Humans; Intraoperative Care; Lymph Node Excision; Lymphatic Metastasis; Multicenter Studies as Topic; Neoplasm Staging; Predictive Value of Tests; Prospective Studies; Quality Control; Radionuclide Imaging; Radiopharmaceuticals; Randomized Controlled Trials as Topic; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Aggregated Albumin; Technetium Tc 99m Sulfur Colloid

While sentinel lymph node dissection (SLND) provides axillary staging, recent trials question the necessity of removing positive nonsentinel axillary lymph nodes (LN) in breast cancer. We sought to determine the technical feasibility of percutaneous core needle biopsy (PNB) of axillary sentinel lymph nodes (SLNs).. After dual tracer injection, 25 patients underwent intraoperative axillary ultrasound and ultrasound guided per PNB of the axillary LN at the site of radiotracer uptake, followed by standard SLND. The primary outcome measure was successful correlation of PNB with SLN, defined as: (1) similar final pathology in core and SLN and (2) presence of blue staining and/or radiotracer in the core or gross evidence of PNB at the SLN (e.g., transected SLN).. Preincision axillary ultrasound identified a LN (mean size 1.15 ± 0.67 cm) at the site of radioactive tracer in 92 % (23 of 25) of cases. Gross evidence of PNB at the SLN was found in 76 % (19 of 25) of cases. Blue staining, radioisotope, and pathology matched in core and SLN specimens in 36 % (9 of 25), 64 % (16 of 25), and 72 % (18 of 25) of cases, respectively. Overall, successful correlation of core biopsy with SLN occurred in 72 % (18 of 25) of cases.. Results of this phase I study demonstrate that PNB of the SLN is technically feasible, but further refinement of technique is warranted to improve correlation of core biopsy to SLND.

Topics: Adult; Aged; Aged, 80 and over; Axilla; Biopsy, Large-Core Needle; Breast Neoplasms; Carcinoma, Ductal, Breast; Carcinoma, Intraductal, Noninfiltrating; Carcinoma, Lobular; Coloring Agents; Female; Humans; Image-Guided Biopsy; Lymph Node Excision; Lymphatic Metastasis; Mastectomy, Segmental; Middle Aged; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Ultrasonography

In patients with breast cancer (BC), axillary lymph node sampling (ALNS) is a reliable procedure with low morbidity, alternative or complementary to sentinel lymph node biopsy (SLNB), which may improve the detection rate of axillary node metastases as compared to SLNB alone in staging the axilla. The aim of this study was to assess the usefulness of ALNS in conjunction with SLNB in improving the sensitivity of SLNB alone at frozen section examination. One hundred and twelve women (median age 56 years, range 29-71 years) with BC underwent SLNB using a combined radioisotope and isosulfan blue dye technique. Two groups of age- and tumor size-matched patients were prospectively randomized: Group A (SLNB alone, 55 women) and group B (SLNB plus ALNS, 57 women). Intraoperative examination showed SN involvement in 32 (28.6%) patients: group A = 14 (25.5%), group B = 18 (31.6%), whilst the final pathology showed axillary node involvement in 7 further cases (group A = 5, group B = 2). The sensitivity and accuracy were 73.7% vs. 90.0% (p = 0.23) and 90.9% vs. 94.7% (p = 0.49), group A vs. B, respectively. Multivariate analysis showed that age >65 years and body mass index independently correlated with the amount of axillary drainage in both groups, which was 47.5 ± 11.3 and 49.6 ± 12.2 ml (A vs. B, p = NS), respectively. In conclusion, in our preliminary study, ALNS in conjunction with SLNB is a low-risk procedure, useful to reduce the false-negative rate of SLNB and to improve the accuracy of intraoperative evaluation of the axillary nodes in patients with BC.

Topics: Adult; Aged; Breast Neoplasms; Female; Frozen Sections; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Sentinel-lymph-node (SLN) surgery was designed to minimise the side-effects of lymph-node surgery but still offer outcomes equivalent to axillary-lymph-node dissection (ALND). The aims of National Surgical Adjuvant Breast and Bowel Project (NSABP) trial B-32 were to establish whether SLN resection in patients with breast cancer achieves the same survival and regional control as ALND, but with fewer side-effects.. NSABP B-32 was a randomised controlled phase 3 trial done at 80 centres in Canada and the USA between May 1, 1999, and Feb 29, 2004. Women with invasive breast cancer were randomly assigned to either SLN resection plus ALND (group 1) or to SLN resection alone with ALND only if the SLNs were positive (group 2). Random assignment was done at the NSABP Biostatistical Center (Pittsburgh, PA, USA) with a biased coin minimisation approach in an allocation ratio of 1:1. Stratification variables were age at entry (≤ 49 years, ≥ 50 years), clinical tumour size (≤ 2·0 cm, 2·1-4·0 cm, ≥ 4·1 cm), and surgical plan (lumpectomy, mastectomy). SLN resection was done with a blue dye and radioactive tracer. Outcome analyses were done in patients who were assessed as having pathologically negative sentinel nodes and for whom follow-up data were available. The primary endpoint was overall survival. Analyses were done on an intention-to-treat basis. All deaths, irrespective of cause, were included. The mean time on study for the SLN-negative patients with follow-up information was 95·6 months (range 70·1-126·7). This study is registered with ClinicalTrials.gov, number NCT00003830.. 5611 women were randomly assigned to the treatment groups, 3989 had pathologically negative SLN. 309 deaths were reported in the 3986 SLN-negative patients with follow-up information: 140 of 1975 patients in group 1 and 169 of 2011 in group 2. Log-rank comparison of overall survival in groups 1 and 2 yielded an unadjusted hazard ratio (HR) of 1·20 (95% CI 0·96-1·50; p=0·12). 8-year Kaplan-Meier estimates for overall survival were 91·8% (95% CI 90·4-93·3) in group 1 and 90·3% (88·8-91·8) in group 2. Treatment comparisons for disease-free survival yielded an unadjusted HR of 1·05 (95% CI 0·90-1·22; p=0·54). 8-year Kaplan-Meier estimates for disease-free survival were 82·4% (80·5-84·4) in group 1 and 81·5% (79·6-83·4) in group 2. There were eight regional-node recurrences as first events in group 1 and 14 in group 2 (p=0·22). Patients are continuing follow-up for longer-term assessment of survival and regional control. The most common adverse events were allergic reactions, mostly related to the administration of the blue dye.. Overall survival, disease-free survival, and regional control were statistically equivalent between groups. When the SLN is negative, SLN surgery alone with no further ALND is an appropriate, safe, and effective therapy for breast cancer patients with clinically negative lymph nodes.. US Public Health Service, National Cancer Institute, and Department of Health and Human Services.

Topics: Axilla; Breast Neoplasms; Canada; Chemotherapy, Adjuvant; Coloring Agents; Disease-Free Survival; Female; Humans; Kaplan-Meier Estimate; Lymph Node Excision; Lymphatic Metastasis; Mastectomy, Modified Radical; Mastectomy, Segmental; Middle Aged; Neoplasm Recurrence, Local; Proportional Hazards Models; Radiopharmaceuticals; Radiotherapy, Adjuvant; Risk Assessment; Risk Factors; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Time Factors; Treatment Outcome; United States

To describe the accuracy of SLN mapping in patients with a preoperative diagnosis of grade 1 endometrial cancer.. A prospective, non-randomized study of women with a preoperative diagnosis of endometrial cancer and clinical stage I disease was conducted. A subset analysis of patients with a preoperative diagnosis of grade 1 endometrial endometrioid cancer was performed. All patients had preoperative lymphoscintigraphy with Tc99m on the day of or day before surgery followed by an intraoperative injection of 2 cm(3) of isosulfan or methylene blue dye deep into the cervix or both cervix and fundus. All patients underwent hysterectomy, bilateral salpingo-oophorectomy, and regional nodal dissection. Hot and/or blue nodes were labeled as SLNs and sent for histopathological analysis.. Forty-two patients with a preoperative diagnosis of grade 1 endometrial carcinoma treated from 3/06 to 8/08 were identified. Twenty-five (60%) had laparoscopic surgery; 17 (40%) were treated by laparotomy. Preoperative lymphoscintigraphy visualized SLNs in 30 patients (71%); intraoperative localization of the SLN was possible in 36 patients (86%). A median of 3 SLNs (range, 1-14) and 14.5 non-SLNs (range, 4-55) were examined. In all, 4/36 (11%) had positive SLNs-3 seen on H&E and 1 as cytokeratin-positive cells on IHC. All node-positive cases were picked up by the SLN; there were no false-negative cases. The sensitivity of the SLN procedure in the 36 patients who had an SLN identified was 100%.. Sentinel lymph node mapping using a cervical injection with combined Tc and blue dye is feasible and accurate in patients with grade 1 endometrial cancer and may be a reasonable option for this select group of patients. Regional lymphadenectomy remains the gold standard in many practices, particularly for the approximately 15% of cases with failed SLN mapping.

Topics: Adult; Aged; Aged, 80 and over; Endometrial Neoplasms; Female; Humans; Hysterectomy; Intraoperative Care; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Methylene Blue; Middle Aged; Neoplasm Staging; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Radioactive colloid with a gamma probe is the most effective method of identifying sentinel lymph nodes (SLN). Nevertheless, since vital blue dyes are also helpful for visually identifying SLN during surgical dissection, they are often used together with radioactive colloid. There has occasionally been a shortage of lymphazurin blue (LB) dye for use in sentinel lymph node biopsies (SLNB). There have also been reports of anaphylactic reactions to the use of LB dye. Therefore, we were interested in using methylene (MB) blue dye to aid in the visualization of the SLN for biopsy because of its ready availability and greater safety. The purpose of this study of SLN biopsies was to compare the effectiveness of MB with that of LB dye.. We randomly assigned 159 consecutive patients with intermediate and high-risk melanomas, who were treated by a single surgeon at the Yale Melanoma Unit between January 10, 2005, and June 13, 2007 with SLN biopsy, with radioactive colloid and either LB or MB.. A total of 443 SLN were identified and removed from these 159 consecutive patients. MB dye was found to be as effective as LB dye in visually identifying SLN: blue dye was visible in 62% of SLN in the MB group compared with 58% in the LB group. When the SLN were separated into three anatomic locations the visualization results were LB 36% and MB 72% (P = 0.010) for head and neck, LB 65% and MB 61% (P = 0.919) for axilla, and LB 59% and MB 67% (P = 0.001) for groin.. SLN were identified in all 158 patients. Approximately 60% of these SLN were also visibly blue. In the cervical and groin regions, MB dye was more visible in the SLN than was the LB dye, and in the axilla the SLN were equally stained blue by both dyes. Generally, if surgeons wish to use intradermal injections of vital blue dye to help visualize SLN, we have found in this study that MB is at least as effective as LB for the visualization of these SLN. The cost of MB is less than that of LB.

Topics: Coloring Agents; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Melanoma; Methylene Blue; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid

To provide data from a US center on laparoscopic (LSC) approach to sentinel lymph node (SLN) detection in cervix cancer with detailed time analysis.. This prospective trial enrolled patients with stage IA2-IIA cervix cancer undergoing primary radical surgery. Tc-99 radiocolloid was injected the morning of surgery, followed by hybrid SPECT/CT lymphoscintigraphy. Blue dye injection occurred just prior to incision. After bilateral LSC SLN detection, all patients received complete LSC pelvic lymphadenectomy. Institutional SLN protocol was followed for frozen section, hematoxylin and eosin, and cytokeratin staining.. Between December 2003 and February 2006, 20 enrolled patients received 9 LSC-assisted radical vaginal hysterectomies, 7 radical abdominal hysterectomies, 2 LSC-assisted radical vaginal trachelectomies, and 2 LSC lymphadenectomies alone (secondary to positive lymph nodes). Mean tumor size was 2.5 cm. Nineteen percent of the 64 SLNs were found in unusual sites, including common iliac (11%), presacral (5%) and para-aortic (3%). The negative predictive value was 100%. The combined technique detected SLNs bilaterally in all patients. If blue dye alone was used, this rate would have dropped to 67.5% and was negatively correlated with elapsed surgical time (-0.7; p=0.002). The ability to visualize blue SLNs remained steady for 30 min and was completely gone by 50 min.. Laparoscopic SLN mapping can be newly introduced into gynecologic oncology centers with high detection rates and negative predictive values. The visualization of blue dye in SLNs is transient, and this negative time correlation may explain the previously reported inferior detection rates with this technique. CLINICAL TRIAL REGISTRATION.: ClinicalTrials.gov, http://www.clinicaltrials.gov, NCT 00205010.

Topics: Adult; Aged; Coloring Agents; Female; Humans; Laparoscopy; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Uterine Cervical Neoplasms

Subareolar or periareolar injection of radioactive technetium sulfur colloid is equivalent to other injection techniques for breast cancer sentinel lymph node (SLN) biopsy.. Prospective, multicenter clinical trial.. A total of 3961 individuals with clinical stage I and II breast cancer.. All patients underwent attempted SLN biopsy followed by completion axillary dissection. Injection technique was determined by the preference of each participating surgeon. Most surgeons had little or no experience with SLN biopsy before participation in this study.. The SLN identification and false-negative rates.. An SLN biopsy was performed in 3961 patients using blue dye alone or radioactive colloid plus blue dye. Subareolar and periareolar radioactive colloid injection techniques were associated with SLN identification rates of 99.3% and 95.6%, respectively, with false-negative rates of 8.3% and 8.9%, respectively. The identification rates were significantly higher for these 2 techniques than for peritumoral injection of radioactive colloid (91.1%) or the use of blue dye alone (88.5%) (P<.001). The false-negative rates were similar for all techniques.. Although many medical centers have adopted subareolar and periareolar radioactive colloid injections because of their simplicity and convenience, a paucity of data from a few single-institutional studies has existed to substantiate the false-negative rates associated with these techniques. The results of this multicenter study establish the validity of subareolar and periareolar radioactive colloid injections and support the hypothesis that the lymphatic drainage of the entire breast is to the same few SLNs.

Topics: Adult; Aged; Axilla; Breast Neoplasms; Female; Humans; Injections; Lymph Node Excision; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Nipples; Predictive Value of Tests; Prospective Studies; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

To determine the factors associated with false-negative results on sentinel node biopsy and sentinel node localization (identification rate) in patients with breast cancer enrolled in a multicenter trial using a combination technique of isosulfan blue with technetium sulfur colloid (Tc99).. Sentinel node biopsy is a diagnostic test used to detect breast cancer metastases. To test the reliability of this method, a complete lymph node dissection must be performed to determine the false-negative rate. Single-institution series have reported excellent results, although one multicenter trial reported a false-negative rate as high as 29% using radioisotope alone. A multicenter trial was initiated to test combined use of Tc99 and isosulfan blue.. Investigators (both private-practice and academic surgeons) were recruited after attending a course on the technique of sentinel node biopsy. No investigator participated in a learning trial before entering patients. Tc99 and isosulfan blue were injected into the peritumoral region.. Five hundred twenty-nine patients underwent 535 sentinel node biopsy procedures for an overall identification rate in finding a sentinel node of 87% and a false-negative rate of 13%. The identification rate increased and the false-negative rate decreased to 90% and 4.3%, respectively, after investigators had performed more than 30 cases. Univariate analysis of tumor showed the poorest success rate with older patients and inexperienced surgeons. Multivariate analysis identified both age and experience as independent predictors of failure. However, with older patients, inexperienced surgeons, and patients with five or more metastatic axillary nodes, the false-negative rate was consistently greater.. This multicenter trial, from both private practice and academic institutions, is an excellent indicator of the general utility of sentinel node biopsy. It establishes the factors that play an important role (patient age, surgical experience, tumor location) and those that are irrelevant (prior surgery, tumor size, Tc99 timing). This widens the applicability of the technique and identifies factors that require further investigation.

Topics: Adult; Aged; Aged, 80 and over; Analysis of Variance; Breast Neoplasms; False Negative Reactions; Female; Humans; Lymphatic Metastasis; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Sentinel lymph node (SLN) biopsy is fast becoming the standard for testing lymph node involvement in many institutions. However, questions remain as to the best method of injection. The authors hypothesized that a subareolar injection of material would drain to the same lymph node as a peritumoral injection, regardless of the location of the tumor.. To test this theory, 68 patients with 69 operable invasive breast carcinomas and clinically node-negative disease were enrolled in this single-institution Institutional Review Board-approved trial. Patients were injected with 1.0 mCi of technetium-99 sulfur colloid (unfiltered) in the subareolar area of the tumor-bearing breast. Each patient received an injection of 2 to 5 cc of isosulfan blue around the tumor. Radioactive SLNs were identified using a hand-held gamma detector probe.. The average age of patients entered into this trial was 55.2 +/- 13.4 years. The average size of the tumors was 1.48 +/- 1.0 cm. Thirty-two percent of the patients had undergone previous excisional breast biopsies. Of the 69 lesions, 62 (89.9%) had SLNs located with the blue dye and 65 (94.2%) with the technetium. In four patients, the SLN was not located with either method. All blue SLNs were also radioactive. All located SLNs were in the axilla. Of the 62 patients in which the SLNs were located with both methods, an average of 1.5 +/- 0.7 SLNs were found per patient, of which 23.2% had metastatic disease. All four patients in which no SLN was located with either method had undergone prior excisional biopsies.. The results of this study suggest that subareolar injection of technetium is as accurate as peritumoral injection of blue dye. Central injection is easy and avoids the necessity for image-guided injection of nonpalpable breast lesions. Finally, subareolar injection of technetium avoids the problem of overlap of the radioactive zone of diffusion of the injection site with the radioactive sentinel lymph node, particularly in medial and upper outer quadrant lesions.

Topics: Adult; Aged; Aged, 80 and over; Biopsy; Breast Neoplasms; Female; Humans; Injections; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Nipples; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Technetium Tc 99m Sulfur Colloid

Lymph node involvement is a strong predictor of disease recurrence and patient survival in vulvar cancer. The aim of the study was to evaluate the feasibility of sentinel lymph node (SLN) screening, the incidence of skip metastases, and lymph node lymphangiogenesis.. Fifty-five patients participated in this prospective, single centre study. A double SLN screening method was employed using radiocolloid (technetium-99 sulfur colloid) and 1.0% Isosulfan Blue. Immunohistochemistry, using a mouse monoclonal antibody against D2-40, was used to evaluate lymphatic vessel density (LVD). All calculations were performed using STATISTICA software v. 10 (StatSoft, USA, 2011); p < 0.05 was considered significant.. Using both methods of SLN detection, 100% accuracy was achieved, and skip metastases were diagnosed in only one woman (1.82%). Peri-tumour median LVD was significantly increased compared with matched intra-tumour samples (p < 0.001), while median LVD was significantly lower in negative, compared with positive SLN, regardless of whether matched non-SLN were negative (p < 0.001) or positive (p = 0.005). Metastatic SLN exhibited significantly higher median LVD compared with matched negative non-SLN (p = 0.015), while no significant difference in median LVD was detected between positive SLN and matched positive non-SLN. However, negative SLN had a significantly higher median LVD compared with matched negative non-SLN (p = 0.012).. SLN detection is a safe and feasible procedure in vulvar cancer. In patients without nodular involvement, SLN, compared with non-SLN, exhibited significantly higher median LVD, which may be an indication of its preparation to host metastases, and thus requires further investigation.

