technetium-tc-99m-sulfur-colloid and Breast-Neoplasms

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 periareolar injection of blue dye or technetium colloid. The optimal site for injection of mapping tracers is controversial in SLN. The peritumoral injection provides information on the deep lymphatic drainage and the internal mammary chain. The advantages of periareolar injection are simplicity, the ability to perform it in non-palpable tumors, and the potential enhancement of uptake via the subareolar lymphatic plexus. The results of multiinstitutional study have indicated that superficial injection (periareolar or peritumoral) is associated with a better identification rate and an equal false-negative rate compared to deep peritumoral (PT) injection. However, the false-negative rate of periareolar injection has not been formally demonstrated.

Topics: Breast Neoplasms; Coloring Agents; Female; Humans; Injections; Lymphatic Metastasis; Multicenter Studies as Topic; Neoplasm Staging; Radiopharmaceuticals; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

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

Sentinel lymph node biopsy is now a widely accepted method of axillary lymph node staging for invasive breast cancer. This review encompasses the historical perspective of surgical management of the axilla; the data that has emerged over the last decade highlighting the accuracy, safety, and applicability of this procedure; and the technical details necessary to perform this procedure. Successful adaptation of sentinel node biopsy implies that the operator has a high identification rate and a low false-negative rate, as well as the collaborations with the other involved disciplines: pathology, radiology, and nuclear medicine.

Topics: Breast Neoplasms; False Negative Reactions; Female; Histocytological Preparation Techniques; Humans; Lymph Nodes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Many studies have demonstrated that sentinel nodes can accurately determine the regional nodal status in breast cancer and malignant melanoma. Since this was demonstrated sentinel node biopsy has been performed for various solid malignancies. However, the optimal procedure for sentinel node biopsy remains unknown. It is considered that the combination of dye and radiocolloid injection is needed for sentinel node biopsy in breast cancer. As for gastrointestinal tract malignancies, good results were reported in several feasibility studies. A large clinical trial on sentinel node biopsy for gastric cancer will be conducted in the near future, the results of which are highly anticipated.

Topics: Breast Neoplasms; Coloring Agents; Female; Gastrointestinal Neoplasms; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Male; Radionuclide Imaging; Radiopharmaceuticals; Reverse Transcriptase Polymerase Chain Reaction; Sensitivity and Specificity; 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: 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

Topics: Breast Neoplasms; Female; Humans; Injections, Intradermal; Injections, Intralesional; Injections, Intralymphatic; Lymphatic Metastasis; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Aggregated Albumin; Technetium Tc 99m Sulfur Colloid

Sentinel lymph node biopsy is an important new addition to the surgical management of patients with breast carcinoma. Sentinel nodes have a higher chance of containing metastases than do nonsentinel nodes. Sentinel lymph node biopsy provides an opportunity to stage breast carcinoma patients more accurately and to modify subsequent treatment. One of the most exciting current roles of sentinel lymph node biopsy is the ability to stage patients intraoperatively, allowing a one-step axillary lymph node dissection if the sentinel lymph node contains metastatic carcinoma. Currently, intraoperative evaluation of sentinel lymph nodes is performed using imprint cytology with or without rapid cytokeratin staining, frozen sectioning with or without rapid cytokeratin staining, scrape preparations, or some combination of these techniques. We review the relative strengths and weaknesses of these different methodologies. A great deal of controversy exists regarding the management of patients with metastatic breast carcinoma, particularly those patients with occult and micrometastatic disease. These issues are beyond the scope of this article.

Topics: Breast Neoplasms; Female; Frozen Sections; Humans; Intraoperative Care; Keratins; Lymphatic Metastasis; Radionuclide Imaging; Sentinel Lymph Node Biopsy; Staining and Labeling; 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

Lymphoscintigraphy is the injection of radioactive particles that are then imaged as they pass through lymphatic vessels to their respective lymph nodal drainage basins. Lymphoscintigraphy is receiving increasing interest as a means to stage regional lymph nodes in early stage malignancy. Injection and imaging techniques for performing breast and melanoma lymphoscintigraphy are discussed in this article.

Topics: Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Male; Melanoma; Radionuclide Imaging; Radiopharmaceuticals; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid

There is a resurgence of interest in lymphoscintigraphy because of attention to the sentinel node concept and the availability of the surgical gamma probe that can be used in the operating room to localize radiolabeled sentinel nodes. Conventional surgical management of melanoma has been altered for intermediate thickness tumors such that lymph node dissection is performed for a lymph node bed only if the sentinel node is tumor positive on histological exam after gamma probe-guided excision. This approach is cost effective, saving about 80% of these patients (sentinel node tumor negative) the cost and morbidity of unnecessary "elective lymph node dissection." In addition, a biopsy can be performed on all lymph node beds that receive lymphatic drainage from the tumor site thereby improving staging and perhaps survival by providing the most appropriate therapy. Substantial work has been done to develop optimum imaging techniques and the best radiopharmaceutical preparation to achieve accurate, reproducible lymphatic drainage images. Our methodology includes the following intradermal injections of a technetium 99m sulfur colloid (modified preparation) are followed by dynamic imaging (10 seconds per frame); static imaging up to 30 minutes and late imaging at 1 to 2 hours. Images show lymphatic channels that lead to sentinel nodes in 1, 2, 3, or more anatomic locations. Surgical management is altered to include sampling sentinel nodes of nodal beds, many of which would not have been sampled by previous conventional surgical estimates of lymphatic drainage. While clinical success of lymphoscintigraphy and intraoperative probe localization of the sentinel node in melanoma is evident, use of lymphoscintigraphy and the sentinel node concept in breast cancer is investigative, but promising. The radiopharmaceutical is injected around the tumor in the breast followed by imaging to delineate lymphatic drainage to the sentinel node(s). Optimum methodologies for radiopharmaceutical, volume and/or activity of injectate, and imaging have yet to be determined. Breast lymphatic drainage can be to axilla, internal mammary, and/or supraclavicular nodes in any combination.

Topics: Breast Neoplasms; Female; Humans; Intraoperative Care; Lymph Nodes; Lymphatic Metastasis; Male; Melanoma; Neoplasm Staging; Radionuclide Imaging; Radiopharmaceuticals; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid

Topics: Antimony; Ascites; Breast Neoplasms; Colloids; Female; Gastrointestinal Neoplasms; Gold Colloid, Radioactive; Humans; Indium; Lung Neoplasms; Lymphoscintigraphy; Male; Melanoma; Mercury Radioisotopes; Methods; Neoplasm Staging; Organotechnetium Compounds; Ovarian Neoplasms; Phytic Acid; Prostatic Neoplasms; Radioisotopes; Sulfur; Technetium; Technetium Compounds; Technetium Tc 99m Sulfur Colloid

Topics: Breast Neoplasms; Hemangioma; Humans; Liver Abscess; Liver Cirrhosis; Liver Diseases; Liver Neoplasms; Organotechnetium Compounds; Phytic Acid; Radiation Injuries; Radionuclide Imaging; Radiotherapy; Sulfur; Technetium; Technetium Tc 99m Sulfur Colloid

Postoperative axillary lymphoscintigraphy has been performed after time-differentiated intercostal and interdigital injections of a 99Tc-labeled sulfur microcolloid in 313 patients suffering from breast cancer who underwent radical surgery with axillary dissection. As demonstrated by the absence of visualized lymph nodes after both injections, the axillary dissection could be considered as complete in only 34.6% of the investigated patients. The greatest part of lymph nodes, remaining after surgery, corresponds to the inferior and central groups (after interdigital injection). In 15% of the cases the intercostal injection leads to the demonstration of external mammary lymph nodes. According to the analysis of 202 cases with at least 1 year follow-up, the existence of visualized residual lymph nodes represents a factor of risk to develop nodal relapse especially in patients with positive peroperative axillary lymph node status who did not receive postoperative X-ray treatment. Upper limb edema occurs in 22.5% of the cases; mainly in patients with negative lymphoscintigraphic findings (demonstrating the interruption of the axillary lymphatic flux) and without nodal irradiation. Postoperative axillary lymphoscintigraphic findings should be evaluated in connection with the peroperative axillary lymph node status as established according to the histological analysis, and should take into account the number of removed lymph nodes. Preoperative axillary lymphoscintigraphy seems to be a less contributive examination technique.

Topics: Adult; Aged; Axilla; Breast Neoplasms; Edema; Female; Humans; Lymph Nodes; Mastectomy; Middle Aged; Postoperative Care; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

In the management of breast carcinomas, the internal mammary lymphoscintigraphy represents a simple, nontraumatic and reproducible technique to visualize and investigate the internal mammary nodes. As suggested by the total absence of visualization of nodes on the operated side in all or in the two upper intercostal spaces, internal mammary chain invasion concerns 30% of the population. This frequency increases with the clinical staging of the tumor, its size, and the extent of the disease in the axilla. It is higher for tumors of inner rather than of outer quadrants. When internal mammary lymphoscintigrams are compared in frontal view to the limits of the usual irradiation fields, parasternal nodes outside these limits or in borderline position are observed in 15 to 34% of the population according to the X-ray technique used. Furthermore, 40% of the tangential irradiation fields does not give an adequate irradiation dose to the internal mammary nodes. In one case out of four, IMLSc allows the reduction of useless heart- and lung-irradiated volumes. Internal mammary node invasion as demonstrated by lymphoscintigraphy has been demonstrated to have a prognostic value as the anatomopathological axillary node status, concerning both survival and disease evolution rates. IMLSc, when compared to the other possible investigation techniques of these nodes (X-ray computed tomography, echography or surgery, etc.), represents at the present time the investigation method of choice with the widest implications (diagnostic, therapeutic, and prognostic).