Topics: Aged; Animals; Antibodies, Monoclonal, Murine-Derived; Carcinoma, Squamous Cell; Female; Groin; Humans; Immunohistochemistry; Lymphangiogenesis; Lymphatic Metastasis; Mice; Neoplasm Staging; Prospective Studies; Rosaniline Dyes; Sentinel Lymph Node; Technetium Tc 99m Sulfur Colloid; Vulvar Neoplasms

Sentinel lymph node (SLN) resection is imperative for breast cancer staging. Axillary reverse mapping (ARM) can preserve arm draining nodes and lymphatics during surgery. ARM is generally performed with isosulfan blue (ISB), restricting its use for concurrent SLN biopsy. Indocyanine green (ICG) could serve as an alternative to ISB for ARM procedures.. SLN mapping and biopsy was performed via periareolar injection of. Twenty-three patients underwent SLN biopsy with or without axillary node dissection and ARM procedures. Twenty of these patients had at least one hot node; 12 patients had SLNs that were only hot, 6 hot/blue/fluorescent, and 2 hot/fluorescent. Overall, crossover of ARM agents with SLNs occurred in 8 cases. Inspection of the axillary cavity after SLN biopsy revealed fluorescent lymphatics and nodes remaining in 14 and 7 patients, respectively. Blue lymphatics and blue nodes were detected in fewer cases.. Nearly one-third of patients showed crossover between breast and arm draining nodes, which provides insight as to why some patients develop lymphedema symptoms after SLN biopsy. ICG and ISB identify similar numbers of SLNs. As such ICG could substitute for ISB in ARM procedures.

Topics: Adult; Aged; Axilla; Breast Neoplasms; Female; Humans; Indocyanine Green; Lymph Node Excision; Lymphatic Metastasis; Middle Aged; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Merkel cell carcinoma (MCC) is a relatively rare skin cancer with high rates of regional lymph node involvement and metastatic spread. National Comprehensive Cancer Network guidelines recommend sentinel lymph node biopsy (SLNB) for staging purposes. The goal of this study is to report our experience utilizing indocyanine green (ICG) fluorescence-based technology to aid in SLNB detection in MCC.. Consecutive MCC patients who underwent SLNB with radioisotope lymphoscintigraphy, with intraoperative handheld gamma probe, and ICG-based fluorescence imaging from 2012 to 2017 were prospectively studied (Cohort A). A group of historical controls that underwent SLNB for MCC with radioisotope lymphoscintigraphy and vital blue dye (VBD) (lymphazurin or methylene blue dye) was also analyzed (Cohort B).. Twenty-four consecutive patients underwent SLNB with lymphoscintigraphy and ICG-based fluorescence and 11 controls underwent SLNB with lymphoscintigraphy and VBD. The localization rate by node with VBD was 63.6% and ICG-based fluorescence was 94.8%. For two patients, a positive sentinel lymph node (SLN) was detected only by ICG-based fluorescence and the nodes were not detected by gamma probe and one patient's only positive node was identified via ICG fluorescence only. VBD or gamma probe did not identify any unique positive SLNs in either cohort B or either cohort, respectively.. In this study, we indicate that ICG-based fluorescence is not only feasible to augment SLN identification, but it has a higher node localization rate as compared to blue dye and it was able to identify positive SLNs otherwise missed by gamma probe. This study suggests the importance of utilizing two modalities to augment SLN identification and that ICG-based fluorescence may be able to identify nodes that would have been otherwise missed by gamma probe. We will continue to follow these patients and enroll more patients in this prospective study to further determine the role that ICG-based fluorescence has in identifying sentinel lymph nodes in MCC.

Topics: Aged; Aged, 80 and over; Carcinoma, Merkel Cell; Feasibility Studies; Female; Fluorescent Dyes; Humans; Indocyanine Green; Lymphatic Metastasis; Lymphoscintigraphy; Male; Methylene Blue; Middle Aged; Neoplasm Staging; Prospective Studies; Radiopharmaceuticals; Reproducibility of Results; Rosaniline Dyes; Sentinel Lymph Node; Sentinel Lymph Node Biopsy; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid

To compare the detection rate (DR) and bilateral optimal mapping (OM) of sentinel lymph nodes (SLNs) in women with endometrial and cervical cancer using indocyanine green (ICG) versus the standard technetium-99m radiocolloid ((99m)Tc) radiotracer plus methylene or isosulfan blue, or blue dye alone.. From October 2010 to May 2015, 163 women with stage I endometrial or cervical cancer (118 endometrial and 45 cervical cancer) underwent SLN mapping with (99m)Tc with blue dye, blue dye alone, or ICG. DR and bilateral OM of ICG were compared respectively with the results obtained using the standard (99m)Tc radiotracer with blue dye, or blue dye alone.. SLN mapping with (99m)Tc radiotracer with blue dye was performed on 77 of 163 women, 38 with blue dye only and 48 with ICG. The overall DR of SLN mapping was 97, 89, and 100 % for (99m)Tc with blue dye, blue dye alone, and ICG, respectively. The bilateral OM rate for ICG was 85 %-significantly higher than the 58 % obtained with (99m)Tc with blue dye (p = 0.003) and the 54 % for blue dye (p = 0.001). Thirty-one women (19 %) had positive SLNs. Sensitivity and negative predictive value of SLN were 100 % for all techniques.. SLNs mapping using ICG demonstrated higher DR compared to other modalities. In addition, ICG was significantly superior to (99m)Tc with blue dye in terms of bilateral OM in women with early stage endometrial and cervical cancer. The higher number of bilateral OM may consequently reduce the overall number of complete lymphadenectomies, reducing the duration and additional costs of surgical treatment.

Topics: Adenocarcinoma; Adult; Aged; Aged, 80 and over; Carcinoma, Squamous Cell; Coloring Agents; Endometrial Neoplasms; Female; Follow-Up Studies; Humans; Indocyanine Green; Middle Aged; Prognosis; Radiopharmaceuticals; Retrospective Studies; Rosaniline Dyes; Sentinel Lymph Node; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Uterine Cervical Neoplasms

Sentinel lymph node (SLN) biopsy has become the standard method of determining regional lymph node involvement in cutaneous melanoma. Although traditionally performed via injection of radioisotope tracers and blue dyes, fluorescent lymphangiography with indocyanine green (ICG) is an attractive alternative.. Fifty two consecutive patients with cutaneous melanoma of the trunk or extremities underwent SLNB. Preoperative lymphoscintigraphy was performed with technetium-99m sulfur colloid (TSC). Peritumoral intradermal injection of isosulfan blue (ISB) and ICG was then performed. Successful identification of a sentinel lymph node via each modality was then assessed.. A total of 77 lymph nodes were identified from the 52 patients (range 1-3). The majority of melanomas were extremity-based, superficial spreading type, and had SLN localized to the axilla. There were no complications related to IcG administration. Rates of SLN detection were 96.2% for TSC, 59.6% for ISB, and 88.5% for IcG (P < 0.05 for ICG vs ISB). On univariate logistic regression analysis, no factors were found to be associated with failure of ICG.. Fluorescent lymphangiography using ICG is an effective method of SLN identification in patients with cutaneous melanoma of the trunk and extremities. When ICG and TSC are used in combination, ISB offers no additional advantage and may be safely omitted.

Topics: Adult; Aged; Aged, 80 and over; Coloring Agents; Female; Fluorescence; Follow-Up Studies; Humans; Indocyanine Green; Lymph Nodes; Lymphoscintigraphy; Male; Melanoma; Melanoma, Cutaneous Malignant; Middle Aged; Neoplasm Staging; Prognosis; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid; Young Adult

We hypothesize that mapping the lymphatic drainage of the arm with blue dye (axillary reverse mapping [ARM]) during axillary lymphadenectomy decreases the likelihood of disruption of lymphatics and subsequent lymphedema.. This institutional review board-approved study involved 360 patients undergoing sentinel lymph node biopsy (SLNB) and/or axillary lymph node dissection (ALND) from May 2006 to October 2011. Technetium sulfur colloid (4 mL) was injected subareolarly, and 5 mL of blue dye was injected subcutaneously in the volar surface ipsilateral upper extremity (ARM). Data were collected on variations in lymphatic drainage, successful identification and protection of arm lymphatics, crossover, and occurrence of lymphedema.. A group of 360 patients underwent SLNB and/or ALND, 348 of whom underwent a SLNB. Of those, 237 (68.1%) had a SLNB only, and 111 (31.9%) went on to an ALND owing to a positive axilla. An additional 12 of 360 (3.3%) axilla had ALND owing to a clinically positive axilla/preoperative core needle biopsy. In 96% of patients with SLNB (334/348), breast SLNs were hot but not blue; crossover (SLN hot and blue) was seen in 14 of 348 patients (4%). Blue lymphatics were identified in 80 of 237 SLN incisions (33.7%) and in 93 of 123 ALND (75.4%). Average follow-up was 12 months (range, 3-48) and resulted in a SLNB lymphedema rate of 1.7% (4/237) and ALND of 2.4% (3/123).. ARM identified substantial lymphatic variations draining the upper extremities and facilitated preservation. Metastases in ARM-identified lymph nodes were acceptably low, indicating that ARM is safe. ARM added to present-day ALND and SLNB may be useful to lesser rates of lymphedema.

Topics: Axilla; Breast Neoplasms; Coloring Agents; Female; Follow-Up Studies; Humans; Lymph Nodes; Lymphatic Vessels; Lymphedema; Middle Aged; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The lymphatic drainage patterns of the head and neck (H&N) is complex. Therefore, identification of the sentinel lymph node (SLN) for H&N melanoma can be challenging.. Retrospective review of a prospectively collected melanoma database, from February 1997 through October 2008, identified 137 patients with H&N melanoma. All underwent pre-operative lymphoscintigraphy, and after 2007, patients underwent single photon emission computed tomography combined with computed tomography (SPECT/CT).. The mean number of SLNs per patient was 2.6. An SLN was successfully identified in 97% of patients, and in 9%, the SLN was positive for metastatic disease. The majority of patients (88%) drained to a unilateral level. Bilateral drainage occurred in 10%, with only two patients draining outside of the neck. The majority of patients (58%) had an SLN in level IIa (jugulodigastric lymph nodes). The regional recurrence rate was 4%, which all occurred prior to the use of SPECT/CT.. Utilization of SPECT/CT and knowledge of common lymphatic drainage patterns in neck lymph node levels can assist the surgeon in properly locating and excising the SLN with minimal morbidity, limiting unnecessary dissections, as well as reducing false negative results.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Coloring Agents; Female; Head and Neck Neoplasms; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Male; Melanoma; Middle Aged; Neoplasm Recurrence, Local; Radiopharmaceuticals; Retrospective Studies; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid; Tomography, Emission-Computed, Single-Photon; Young Adult

The purpose of this study was to compare lymphosonography (ie, contrast-enhanced ultrasound imaging [US] after interstitial injection of a US contrast agent) for the detection of sentinel lymph nodes (SLNs) in swine with naturally occurring melanoma tumors to lymphoscintigraphy using blue dye-guided surgical dissection as the reference standard. Also, we sought to determine if lymphosonography can be used to characterize SLNs.. Sixty-three swine with 104 melanomas were evaluated. Contrast-specific US was performed after peritumoral injection (1 mL dose) of Sonazoid (GE Healthcare, Oslo, Norway). Lymphoscintigraphy was performed after peritumoral injections of technetium Tc 99m sulfur colloid. Peritumoral injection of 1% Lymphazurin (Ben Venue Labs, Inc, Bedford, OH) was used to guide SLN resection. The accuracy of SLN detection with the two imaging modalities was compared using the McNemar test. The SLNs were qualitatively and quantitatively characterized as benign or malignant based on the lymphosonography results with histopathology and RNA analyses used as the reference standards.. Blue dye-guided surgery identified 351 SLNs. Lymphosonography detected 293 SLNs and 11 false-positives, while lymphoscintigraphy detected 231 SLNs and 20 false-positives. The accuracy of SLN detection was 81.8% for lymphosonography, which was significantly higher than the 63.2% achieved with lymphoscintigraphy (P < .0001). The accuracy of lymphosonography for SLN characterization was 80%. When the size of the enhanced SLN was taken into consideration to characterize SLNs, the accuracy was 86%.. Lymphosonography is statistically better than lymphoscintigraphy for the detection of SLNs in this animal model. The ability to use lymphosonography as a means to characterize SLNs as benign or malignant is limited.

Topics: Animals; Chi-Square Distribution; Coloring Agents; Contrast Media; Disease Models, Animal; Ferric Compounds; Imaging, Three-Dimensional; Iron; Lymph Nodes; Lymphatic Metastasis; Melanoma; Oxides; Predictive Value of Tests; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Statistics, Nonparametric; Swine; Technetium Tc 99m Sulfur Colloid; Ultrasonography; Videotape Recording

Determining how many sentinel lymph nodes (SLNs) should be removed for melanoma is important. The purpose of this study is to determine the frequency at which nodes that are less radioactive than the "hottest" node (which is negative) are positive for melanoma, how low of a radioactivity should warrant harvest, and if isosulfan blue is necessary.. We reviewed 1,152 melanoma patients who underwent lymphoscintigraphy with technetium, with or without blue dye, and SLN dissection from 1996 to 2008. SLNs with radioactivity ≥10% of the "hottest" SLN, all blue nodes, and all suspicious nodes were removed and analyzed. The miss rate was calculated as the proportion of node positive cases in which the "hottest" SLN was negative.. SLNs were identified in 1,520 nodal basins in 1,152 patients. SLN micrometastases were detected in 218 basins (14%) in 204 patients (18%). In 16% of SLN-positive patients (33/204 patients), the positive SLN was found to have a lower radioactive count than the "hottest" SLN, which was negative. In 21 of these cases, the positive SLNs had radioactivity ≤50% of the "hottest" SLN. The 10% rule significantly reduced the miss rate to 2.5% compared with removal of only the "hottest" SLN (miss rate = 16%). Also, blue dye did not significantly decrease the miss rate compared with radiocolloid alone using the 10% rule.. To decrease the miss rate, all SLNs with ≥10% of the ex vivo radioactivity of the "hottest" SLN should be removed and blue dye is not essential.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Coloring Agents; False Negative Reactions; Female; Follow-Up Studies; Humans; Lymph Node Excision; Lymphatic Metastasis; Lymphoscintigraphy; Male; Melanoma; Middle Aged; Neoplasm Micrometastasis; Prognosis; Radiopharmaceuticals; Retrospective Studies; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid; Young Adult

Merkel cell carcinoma (MCC) is a rare, aggressive cutaneous malignancy. Intraoperative imprint cytology (IIC) can potentially avoid second operations for completion lymphadenectomy when nodal metastases are found during nodal staging with sentinel lymph node biopsy (SLN). This represents the first series of IIC for MCC we are aware of and our initial experience. Patients with biopsy-proven MCC underwent SLN (at the time of wide excision) using a double indicator technique with 99technetium sulfur colloid and isosulfan blue. SLN were identified and bisected and touch imprints of each half were made. One half was air-dried and stained with Diff-Quick and the other was fixed with 95 per cent alcohol and stained with hematoxylin and eosin (H&E). Paraffin-embedded sections were examined by H&E. Eighteen patients underwent successful SLN mapping procedures. IIC was negative in 84.2 per cent (16) cases. Three false-negatives occurred with IIC, but there were no false-positives, making the sensitivity 33 per cent and the specificity 100 per cent. Two of four patients with positive pathology-confirmed SLN also had positive IIC. SLN mapping has usefulness in patients with MCC. IIC is feasible and accurate in evaluating the SLN. IIC is a practical diagnostic tool when intraoperative analysis of SLN biopsy is desired for MCC.

Topics: Aged; Aged, 80 and over; Carcinoma, Merkel Cell; Coloring Agents; Female; Humans; Intraoperative Care; Male; Middle Aged; Predictive Value of Tests; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid

To determine the diagnostic accuracy of sentinel lymph node (SLN) detection using lymphoscintigraphy, intraoperative blue dye, and radiocolloid in patients with early-stage cervical cancer.. Intra-cervical injection of technetium-99 sulfur colloid and lymphoscintigraphy were performed preoperatively. Isosulfan blue was injected intra-cervically immediately prior to surgery. SLNs were excised and examined intraoperatively (imprint cytology and frozen section) and postoperatively (H and E histology and immunohistochemistry (IHC) for cytokeratin).. Thirty eight patients were evaluable. Laparoscopy and laparotomy were performed in 28.9% and 71.1%, respectively. Subjects had squamous cell carcinoma (n=26), adenocarcinoma (n=10) or adenosquamous (n=2) histologies. 55.3% had cervical tumors <2 cm. The overall SLN detection rate was 92.1%. The external iliac region just distal to the common iliac bifurcation was the most common SLN location. A mean of 2.1 SLNs were detected per patient with bilateral SLNs observed in 47.4%. On final pathology, metastatic nodal disease was identified in 15.7% of patients. Of these, 83.3% were detected in the SLNs. Sensitivity of SLN detection of metastasis was 100% for patients with cervical tumors <2 cm. However intraoperative evaluation by imprint cytology and frozen section correctly identified lymph node metastasis in only 33.3%.. SLN detection is feasible and accurately reflects pelvic nodal basin status when performed in early-stage cervical cancer patients. However, while current intraoperative pathology techniques for assessing nodal metastases reliably detect metastases larger than 2 mm, they lack sufficient sensitivity to detect micrometastasis and isolated tumor cells.

Topics: Female; Frozen Sections; Humans; Immunohistochemistry; Intraoperative Care; Lymph Nodes; Neoplasm Staging; Postoperative Care; Radionuclide Imaging; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Uterine Cervical Neoplasms

In breast cancer, a combination of radioisotope and blue dye mapping maximizes the success and accuracy of sentinel node (SLN) biopsy. When multiple radioactive nodes are present, there is no single definition of isotope success, but the popular "10% rule" dictates removal of all SLN with counts >10% of the most radioactive node. Here we determine how frequently a positive SLN would be missed by the 10% rule.. Between 9/96 and 12/04, we performed 6,369 successful SLN biopsies using (99m)Tc sulfur colloid and isosulfan blue dye, removing as SLN all radioactive and/or blue nodes, and taking counts from each node ex vivo. Standard processing of all SLNs with a benign frozen section included hematoxylin and eosin (H&E) staining, serial sectioning, and immunohistochemistry (IHC).. 33% of patients (2,130/6,369) had positive SLNs. Of these patients, 1,387/2,130 (65%) had >1 SLN identified. The most radioactive SLN was benign in 29% (398/1,387), and 107/1,387 (8%) had a positive SLN that was neither blue nor the hottest. From this group 1.7% (24/1387) of patients had positive SLN with counts <10% radioactive counts of the hottest node. The 10% rule captured 98.3% of positive nodes in patients with multiple SLNs. No patient characteristics were predictive of failure of the 10% rule.. With combined isotope and blue dye mapping, the 10% rule is a robust guideline and fails to identify only 1.7% (24/1387) of all SLN-positive patients with multiple SLNs. This guideline appears to be equally valid for all subsets of patients.

Topics: Adult; Aged; Aged, 80 and over; Breast Neoplasms; Carcinoma, Intraductal, Noninfiltrating; Carcinoma, Lobular; Coloring Agents; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Neoplasm Staging; Prognosis; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Sentinel lymph node biopsy (SLNB) has only been recently used for childhood neoplasms.. We reviewed all patients younger than 19 years who underwent SLNB for 5 years.. Twenty patients were identified (11 male, 9 female). Sentinel lymph node biopsy was performed for 10 sarcomas (5 synovial, 3 rhabdomyosarcoma, 1 epitheliod, 1 other); 9 skin neoplasms (4 melanomas, 3 Spitz nevi, 2 melanocytomas); and 1 acinic cell carcinoma. All patients underwent Technetium 99m sulfur microcolloid injection and 4-quadrant subdermal injection with Lymphazurin 1% (Autosuture, Norwalk, Conn). Six patients required either sedation for lymphoscintigraphy. Intraoperative gamma probe was used. Primary lesions were found in lower extremity (n = 8), upper extremity (n = 6), trunk (n = 3), and head and neck (n = 3). The lymphatic basins were inguinal (n = 8), axilla (n = 8), neck (n = 3), and both inguinal and axilla (n = 1). At least one lymph node was identified in each procedure. Of 20 patients, 5 (25%) had metastatic disease (4 skin neoplasms and 1 sarcoma). There were no complications in our series, and all patients are alive with no recurrence at an average follow-up of 2.2 years.. Sentinel lymph node biopsy allows for an accurate biopsy in children. However, some younger patients may require sedation, and it may be more challenging to isolate the sentinel node.

Topics: Adolescent; Carcinoma, Acinar Cell; Child; Child, Preschool; Coloring Agents; Female; Humans; Hypnotics and Sedatives; Intraoperative Care; Lymphatic Metastasis; Male; Melanoma; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Rosaniline Dyes; Sarcoma; Sentinel Lymph Node Biopsy; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid; Young Adult

To present our experience in the therapeutic approach of the sentinel node biopsy (SNB) in patients with previous excision of the breast cancer, divided in non-palpable and palpable lesions, in comparison with time treatment and stagement of breast cancer.. In the period 2001-2006, 138 patients with prior diagnostic excisional biopsy (96 non-palpable and 42 palpable breast cancer) and 328 without previous surgery (32 non-palpable; 296 palpable cancer) were treated. The combined technique ((99m)Tc-colloidal rhenium and isosulfan blue dye) was the approach for sentinel lymph node (SLN) detection. Axillary lymph node dissection (ALND) was completed only when the SLN was positive for metastasis or not located.. Detection rate, if there was prior surgery, was 95% for non-palpable and 98% for palpable cancer, and 99% for one-time treatment group. Metastasis rate in the SLN was 15% in non-palpable cancer (14/91), significantly smaller than in palpable breast cancer (39% if prior surgery and 37% in one-time surgery). According to tumoral size, ALND metastasis rate was similar for T1 and T2 tumors (43-44%). In the follow-up of the groups with prior diagnostic biopsy or surgery of the breast cancer we have not found any false negative in the axilla.. The detection of the SLN is also feasible in patients with previous surgery of breast cancer. Because SLN metastasis rates are significantly smaller in non-palpable lesions, the effort in screening programs for early detection of breast cancer and also in improving histopathological confirmation of malignancy with ultrasound or stereotactic guided core biopsies must continue.

Topics: Adult; Aged; Aged, 80 and over; Axilla; Breast Neoplasms; Coloring Agents; Female; Humans; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Palpation; Radionuclide Imaging; Radiopharmaceuticals; Rhenium; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

We hypothesized that high-volume surgeons performing sentinel lymph node (SLN) biopsy at an academic medical center (AMC) would have the same identification rates at suburban surgical centers (SSCs).. Twenty-one surgeons performed 1199 SLN biopsies in 1187 clinically node-negative patients with an intraoperative gamma probe (IOGP) plus blue dye (at AMC) or blue dye alone (at SSCs). Demographic, radiologic, and pathological data were analyzed by generalized estimating equations logistic regression models.. Four surgeons (group 1) performed 877 procedures (361, 247, 152, and 117 cases each), 426 with and 451 without IOGP. Seventeen surgeons (group 2) performed 322 procedures (2-92 cases each), 173 with and 149 without IOGP. Group 1 found 411 SLNs (96.5%) with and 419 (92.9%) without IOGP (P = .024). Group 2 found 163 (94.2%) with and 117 (78.5%) without IOGP (P < .0001). The odds of finding the SLN was 2.9 times higher with IOGP (95% confidence interval [95% CI], 1.8, 4.7; P < .001) and 2.7 times higher by group 1 than group 2 surgeons (95% CI, 1.7, 4.3; P < .001), controlling for tumor size and surgery type.. High-volume surgeons identified more SLNs with IOGP (at the AMC) than without (at the SSCs). They also were more efficient than low-volume surgeons when blue dye alone was used. Low-volume surgeons were almost as efficient as high-volume surgeons when they used IOGP. Optimal identification of SLNs requires nuclear medicine facilities.

Topics: Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Lymph node status is the most important prognostic factor in cervical cancer. Sentinel lymph node (SLN) procedures have been purported to reduce peri- and postoperative morbidity and operative time.. All patients with surgically managed clinical FIGO stage IA/B1 cervical cancer underwent SLN followed by pelvic lymphadenectomy with technetium+/-lymphazurin from April 2004 to April 2006. 0.1-0.2 mci of filtered sulfur colloid technetium was injected submucosally into 4 quadrants of the exocervix. Lymphazurin (4cc) was only used if technetium was unsuccessful in identifying bilateral sentinel lymph nodes. Serial microsections at 5 microm intervals were performed and stained intraoperatively. Complete pelvic node dissections were performed in all patients.. Forty-two patients underwent SLN, prior to full pelvic lymphadenectomy. Thirty-nine patients were included for the purposes of this study. The incidence in detecting at least one sentinel node was 98% per patient, and 85% per side. Identification of bilateral sentinel lymph nodes was successful in 28 cases (72%). The median number of SLN/side was 2. Three patients were found to have metastatic tumor to lymph nodes. No false negatives were identified. No adverse effects were noted.. SLN biopsy in cervical cancer is feasible to do, with a low false negative rate. We believe SLN should be evaluated per side and not per patient, that a pelvic lymphadenectomy is otherwise required. By following this protocol, the false negative rate can be minimized. The combined reported FN rate in the literature is 1.8%. If our definition is applied, the majority of reported false negative SLN is not actual false negatives.

Topics: Adult; Aged; Female; Humans; Hysterectomy; Lymph Node Excision; Lymph Nodes; Middle Aged; Neoplasm Staging; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium; Technetium Tc 99m Sulfur Colloid; Uterine Cervical Neoplasms

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.. 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.. 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%.. 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.

Topics: Adult; Aged; Aged, 80 and over; Carcinoma, Squamous Cell; Coloring Agents; Humans; Inguinal Canal; Male; Middle Aged; Neoplasm Staging; Penile Neoplasms; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Topics: Anaphylaxis; Breast Neoplasms; Coloring Agents; Female; Humans; Mastectomy, Segmental; Middle Aged; Neoplasm Staging; Postoperative Complications; Risk Factors; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Sentinel lymph node (SLN) mapping has emerged as a less invasive method for axillary lymph node staging in patients with breast cancer. Blue dye and radioisotopes are commonly used agents to localize SLNs, but the optimal site for the injection of these agents continues to be debated. In this study, we evaluated whether subareolar injection of blue dye led to the identification of the same SLNs as peritumoral injection of technetium colloid.. From March 2003 to August 2006, 124 patients with invasive breast cancer, diagnosed by core needle biopsy, were included in this study. Demographic and clinical data were abstracted from medical records. Approximately 1 h prior to surgery, all patients had peritumoral injection of 37 Mbq of Tc-99m-sulfur colloid. In the operating room, 3 to 5 mL of 1% lymphazurin was injected into the subareolar area. SLNs were categorized as radio-labeled-only, blue-only, or radio-labeled + blue. Data were analyzed with 95% exact confidence intervals, Spearman rank coefficient and kappa coefficient.. The mean number of SLNs identified was 1.9 (range 1-5). With the combination of two methods 122 out of 124 patients (98.4%) had successful identification of SLNs. One hundred fifteen patients (92.7%) had SLNs that were blue and 121 patients (97.6%) had radio-labeled SLNs. One hundred fourteen patients had at least one SLN that was both blue and radio-labeled, yielding a concordance rate of 91.9% (95% CI, 0.88-0.98). Metastatic disease was identified in SLNs of 28 patients. All lymph nodes with evidence of metastasis were both blue and radio-labeled.. Our study showed a high degree of concordance between subareolar blue dye and peritumoral radiocolloid in identification of SLNs. These results further support that the breast parenchyma and subareolar plexus drain to similar SLNs within the axilla. These two techniques can complement each other in localizing SLNs with a high success rate.

Topics: Adult; Aged; Aged, 80 and over; Biopsy, Needle; Breast Neoplasms; Coloring Agents; Female; Histological Techniques; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Preoperative parenchymal or peritumoral (PT) injection of (99m)Tc-labeled sulfur colloid (TcSC) is the standard method for sentinel lymph node (SLN) identification in patients with breast cancer. Limitations of this method include variable identification rates, slow transit times, and painful injections. We hypothesize that TcSC will travel to the SLN within minutes after injection into the subareolar (SA) lymphatics, thus making an intraoperative injection technique feasible.. One hundred twenty-two women with invasive breast cancer were enrolled onto this prospective study. Immediately after the induction of general anesthesia, patients were injected with 1 to 2 mCi of filtered TcSC in the SA location. Then, 5 mL of 1% isosulfan blue dye was injected into the PT location. The SLN or SLNs were identified as radioactive, blue, or both and removed for pathologic evaluation.. The mean patient age was 56 years. The mean tumor size was 1.5 cm. In 86.1% of patients, a transcutaneous axillary "hot spot" was identified by handheld gamma probe. The mean time from TcSC injection to axillary incision was 17.6 minutes. At least one SLN was identified in 99.2% of patients. The mean number of SLNs identified per patient was 1.83. The mean count of radioactive SLNs was 2715 cps. In 97.2% of patients, blue SLNs were also radioactive.. TcSC injected into the SA lymphatics rapidly drains to the SLN. The radioactive SLN is easily and quickly identified after an intraoperative SA TcSC injection. The simplicity of this method eliminates the inherent problems associated with standard PT injection.

Topics: Adult; Aged; Aged, 80 and over; Breast Neoplasms; Carcinoma, Ductal, Breast; Carcinoma, Lobular; Coloring Agents; Female; Humans; Injections, Subcutaneous; Intraoperative Period; Lymphatic Metastasis; Middle Aged; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Guidelines for the learning period of sentinel lymph node biopsy in breast cancer do not address important details such as the false negative rate way of calculation and the number of patients with positive axilla that should be included among the cases of this period. The aim of this study was to identify refinement points which should be included in the guidelines.. We studied 138 breast cancer cases of the sentinel lymph node biopsy learning period of three surgeons. The sentinel node was identified using isosulfan blue or technetium sulfur colloid or both. All patients underwent complementary axillary dissection.. All three surgeons (A, B, C) fulfilled the guidelines' false negative rate criteria of 5, 0 and 5%, respectively, after 20 cases. However, only six, 10 and 10 cases with positive axilla, respectively, were included and the false negative rates using only these cases were 17, 0 and 10%, respectively.. Current guidelines may lead surgeons to inappropriate conclusions about their ability to perform sentinel lymph node biopsy with an acceptable false negative rate. The learning period should include as many cases with positive axilla as possible and the false negative rate should be calculated only on those patients.

Topics: Adult; Aged; Axilla; Breast Neoplasms; Clinical Competence; False Negative Reactions; Female; Guideline Adherence; Humans; Lymphatic Metastasis; Middle Aged; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The combination of isosulfan blue (Lymphazurin) 1% and 99(m)Tc sulfur colloid (TSC) may improve the feasibility and accuracy of lymphatic mapping for colorectal cancer.. At laparotomy, 1 to 2 mL of isosulfan blue and 1 mCi of TSC were injected subserosally. Sentinel lymph node (SLN) designation was based on blue staining for isosulfan blue and increased radioactivity for TSC. Focused pathologic analysis of the SLNs and standard pathologic examination of the remaining specimen were performed.. A total of 57 consecutive patients were studied (median age, 71 years; 27 men and 30 women). Mapping was successful in 100% of patients with isosulfan blue and in 89% with TSC (P =.47). Lymphatic mapping was accurate in 93% of patients with isosulfan blue versus 92% with TSC (P =.53). The combined accuracy was 95%. A total of 709 lymph nodes were found (12.4 per patient): 553 non-SLNs (5.6% nodal positivity) versus 156 SLNs (16.7% nodal positivity; P <.0001). Isosulfan blue detected 152 SLNs, TSC detected 100, and both modalities detected 96. Of the SLNs detected by isosulfan blue only, 10.7% had nodal metastases, whereas 19.8% of SLNs detected with both modalities had nodal metastases (P =.028). Nodal disease was detected in 41% of patients with invasive carcinoma. Metastases were detected only in the SLNs in 26% and only by micrometastases in 11% of these patients.. These data confirm the efficacy of isosulfan blue and TSC for SLN mapping in colorectal tumors. No significant difference with respect to feasibility or accuracy exists between isosulfan blue and TSC. The metastatic yield is significantly higher in SLNs identified by both modalities compared with isosulfan blue only.

Topics: Aged; Colorectal Neoplasms; Female; Humans; Lymphatic Metastasis; Male; Prospective Studies; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Topics: Anaphylaxis; Breast Neoplasms; Female; Humans; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

We report the use of a thorough intraoperative sentinel lymph node (SLN) biopsy screening procedure for patients with small N0 breast tumors.. Sixty-eight consecutive female patients with monofocal stage I or "small" stage II (ie, 2.1-3.0 cm) N0 tumors received intraoperative SLN screening according to a procedure on the basis of comprehensive histologic analysis and cytokeratin immunohistochemical determination (CkID) of adjacent frozen sections of the SLN taken at 50-microm cutting levels.. The maximum duration of intraoperative analysis including CkID was 40 minutes. Positive SLN were found in 15/68 (22%) patients (always in a single node); they included 5 instances of micrometastasis and 3 of carcinomatous lymphangitis. In the 14 patients who underwent axillary lymph node dissection, no further metastasis was found at histologic analysis or CkID. SLN positivity correlated with histologic type (P=.044), intratumoral or peritumoral vascular invasion (P<.001) and Mib1 score (P=.042).. It is possible for an experienced team to perform intraoperative SLN screening for T1 or small T2 N0 breast tumors with frozen sections taken at 50-microm cutting levels. This procedure facilitates identification of micrometastasis, as well as of carcinomatous lymphangitis to help understand the biologic implications of these small lesions in the long term. SLN positivity appears to correlate with histologic type, intratumoral/peritumoral vascular invasion and Mib1 score.

Topics: Adult; Aged; Breast Neoplasms; Carcinoma; Female; Humans; Intraoperative Period; Middle Aged; Neoplasm Staging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Because of surveillance strategies in patients with known Barrett's esophagus, more patients with high-grade dysplasia or early cancer in the distal esophagus and at the esophagogastric junction are identified. The need for and extent of lymphadenectomy in such patients are controversial. The technique of sentinel lymph node dissection (SLND) to diagnose early lymphatic spread is applied increasingly in tumors of the gastrointestinal tract. The poorly defined lymphatic drainage of the esophagogastric junction has so far prevented many investigators from performing SLND in tumors of this anatomic region. We report the first results of SLND in Barrett's and cardia cancer. The preliminary experience indicates that the method is, even in this anatomical area, feasible and yields good results in early tumors. In advanced tumors, the method lacks sensitivity. Mapping should be done with blue dye and a radiocolloid. The concept of sentinel lymph node mapping and detection thus may open the door to individualized therapy for patients with high-grade dysplasia in a Barrett's esophagus or with early Barrett's and cardia cancer.

Topics: Adenocarcinoma; Algorithms; Barrett Esophagus; Cardia; Coloring Agents; Esophageal Neoplasms; Esophagectomy; Esophagogastric Junction; Humans; Lymph Nodes; Lymphatic Metastasis; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Stomach Neoplasms; Technetium Tc 99m Sulfur Colloid

We evaluated the feasibility of the sentinel lymph node technique to refine staging and potentially individualize therapy for anal cancer. Seventeen patients with cancer of the anal canal underwent peritumoral injection of 99mTc-colloid, followed 17 hours later by lymphoscintigraphy. A selective lymph node biopsy (SLNB) was attempted in 12 of 13 cases with scintigraphically detected SLNs. Lymph node metastases were present in 5 of 12 cases (42%); in 2 of these 5 cases, micrometastases were detected only by immunohistochemical staining. Hence, SLNB refines the diagnostic workup for anal cancer and provides an accurate basis for individualized therapy.

Topics: Adult; Aged; Aged, 80 and over; Anus Neoplasms; Carcinoma, Squamous Cell; Coloring Agents; Feasibility Studies; Female; Humans; Male; Middle Aged; Neoplasm Staging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The purpose of this study was to evaluate 2 different injection techniques for lymphoscintigraphy to determine the axillary sentinel lymph node (SLN) in patients with breast cancer.. Thirty-six patients with early breast cancer were studied prospectively. Both peritumoral (PT) and subdermal (SD) injections were performed on each patient with Tc-99m rhenium sulfide colloid. PT injections were done 1 to 8 days before surgery and SD injections were done on the day of operation. An intraoperative gamma probe was used to explore the axillary SLNs prior to tumor excision and axillary dissection. All surgical specimens were evaluated histopathologically.. In 19 of 36 patients, the same lymphatic drainage sites were observed with both techniques. Of these, 17 patients showed only axillary, 1 showed axillary and internal mammary (IM), and 1 showed axillary and subclavicular drainage sites. With PT injections 26 of 36 patients (72%), and with SD injections 33 of 36 patients (92%), showed axillary drainage and axillary SLNs. With PT injections 9 patients, and with SD injections only 2 patients, did not show any drainage site. During the operation with a gamma probe, axillary SLNs were excised in 35 patients (success rate, 97%). IM drainage was seen in 8 of 36 patients who underwent PT injections and in 3 of 36 with SD injections.. The success rate was found to be higher with the SD injection technique than with PT injections to visualize the axillary SLN. To increase the visualization of both axillary and IM SLNs, it may be useful to perform lymphoscintigraphy with SD and PT injections together.

Topics: Axilla; Breast Neoplasms; Coloring Agents; Female; Humans; Injections, Intradermal; Injections, Intralesional; Lymph Nodes; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Rhenium; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Compounds; Technetium Tc 99m Sulfur Colloid

Criteria are needed that could be used to terminate a sentinel lymphadenectomy for breast cancer prior to removing every sentinel lymph node, without increasing false negative rates.. Quantitative information on the radioactivity and color of sentinel lymph nodes removed from 541 breast cancer patients was correlated with pathologic information to determine when a sentinel lymphadenectomy could be terminated based on characteristics of the initially removed nodes.. Tumor was found in the first two sentinel lymph nodes removed in 127 of 129 node-positive patients. In 65% of patients who were able to be evaluated, the most radioactive lymph node was a positive lymph node. When any axillary lymph node was blue, then the first tumor-containing sentinel lymph node was also blue.. Removal of the most radioactive lymph node does not insure accurate assessment of the axilla. Removal of two sentinel lymph nodes accurately staged 98.4% of node-positive patients and 99.6% of the entire study population.