Topics: Breast; Breast Neoplasms; Female; Follow-Up Studies; Humans; Lymph Nodes; Neoplasm Staging; Prognosis; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

Injection of Tc99m to localize nodes for sentinel lymph node biopsy is reported by patients as very painful. The purpose of this study was to determine if anesthetic cream reduces pain associated with periareolar injection of Tc99m and to help elucidate conflicting literature regarding the efficacy of anesthetic cream for this procedure.. A randomized, double-blind, placebo-controlled methodology was used for adult females with breast cancer undergoing periareolar injection of Tc99m for sentinel lymph node biopsy. Pain levels were compared using anesthetic cream (2.5% lidocaine/2.5% prilocaine) vs. placebo. Patient exclusion criteria included use of opioids or adjuvant pain medication or injecting Tc99m the day before surgery. The Numerical Rating Scale was used to assess pain levels immediately after the injections.. Comparing 23 experimental and 26 control patients, there was no significant difference between the experimental (median = 4) and the control group (median = 5) on level of pain experienced U= 0.492, P > .05.. The experimental group had a slightly lower median pain score; however, there was no statistically significant difference between those who used the cream compared with those who used a placebo, supporting the conclusion that anesthetic cream does not reduce pain during Tc99m injections. This study adds to the current literature to provide a stronger position that there is no benefit to using anesthetic cream for this procedure.

Topics: Adult; Aged; Aged, 80 and over; Anesthetics, Local; Breast Neoplasms; Double-Blind Method; Female; Humans; Injections; Lymphatic Metastasis; Middle Aged; Ointments; Pain; Pain Measurement; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

No prior trials have compared sentinel lymph node (SLN) identification outcomes between Tc-99m tilmanocept (TcTM) and Tc-99m sulfur colloid (TcSC) in breast cancer (BC).. We report on the secondary outcomes from a randomized, double-blinded, single surgeon clinical trial comparing post-injection site pain between TcTM and TcSC. Patients were randomized to receive a preoperative single, peritumoral intradermal injection of TcTM or TcSC. The number of total, "hot", and blue nodes detected and removed were compared between groups.. Fifty-two (27-TcSC and 25-TcTM) patients were enrolled and underwent definitive surgical treatment. At least one "hot" SLN was detected in all patients. Three (5.8%) patients had a disease positive-SLN. The total number of SLNs removed was 61 (mean 2.26 (standard deviation (SD) 0.90)) in the TcSC group and 54 (mean 2.16 (SD 0.90)) in the TcTM group, P = 0.69. The total number of "hot" nodes in the TcSC group was 1.96 (SD 0.76) compared to 2.04 (SD 0.73) in the TcTM group, P = 0.71.. The number of identified SLNs did not differ significantly between TcTM and TcSC. Given that no significant technical advantages exist between the two agents, surgeons should choose a radiopharmaceutical based on cost and side effect profile.

Topics: Breast Neoplasms; Dextrans; Double-Blind Method; Female; Humans; Lymphatic Metastasis; Mannans; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node; Sentinel Lymph Node Biopsy; Technetium Tc 99m Pentetate; Technetium Tc 99m Sulfur Colloid

Invasive chest wall recurrences (CWR) following mastectomy are typically treated with surgical excision, radiation therapy (RT) to the chest wall and supraclavicular (SCV) region, and appropriate systemic therapy. Repeat axillary surgery is not routinely performed if the axilla is clinically negative. We evaluated sentinel node biopsy (SNB) in patients with an isolated invasive CWR, for identification and biopsy rates, non-axillary drainage, and clinical implications for radiation fields and outcome.. Between 2008 and 2013, 12/19 women with an isolated invasive CWR had sentinel node (SN) mapping with Tc99m. Median age was 53 years, and 92% (11/12) had initial path N0 disease. All had prior SNB, with axillary dissection in one patient.. Overall, 83% (10/12) had successful mapping, with 70% (7/10) having an axillary SN. Ninety percent (9/10) had successful axillary node biopsy, with one patient having positive nodes. SCV RT was omitted in those with negative axillary nodes. With a median follow-up of 4.6 years from recurrence, there have been no SCV recurrences and no instances of lymphedema.. SNB is possible in women with an isolated CWR with acceptable identification and biopsy rates. Omission of routine irradiation of the SCV region has not jeopardized regional control and results in decreased morbidity.