Topics: Axilla; Biopsy; Breast Neoplasms; Decision Support Techniques; Evidence-Based Medicine; False Negative Reactions; Humans; Mastectomy; Neoplasm Staging; Practice Guidelines as Topic; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Washington

Although the utility of lymphatic mapping (LM) and sentinel lymph node (SLN) biopsy in patients with melanoma and breast carcinoma has been well documented, this same is not true for patients with colon carcinoma. The authors previously reported a high false-negative rate for SLN biopsy in patients with colon carcinoma using isosulfan blue dye alone. The objective of the current study was to determine whether radiocolloid would increase the sensitivity of LM/SLN biopsy in patients with colon carcinoma.. The authors performed LM on 57 patients with colon carcinoma using both isosulfan blue dye and radiocolloid. The SLN(s) were identified by either their blue color or by increased radioactivity. The SLNs then underwent both routine histologic sectioning and immunohistochemical (IHC) staining for cytokeratins.. An SLN was identified in 56 patients (98%). Radiocolloid was able to identify only 1 additional positive SLN (9%). Overall, it was found that the disease had metastasized to the lymph nodes in 22 patients, even though there was no evidence of disease in the SLN(s) in 11 of those 22 patients on routine histologic sectioning (false-negative rate, 50%; sensitivity, 50%). In five patients, IHC of the SLN was the only indicator of metastatic disease. The inclusion of IHC-positive SLNs in these calculations would decrease the false-negative rate to 17% and would increase the sensitivity of SLN biopsy to 83%.. In the current study, the addition of radiocolloid did not increase the sensitivity of detection of positive SLN(s) compared with the use of isosulfan blue dye alone. IHC of the SLN potentially may increase the sensitivity of LM and reduce the false-negative rate. However, the long-term prognostic significance of IHC in patients with colon carcinoma remains controversial.

Topics: Adult; Aged; Aged, 80 and over; Colonic Neoplasms; Female; Humans; Immunoenzyme Techniques; Keratins; Lymph Nodes; Lymphatic Metastasis; Male; Middle Aged; Prognosis; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

We examined the feasibility of sentinel lymph node biopsy for papillary thyroid cancer. In the dye injection method, 1% of isosulfan blue dye was injected around the tumor of 32 patients intra-operatively, and in the radioisotope (RI) colloid injection method, 99mTc-tin colloid was injected in 23 patients 1 day preoperatively. Lymph node mapping for detection of sentinel nodes was performed after thyroidectomy and central and modified lateral neck lymph node dissections. All dissected nodes were examined postoperatively by hematoxylineosin staining to determine whether or not metastasis was present. In the dye injection method, sentinel lymph nodes were identified in 30 (94%) of the 32 patients. Lymph node metastases were found in 14 patients, and some sentinel lymph nodes had papillary cancer metastasis in 13 patients. There was only 1 false-negative case. Sensitivity and accuracy of sentinel lymph node biopsy was 93% (13/14) and 97% (29/30). With the RI method, detection rate, sensitivity and accuracy of sentinel lymph node biopsy was 96% (22/23), 90% (9/10) and 95% (21/22), respectively. Our preliminary study indicated that sentinel lymph node biopsy was feasible in patients with thyroid cancer. It may be helpful in avoiding unnecessary lymph node dissection and improving quality of life in patients with thyroid cancer.

Topics: Carcinoma, Papillary; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Radiopharmaceuticals; Risk Assessment; Rosaniline Dyes; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Thyroid Neoplasms; Thyroidectomy; Treatment Outcome

Evaluate the use of sentinel lymph node biopsy (SLNB) in staging and directing treatment of patients with conjunctival malignancy.. Retrospective, noncomparative, interventional case reports.. Two patients with conjunctival melanoma underwent SLNB, which consisted of lymphoscintigraphy with injection of sulfur colloid technetium-99m. Lymphazurin blue was injected intraoperatively into the area of prior excision. The combination of a signal through the sulfur colloid technetium-99m and blue staining identified SLNs.. In both patients, the SLNs containing metastatic disease were identified and biopsies obtained, aiding staging and optimal therapy.. Sentinel lymph node biopsy has been recently reported as an aid in evaluating patients with periocular malignancies. These reports of patients with tumor-positive SLNs arising from the lymphatic metastasis of conjunctival malignancies underscore the utility of this important technique in evaluating patients with periocular malignancies.

Topics: Adult; Conjunctival Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Male; Melanoma; Middle Aged; Radionuclide Imaging; Retrospective Studies; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Current conventional surgical and pathological techniques substantially understage colon cancer. This is evidenced by the fact that a significant subset of patients who are stage I and II at the time of colectomy return with distant metastases and ultimately succumb to the disease within the next 5 years. The identification of more nodes within a specimen and the detailed analysis of lymph nodes with advanced pathological techniques such as immunohistochemistry and reverse-transcriptase polymerase chain reaction (RT-PCR) can improve the staging of colon cancer, but are also associated with tremendous financial, time, and labor constraints. Sentinel lymph node (SLN) mapping has provided an avenue of staging colon cancer with high success rates and accuracy rates, while maintaining cost- and time-effectiveness. The ability to reproduce these results is dependent on adherence to the technical details of the procedure, and thereby providing the pathologist with the true SLNs, upon which the advanced pathological studies can be applied. We report our experience of SLN mapping for colon tumors in 209 patients, elaborating on the materials used, technical details, pitfalls, and results of the procedure. Our results show a success rate of 100% (209/209) and an overall accuracy rate for predicting positive or negative metastatic disease of 96.2% (201/209). Nodal metastases were identified in 46.2% (85/184) of patients with invasive disease (stage T1 to T4). The SLN was the exclusive site of metastases in 38.8% (33/85) of these patients, and the nodal disease was detected only as micrometastases in 22.4% (19/85). The skip metastases rate (false negatives) was 9.4% (8/85). SLN mapping is a powerful tool for accurate staging of colon cancer with a high success rate. The upstaging associated with this procedure may reveal disease that might otherwise go undetected by conventional surgical and pathological methods. Those patients who are upstaged can then benefit from adjuvant chemotherapy, which has been shown to improve survival of colon cancer patients with nodal disease by at least 33%.

Topics: Colonic Neoplasms; Coloring Agents; Fluorescein; Humans; Lymphatic Metastasis; Neoplasm Staging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The purpose of this study of sentinel lymph node biopsies (SLN) was threefold: to compare the reliability of lymphazurin blue dye to radioactive technetium 99m sulfur colloid (TC); to evaluate the reliability of frozen section examinations of sentinel lymph nodes; and to determine how much SLN dissections prolonged operative time.. We evaluated the records of 263 consecutive patients with intermediate and high-risk melanomas (1.0 mm or thicker, or Clark Level IV or greater), who were treated by a single surgeon at the Yale Melanoma Unit between October 1, 1997, and September 30, 2001, and followed for more than 18 months.. A total of 655 SLN were identified and removed from these 263 consecutive patients. Radioactive colloid was found to be more reliable (100%) in identifying the SLN than lymphazurin blue dye (51%) in the nodes of the patients. Twenty-eight patients (11%) had positive sentinel lymph nodes, and 2 patients (7%) had false-negative frozen sections. Three patients (11%) had false-negative frozen sections; tumor was found subsequently on permanent sections only after special immunohistochemical stains were used. The location or removal of SLN did not prolong the operative procedure unreasonably, requiring an average of 7 to 20 minutes for removal of SLN, and 33 minutes for frozen section reports, during which time the primary tumor resection and wound coverage were performed.. SLN were found in all 263 patients. All SLN were identified reliably with radioactive colloid. Because blue dye was found in only half of the radioactive nodes, it is not appropriate to use this as the only marker for locating the SLN. This large series of patients attests to the reliability of frozen sections in identifying SLN harboring metastases, with 82% of the patients with nodal metastases identified in this fashion.

Topics: Follow-Up Studies; Frozen Sections; Humans; Lymph Nodes; Lymphatic Metastasis; Melanoma; Radiopharmaceuticals; Reproducibility of Results; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid; Time Factors

To describe one center's experience with sentinel lymph node (SLN) biopsy in patients with eyelid and conjunctival malignancies performed with a smaller volume of technetium than was initially used and a small incision directly overlying the sentinel node(s).. A noncomparative interventional case series of 13 patients with clinically negative regional lymph nodes who underwent SLN biopsy for eyelid or conjunctival malignancies at The University of Texas M. D. Anderson Cancer Center between May 2002 and July 2003. Preoperative lymphoscintigraphy was performed with an injection of 0.3 mCi of technetium Tc-99m sulfur colloid in a volume of 0.2 mL. Images were taken as soon as the first SLN was detected through the gamma camera. Intraoperative mapping was performed with the same volume and concentration of technetium Tc-99m sulfur colloid along with an injection of isosulfan blue dye.. Five patients had conjunctival melanoma, 6 had sebaceous cell carcinoma of the eyelid, and 2 had eyelid melanoma. SLN(s) were identified in all patients. In 12 patients, more than 1 SLN was identified. During surgery, no SLNs were blue. One patient with conjunctival melanoma had an SLN that was positive on histologic examination. There were no ocular or extraocular complications from the procedure except for mild temporary weakness of the marginal mandibular branch of the facial nerve in 2 patients that resolved completely within 4 to 6 weeks and without any further intervention. None of the patients had permanent blue tattooing of the conjunctival surface or eyelid skin.. Our experience suggests that lymphoscintigraphy and SLN biopsy with a small volume of technetium Tc-99m sulfur colloid and small incisions, even without the use of the blue dye, can identify SLNs in patients with conjunctival and eyelid malignancies, and can be performed safely.

Topics: Adenocarcinoma, Sebaceous; Adult; Aged; Aged, 80 and over; Coloring Agents; Conjunctival Neoplasms; Eyelid Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Male; Melanoma; Middle Aged; Radiography; Radionuclide Imaging; Rhenium; Rosaniline Dyes; Sebaceous Gland Neoplasms; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Isosulfan blue has been traditionally used as a tracer to map the lymphatic system during identification of the sentinel lymph node. However, allergic reactions may be life threatening. We compared the efficacy of methylene blue dye as a tracer for sentinel lymph node biopsy to isosulfan blue dye. In an analysis of 164 cases, there was no clinical or statistically significant difference in the success rate of sentinel node biopsy (P = 0.22), the number of blue sentinel nodes harvested (P = 0.46), the concordance with radioactive sentinel nodes (P = 0.92), or the incidence of metastases (P = 0.87) when methylene blue tracer was compared to isosulfan blue. No adverse reaction to either blue dye was observed. In conclusion, intraparenchymal injection of methylene blue dye is a reliable tracer for the lymphatic system and nodal identification during sentinel node mapping for breast cancer. It is safe, inexpensive, and readily available.

Topics: Adult; Aged; Breast Neoplasms; Case-Control Studies; Coloring Agents; Female; Humans; Lymphatic Metastasis; Methylene Blue; Middle Aged; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Treatment Outcome

Lymphoscintigraphy (LS) may identify sentinel lymph nodes (SLNs) outside the axilla. Biopsy of these nodes could improve the accuracy of lymphatic mapping (LM) for breast cancer (BC) if a significant number of tumor-positive extra-axillary sentinel nodes are identified. To address this, we evaluated the impact of the use of preoperative LS and biopsy of axillary and internal mammary SLNs in women with BC. From October 1997 to July 2003, 175 women with breast cancer received technetium sulfur colloid, and images were obtained. Isosulfan blue dye was injected intraoperatively, and LM of the axillary and internal mammary lymph node basins was performed with a hand-held gamma probe. The anatomic location and histologic status of all SLNs identified with LS and LM was recorded, and the impact of the findings on LS and internal mammary LM were evaluated. LS showed SLN in 127/175 (73%) women and "hot spots" were found with the gamma probe in 142/175 (81%). At least one SLN was identified by LM in 168/175 (96%) patients, and 48/168 (29%) had metastases. One hundred sixty-two of 168 (96%) patients had SLN exclusively in the axilla. Only 10 of 175 (6%) women had internal mammary (IM) SLNs seen on LS. LM identified IM sentinel nodes in 6 of these 10 patients, but none were involved with tumor. Preoperative lymphoscintigraphy and biopsy of internal mammary sentinel nodes do not enhance the accuracy of lymphatic mapping for breast cancer. Omitting lymphoscintigraphy reduces the complexity and cost of lymphatic mapping without compromising the identification of tumor-positive sentinel nodes.

Topics: Adult; Aged; Aged, 80 and over; Axilla; Breast Neoplasms; Coloring Agents; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Mastectomy; Middle Aged; Preoperative Care; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Sternum; Technetium Tc 99m Sulfur Colloid; Treatment Outcome

This prospective multicenter study was performed to assess the reliability of sentinel lymph node (SLN) biopsy in breast cancer and to analyze factors potentially influencing success rates.. In 21 departments, SLN biopsy and consecutive axillary lymph node dissection were performed in 814 breast cancer patients. The 80 surgeons involved were free in the choice of lymphography technique. The detection rate and the sensitivity, as well as the impact of lymphography technique, patient selection, technical procedure and learning curves, were evaluated.. The blue dye technique was used in 137 patients, radiocolloid in 169 patients, and combined blue dye/radiocolloid in 508 patients. The identification rate for the sentinel node was 83.9% for the entire group and showed a significant dependence on the lymphography technique (blue dye, 71.6%; radiocolloid, 78.8%; combined blue dye and radiocolloid, 89.6%). The overall sensitivity in detecting lymph node metastases was 91.3%. Immunostaining for cytoceratine revealed micrometastases in 19 (5.1%) of 374 patients in whom H/E staining was negative. The combined subdermal/peritumoral injection of the colloid showed a significantly higher identification rate than subdermal or peritumoral injection alone (96.8%, 84.6%, 78.6%; p < 0.001). There was also a significant higher detection rate in cases of SLN biopsy performed prior to lumpectomy, compared to SLN biopsy following lumpectomy (94.7% versus 82.8%; p < 0.001). Furthermore, there was a close correlation between the number of performed examinations and the detection rate.. SLN mapping predicts the axillary lymph node status accurately. Learning curves and several technical features influence the detection rate significantly. However, the false negative rate was independent of experience and injection technique.

Topics: Adult; Aged; Aged, 80 and over; Breast Neoplasms; Female; Humans; Lymphatic Metastasis; Lymphography; Middle Aged; Prospective Studies; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Multicentric or multifocal breast cancer is considered as one of the limitations for sentinel lymph node (SLN) localization. We did a retrospective analysis to evaluate the success rate, sensitivity, accuracy, and negative predictive values of SLN localization in multicentric or multifocal breast lesions.. Fifty-nine patients with multifocal or multicentric breast lesions proven by either fine-needle aspiration (19/59), core biopsy (39/59), or lumpectomy (8/59) underwent SLN localization. Of these patients, 46 had SLN localization by both radiocolloid and blue dye, and 13 had SLN localization by radiocolloid alone. Approximately 10 MBq (99m)Tc-labeled unfiltered sulfur colloid in 0.3-0.4 mL were injected intradermally over the 1 or 2 breast tumor locations 2-4 h before surgery. During surgery, vital blue dye was injected intraparenchymally in 4-6 places around the tumor. All lymph nodes with counts of >10 times that of the background counts, whether or not blue dye positive, and all blue dye-positive lymph nodes, whether or not radiocolloid positive, were excised and labeled accordingly. All lymph nodes underwent frozen sectioning and were examined by hematoxylin and eosin and immunohistologic (cytokeratin) staining.. Of the 59 patients, 48 had axillary lymph node dissection irrespective of the results of pathologic examination of the SLN. The success rate, sensitivity, negative predictive value, and accuracy were 93%, 100%, 100%, and 100% using the radiocolloid probe, 87%, 100%, 100%, and 100% using blue dye, and 93.5%, 100%, 100%, and 100% using combined methods, respectively. Concordance between blue dye and radiocolloid was 91% (the incidence of the number of sentinel nodes detected was 37.5%, 30.3%, 10.7%, and 21.4% for 1, 2, 3, and 4 or more lymph nodes, respectively). Metastatic lymph node involvement was found in 39.5% of patients.. The sentinel node localization approach showed a high negative predictive value in breast cancer patients with multifocal or multicentric lesions, contrary to the common belief of significant false-negative results in these patients.

Topics: Adult; Aged; Aged, 80 and over; Biopsy, Needle; Breast Neoplasms; Carcinoma, Ductal, Breast; False Negative Reactions; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Mastectomy; Mastectomy, Segmental; Middle Aged; Neoplasm Staging; Palpation; Radionuclide Imaging; Radiopharmaceuticals; Reproducibility of Results; Retrospective Studies; Rosaniline Dyes; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Few studies have attempted to critically identify patient- and tumor-related factors that limit sentinel node biopsy (SNB). These studies have been limited by sample size and surgeon variability. The present study attempts to enumerate these limitations in a unique group of patients. One hundred twenty-five SNBs performed by a single surgeon between May 1997 and June 2001 were reviewed. Overall SNB was successful in 96 per cent of patients with a 97 per cent correlation with the axillary node dissection. Sentinel node identification was not affected by age, tumor size, tumor location, prior segmental resection, or neoadjuvant therapy. No false negatives were noted in the neoadjuvant group. The use of blue dye alone significantly understaged patients when compared with isotope alone (P = 0.02). SNB is a highly accurate method to identify axillary metastases and its limitations are not affected by patient or tumor related factors. In the present study SNB detection by both isotope and blue dye has been shown to be superior to blue dye alone. This finding demonstrates that these limitations may be overcome with the standardization of the technique used.

Topics: Age Factors; Bias; Biopsy; Breast Neoplasms; False Negative Reactions; Humans; Lymph Node Excision; Mastectomy; Middle Aged; Neoadjuvant Therapy; Neoplasm Staging; Radiopharmaceuticals; Rosaniline Dyes; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The goal of this study was to identify one or more inguinal sentinel nodes in patients with primary squamous cell carcinoma of the vulva and to determine the ability of the sentinel node to predict metastasis to the inguinal lymphatic basin.. Techniques employing technetium-99m (Tc-99m) sulfur colloid and isosulfan blue dye were utilized to identify sentinel nodes in the inguinal lymphatic beds. Technetium-99m sulfur colloid was injected intradermally at the tumor margins 90-180 min preoperatively followed by a similar injection of isosulfan blue dye 5-10 min before the groin dissection. A handheld collimated gamma counter was employed to identify Tc-99m-labeled sentinel nodes. Lymphatic tracts that had taken up blue dye and their corresponding sentinel node were also identified and retrieved. A completion inguinal dissection was then performed. Each sentinel node was labeled as hot and blue, hot and nonblue, or cold and blue. The sentinel nodes were subjected to pathologic examination with step sections and nonsentinel nodes were evaluated in the standard fashion.. Twenty-one patients with a median age of 79 were entered onto protocol and a total of 31 inguinal node dissections were performed. A sentinel node was identified in 31/31 (100%) groin dissections with the use of Tc-99m. Isosulfan blue dye identified a sentinel node in 19/31 (61%) groin dissections. Surgical staging revealed 7 patients with stage I disease, 5 with stage II disease, 5 with stage III disease, and 4 with stage IV disease. Lymph nodes in 9 groin dissections were found to have metastatic disease, and in 4 of these dissections, the sentinel node was the only positive node. Lymph nodes in 22 groin dissections had no evidence of metastasis. No false-negative sentinel lymph nodes were obtained (sentinel node negative and a nonsentinel node positive).. Tc-99m sulfur colloid is superior to isosulfan blue dye in the detection of sentinel nodes in inguinal dissections of patients with vulvar cancer. A sentinel node dissection utilizing Tc-99m alone can identify a sentinel node in all inguinal dissections. Pathologic examination with step sections has shown the sentinel node to be an accurate predictor of metastatic disease to the inguinal nodal chain.