Topics: Adult; Axilla; Biomarkers, Tumor; Breast Neoplasms; Female; Follow-Up Studies; Humans; Immunoenzyme Techniques; Lymph Node Excision; Lymph Nodes; Mastectomy; Middle Aged; Neoplasm Invasiveness; Neoplasm Recurrence, Local; Neoplasm Staging; Prognosis; Radiotherapy Planning, Computer-Assisted; Receptor, ErbB-2; Receptors, Estrogen; Receptors, Progesterone; Retrospective Studies; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Thoracic Wall

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

No prior studies have examined injection pain associated with Technetium-99m Tilmanocept (TcTM).. This was a randomized, double-blinded study comparing postinjection site pain between filtered Technetium Sulfur Colloid (fTcSC) and TcTM in breast cancer lymphoscintigraphy. Pain was evaluated with a visual analogue scale (VAS) (0-100 mm) and the short-form McGill Pain Questionnaire (SF-MPQ). The primary endpoint was mean difference in VAS scores at 1-min postinjection between fTcSC and TcTM. Secondary endpoints included a comparison of SF-MPQ scores between the groups at 5 min postinjection and construction of a linear mixed effects model to evaluate the changes in pain during the 5-min postinjection period.. Fifty-two patients underwent injection (27-fTcSC, 25-TcTM). At 1-min postinjection, patients who received fTcSC experienced a mean change in pain of 16.8 mm (standard deviation (SD) 19.5) compared with 0.2 mm (SD 7.3) in TcTM (p = 0.0002). At 5 min postinjection, the mean total score on the SF-MPQ was 2.8 (SD 3.0) for fTcSC versus 2.1 (SD 2.5) for TcTM (p = 0.36). In the mixed effects model, injection agent (p < 0.001), time (p < 0.001) and their interaction (p < 0.001) were associated with change in pain during the 5-min postinjection period. The model found fTcSC resulted in significantly more pain of 15.2 mm (p < 0.001), 11.3 mm (p = 0.001), and 7.5 mm (p = 0.013) at 1, 2, and 3 min postinjection, respectively.. Injection with fTcSC causes significantly more pain during the first 3 min postinjection compared with TcTM in women undergoing lymphoscintigraphy for breast cancer.

Topics: Breast Neoplasms; Dextrans; Double-Blind Method; Female; Follow-Up Studies; Humans; Lymph Nodes; Lymphoscintigraphy; Mannans; Middle Aged; Neoplasm Staging; Pain; Prognosis; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Pentetate; Technetium Tc 99m Sulfur Colloid

A practice standard in sentinel lymph node (SLN) mapping in breast cancer is intradermal injection of technetium-99m sulfur colloid (Tc-99m), resulting in significant patient discomfort and pain. A previous randomized controlled trial showed that adding lidocaine to Tc-99m significantly reduced radioisotope injection-related pain. We tested whether 1 % lidocaine admixed with Tc-99m affects feasibility of SLN mapping.. Between January 2006 and April 2009, 140 patients with early breast cancer were randomly assigned (1:1:1:1) to receive standard topical 4 % lidocaine cream and intradermal Tc-99m (control) or to one of three other study groups: topical placebo cream and injection of Tc-99m containing sodium bicarbonate (NaHCO3), 1 % lidocaine, or both. All SLN data were collected prospectively.. Study groups were comparable for clinicopathological parameters. As previously reported, the addition of 1 % lidocaine to the radioisotope solution significantly improved patient comfort. Overall SLN identification rate in the trial was 93 %. Technical aspects of SLN biopsy were similar for all groups, including time from injection to operation, first SLN (SLN 1) gamma probe counts, ex vivo counts for SLN 1 and SLN 2, and axillary bed counts. SLN identification rates were comparable statistically: control (96 %), lidocaine (90 %), sodium bicarbonate (97 %), and sodium bicarbonate-lidocaine (90 %). The control group had a significantly higher SLN 2/SLN 1 ex vivo count ratio, and the number of SLNs detected was significantly reduced in the lidocaine versus no-lidocaine groups (p < 0.05).. Addition of 1 % lidocaine to standard radioisotope solution for SLN mapping in breast cancer is associated with fewer SLNs detected, but it does not appear to compromise SLN identification.