Topics: Carcinoma, Squamous Cell; Female; Humans; Inguinal Canal; Lymphatic Metastasis; Predictive Value of Tests; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Vulvar Neoplasms

Treatment of malignant melanoma of the external ear presents unique challenges. Because of the significant debate regarding the efficacy and validity of using sentinel lymph node mapping for the treatment of ear melanomas, data for a population of patients with melanomas of the ear who underwent surgical excision and reconstruction were reviewed to determine the efficacy of sentinel node mapping. A retrospective chart review of cases treated by a single surgical oncologist was performed. All patients who were treated for malignant melanomas and required reconstruction of the external ear by the plastic surgical service between 1995 and 2001 were identified. Nineteen patients were selected, of whom nine underwent sentinel node mapping. The average age of the patients was 65.2 years. Evaluation of melanoma depth, medical history, surgical margins, lymph node metastasis, and recurrence was performed. Lymphoscintigraphy with technetium-99-sulfur colloid and 1% Lymphazurin (isosulfan blue; Zenith Parenterals, Rosemont, Ill.) demonstrated widely variable lymphatic drainage patterns. The lower tail of the parotid gland and the upper cervical area were the two most common locations. The average number of sentinel nodes identified and removed was 3.7. The average Breslow thickness for these patients was 2.3 mm. None of these patients demonstrated micrometastatic disease in their sentinel nodes. The most common reconstructive procedure after surgical resection was the use of rotational advancement flaps. Localization of radioactivity, as detected with external technetium-99 scanning, was the most reliable method for detection of the sentinel lymph node basins and the individual nodes. The average value for the primary injection site was 8375 counts per second, and the average value for the nodes removed was 973.5 counts per second. Of the nine patients who underwent sentinel lymph node mapping, only one, with an initial lesion depth of 5 mm, developed a local recurrence. The average follow-up period in this study was 21 months (range, 12 to 79 months). All patients in this study were evaluated at least 1 year after the initial surgical resection. Patients were monitored by the same surgical oncologist every 3 months for the first 2 years. Little can be found in the literature regarding the efficacy of sentinel node biopsies for ear melanomas. Larger studies are indicated; however, it seems that this method is practical for designing therapeutic methods for patients

Topics: Aged; Ear Neoplasms; Ear, External; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Male; Melanoma; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid

Sentinel lymph node (SLN) mapping has substantially changed the nature of surgery for cancer of the breast. Variables such as tracer type, volume, injection site, timing, and surgical experience have all been extensively evaluated. However, little attention has been paid to the technique of massage for SLN procedures. We sought to evaluate the effects of three different massage techniques on mapping success or accuracy of SLN mapping for breast cancer. All lymphatic mapping procedures for breast cancer at our tertiary-care center were performed by three experienced surgeons using both colloid and dye followed by a 5-minute massage. All data pertaining to SLN identification, histopathology, tumor characteristics, and patient demographics were entered into the Breast Care Center database. Consistent and uniquely differing massage techniques classified as resuscitative, buffer, or knead-like were each used by a specific surgeon. The last 25 consecutive cases performed by two surgeons and the last 24 by one surgeon were evaluated. The overall rate of SLN identification was 97 per cent, and the overall accuracy was 98.7 per cent. There was no statistically significant difference in the rate of SLN identification or accuracy between techniques. The proportions of blue-stained SLNs were similar, but the resuscitative technique yielded fewer hot SLNs (Fisher's exact test, P = 0.02). This method also yielded one false negative case. The three different massage techniques yielded a similar number of blue-stained SLNs. The resuscitative technique yielded fewer hot SLNs than the kneading and buffer methods. Our results failed to demonstrate a superior breast massage technique for identifying sentinel nodes. A larger randomized trial is needed to confirm these findings.

Topics: Adult; Aged; Aged, 80 and over; Axilla; Breast Neoplasms; Female; Humans; Lymph Nodes; Massage; Middle Aged; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

To investigate the clinical value of combined dye-isotope technique in detecting sentinel lymph node (SLN) and to examine whether the characteristics of SLN accurately predict cervical lymph node metastasis in lingual carcinoma.. Thirty patients with lingual carcinoma without lymph metastasis were injected with a dose of about 18.5 MBq of (99m)Tc-SC (sulfur colloid), around the tumor tissues before surgery, and lymphoscintigraphy was performed 5, 10, 30, 60 minutes, and 6 hours after injection. In the following day, all patients were injected with isosulfan blue dye around the primary tumor during surgery to trace SLN and underwent standard cervical lymph node dissection after SLN dissection. The pathological results of SLN were compared with standard lymph node dissection for their ability to accurately predict the final pathological status of the cervical lymph nodes.. SLN was successfully identified in 100% of the patients. Both positive and negative predictive values of SLN were 100%. The accuracy rate was 100%, and there were no false negatives.. The detection of SLN using combined dye-isotope technique could accurately predict cervical lymph node metastasis in lingual carcinoma.

Topics: Adult; Aged; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Male; Middle Aged; Neck; Radiopharmaceuticals; Rosaniline Dyes; Technetium Tc 99m Sulfur Colloid; Tongue Neoplasms

Assessment of sentinel nodes to predict metastases in a regional nodal basin is valuable for staging patients with melanoma and breast carcinoma. This study tested whether injection of isosulfan blue and technetium-99 could identify mediastinal sentinel nodes in patients with lung carcinoma and determine whether sentinel node histology predicts distal nodal metastases.. Isosulfan blue and technetium-99 were injected into the tumor and pulmonary resection performed. The hilum and mediastinum were assessed visually and with the gamma probe, and a mediastinal nodal dissection was performed.. Thirty-one patients were evaluated. Three patients had positive sentinel nodes and positive distal mediastinal nodes. Twenty-two patients had negative sentinel nodes and negative distal nodes. No sentinel node was identified in 6 patients and 2 patients had two sentinel nodes.. These data demonstrate that this rapid, simple technique can identify sentinel nodes in the mediastinum and that the sentinel node is an accurate predictor of distal nodal metastases in patients with lung cancer.

Topics: Aged; Carcinoid Tumor; Carcinoma, Non-Small-Cell Lung; Carcinoma, Small Cell; Female; Humans; Injections, Intralesional; Lung Neoplasms; Lymph Node Excision; Lymphatic Metastasis; Male; Middle Aged; Neoplasm Staging; Pneumonectomy; Prognosis; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

We have previously demonstrated the utility, accuracy, and advantages of a subareolar (SA) site of injection for blue dye compared with an intraparenchymal site. In later studies we advocated the additional use of preoperative SA-injected technetium 99m-labeled sulfur colloid as a directional aid in finding blue-stained sentinel lymph nodes (SLNs). Paramount to the usefulness of this dual-tracer, same-site technique is the degree to which SA-injected blue dye and SA-injected radiocolloid migrate concordantly and are deposited within the same sentinel nodes. The purpose of this study was to document the correlation and accuracy of SLN biopsy using blue dye and radiocolloid when both nodal markers are injected by the same SA route.. Between September 1999 and February 2002 (29 months), 185 consecutive patients with 187 operable breast cancers underwent 187 attempted SLN biopsies by a dual-tracer, same-site injection technique using the SA approach for both agents. Unfiltered technetium 99m-labeled sulfur colloid (1 mCi [37 MBq]) was SA-injected 30 to 45 minutes preoperatively; and just after anesthetic induction, 3 mL of 1% isosulfan blue dye was injected by the same SA route. SLN biopsies or complete axillary dissections were carried out, and SLNs identified during these procedures were classified as containing both blue dye and radioactivity ("blue-hot" nodes), radioactivity alone ("hot-only" nodes), or blue dye alone ("blue-only" nodes). Cases were categorized and tabulated based on the presence or absence of these three types of SLNs.. Of the 187 procedures, a SLN was identified successfully in 184 cases, indicating an SLN identification rate of 98.4% (95% confidence interval, 96.6% to 100.2%). In these 184 cases, a blue-hot node was present in 94.5% (n = 174 of 184). An SLN was positive in 50 cases, or 27.2% of the total group (n = 50 of 184). A blue-hot node was the only positive SLN in 43 of these 50 cases, or 86% of the node-positive cases. There were no false negatives in 20 confirmatory axillary node dissections carried out to document the findings of a negative SLN. A correlation analysis revealed that in 98.9% of cases (174 of 176), blue nodes were also radioactive ("blue-hot" case concordance = 98.9%). In 95.1% of cases (174 of 183), hot nodes had also taken up blue dye ("hot-blue" case concordance = 95.1%).. Using SA injections of both blue dye and radiocolloid, we achieved an SLN identification rate of 98.4% (184 of 187 cases), a false-negative rate of 0% (0 of 20 cases), and an accuracy in predicting the malignant status of the axilla of 100% (70 of 70 cases). The case concordance rate ranged between 98.9% ("blue-hot concordance") and 95.1% ("hot-blue concordance"). The present study is the first to evaluate dual-tracer, same-site SA injections of blue dye and radiocolloid. By demonstrating a high case concordance rate, a high SLN identification rate, and a 0% false-negative rate, this study adds further support to the validity and accuracy of same-site SA injections of both blue dye and radiocolloid during SLN biopsy in breast cancer.

Topics: Adult; Aged; Aged, 80 and over; Axilla; Breast Neoplasms; False Negative Reactions; Female; Humans; Injections; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Lung cancer is the most frequent cause of cancer death in the United States. The pattern of regional lymph node involvement is a major prognostic factor in a patient with nonsmall cell lung cancer. The accuracy of information obtained about the lymph node status of lung cancer patients can be potentially increased by sentinel node lymphatic mapping. This technique has been well studied in melanoma and breast cancer. It may be useful in increasing the detection of micrometastases and in decreasing the morbidity from complete mediastinal lymphadenectomy. We report an animal pilot study of pulmonary lymphatic mapping. The aim of our study was to gain experience in the surgical techniques for pulmonary sentinel node lymphatic mapping in an animal model prior to its application in humans. Technetium sulfur colloid and isosulfan blue dye were injected into different lobes of the lung followed by attempts to identify the sentinel node draining that specific portion of the lung. Technetium sulfur colloid identified the sentinel node in five of six dogs within 20 min after the radiotracer was injected into the lung parenchyma. Isosulfan blue dye identified the sentinel node in three of six dogs within 5 min. Both the agents are potentially useful, but we found greater technical ease in identifying the sentinel node with technetium sulfur colloid. Two single-institution pilot studies in humans have been performed. A multicentered study to validate and further refine this technique is necessary. Advanced pathologic techniques such as immunohistochemistry and reverse transcriptase-polymerase chain reaction can be used to enhance the accuracy of staging. This may facilitate proper application of novel therapeutic strategies to improve the current dismal prognosis of this disease.

Topics: Animals; Dogs; Lymph Nodes; Lymphatic System; Lymphoscintigraphy; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Sentinel lymph node biopsy is a minimally invasive method to stage the regional lymphatics that has revolutionized the management of patients with intermediate-thickness cutaneous melanoma. Head and neck surgeons have been encouraged by the accuracy of sentinel lymph node biopsy in cutaneous melanoma and have applied the technique to patients with head and neck squamous cell carcinoma (HNSCC). The objectives of the study were 1) to study the feasibility and accuracy of sentinel lymph node biopsy as a method to stage the regional lymphatics in HNSCC and 2) to determine whether there are qualitative differences between the cutaneous and mucosal lymphatics that would affect the technique used in HNSCC.. Two methods of investigation were employed: a prospective laboratory study using a feline model for sentinel lymph node biopsy and a retrospective review of patients who received lymphoscintigraphy before neck dissection and intraoperative identification of the sentinel lymph node.. Lymphoscintigraphy and a gamma probe were used in four felines to study the kinetics of technetium-labeled sulfa colloid (Tc-SC) in the mucosal lymphatics. In the second part of the feline study, eight subjects were studied intraoperatively. Tc-SC and isosulfan blue dye were used to study the injection technique for the mucosal lymphatics and to determine the time course of the dye and Tc-SC to the sentinel lymph node. In Part II of the present study, a retrospective review of 33 patients with HNSCC was conducted. Twenty patients (stage N0) whose treatment included elective neck dissection were studied with preoperative lymphoscintigraphy and underwent intraoperative identification of the sentinel lymph node to determine the accuracy and feasibility of sentinel lymph node biopsy. Eight patients with palpable neck disease and five patients with recurrent or second primary disease whose previous treatment included neck dissection were also studied with lymphoscintigraphy before neck dissection.. In the feline study, both Tc-SC and isosulfan blue dye traversed the lymphatics rapidly, appearing in the sentinel lymph node in less than 5 minutes. Modification of the injection technique used for cutaneous melanoma was required to depict the sentinel lymph node of the base of tongue. In the human study, the sentinel lymph node was accurately identified in 19 of 20 (95%) N0 patients. On average, 2.9 sentinel lymph nodes (range, 1-5) were identified in 2.2 (range, 1-4) levels of the neck. Sentinel lymph nodes were bilateral in 4 of 19 patients. When the sentinel lymph node was identified, it accurately predicted the pathological nodal status of the regional lymphatics. Three of 20 patients had cervical metastases, and the sentinel lymph node was identified in 2 of 3 patients with pathologic nodes (pN+). Focal areas of radiotracer uptake were identified in seven of eight patients with palpable disease. These areas corresponded to the level with palpable disease in four patients. The lymphatics delineated by lymphoscintigraphy in the five patients with previous neck dissection were outside the levels that had been dissected. Lymphoscintigraphy depicted collateral patterns of lymphatic drainage.. Sentinel lymph node biopsy is technically feasible and is a promising, minimally invasive method for staging the regional lymphatics in patients with stage N0 HNSCC. Lymphoscintigraphy alone may determine the levels that require treatment in patients with disrupted or previously operated cervical lymphatics.

Topics: Adult; Aged; Animals; Carcinoma, Squamous Cell; Cats; Feasibility Studies; Head and Neck Neoplasms; Humans; Lymphatic System; Lymphoscintigraphy; Melanoma; Middle Aged; Neck Dissection; Neoplasm Staging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid

Sentinel lymph node (SLN) mapping has revolutionized the way we stage breast cancer. A blue dye technique (BD) and the use of a radiotracer with the assistance of a gamma-detecting probe (GDP) have been used for the identification of the sentinel nodes. Some groups have suggested that only one technique is necessary. The reported false negative rates have been 0 to 12 per cent and success rates as low as 65 per cent. We have prospectively evaluated these techniques and have used both for the identification of the SLN. Ten surgeons participated in this study. From April 1998 through May 1999, 58 patients underwent SLN mapping followed by an axillary lymph node dissection. After the injection of 0.3 to 1.96 mCi of filtered sulfur colloid diluted to 4 mL all patients had preoperative lymphoscintigraphy. Five minutes before surgery 3 to 5 mL of isosulfan blue was injected around the tumor or tumor bed. Even though preoperative lymphoscintigraphy identified an SLN in 35 patients (63%) successful intraoperative detection of an SLN was possible using both techniques in 53 patients (91%). The SLN was detected by the BD and the GDP in 37 (65%) and 45 (80%) respectively. Nineteen patients (33%) were positive for metastatic disease in the axilla. Twenty-two (19%) of 113 SLNs removed were positive for disease. All cases of metastatic disease in the axilla were detected by the mapping technique. False negative rate was 0 per cent. In 11 patients the only positive node was the sentinel node (58%). Furthermore six (32%) patients were upstaged by the use of immunostains for cytokeratin. Twenty-two positive SLNs were detected in the 19 patients. The positive lymph node was identified only by BD in four patients (21%), only by GDP in six patients (31%), and by both techniques in nine patients (47%). We conclude that if only one technique had been used the false negative rate could have been as high as 32 per cent. Both techniques must be used to obtain a low false negative rate and high yield in the identification of the SLN.

Topics: Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymphatic Metastasis; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Sentinel lymph node (SLN) biopsy is an accurate technique to determine the metastatic status of lymph nodes. Radionuclide guidance makes the procedure easier and improves the success rate. Coordinating the operating room and nuclear medicine schedules causes delays when same-day radionuclide injection is used. We hypothesized that injection of 99m-Tc sulfur colloid immediately preoperatively is effective in SLN detection. We analyzed a prospective database of 70 patients treated at Harbor-UCLA Medical Center. The first 39 patients underwent completion axillary dissection (Group A) and subdermal injection of sulfur colloid immediately before surgery. A second group of 31 patients (Group B) had intraparenchymal injection immediately before surgery. We used isosulfan blue in all cases. SLNs were identified in 97 per cent of cases. SLNs were radioactive in 94 per cent and blue in 90 per cent. In Group A the accuracy and the positive and negative predictive values of SLN biopsy were 100 per cent. SLN counts per second ranged from 22 to 1700. The mean count per second was 290 +/- 281 (mean +/- standard deviation). Subdermal and intraparenchymal injections were equally successful (93% vs 92%). In conclusion injection of radiocolloid and isosulfan blue immediately preoperatively is highly successful and accurate in the detection of SLNs in breast cancer. It avoids operating room schedule delays.

Topics: Adult; Aged; Breast Neoplasms; Female; Humans; Injections; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Predictive Value of Tests; Preoperative Care; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Time Factors

Anal melanoma represents only 1% of all melanomas. Owing to delayed diagnosis and early metastasis, the prognosis is uniformly poor. Sentinel lymph node (SLN) biopsy has become the preferred method of nodal staging method for cutaneous melanoma. The role of SLN biopsy for staging of anal melanoma remains unclear. We report a 39-yr-old Caucasian woman who presented with a history of chronic hemorrhoidal pain. She noted a pedunculated peri-anal mass associated with bleeding. Upon biopsy, the lesion was found to be a 6-mm thick primary anal melanoma. There was no evidence of metastatic disease on preoperative imaging studies. She underwent wide local excision of the peri-anal site of the primary melanoma and intra-operative lymphatic mapping with both isosulfan blue and filtered technetium sulfur colloid. With the guidance a lymphoscintigram, ipsilateral inguinal sentinel lymphadenectomy identified five nodes, all of which were both "hot" and blue. One node was found to have a 1-mm metastatic deposit. Subsequently, the patient was treated with adjuvant radiation therapy to the primary site as well as to the superficial and deep inguinal nodal basins. She also received four cycles of biochemotherapy. SLN biopsy appears feasible for staging the superficial inguinal lymph nodes in patients with anal melanoma. However, the impact of SLN biopsy, early detection of occult metastasis, and adjuvant systemic and radiation therapy on the long-term survival of patients with anal melanoma is uncertain.

Topics: Adult; Anus Neoplasms; Chemotherapy, Adjuvant; Coloring Agents; Combined Modality Therapy; Female; Humans; Lymphatic Irradiation; Lymphatic Metastasis; Melanoma; Neoplasm Proteins; Neoplasm Staging; Radionuclide Imaging; Radiopharmaceuticals; Radiotherapy, Adjuvant; Rosaniline Dyes; S100 Proteins; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

To report the results of sentinel lymph node biopsy (SLNB) for cutaneous head and neck melanomas (CMHNs).. Consecutive series followed for a median of 20 months.. Tertiary cancer care center.. Fifty-six individuals with clinically node-negative CMHN, median Breslow thickness, 2.6 mm (range, 0.2-20.0 mm).. Preoperative technetium 99m sulfur colloid lymphoscintigraphy (PLSG) followed within 4 hours by intraoperative handheld gamma probe localization (IHGP). Intraoperative injection of 1% isosulfan blue dye (IBD) was used in 48 patients. Immediate completion nodal dissection was performed for metastatic SLNs on intraoperative frozen section analysis and monitoring for negative SLNs.. Rate of SLN identification, SLN and non-SLN positivity, same-basin recurrence, and disease-specific and recurrence-free survival.. Combination of IHGP and IBD improved SLN identification to 96% from 93% for IHGP and 73% for IBD alone. Four patients had a positive SLN on frozen section analysis. A negative SLNB correctly predicted regional nodal control in 47 of 48 patients but missed 1 of 5 patients who had regional lymphatic disease. All 4 patients who failed SLNB remain alive and free of recurrent disease. Two-year Kaplan-Meier disease-specific and relapse-free survival was 91% and 88%, respectively. Two-year disease-specific survival was 93% for SLN-negative patients and 50% for SLN-positive patients (P=.20).. Combining PLSG with IHGP and IBD improves the success rate of SLNB. Although SLNB is a reliable indicator of the status of the draining lymphatic basins in CMHN, patients with negative SLNs must be observed for longer periods to understand the true implications of the procedure.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Child; Female; Frozen Sections; Head and Neck Neoplasms; Humans; Male; Melanoma; Middle Aged; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Skin Neoplasms; Survival Rate; Technetium Tc 99m Sulfur Colloid

Controversy exists regarding the influence of sentinel lymph node (SLN) mapping technique or patient variables on the success rate of SLN mapping. We undertook a prospective study in a single institution series to evaluate multiple variables that could adversely affect SLN identification rates.. Data were collected on 174 patients who underwent 177 SLN mapping procedures followed by axillary dissection from October 1996 through January 2000. Patient demographics, body mass index (BMI), biopsy method, tumor size, palpability, and location were recorded. SLNs were identified by blue dye only (n = 31), Tc-99m sulfur colloid only (n = 34), or combined techniques (n = 112). Data were analyzed by logistic regression analysis and expressed as the probability of failure to map the SLN.. SLNs were identified successfully in 150 of 177 procedures (85%) with a false negative rate of 3.7%. Mapping success reached 93% using combination blue dye and isotope. Variables found to adversely affect SLN mapping success and the odds ratio of failure (OR) included lower inner quadrant (LIQ) location (OR 35.6), blue dye only (OR 42.4), BMI >30 and upper outer quadrant (UOQ) location (OR 14.6), and nonpalpable UIQ location (OR 25). LIQ location adversely affects mapping success independent of technique, tumor size, or obesity. Obesity and nonpalpability were adverse factors when tumors were located in the UOQ and UIQ, respectively. Age, biopsy technique, and tumor diameter did not affect SLN mapping success.. SLN mapping success is influenced by technique and tumor location, with best results achieved using combined techniques and for lesions located in quadrants other than the LIQ. Obesity and tumor palpability influence success in the context of tumor location.

Topics: Axilla; Breast Neoplasms; Breast Neoplasms, Male; Female; Humans; Lymph Node Excision; Male; Middle Aged; Prospective Studies; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The technique of lymphatic mapping and sentinel lymph node (SLN) biopsy is rapidly becoming the preferred method of staging the axilla of the breast cancer patient. This report describes the impact of postinjection massage on the sensitivity of this surgical technique.. Lymphatic mapping at the H Lee Moffitt Cancer Center is performed using a combination of isosulfan blue dye and Tc99m labeled sulfur colloid. Data describing the rate of SLN identification and the node characteristics from 594 consecutive patients were calculated. Patients who received a 5-minute massage after injection of blue dye and radiocolloid were compared with a control group in which the patients did not receive a postinjection massage.. When compared with controls, the proportion of patients who had their SLN identified using blue dye after massage increased from 73.0% to 88.3%, and the proportion of patients who had their SLN identified using radiocolloid after massage increased from 81.7% to 91.3%. The overall rate of SLN identification increased from 93.5% to 97.8%. The proportion of nodes that were stained blue among those removed increased from 73.4% to 79.7% after massage.. As experience increases with this new procedure, the surgical technique of lymphatic mapping continues to evolve. The addition of a postinjection massage significantly improves the uptake of blue dye by SLNs and may also aid in the accumulation of radioactivity in the SLNs, further increasing the sensitivity of this procedure.

Topics: Breast Neoplasms; Female; Humans; Massage; Neoplasm Staging; Radiopharmaceuticals; Rosaniline Dyes; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Sentinel node biopsy (SNB) for melanoma, with its intradermal (ID) injection, has a higher success rate than SNB for breast cancer, which is typically performed with a subcutaneous (SC) or peritumor injection. It is hypothesized that this is in part due to a slower transit time of lymphatic mapping agents through the parenchymal lymphatics of the breast. No study has investigated differences in transit time between different tissues to account for this clinical observation. The goal of the study was to compare transit time between ID and SC injections with common agents used in lymphatic mapping.. Four injection sites on five domestic pigs were used. Sites were bilateral and included cervical, forelimb, hindlimb, and flank areas. Agents included technetium sulfur colloid (Tc99, filtered and unfiltered), isosulfan blue (IB) dye, and fluorescein (FL) dye. At each site both ID and SC injections were made and the transit time to reach the sentinel node was recorded. The transit time differences were calculated per centimeter distance from the draining lymph node basin.. Sentinel nodes were identified draining all sites and found to be hot, blue, or fluorescent (using a Wood's lamp for identification). The cervical and forelimb injection sites drained to the same cervical lymph node basin and both SC and ID injection sites drained to the same sentinel node. Similarly, the hindlimb and flank injection sites both drained to inguinal lymph node basins. The slowest transit time occurred with Tc99 injected SC and the fastest occurred with Tc99 injected ID, whereas both FL dye and IB traveled rapidly to the sentinel node whether injected SC or ID. Large differences were found using unfiltered Tc99 depending on its injection ID (2.7 s/cm +/- 0.5) vs SC (249 s/cm +/- 14.7, P = 0.008).. Tc99 ID injections were significantly faster than SC injection. The slowest and fastest SC injection agents were unfiltered Tc99 and IB, respectively. Dermal injections provide faster transit of lymphatic agents and may improve the identification rate when applied to patients with breast cancer.

Topics: Animals; Contrast Media; Fluorescein; Injections, Intradermal; Injections, Subcutaneous; Lymph; Lymph Nodes; Radiopharmaceuticals; Rosaniline Dyes; Swine; Technetium Tc 99m Sulfur Colloid; Time Factors

Topics: Breast Neoplasms; Female; Humans; Injections, Subcutaneous; Lymphatic Metastasis; Nipples; Preoperative Care; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Time Factors

Sentinel lymph node (SLN) biopsy has become a standard method of staging patients with cutaneous melanoma. Sentinel lymph node biopsy usually is performed by intradermal injection of a vital blue dye (isosulfan blue) plus radioactive colloid (technetium sulfur colloid) around the site of the tumor. Intraoperative gamma probe detection has been shown to improve the rate of SLN identification compared to the use of blue dye alone. However, multiple sentinel nodes often are detected using the gamma probe. It is not clear whether these additional lymph nodes represent true sentinel nodes, or second-echelon lymph nodes that have received radiocolloid particles that have passed through the true sentinel node. This analysis was performed to determine the frequency with which these less radioactive lymph nodes contain metastatic disease when the most radioactive, or "hottest," node does not.. In the Sunbelt Melanoma Trial, 1184 patients with cutaneous melanoma of Breslow thickness 1.0 mm or more had sentinel lymph nodes identified. Sentinel lymph node biopsy was performed by injection of technetium sulfur colloid plus isosulfan blue dye in 99% of cases. Intraoperative determination of the degree of radioactivity of sentinel nodes (ex vivo) was measured, as well as the degree of blue dye staining.. Sentinel nodes were identified in 1373 nodal basins in 1184 patients. A total of 288 of 1184 patients (24.3%) were found to have sentinel node metastases detected by histology or immunohistochemistry. Nodal metastases were detected in 306 nodal basins in these 288 patients. There were 175 nodal basins from 170 patients in which at least one positive sentinel node was found and more than one sentinel node was harvested. Blue dye staining was found in 86.3% of the histologically positive sentinel nodes and 66.4% of the negative sentinel nodes. In 40 of 306 positive nodal basins (13.1%), the most radioactive sentinel node was negative for tumor when another, less radioactive, sentinel node was positive for tumor. In 20 of 40 cases (50%), the less radioactive positive sentinel node contained 50% or less of the radioactive count of the hottest lymph node. The cervical lymph node basin was associated with an increased likelihood of finding a positive sentinel node other than the hottest node.. If only the most radioactive sentinel node in each basin had been removed, 13.1% of the nodal basins with positive sentinel nodes would have been missed. It is recommended that all blue lymph nodes and all nodes that measure 10% or higher of the ex vivo radioactive count of the hottest sentinel node should be harvested for optimal detection of nodal metastases.

Topics: Chi-Square Distribution; False Negative Reactions; Female; Humans; Male; Melanoma; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid

The purpose of this study was to compare the results of isotope injection the morning of surgery (1-d protocol) with isotope injection the day before surgery (2-d protocol) in patients having sentinel lymph node (SLN) biopsy for breast cancer.. The 1-d (protocol 1) and 2-d (protocol 2) protocols included 514 and 152 patients, respectively, treated contemporaneously by surgeons experienced with the SLN biopsy technique. All had preoperative lymphoscintigraphy (LSG) and SLN biopsy using both blue dye and (99m)Tc-sulfur colloid. All patients had a single-site intradermal injection of unfiltered (99m)Tc-sulfur colloid in 0.05 mL normal saline: 3.7 MBq (0.1 mCi) on the morning of surgery for protocol 1 and 18.5 MBq (0.5 mCi) on the afternoon before surgery for protocol 2.. The patients in protocols 1 and 2 were comparable in terms of age, tumor size, tumor location, histologic type, node positivity, and frequency of a previous surgical biopsy. Comparing protocols 1 and 2, early (30 min) LSG images found the SLN equally often (69% vs. 68%). Isotope identified the SLN equally often at surgery (93% vs. 97%) as did isotope plus dye (98% vs. 99%). A comparable number of SLNs was found (2.5 vs. 2.8 per axilla), and the concordance between isotope and dye in the SLN was also comparable (97% vs. 95%). Late LSG images (at 2 h, possible only for protocol 2) identified the SLN in significantly more patients compared with early images (86% vs. 68%).. With unfiltered (99m)Tc-sulfur colloid injected intradermally, the results of SLN biopsy under the 1-d and 2-d protocols are virtually identical. A 2-d protocol allows increased efficiency in scheduling, both for nuclear medicine physicians and for the operating room, with no compromise in the effectiveness of SLN mapping.

Topics: Adult; Aged; Aged, 80 and over; Breast Neoplasms; Female; Humans; Lymph Nodes; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Time Factors

During sentinel lymph node (SLN) biopsy for breast cancer, most authors report identifying a mean of 1 to 3 SLNs, but a range of 1 to 8 (or more) SLNs per patient. A significant minority of patients have 4 or more SLNs. Here we seek to determine the significance for the breast cancer patient of finding multiple SLNs, and whether there is an optimal threshold number of SLNs that should be removed.. 1,561 patients who underwent successful SLN biopsy using blue dye and radioisotope in combination. Each SLN site was categorized prospectively by the operating surgeon as a dye success, an isotope success, or both. All SLNs containing counts at least four times greater than the postexcision axillary background were considered to be isotope successes.. Fifteen percent of patients (241) had multiple (>3) SLNs. Ninety-eight percent of node-positive patients (440 of 449) were identified within the first three SLN sites examined. In 2% of all SLN positive patients (9 of 449) or 4% of patients with multiple SLN (9 of 241), a positive SLN was detected at site four or more. In eight patients the first positive SLN was found at sites four or more. Blue dye and isotope were equally effective in identifying metastases in patients with multiple SLNs.. Fifteen percent of patients having SLN biopsy for breast cancer have multiple SLNs. Although 98% of positive SLNs were identified within the first three sites sampled, a small number of patients had their first positive SLN at sites 4 to 8. These data suggest that there is no absolute upper threshold for the number of SLNs that should be removed. Sampling a few additional SLNs probably adds little morbidity to the procedure, yet may significantly alter the treatment of some individuals. SLN biopsy should be continued until all blue and hot nodes are removed.

Topics: Breast Neoplasms; Carcinoma in Situ; Carcinoma, Ductal, Breast; Carcinoma, Lobular; Female; Humans; Lymphatic Metastasis; Male; Middle Aged; Neoplasm Staging; Patient Selection; Prospective Studies; Radiopharmaceuticals; Rosaniline Dyes; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Current literature has suggested that sentinel node biopsy may eventually replace axillary dissection as the nodal staging procedure of choice in early breast cancer. The goals of our study were to determine the accuracy of the sentinel node in predicting axillary nodal status and to evaluate the feasibility of incorporating sentinel node biopsy into a general surgical practice.. Between June 1999 and August 2000, 158 clinically node negative women with a histological diagnosis of T1 or T2 breast cancer were enrolled in the study. Both technetium sulfur colloid radiotracer and isosulfan blue dye were used to guide sentinel node biopsy. Sentinel node biopsy was always followed by a complete axillary dissection. The histopathology of sentinel nodes using serial sectioning and cytokeratin immunohistochemistry was compared with that of the nonsentinel nodes evaluated with routine hematoxylin and eosin stain.. The overall sentinel node detection rate was 84% (89 of 106 patients). Sentinel node biopsy was most successful when a combination of radiotracer and dye was used. The staging accuracy of sentinel node biopsy was 98% (87 of 89); the sensitivity of the method was 94% (34 of 36); the false negative rate was 6% (2 of 36); the negative predictive value was 96% (53 of 55); and the rate of metastases to the sentinel node only was 56% (20 of 36). The results varied considerably among surgeons.. The findings in our study support the hypothesis that the sentinel node is an accurate predictor of axillary nodal status in women with early breast cancer. These results suggest that the excellent findings in the literature can be reproduced by a group of general surgeons in a community-based hospital.

Topics: Adult; Aged; Breast Neoplasms; False Negative Reactions; Female; Humans; Lymphatic Metastasis; Middle Aged; Predictive Value of Tests; Radiopharmaceuticals; Rosaniline Dyes; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Radioisotope mapping is an essential technical component of sentinel lymph node (SLN) biopsy, and most authors define isotope success by an arbitrary threshold SLN-to-background ratio. Few studies have examined the degree to which the relative level of SLN counts correlates with the presence of metastasis. Having removed the SLN with the highest counts, how far should the surgeon persist in removing additional SLN which contain much lower levels of isotope?. We performed SLN biopsy, using both radioisotope and blue dye, in 2285 consecutive patients with stage I-II breast cancer. Successful isotope localization was defined as an ex vivo SLN-to-axillary background count ratio of at least 4:1, and enhanced pathologic analysis (serial sections and immunohistochemistry) was used throughout.. Among the 1566 patients with more than one SLN site identified, the SLN contained metastasis in 463 (30%). In 369 (80%) of these SLN-positive cases, the SLN with the highest count contained tumor, but in 94 (20%) it was benign. Among these 94: (1) the counts of the hottest benign SLN exceeded those of the histologically positive SLN by a ratio of at least 10:1 in 31% (29 of 94) of cases, (2) the counts of the positive SLN were < 4:1 those of the axillary background in 16% (15 of 94) of cases, and (3) blue dye failed to identify 27% of positive SLN. No optimum ratio of SLN-to-SLN or SLN-to-background counts identified the positive SLN in all cases.. Although the SLN with the highest counts is positive in 80% of breast cancer patients with multiple SLN, neither a relatively high isotope count nor the presence of blue dye consistently predict SLN positivity in all breast cancer patients. For maximum accuracy, SLN biopsy requires (1) the removal of all nodes containing isotope regardless of the relative magnitude of counts, (2) the concurrent use of blue dye to salvage those procedures in which isotope fails, and (3) the removal of all clinically suspicious non-SLN.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Breast Neoplasms; Child; Female; Humans; Lymphatic Metastasis; Male; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Among the advocates of blue dye, isotope, or combined dye-isotope mapping of the sentinel lymph node (SLN) for breast cancer, there is no universal consensus as to which technique is optimal and whether the relative value of each method changes with increasing experience. The objective of this study was to examine the relative contributions of blue dye and radioisotope to successful identification of the SLN as the SLN-mapping technique evolved over our first 2,000 consecutive cases.. Using the first 2,000 consecutive SLN biopsy procedures for breast cancer, performed by eight surgeons (none previously experienced in SLN techniques) at one institution, using a combined technique of blue dye and isotope mapping, we report the institutional learning curve and the relative contributions of dye and isotope to identifying both the SLN and the positive SLN, by increments of 500 cases.. Comparing the first 500 with the most recent 500 cases, success in identifying the SLN by blue dye did not improve with experience, although success in isotope localization steadily increased, from 86% to 94% (p < 0.00005). With the increasing success of isotope mapping, the marginal benefit of blue dye (the proportion of cases in which the SLN was identified by blue dye alone) steadily declined, from 9% to 3% (p = 0.0001). Parallel to this trend, the proportion of positive SLNs identified by blue dye did not change with experience (89% to 90%), but isotope success steadily increased, from 88% to 98% (p = 0.0015). The proportion of positive SLNs identified by blue dye alone declined from 12% to 2% (p = 0.0015).. Using a combined technique of blue dye and radioisotope mapping, and with refinement of the radioisotope technique, we report 97% success identifying the SLN. Although we continue to recommend the use of both methods in SLN mapping for breast cancer, we observe with experience a declining marginal benefit for blue dye.

Topics: Breast Neoplasms; Dose-Response Relationship, Radiation; Female; Humans; Injections, Intralesional; Lymph Node Excision; Lymph Nodes; Neoplasm Staging; Predictive Value of Tests; Radionuclide Imaging; Retrospective Studies; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The surgical management of breast cancer has changed markedly with the development of lymphatic mapping and sentinel lymph node (SLN) biopsy. Lymphatic mapping technique varies with respect to injection method, mapping agent, and surgical technique. The decision to pursue the internal mammary nodes (IMN) is another source of controversy.. From April 1998 to November 2000, 1,470 patients underwent lymphatic mapping for breast cancer and were prospectively entered into the breast database. The combined technique method was used, consisting of both isosulfan blue dye and technetium-99 labeled sulfur colloid. Patients with inner quadrant lesions and suspicion for internal mammary metastasis had preoperative lymphoscintigraphy. Those with internal mammary radioactivity noted by either lymphoscintigraphy or gamma probe underwent removal of the internal mammary sentinel nodes.. Thirty-six of the 1,470 (2.4%) patients mapped had at least 1 internal mammary lymph node removed. Inner quadrant lesions were present in 24 of the 36 (67%) IMN mapped patients. Of the 36 patients mapping to the IM area, 5 (14%) had at least 1 IM node positive. Two of the 5 (40%) had only IM metastasis, with 1 of these patients having 5 of 5 IMN positive and no disease detected in her axilla. A total of 2 of the 5 (40%) IM positive patients had more than 1 IMN positive. Twenty-eight of the 36 (78%) IM node harvested patients had preoperative lymphoscintigraphy, with 18 (64%) IMN appearing on imaging. Complications occurred in 3 of the 36 (8%) IMN mapped patients, without clinical significance.. Mapping to the IMN basin with the finding of metastasis results in N3 disease by the current staging system. The consequence for these patients is radiation therapy to the IMN basin. It is significant to note that 14% (5 of 36) were upstaged as result of IMN detection and 40% (2 of 5) had multiple positive IMNs. Substantial disease was detected in these 5 patients necessitating additional radiation therapy while avoiding IM radiation and its attendant complications in 86% of patients mapping to the IM basin.