Topics: Adult; Aged; Aged, 80 and over; Anesthetics, Local; Breast Neoplasms; Double-Blind Method; Female; Humans; Lidocaine; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Pain; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Sentinel node biopsy (SNB) was initially conceived as excision of the first station axillary lymph node(s) (LN) identified by radioactive and/or blue dye uptake. The definition was subsequently enlarged to also include palpable lymph nodes in the vicinity of sentinel node(s) (SN). We reasoned that the excision of this combination of nodes might be best achieved by sampling the lower axilla.. Each patient underwent low axillary sampling (LAS) and identification of SN in the excised specimen followed by complete axillary lymph node dissection (ALND). LAS was defined as excision of all fibrofatty tissue overlying the second digitation of serratus anterior below the intercostobrachial nerve and was carried out following a pre-operative injection of radioactive colloid and an intra-operative injection of blue dye. Blue and/or hot nodes (B&/HN) in the dissected tissue and remaining axilla, along with any palpable nodes within the sampled tissue, were defined as SN. The primary endpoint of the study was to compare false negative rates (FNR) of SN with that of LAS in predicting axillary LN status (NCT00128362).. The study was performed between March 2004 and December 2011 in 478 women with clinically node negative axilla. On histopathological evaluation the median tumor size was 2.5 cm and axillary nodal metastases were found in 34.1% of patients. The FNR of SNB (12.7%, 95% CI 8.1-19.4) and LAS (10.5%, 95% CI 6.6-16.2) were not significantly different (p = 0.56). The FNR of B&/HN alone, without palpable nodes, (29.0%, 95% CI 22.5-36.6) was significantly inferior to those of SNB (p = 0.0007) and LAS (p = 0.0003).. LAS is as accurate as SNB in predicting axillary LN status in women with clinically node negative operable breast cancer. Confining SNB procedure to excision of B&/HN, significantly increases the risk of leaving behind metastatic lymph nodes in the axilla. LAS is an effective and low cost procedure that minimizes axillary surgery and can be implemented widely. Registry Name: Clinicaltrials.gov.. NCT00128362.

Topics: Adipose Tissue; Axilla; Breast Neoplasms; Coloring Agents; False Negative Reactions; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Methylene Blue; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Disparity between patient report and physician perception of pain from radiotracer injection for sentinel node biopsy is thought to center on the severity of the intervention, ethnic composition of population queried, and socioeconomic factors.. The objectives of this study were, first, to explore agreement between physicians' and their breast cancer patients' pain assessment during subareolar radionucleotide injection; and second, to evaluate potential ethnic differences in ratings.. A trial was conducted, from January 2006 to April 2009, where 140 breast cancer patients were randomly assigned to standard topical lidocaine-4% cream and 99mTc-sulfur colloid injection, or to one of three other groups: placebo cream and 99mTc-sulfur colloid injection containing NaHCO3, 1% lidocaine, or NaHCO3 + 1% lidocaine. Providers and patients completed numeric pain scales (0-10) immediately after injection.. Patients and providers rated pain similarly over the entire cohort (median, 3 vs 2, P = 0.15). Patients rated pain statistically significantly higher than physicians in the standard (6 vs 5, P = 0.045) and placebo + NaHCO3 (5 vs 4, P = 0.032) groups. No significant difference in scores existed between all African Americans and their physicians (3 vs 4, P = 0.27).. Patient-physician pain assessment congruence over the less painful injections and their statistically similar scores with the more painful methods suggests the importance of utilizing the least painful method possible. Providers tended to underestimate patients with the highest pain ratings-those in the greatest analgesic need. Lack of statistical difference between African American and physician scores may reflect the equal-access-to-care over the entire patient cohort, supporting the conclusion that socioeconomic factors may lie at the heart of previously reported discrepancies.

Topics: Adult; Aged; Aged, 80 and over; Breast Neoplasms; Cohort Studies; Female; Humans; Injections; Lidocaine; Lymph Nodes; Middle Aged; Pain; Pain Measurement; Patients; Physicians; Radionuclide Imaging; Radiopharmaceuticals; Rhenium; Technetium Tc 99m Sulfur Colloid

Wire localization (WL) is traditionally performed before excisional biopsy for patients with nonpalpable breast lesions, but it has several disadvantages. Our current study examines whether the method of radiocolloid combined with methylene dye localization (RCML) has an advantage over WL.. From August 2006 to May 2009, 157 patients with nonpalpable breast lesions classified as BI-RADS category 5 were enrolled in our study. Of the 157 patients, 78 were assigned to WL and 79 to RCML. The status of surgical margins, weight of specimens, length of incisions, and duration of operation were compared between these two groups.. All patients were diagnosed after first excisional biopsy. The patients with malignancy accounted for 55.1% in WL group, and 53.2% in RCML group. For malignant lesions, fewer patients undergoing RCML had close or involved surgical margins than did those who had WL (19.0% vs. 39.5%, P = .038). The mean weight of specimen was 45.2 g in WL group and 39.0 g in RCML group (P < .001). The mean length of incision was 44.8 mm in WL group and 36.3 mm in RCML group (P < .001). The mean time of operation was 16.3 min for WL and 14.7 min for RCML (P = .001).. RCML provides precise identification of the site of the nonpalpable lesion and a visible marker to the lesion for surgeons and allows rapid, easy, and accurate excision of nonpalpable breast lesions. Therefore, RCML is a promising alternative to WL.