Topics: Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Prospective Studies; Radionuclide Imaging; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Sentinel lymph node biopsy (SLNB) is an alternative to axillary dissection for many breast cancer patients. Cases of anaphylactic reaction to the isosulfan blue dye used during SLNB have recently been reported. No study on the incidence of serious anaphylactic reactions during SLNB for breast cancer has been reported.. We reviewed 639 consecutive SLNBs for breast cancer performed at our institution. Sentinel lymph node biopsy was performed using both isosulfan blue dye and technetium-99m sulfur colloid. Cases of anaphylaxis were reviewed in detail.. Overall, 1.1% of patients had severe anaphylactic reactions to isosulfan blue requiring vigorous resuscitation. No deaths or permanent disability occurred. In patients with anaphylaxis, hospital stay was prolonged by a mean of 1.6 days. In 1 patient, the anaphylactic reaction required termination of the operation.. Prompt recognition and aggressive treatment of anaphylactic reactions to isosulfan blue are critical to prevent an adverse outcome. Lymphatic mapping with blue dye should be performed in a setting where personnel are trained to recognize and treat anaphylaxis.

Topics: Aged; Anaphylaxis; Breast Neoplasms; Humans; Middle Aged; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

To investigate the feasibility and safety of preoperative lymphoscintigraphy and sentinel lymph node (SLN) biopsy for conjunctival melanoma.. A 49-year-old man with a biopsy-proven malignant melanoma of the conjunctiva (caruncle) underwent preoperative lymphoscintigraphy and SLN biopsy using a technique in which both isosulfan blue dye and technetium Tc 99 m sulfur colloid were injected in the subconjunctival space around the primary lesion. The conjunctival melanoma was excised just before identification and removal of the SLNs. The SLNs were excised along with concomitant dissection of their associated lymph node basins. The SLNs were evaluated histologically using serial sectioning and immunohistochemical staining with antisera against the S-100 protein and the melanoma antigen HMB-45.. Three SLNs were identified in the left submandibular and the left upper and middle jugular lymph node basins during the preoperative lymphoscintigraphy. The same three SLNs were successfully identified in the operating room. The SLNs were histologically negative, and the immunohistochemical staining against S-100 and HMB-45 was also negative. We did not observe any immediate adverse effects on the globe or the periocular structures from lymphatic mapping and SLN biopsy. By 24 hours after injection of blue dye, only a faint trace of blue was visible on the ocular surface.. Preoperative lymphoscintigraphy and SLN biopsy can be performed safely in patients with conjunctival melanoma. A larger study is planned to determine the sensitivity of this technique for the detection of occult regional nodal disease in patients with conjunctival melanoma.

Topics: Antigens, Neoplasm; Conjunctival Neoplasms; Feasibility Studies; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Male; Melanoma; Melanoma-Specific Antigens; Middle Aged; Neoplasm Proteins; Radionuclide Imaging; Rosaniline Dyes; S100 Proteins; Safety; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Radiopharmaceutical agents appear to improve the accuracy of sentinel node (SN) identification in patients with early-stage melanoma, but the optimal radiopharmaceutical agent and its timing from injection to surgery remain controversial. We undertook this investigation to examine the utility of 3 methods of intraoperative lymphatic mapping with radiopharmaceutical-directed sentinel lymphadenectomy (LM/SL). We suspected that concurrent injection of radiopharmaceutical and blue-dye would lead to the greatest success of SN identification.. The study was composed of 247 consecutive patients who had American Joint Committee on Cancer stage I or II melanoma. Before LM/SL, all patients underwent cutaneous lymphoscintigraphy by 1 of 3 techniques: technetium 99m (Tc 99m) human serum albumin (HSA) injected at least 24 hours before LM/SL (124 patients), Tc 99m filtered sulfur colloid (SC) injected no more than 4 hours before LM/SL (same-day SC, 95 patients), or Tc 99m SC injected at least 18 hours before LM/SL (prior-day SC, 28 patients). At the time of LM/SL, isosulfan blue dye was injected alone (SC groups) or with a second dose of HSA (HSA group). A hand-held gamma probe was used to determine the radioactive (hot) counts of blue-stained and nonstained nodes, and the in vivo and ex vivo node-to-background count ratios of the nodes were compared.. Preoperative LS identified 299 drainage basins; LM/SL identified at least 1 SN in 119 (98%) of 121 basins using same-day SC, 142 (97%) of 146 basins using HSA, and 32 (100%) of 32 basins using prior-day SC. There was no difference (P = .62) in the accuracy rate between the 3 techniques. The total number of SNs was 463. Same-day SC yielded higher intraoperative node-to-background count ratios than did either of the other techniques (P < .0001). Same-day SC also had the greatest relative change in radioactivity between the blue sentinel node and the post-excision basin (P < .0001), and the highest rate of SNs that were both blue and hot (in vivo or ex vivo ratio > or = 2, P = .05).. LS and LM/SL performed on the same day with a single injection of filtered Tc 99m SC serves as the most useful method for probe-directed LM/SL. This technique demonstrated the highest in vivo and ex vivo count ratios, fall-off of radioactivity between the excised nodes and post-excision basin, and concordance between blue dye and hot nodes. It should be recommended as the method of choice for probe-directed LM/SL.

Topics: Humans; Lymph Node Excision; Lymph Nodes; Melanoma; Organotechnetium Compounds; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Surveillance; Serum Albumin; Technetium Tc 99m Sulfur Colloid

The sentinel node concept is valid for penile cancer, melanoma, breast cancer and is probably also applicable to other solid malignancies. Sentinel nodes are the one or two initial nodes in the regional nodal drainage basin encountered by the lymphatic effluent from a tumour, which can be identified with an injection of vital dye or other lymphogogue. Sentinel lymph node dissection (SLND), a minimally invasive procedure with negligible morbidity, has therefore been utilized as an alternative to complete axillary lymph node dissection (ALND) for staging breast cancer. Examination of sentinel nodes provides a focused histopathological assessment of tissue most likely to harbour metastases, providing enhanced staging accuracy with a low false-negative rate. Tumour-free sentinel nodes are predictive of a tumour-free axilla, thereby allowing for the possibility of SLND without ALND and sparing patients the morbidity of ALND. Most of the experience from SLND has been obtained for axillary sentinel nodes. However, sentinel nodes have been identified in nonaxillary sites, such as the internal mammary nodes, but data on SLND for these regions is scarce. The ultimate role of SLND in breast cancer, which may be to identify sentinel-node-negative patients or even those with sentinel node metastases who can safely avoid ALND without sacrificing regional control and possibly gain a therapeutic benefit, cannot be defined before we have the results of large trials that are currently in progress.

Topics: Axilla; Breast Neoplasms; Female; Humans; Intraoperative Period; Lymph Node Excision; Lymphatic Metastasis; Neoplasm Staging; Radiopharmaceuticals; Rosaniline Dyes; Survival Analysis; Technetium Tc 99m Sulfur Colloid

Management of the regional lymph nodes remains the most controversial aspect of treating patients with intermediate-thickness cutaneous melanoma. Prospective studies have failed to demonstrate a significant survival advantage for patients undergoing elective lymph node dissection. The sentinel lymph node dissection (SLND) technique has been proposed as a method of accurately identifying patients with occult metastases in whom a regional lymph node dissection would be indicated. The majority of studies evaluating this technique have come from academic centers, most with dedicated melanoma clinics. This report describes the initial experience with SLND at a community hospital. Fifteen patients with intermediate-thickness primary cutaneous melanoma underwent preoperative lymphoscintigraphy with 99Tc-sulfur colloid. In addition, intraoperative lymphatic mapping using intradermally injected isosulfan blue was performed. Dissection was guided by radioactivity levels (in counts per second) as measured by a hand-held gamma probe. The resected lymph node or nodes were evaluated for micrometastases using routine hematoxylin and eosin staining and immunohistochemistry with S-100 and HMB-45. All patients were followed clinically for any evidence of recurrence. A sentinel node(s) was identified on preoperative lymphoscintigraphy in all 15 patients (100%). A single sentinel node was identified in 11 of 15 (73%), two nodes in 3 (20%), and one node in 1 (6.7%). The hand-held gamma probe reading correlated well with the site marked the "hot spot" (600-15,320 cps for the hot spot versus 10-350 cps for background). The sentinel lymph node was successfully identified and resected in all 15 patients. Blue-stained lymphatics and/or lymph nodes were present in 8 of 15 (53%) cases. Histopathology was negative for evidence of occult micrometastases in all patients. At mean follow-up of 221 days, all 15 patients remain with no evidence of disease. The outcomes for mapping and harvesting the sentinel node at a community institution compare favorably with results at major academic institutions. SLND may therefore be offered to patients with intermediate-thickness cutaneous melanoma in the community hospital setting with regional lymph node dissection and adjuvant interferon alpha-2b as options for patients with nodal micrometastases.

Topics: Adult; Aged; Aged, 80 and over; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Male; Melanoma; Middle Aged; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid

To evaluate the role of preoperative lymphoscintigraphy in sentinel lymph node (SLN) biopsy for breast cancer.. Numerous studies have demonstrated that SLN biopsy can be used to stage axillary lymph nodes for breast cancer. SLN biopsy is performed using injection of radioactive colloid, blue dye, or both. When radioactive colloid is used, a preoperative lymphoscintigram (nuclear medicine scan) is often obtained to ease SLN identification. Whether a preoperative lymphoscintigram adds diagnostic accuracy to offset the additional time and cost required is not clear.. After informed consent was obtained, 805 patients were enrolled in the University of Louisville Breast Cancer Sentinel Lymph Node Study, a multiinstitutional study involving 99 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. Preoperative lymphoscintigraphy was performed at the discretion of the individual surgeon. Biopsy of nonaxillary SLNs was not required in the protocol. Chi-square analysis and analysis of variance were used for statistical comparison.. Radioactive colloid injection was performed in 588 patients. In 560, peritumoral injection of isosulfan blue dye was also performed. A preoperative lymphoscintigram was obtained in 348 of the 588 patients (59%). The SLN was identified in 221 of 240 patients (92.1%) who did not undergo a preoperative lymphoscintigram, with a false-negative rate of 1.6%. In the 348 patients who underwent a preoperative lymphoscintigram, the SLN was identified in 310 (89.1%), with a false-negative rate of 8.7%. A mean of 2.2 and 2. 0 SLNs per patient were removed in the groups without and with a preoperative lymphoscintigram, respectively. There was no statistically significant difference in the SLN identification rate, false-negative rate, or number of SLNs removed when a preoperative lymphoscintigram was obtained.. Preoperative lymphoscintigraphy does not improve the ability to identify axillary SLN during surgery, nor does it decrease the false-negative rate. Routine preoperative lymphoscintigraphy is not necessary for the identification of axillary SLNs in breast cancer.

Topics: Axilla; Biopsy; Breast Neoplasms; False Negative Reactions; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Preoperative Care; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Technetium Tc 99m Sulfur Colloid

Lymphatic mapping with sentinel node biopsy is used widely in adult melanoma and breast cancer to determine nodal status without the morbidity associated with elective lymph node dissection. This technique can be used in children to determine lymph node status with limited dissection and accurate interpretation. The authors report their initial experience.. The charts of patients who underwent lymphatic mapping with sentinel node biopsy were reviewed retrospectively. Lymphoscintigraphy was performed in patients with truncal lesions 24 hours before surgery to determine the draining nodal basin (for surgical mapping). The tumors were injected 1 hour preoperatively with technetium sulfur colloid and in the operating room with Lymphazurin blue. The draining basin was examined using a radioisotope detector. The blue nodes with high counts were localized and removed. If nodal metastases were identified, lymph node dissection was recommended. Four patients were injected only with Lymphazurin blue.. Thirteen children (7 girls, 6 boys; mean age, 7 years) underwent lymphatic mapping with sentinel node biopsy. The tumor types were as follows: 8 malignant melanoma (6 extremity, 2 truncal), 1 malignant peripheral nerve sheath tumor, 1 alveolar soft part sarcoma, and 3 rhabdomyosarcoma. A mean of 2.4 nodes (range, 1 to 6) were removed from each patient. Six patients had a positive sentinel node. Formal lymph node dissection was performed on 4 of the 6 patients, 1 of whom had further nodal disease with 2 of 13 nodes containing micrometastases. One of the 6 patients refused lymph node dissection and adjuvant therapy; the final patient had rhabdomyosarcoma, a malignancy for which lymph node dissection is not indicated. Pulmonary metastasis developed 26 months after diagnoses in the patient with alveolar soft part sarcoma and a negative sentinel node. This patient was injected only with Lymphazurin blue at the time of sentinel node biopsy and refused adjuvant therapy. There have been no other recurrences. There were no complications related to lymphatic mapping or sentinel node biopsy.. Lymphatic mapping with sentinel node biopsy, using both technetium-labeled sulfur colloid and Lymphazurin blue, can be performed safely in pediatric skin and soft tissue malignancies. Further study with long-term follow-up will determine the utility and accuracy of this technique in pediatric malignancies.

Topics: Biopsy; Child; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Male; Radiopharmaceuticals; Rosaniline Dyes; Technetium Tc 99m Sulfur Colloid

Previous studies have demonstrated the feasibility of sentinel lymph node (SLN) biopsy for nodal staging of patients with breast cancer. However, unacceptably high false-negative rates have been reported in several studies, raising doubt about the applicability of this technique in widespread surgical practice. Controversy persists regarding the optimal technique for correctly identifying the SLN. Some investigators advocate SLN biopsy using injection of a vital blue dye, others recommend radioactive colloid, and still others recommend the use of both agents together.. A total of 806 patients were enrolled by 99 surgeons. SLN biopsy was performed by single-agent (blue dye alone or radioactive colloid alone) or dual-agent injection at the discretion of the operating surgeon. All patients underwent attempted SLN biopsy followed by completion level I/II axillary lymph node dissection to determine the false-negative rate.. There was no significant difference (86% v 90%) in the SLN identification rate among patients who underwent single- versus dual-agent injection. The false-negative rates were 11.8% and 5.8% for single- versus dual-agent injection, respectively (P <.05). Dual-agent injection resulted in a greater mean number of SLNs identified per patient (2. 1 v 1.5; P <.0001). The SLN identification rate was significantly less for patients older than 50 years as compared with that of younger patients (87.6% v 92.6%; P =.03). Upper-outer quadrant tumor location was associated with an increased likelihood of a false-negative result compared with all other locations (11.2% v 3. 9%; P <.05).. In multi-institutional practice, SLN biopsy using dual-agent injection provides optimal sensitivity for detection of nodal metastases. The acceptable SLN identification and false-negative rates associated with the dual-agent injection technique indicate that this procedure is a suitable alternative to routine axillary dissection across a wide spectrum of surgical practice and hospital environments.

Topics: Axilla; Biopsy; Breast Neoplasms; False Negative Reactions; Female; Humans; Injections; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Rosaniline Dyes; Sensitivity and Specificity; Technetium Tc 99m Sulfur Colloid

Multiple radioactive lymph nodes are often removed during the course of sentinel lymph node (SLN) biopsy for breast cancer when both blue dye and radioactive colloid injection are used. Some of the less radioactive lymph nodes are second echelon nodes, not true SLNs. The purpose of this analysis was to determine whether harvesting these less radioactive nodes, in addition to the "hottest" SLNs, reduces the false-negative rate.. Patients were enrolled in this multicenter (121 surgeons) prospective, institutional review board-approved study after informed consent was obtained. Patients with clinical stage T1-2, N0, M0 invasive breast cancer were eligible. This analysis includes all patients who underwent axillary SLN biopsy with the use of an injection of both isosulfan blue dye and radioactive colloid. The protocol specified that all blue nodes and all nodes with 10% or more of the ex vivo count of the hottest node should be removed and designated SLNs. All patients underwent completion level I/II axillary dissection.. SLNs were identified in 672 of 758 patients (89%). Of the patients with SLNs identified, 403 patients (60%) had more than 1 SLN removed (mean, 1.96 SLN/patient) and 207 patients (31%) had nodal metastases. The use of filtered or unfiltered technetium sulfur colloid had no impact on the number of SLNs identified. Overall, 33% of histologically positive SLNs had no evidence of blue dye staining. Of those patients with multiple SLNs removed, histologically positive SLNs were found in 130 patients. In 15 of these 130 patients (11.5%), the hottest SLN was negative when a less radioactive node was positive for tumor. If only the hottest node had been removed, the false-negative rate would have been 13.0% versus 5.8% when all nodes with 10% or more of the ex vivo count of the hottest node were removed (P =.01).. These data support the policy that all blue nodes and all nodes with 10% or more of the ex vivo count of the hottest SLN should be harvested for optimal nodal staging.

Topics: Biopsy; Breast Neoplasms; False Negative Reactions; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Mastectomy; Mastectomy, Segmental; Middle Aged; Neoplasm Staging; Radionuclide Imaging; Radiopharmaceuticals; Reproducibility of Results; Rosaniline Dyes; Technetium Tc 99m Sulfur Colloid

Sentinel lymph node biopsy (SLNB) has emerged as a reliable, accurate method of staging the axilla for early breast cancer. Although widely accepted for T1 lesions, its use in larger tumors remains controversial. This study was undertaken to define the role of SLNB for T2 breast cancer.. From a prospective breast sentinel lymph node database of 1,627 patients accrued between September 1996 and November 1999, we identified 223 patients with clinical T1-2N0 breast cancer who underwent 224 lymphatic mapping procedures and SLNB followed by a standard axillary lymph node dissection (ALND). Preoperative lymphatic mapping was performed by injection of unfiltered technetium 99 sulfur colloid and isosulfan blue dye. Data about patient and tumor characteristics and the status of the sentinel lymph nodes and the axillary nodes were analyzed. Statistics were performed using Fisher's exact test.. Two hundred four of 224 sentinel lymph node mapping procedures (91%) were successful. Median tumor size was 2.0 cm (range 0.2 to 4.8 cm). One hundred forty-five of the 204 patients had T1 lesions and 59 patients had T2 lesions. There were 92 pathologically positive axillae, 5 (5%) of which were not evident either by SLNB or by intraoperative clinical examination. The false-negative rate and accuracy were not significantly different between the two groups, but axillary node metastases were observed more frequently with T2 than with T1 tumors (p = 0.005); other factors, including patient age, prior surgical biopsy, upper-outer quadrant tumor location, and tumor lymphovascular invasion were not associated with a higher incidence of false-negative SLNB in either T1 or T2 tumors.. SLNB is as accurate for T2 tumors as it is for T1 tumors. Because no tumor or patient characteristics predict a high false-negative rate, all patients with T1-2N0 breast cancer should be considered candidates for the procedure. Complete clinical examination of the axilla should be undertaken to avoid missing palpable axillary nodal metastases.

Topics: Adult; Aged; Aged, 80 and over; Algorithms; Axilla; Breast Neoplasms; Decision Trees; False Negative Reactions; Female; Humans; Immunohistochemistry; Intraoperative Care; Lymph Node Excision; Middle Aged; Neoplasm Staging; Palpation; Patient Selection; Predictive Value of Tests; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Survival Analysis; Technetium Tc 99m Sulfur Colloid

A 30-year-old white woman with a primary malignant melanoma of her right back at the Sappey line, 4 cm from the midline at the L2 level, underwent preoperative lymphoscintigraphy and intraoperative mapping of the sentinel lymph node using lymphazurin injection at the primary site and a hand-held gamma probe. Lymphoscintigraphy showed one sentinel lymph node in each breast and another one in the right axilla. These three sentinel lymph nodes were accurately identified using a hand-held gamma probe during operation. An additional sentinel and one nonsentinel lymph node from the right axilla were harvested. All four sentinel lymph nodes were blue and showed significantly elevated radioactivity compared with background. Histologic analysis showed that all these lymph nodes were negative for metastatic melanoma. She has been followed for a period of 26.7 months since her selective sentinel lymphadenectomy and has been free of disease to date. This case illustrates the importance of preoperative lymphoscintigraphy in identifying in-transit sentinel lymph nodes in both breasts in addition to the clinically predictable sentinel lymph node(s) in the right axilla.