Topics: Adult; Aged; Biopsy; Breast; Breast Neoplasms; Carcinoma, Ductal, Breast; Female; Follow-Up Studies; Humans; Methylene Blue; Middle Aged; Neoplasm Staging; Prognosis; Radiopharmaceuticals; Survival Rate; Technetium Tc 99m Sulfur Colloid

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

Invisible NIR fluorescent light can provide high sensitivity, high-resolution, and real-time image-guidance during oncologic surgery, but imaging systems that are presently available do not display this invisible light in the context of surgical anatomy. The FLARE imaging system overcomes this major obstacle.. Color video was acquired simultaneously, and in real-time, along with two independent channels of NIR fluorescence. Grayscale NIR fluorescence images were converted to visible "pseudo-colors" and overlaid onto the color video image. Yorkshire pigs weighing 35 kg (n = 5) were used for final preclinical validation of the imaging system. A six-patient pilot study was conducted in women undergoing sentinel lymph node (SLN) mapping for breast cancer. Subjects received (99m)Tc-sulfur colloid lymphoscintigraphy. In addition, 12.5 microg of indocyanine green (ICG) diluted in human serum albumin (HSA) was used as an NIR fluorescent lymphatic tracer.. The FLARE system permitted facile positioning in the operating room. NIR light did not change the look of the surgical field. Simultaneous pan-lymphatic and SLN mapping was demonstrated in swine using clinically available NIR fluorophores and the dual NIR capabilities of the system. In the pilot clinical trial, a total of nine SLNs were identified by (99m)Tc- lymphoscintigraphy and nine SLNs were identified by NIR fluorescence, although results differed in two patients. No adverse events were encountered.. We describe the successful clinical translation of a new NIR fluorescence imaging system for image-guided oncologic surgery.

Topics: Aged; Animals; Breast Neoplasms; Coloring Agents; Female; Fluorescence; Fluorometry; Humans; Indocyanine Green; Intraoperative Period; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Pilot Projects; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Surgery, Computer-Assisted; Sus scrofa; Technetium Tc 99m Sulfur Colloid

Lymphoseek is a receptor-binding radiopharmaceutical specifically designed for sentinel lymph node (SLN) mapping. We conducted a clinical trial which measured the injection site clearance and sentinel lymph node accumulation after a single intradermal injection of Lymphoseek or unfiltered [(99m)Tc]sulfur colloid (TcSC) using a "2-day" protocol for SLN mapping of breast cancer. Eleven patients with breast cancer participated in this study. Five patients received an intradermal administration of 1.0 nmol of (99m)Tc-labeled Lymphoseek; SLN mapping was performed on four subjects within 19 to 27 h. Six subjects received an intradermal administration of TcSC; SLN mapping was performed on five subjects within 18 to 26 h. Lymphoseek exhibited a significantly (P<.001) faster injection site clearance than TcSC. The mean Lymphoseek clearance half-time was 2.18+/-1.09 h compared to 57.4+/-92.8 h for TcSC. The mean sentinel lymph node uptake of Lymphoseek (1.5+/-1.7%) and TcSC (3.5+/-3.1%) was statistically equivalent (P=.213). When an intradermal injection is employed, Lymphoseek demonstrated faster injection site clearance than unfiltered [(99m)Tc]sulfur colloid and persistent SLN accumulation for at least 24 h.

Topics: Aged; Breast Neoplasms; Dextrans; Female; Humans; Injections, Intradermal; Lymph Nodes; Mannans; Middle Aged; Organotechnetium Compounds; Pentetic Acid; Radioactivity; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Pentetate; Technetium Tc 99m Sulfur Colloid; Time Factors