Topics: Adult; Axilla; Back; Breast; Breast Neoplasms; Female; Humans; Lymph Nodes; Melanoma; Radionuclide Imaging; Rosaniline Dyes; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid

Sentinel lymph node (SLN) biopsy has emerged as a novel approach for identifying patients with melanoma and regional nodal micrometastasis who may benefit from full nodal basin resection. To identify the pattern of tumor lymphatic drainage and the SLN, lymphoscintigraphy has been performed using primarily 99mTc-sulfur colloid (SC). In this study, we compare the efficacy of SLN biopsy using 99mTc-human serum albumin (HSA) with SLN biopsy after SC-based lymphoscintigraphy.. One hundred and six patients with localized cutaneous melanoma were studied. Lymphoscintigraphy was performed after intradermal injection of HSA in 85 patients and SC in 21 patients. Four patients underwent lymphoscintigraphy twice, once with SC and once with HSA. Dynamic images were acquired for up to 1 h, followed by high-count images of the SLN in various projections so that the most likely site was marked on the skin for biopsy. Intraoperatively, blue dye was injected around the primary site. Twenty-four patients underwent SLN dissection directed by preoperative lymphoscintigraphy and vital blue dye mapping; in the remaining 80 patients, a gamma probe was added intraoperatively to the localization procedure. Two patients underwent mapping with gamma probe alone.. Draining lymphatic basins and nodes were identified by lymphoscintigraphy in all patients. The SLN was identified in 95% of patients when both blue dye and intraoperative gamma probe were used. When 99mTc-HSA was used for imaging, 98% of the SLNs ultimately identified were radiolabeled, and 82% were both hot and blue. Of the SLN recovered with SC, all the nodes were radiolabeled; however, there was only 58% hot and blue concordance. Greater numbers of SLNs were removed in the SC group (median 2.0 versus 1.0, P = 0.02); however, the incidence of micrometastasis was statistically similar in both HSA and SC cohorts. In the 4 patients examined with both tracers, SLN mapping was similar.. Although SC has been the radiotracer of choice for SLN mapping in melanoma, HSA appears to be a suitable alternative, with identical success rates. In fact, the higher concordance between hot and blue nodes using HSA suggests superiority of this tracer for this purpose.

Topics: Biopsy; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Male; Melanoma; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Skin Neoplasms; Technetium Tc 99m Aggregated Albumin; Technetium Tc 99m Sulfur Colloid

Topics: Biopsy; Humans; Lymph Nodes; Lymphatic Metastasis; Melanoma; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Skin Neoplasms; Technetium Tc 99m Aggregated Albumin; Technetium Tc 99m Sulfur Colloid

Lymphatic mapping and sentinel lymph node (SLN) biopsy are new techniques that accurately provide crucial staging information while inflicting far less morbidity than complete axillary dissection. As these techniques continue to gain acceptance, issues such as adequacy of training, certification, and outcomes measures become increasingly important. The purpose of this paper is to report the initial lymphatic mapping experience at the H Lee Moffitt Cancer Center and Research Institute and to provide a detailed description of the technical aspects of lymphatic mapping.. From April 1994 to April 1998, 700 patients with newly diagnosed breast cancers underwent an IRB-approved prospective trial of lymphatic mapping using a combination of Lymphazurin (USSC, Norwalk, CT) blue dye and filtered technetium 99m-labeled sulfur-colloid. Failure of the procedure was defined as the inability to detect an SLN by either radiocolloid uptake within a lymph node by the gamma probe or the inability to visualize blue staining of a lymph node. Learning curves were then generated as the failure rate versus serial number of patients for each of the 5 surgeons involved in this study.. The SLN was identified in 665 of 700 patients (95.0%). A total of 1,348 SLNs were successfully removed, of which 238 (17.7%) were positive for metastatic disease in 176 of 665 patients (26.5%). In patients who underwent a complete axillary dissection after SLN biopsy, SLNs were identified in 173 of 186 patients (93.0%). Of the 173 patients, 53 patients (30.6%) had positive SLNs and 120 patients (69.4%) had negative SLNs. In the 120 patients with negative SLNs, one patient was found to have disease on complete dissection, for a false-negative rate of 0.83% (95% CI: 0.02%, 4.6%). A learning curve representing the mean of the 5 surgeons' experience indicates that on average 23 patients are required by an individual surgeon to achieve a 90% +/- 4.5% success rate and 53 patients are required to achieve a 95% +/- 2.3% success rate (p = 0.05).. These data validate lymphatic mapping and SLN biopsy as indispensable tools in the surgical treatment of breast cancer. With adequate multidisciplinary training, these techniques can be readily implemented at institutions treating breast cancer.

Topics: Biopsy; Breast; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Neoplasm Staging; Prospective Studies; Radionuclide Imaging; Rosaniline Dyes; Sensitivity and Specificity; Technetium Tc 99m Sulfur Colloid

To determine the usefulness of lymphatic mapping and SLN biopsy, two distinct aspects of the technique must be evaluated, mapping success rates and mapping accuracy. The mapping success rate simply reflects the ability to successfully map a SLN. Mapping accuracy is reflected by the false-negative rate defined as the proportion of patients with axillary metastases among those in whom the SLN is negative for disease. It is critical within each institution that these two measurements be obtained to validate the multidisciplinary collaborative effort. It seems that surgeons with appropriate training should be able to map with 85% efficiency with zero or one false-negative cases in their first 10 patients with metastatic disease. It is our recommendation that individual surgeons join together and follow an institutional (IRB approved) protocol for lymphatic mapping in which each surgeon is required to perform at least 30 procedures of SLN biopsy followed by completion axillary lymph node dissections (phase I). There are several advantages for surgeons and patients to participate in national trials as a new technique is established: 1. Patients are fully informed. 2. For those patients who have SLN biopsy followed by a CLND (phase I), there is still an added advantage in that the SLN can be scrutinized more closely resulting in more accurate staging. 3. The surgeon and the institution can be reimbursed even while the surgeon is on the learning curve. 4. It provides for good publicity for the institution. The data should be reviewed for each surgeon after completing the first 30 cases. If the aforementioned goals of 85% success with one or fewer false-negative cases is achieved, then the individual surgeon may move on to a second (phase II) mapping protocol. In phase II, a SLN biopsy is performed and a CLND is performed only if a SLN cannot be located or the SLN contains metastases. Should the aforementioned criteria not be met, then additional procedures or onsite intraoperative mentoring may be required to further evaluate the deficiencies of the mapping procedure by the surgeon or institution. Remember that failure to map may be a function of surgical skill, nuclear medicine injection methodology, or the pathologic evaluation of the SLN. Should institutional problems arise, onsite mentoring may be helpful by someone with adequate mentoring skills to troubleshoot a potential problem. The previously outlined recommendations are similar to the recently published

Topics: Axilla; Biopsy; Breast Neoplasms; Certification; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Radiopharmaceuticals; Rosaniline Dyes; Technetium Tc 99m Sulfur Colloid

Because of its high cost and attendant morbidity, the necessity of axillary dissection in patients with small invasive primary tumors has been questioned. Lymphatic mapping with sentinel lymph node (SLN) biopsy is an alternative to complete axillary dissection; however, researchers have excluded patients with T1A-T1B lesions. Seven hundred patients with newly diagnosed breast cancers underwent an Institutional Review Board-approved prospective trial of intraoperative lymphatic mapping using a combination of Lymphazurin and filtered technetium-labeled sulfur colloid. An SLN was defined as a blue node and/or hot node with a 10:1 ex vivo radioactivity ratio in the SLN versus non-SLNs. All SLNs were evaluated by both hematoxylin and eosin and cytokeratin immunohistochemical stains. Of the 700 patients, 665 (95.0%) were mapped successfully. One hundred ninety-six (28.0%) had T1A-T1B tumors. Forty patients (20.4%) with T1A-T1B tumors had metastases to the SLNs. We conclude that breast cancer SLN mapping is highly accurate and sensitive when combined dye techniques (radiocolloid and vital blue dye) are utilized. This technique is particularly useful in patients with small invasive primary tumors, which, despite their size, still demonstrate a significant rate of axillary metastasis. These patients should not be excluded from lymphatic mapping protocols.

Topics: Aged; Axilla; Biopsy; Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Technetium Tc 99m Sulfur Colloid

Identification of sentinel lymph nodes (SLNs) using lymphoscintigraphy, the blue dye technique and intraoperative lymphatic mapping with a gamma-detecting probe has become the standard of care in diagnosing and treating melanoma. Numerous clinical studies have proven the reliability of predicting the histology of remaining lymph nodes in the lymphatic basin from the histologic evaluation of the SLNs. Technical and clinical factors presented in this paper have been shown to increase the accuracy of localization of SLNs. The nuclear medicine technologist shares a vital role in the radiopharmaceutical preparation and administration for preoperative lymphoscintigraphy and intraoperative lymphatic mapping in patients with melanoma.

Topics: Humans; Intraoperative Period; Lymph Nodes; Lymphatic Metastasis; Melanoma; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid

The technique of sentinel lymph node (SLN) biopsy for melanoma provides accurate staging information because the histology of the SLN reflects the histology of the entire basin, particularly when the SLN is negative.. We combined two mapping techniques, one using vital blue dye and the other using radiolymphoscintigraphy with a hand-held gamma Neoprobe, to identify the SLN in 600 consecutive patients with stage I-II melanoma. The SLNs were examined using conventional histopathology and immunohistochemistry for S-100.. Eighty-three (13.9%) patients had micrometastatic disease in the SLNs. Thirty percent of patients with primary melanomas greater than 4.0 mm in thickness had positive SLNs, followed by 48 of 267 (18%) of patients with tumors between 1.5 mm and 4 mm, and 12 of 169 (7%) of those with lesions between 1.0 mm and 1.5 mm. No patient with a tumor less than 0.76 mm in thickness had a positive SLN. Sixty-four of the 83 SLN-positive patients consented to undergo complete lymph node dissection (CLND), and five of 64 (7.8%) of the CLNDs were positive. All patients with positive CLNDs had tumor thicknesses greater than 3.0 mm.. The rate of SLN-positive patients increases with increasing thickness of the melanoma. SLN-positive patients with primary lesions less than 1.5 mm in thickness may have disease confined to the SLN, thus rendering higher-level nodes free of disease, and may not require a CLND.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Biopsy; Child; Extremities; Female; Follow-Up Studies; Gamma Cameras; Head and Neck Neoplasms; Humans; Immunohistochemistry; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Male; Melanoma; Middle Aged; Neoplasm Staging; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; S100 Proteins; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid; Thoracic Neoplasms

Sentinel lymph node biopsy (SNB) in breast cancer may be used in place of axillary lymph node dissection (ALND) if SNB accurately stages the axilla. This study assessed the success and accuracy of axillary SNB with isosulfan blue (ISB) and technetium-99 sulfur colloid (TSC) compared to ALND.. Forty-two women with T1 or T2 breast cancer underwent SNB and ALND. Sixty to 90 minutes before anesthetic induction, a mixture of 3 mL ISB and 1 mCi TSC was injected around the primary cancer or prior biopsy site. Intraoperatively, the SLN was identified using a gamma detector (Neoprobe 1000) or by visualization of the blue-stained lymph node and afferent lymphatics. The SLN was excised separately, and a level I/II ALND was completed. The histologic findings of the axillary contents and SLN were compared.. An axillary SLN was found in 38 of 42 (90%) cases. SLN localization rate and predictive value were the same for women who had and those who had not undergone excisional biopsy before the date of SNB. Fifteen of 42 (36%) patients had lymph node metastases. The SLN was positive in all women with axillary metastases (negative predictive value, 100%).. If confirmed by larger series, a negative SNB may eliminate the need for ALND for select women with breast cancer.

Topics: Adult; Aged; Aged, 80 and over; Biopsy; Breast Neoplasms; Female; Gamma Cameras; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Lymphatic System; Mastectomy; Mastectomy, Segmental; Middle Aged; Monitoring, Intraoperative; Neoplasm Staging; Predictive Value of Tests; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Technetium Tc 99m Sulfur Colloid

The purpose of this study was to determine whether the sentinel lymph node (SLN) localization technique, which uses blue dye and 99mTc-labeled sulfur colloid, provides advantages over blue dye alone in the management of patients with stages I and II cutaneous melanoma.. The records of 626 consecutive patients with melanoma who underwent lymphatic mapping and SLN biopsy between 1991 and 1997 at the M.D. Anderson Cancer Center were reviewed. Lymphatic mapping was performed with isosulfan blue dye alone (n = 252) or in combination with 99mTc-labeled sulfur colloid accompanied by a hand-held gamma probe (n = 374). SLNs were defined as those that stained blue or demonstrated increased focal radiotracer uptake.. SLN identification rates improved from 87% (dye alone) to 99% (dye and colloid) (P < .0001) with the combined technique in all anatomic sites examined. The mean number of SLNs harvested from each basin was significantly greater in the patients mapped with dye and colloid (1.74 vs 1.31; P < .0001). Occult metastatic disease was identified in 17.5% of all patients and did not significantly differ between groups. In 92% of patients who had at least one positive SLN and were mapped with both agents, lymphatic metastases were identified in the SLN that contained the greatest radiotracer uptake.. SLN identification is enhanced by the addition of radiolabeled sulfur colloid and intraoperative use of the hand-held gamma probe and may identify SLNs missed by the blue dye alone. These data support the combined use of radiolabeled sulfur colloid and blue dye in lymphatic mapping procedures to improve the nodal staging of stages I and II melanoma.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Biopsy; Child; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Male; Melanoma; Middle Aged; Neoplasm Staging; Prognosis; Rosaniline Dyes; Technetium Tc 99m Sulfur Colloid

The sentinel lymph node is the first node or nodes to drain a cutaneous melanoma. Sentinel lymph node biopsy is performed to determine whether regional metastases are present. The authors' experience with the new technique of sentinel lymph node biopsy for melanoma of the head and neck is reported.. During the period of January of 1992 to December of 1995, 58 consecutive patients were identified from the melanoma database who had localization of the sentinel lymph node for primary cutaneous melanoma of the head and neck. Techniques for identification of the sentinel node(s) include preoperative lymphoscintigraphy and intraoperative Lymphazurin dye (vital blue dye) and technetium-99m-labeled sulfur colloid injection around the primary tumor site with Neoprobe mapping.. Fifty-eight patients (13 female, 45 male), mean age 61 years, with melanoma of the head and neck with a mean Breslow thickness of 2.21 mm. (range, 0.82-6.87 mm.) and no regional lymphadenopathy underwent sentinel node mapping. The sentinel node was successfully identified in 55 patients (95 percent). Blue dye was visualized in 85 of 126 sentinel nodes excised (67 percent), whereas the remainder of the sentinel nodes were localized with the Neoprobe. Forty-nine patients who had successful mapping and sentinel node biopsy had no evidence of metastatic disease in the sentinel node or other nodes in the basin. Six of the fifty-five patients (11 percent) had evidence of micrometastatic disease, and all six had the sentinel node as the only site of metastasis. Five of six patients with micrometastases had a subsequent neck dissection and/or superficial parotidectomy. None of these patients had evidence of "skip metastases" with a negative sentinel node and higher level nodes positive for metastases. In total, 6 of the 18 sentinel nodes (33 percent) identified in these six patients contained micrometastatic disease, whereas none of the 139 other nodes sampled had any evidence of metastases. The exact probability that all six unpaired observations would consist of involvement of only the sentinel nodes is p = 0.0312.. By combining the two mapping techniques in patients with melanoma of the head and neck, the sentinel node(s) can be mapped and identified individually, similar to melanoma in other locations. The sentinel nodes have been shown to contain the first evidence of regional metastatic melanoma. This staging information can be used to plan therapeutic node dissections and adjuvant therapy that may have a survival benefit in patients with stage III melanoma of the head and neck. Lymphatic mapping can be used to make the surgical care of the melanoma patient more conservative, so that only those patients with solid evidence of regional node metastases are subjected to the morbidity and expense of a complete node dissection and the toxicities of adjuvant therapy.

Topics: Biopsy; Female; Head; Humans; Lymph Nodes; Lymphatic Metastasis; Male; Melanoma; Middle Aged; Neck; Radionuclide Imaging; Rosaniline Dyes; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid

Selective lymphadenectomy or "sentinel node" biopsy has been introduced recently by Morton and colleagues (Arch Surg 1992;127:392-9) to stage patients with intermediate and thick malignant melanomas. It has proven to be an effective way to identify nodal basins at risk for metastasis without the morbidity of a complete lymph node dissection. The majority of biopsies can be performed under local anesthesia with small incisions, but technical difficulties occasionally result in unsuccessful explorations. Identification of the sentinel node can be enhanced by a intraoperative radiolymphoscintigraphy, a technique introduced Alex and Krag (Surg Oncol 1993;137-43) that uses radiolabeled sulfur colloid and a hand-held gamma probe.. We used intraoperative radiolymphoscintigraphy in conjunction with 1% lymphazurin blue dye to define the sentinel node(s) in 148 patients with greater than 0.76 mm in thickness or Clark level IV melanomas. Sentinel lymph nodes were isolated, harvested, and examined using conventional histopathology, and immunohistochemistry for S-100 and HMB-45 antibodies.. The overall success rate of sentinel lymph node localization was 97% using a combination of the two techniques. Twenty-one (14%) patients had micrometastasis, and 17 of these subsequently underwent complete lymph node dissection. A total of 220 of 275 (80%) sentinel nodes harvested were radioactive or "hot" compared with 165 of 275 (60%) with the blue dye alone. Four of the patients with micrometastasis had sentinel nodes positive by gamma probe, but negative by blue dye mapping techniques.. Our results suggest that intraoperative radiolymphoscintigraphy using a hand-held gamma detecting probe improves the identification of sentinel lymph nodes during selective lymphadenectomy. This may reduce the number of "unsuccessful explorations" using the vital blue dye technique for lymphatic mapping, and appeal to a greater variety of surgeons, including dermatologic surgeons.

Topics: Biopsy; Contrast Media; Gamma Cameras; Humans; Intraoperative Period; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Lymphoscintigraphy; Melanoma; Rosaniline Dyes; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid

The initial draining lymph node (Sentinel node) of a tumour may reflect the status of the tumours spread to the remaining lymphatic bed. The sentinel node, which has been reported to predict metastatic melanoma, has recently been localized by a new invasive technique [1]. The goal of our pre-clinical trial was to test a non-invasive technique to localize the sentinel node. Gamma-probe guided localization was used to identify and then surgically remove the first draining lymph node(s) in 16 inguinal lymphatic basins of eight cats. This method was found to be comparable to an invasive method using a blue dye. Gamma-probe localization has several potential advantages in that it can: (a) precisely locate on the surface of the skin the position of an underlying lymph node, (b) intraoperatively guide the surgeon to the lymph node during dissection, (c) verify that the correct node has been biopsied, (d) determine the possible presence of residual lymph nodes, (e) allow lymph nodes to be harvested through a small incision as opposed to raising a skin flap, and (f) be rapidly and easily performed.

Topics: Animals; Cats; Groin; Lymph Nodes; Lymphatic Metastasis; Melanoma; Radiometry; Radionuclide Imaging; Rosaniline Dyes; Technetium Tc 99m Sulfur Colloid