Sentinel-lymph-node (SLN) mapping and biopsy maintains staging accuracy in early breast cancer and identifies patients for selective lymphadenectomy. SLN mapping requires injection of technetium-99m-sulfur colloid-an effective but sometimes painful method, for which better pain-management strategies are needed. In this randomised, double-blind trial, we compared degree of pain between standard radiocolloid injection and pH-adjusted and lidocaine-supplemented formulations for patients undergoing SLN mapping for breast cancer.. Between Jan 13, 2006, and April 30, 2009, 140 patients with early breast cancer were randomly assigned in a 1:1:1:1 fashion to receive the standard topical 4% lidocaine cream and injection of [(99m)Tc]Tc-sulfur colloid (n=35), or to one of three other study groups: topical placebo cream and injection of Tc-sulfur colloid containing either sodium bicarbonate (n=35), 1% lidocaine (n=35), or sodium bicarbonate and 1% lidocaine (n=35). The randomisation sequence was computer generated, and all patients and investigators were masked to treatment allocation. The primary endpoint was patient-reported breast pain immediately after radioisotope injection, using the Wong-Baker FACES pain rating scale and McGill pain questionnaire, analysed in the per-protocol population. This study is registered with ClinicalTrials.gov, number NCT00940199.. 19 of the 140 patients enrolled were excluded from analysis: nine declined study participation or sought care elsewhere, nine did not undergo SLN mapping because of disease extent or a technical problem, and one had unreliable data. There were no adverse events. Mean pain scores on the Wong-Baker scale (0-10) were: 6.0 (SD 2.6) for those who received standard of practice, 4.7 (3.0) for those who received radiocolloid plus bicarbonate, 1.6 (1.4) for those who received radiocolloid plus 1% lidocaine, and 1.6 (1.3) for those who received radiocolloid plus bicarbonate and 1% lidocaine (p<0.0001). Mean pain rating, according to the McGill questionnaire (0-78), was 17.5 (SD 11.8) for the standard-of-care group, 15.4 (14.4) for the sodium bicarbonate group, 4.6 (4.5) for the 1% lidocaine group, and 3.4 (5.1) for the sodium bicarbonate plus 1% lidocaine group (p<0.0001). SLN identification rates for each group were: 96% for the standard of care, 97% for sodium bicarbonate, 90% for 1% lidocaine, and 90% for sodium bicarbonate plus 1% lidocaine group (p=0.56).. For centres that use radiocolloid injections for SLN mapping in patients with early breast cancer, the addition of 1% lidocaine to the radioisotope solution can improve patient comfort, without compromising SLN identification.. US Military Cancer Institute, the Clinical Breast Care Project, and the Army Regional Anesthesia and Pain Management Initiative.

Topics: Adolescent; Adult; Anesthetics, Local; Breast Neoplasms; Double-Blind Method; Drug Combinations; Female; Humans; Injections, Intradermal; Lidocaine; Middle Aged; Pain; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The imaging probe (IP) is a high-resolution (HR), 1-in(2) field-of-view hand-held gamma camera. We used it to detect breast cancer sentinel node (SN).. We divided 120 T1 breast cancer patients, who underwent Anger camera lymphoscintigraphy (ACL), in two subgroups of 60 patients who were age, body mass index, and cancer size matched: subgroup A (SA) and B (SB). SN was detected with a common gamma probe (GP) in SA, with IP plus GP in SB.. Surgeons removed radioactive nodes without exceeding four nodes. Eighty-two (82) SNs were taken off in SA and 105 in SB (p<0.01). Of SA, 22 of 60 patients and 36 of 60 patients of SB showed more than 1 node, and 3 of them showed 3 nodes and 1 showed 4 nodes. Thirteen (13) patients resulted N(+) (21.6%) in SA. Ten (10) patients of SA showed an invasion on the hottest nodes and 3 on the second nodes. In the SB, 18 patients (25%) showed invasion. Sixteen (16) invasions were on hot, 4 on second, and 1 on the third node. Withdrawal time of SN was 11.25+/-4.7 minutes for SA and 7.4+/-2.8 minutes for SB (p<0.025).. SN biopsy with IP is fast and discovers more SNs and more invasions than ACL.

Topics: Breast Neoplasms; Carcinoma, Ductal, Breast; Female; Gamma Cameras; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Radionuclide Imaging; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

To compare, intra-individually, the detection rates of sentinel node on lymphoscintigraphy performed on the day of injection (D0) and on the following day (D1) in breast carcinoma. We also compared 2-day and 1-day protocols in the two groups of patients.. The 2-day and 1-day protocols included 76 patients in group 1 and 23 patients in group 2. Patients from group 1 underwent lymphoscintigraphy twice--at 2 h (lymphoscintigraphy 1) and 18 h (lymphoscintigraphy 2) post-injection at four sites periareolar using 99mTc sulfur colloid. Patients from group 2 underwent lymphoscintigraphy only at 2 h post-injection. The detection rates and the number of sentinel nodes were compared in the two lymphoscintigraphy examinations for group 2.. The detection rate on lymphoscintigraphy in group 1 was 92% at D0 and 96% at D1. The overall agreement between lymphoscintigraphy 1 and lymphoscintigraphy 2 was 69/76 (91%). In 2/76 women, the sentinel node disappeared at D1 on lymphoscintigraphy, but remained detectable during surgery, and in 5/76 women, the sentinel node appeared at D1 on lymphoscintigraphy. The mean number of sentinel nodes detected on lymphoscintigraphy was 2.05+/-0.14 at D0 and 1.76+/-0.11 at D1 (P=0.004) in group 2, the detection rate of the sentinel node was 20/23 (87%).. Our study demonstrated that for patients undergoing the 2-day protocol for sentinel node procedure in early stage breast cancer, the optimal imaging time would be to perform lymphoscintigraphy 1 h after injection, with the possibility of imaging patients the following day in cases where lymphoscintigraphy was negative.

Topics: Breast Neoplasms; Female; Humans; Image Enhancement; Injections; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Observer Variation; Radionuclide Imaging; Radiopharmaceuticals; Reproducibility of Results; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Time Factors

In this article, we will discuss the achievement of early dynamic lymphoscintigraphic protocol and compare detection of sentinel node between benign and malignant breast tumors, and whether pathologic factor is related or not.. During a six-month period, consecutive fifty-nine patients were enrolled into our study. The average age of patients was 47.6 +/- 9.8 years and all of them were clinically suspected of having breast cancer. The average tumor was 2.1 +/- 1.1 cm in size. First, Tc-99m sulfur colloid was injected around corners of palpable mass or biopsy cavity by the hybrid injection method. Immediately thereafter, dynamic protocol of lymphoscintigraphy, with 10 sec per frame for 60 frames was performed by established simultaneous dual-head vertical angle imaging technique. And delayed two-hour image was also acquired. All patients underwent surgery sixteen to twenty hours later and had a final pathological diagnosis.. Among 59 patients, 14 of them were diagnosed with fibroadenoma and the other 45 cases with malignant conditions, infiltrating duct carcinoma mostly. The average age of the two groups was similar. From the summation image of dynamic study, identified axillary sentinel nodal activity was found as 80% in the group of benign breast tumor, but only 48% in the group of malignant breast tumor. In more than 88% of patients, sentinel lymph node was detectable on the delayed two-hour image between the two groups.. Early dynamic protocol of pre-operative lymphoscintigraphy is helpful to clarify the relationship between the local lymphatic drainage basin and sentinel nodal uptake. However, this short period of protocol is not always achievable to detect sentinel node, especially in the group with breast malignant lesions.

Topics: Adult; Aged; Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Prognosis; Radionuclide Imaging; Radiopharmaceuticals; Reproducibility of Results; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Time Factors

Multiple injection routes, including intradermal (ID), intraparenchymal (IP), and subareolar (SA), are used for 99mTc-sulfur colloid administration for sentinel lymph node (SLN) mapping and biopsy in breast cancer. The aim of this study was to compare localization by ID, IP, and SA injection routes based on preoperative lymphoscintigraphy and intraoperative identification.. Four hundred prospectively randomized breast cancers underwent SLN mapping and biopsy.. Preoperative lymphoscintigraphy demonstrated localization to the axilla in 126/133 (95%) ID, 82/132 (62%) IP, and 96/133 (72%) SA (P < 0.001 ID vs. IP and ID vs. SA; P = 0.081 IP vs. SA), with a mean duration of preoperative lymphoscintigraphy of 139 +/- 18 minutes. Mean time to first localization when localization was demonstrated on preoperative lymphoscintigraphy was 8 +/- 14 minutes for ID, 53 +/- 49 for IP, and 22 +/- 29 for SA (P < 0.001 ID vs. IP and ID vs. SA; P = 0.003 IP vs. SA). Intraoperative identification of a SLN at the time of SLN biopsy was successful in 133/133 (100%) ID, 121/134 (90%) IP, and 126/133 (95%) SA (P < 0.001 ID vs IP; P = 0.014 ID vs. SA; P = 0.168 IP vs. SA), with a mean time from injection of 99mTc-sulfur colloid to start of SLN biopsy of 288 +/- 71 minutes. Mean intraoperative time to harvest the first SLN was 9 +/- 4 minutes for ID, 13 +/- 6 for IP, and 12 +/- 6 for SA (P < 0.001 ID vs. IP and ID vs. SA; P = 0.410 IP vs. SA).. The ID injection route demonstrated a significantly greater frequency of localization, decreased time to first localization on preoperative lymphoscintigraphy, and decreased time to harvest the first SLN. This represents the first prospective randomized clinical trial to confirm superiority of the ID route for administration of 99mTc-sulfur colloid during SLN mapping and biopsy in breast cancer.

Topics: Breast Neoplasms; Drug Administration Routes; Female; Humans; Injections, Intradermal; Injections, Intralesional; Lymph Nodes; Lymphatic Metastasis; Lymphography; Middle Aged; Preoperative Care; Prospective Studies; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

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

Topics: Adult; Aged; Axilla; Breast Neoplasms; Carcinoma; Feasibility Studies; Female; Humans; Injections; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Prognosis; Radionuclide Imaging; Radiopharmaceuticals; Reproducibility of Results; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Tissue Distribution

To evaluate the efficacy of the surgical gamma probe (SGP) after peritumoral injection of Tc-99m MIBI and filtered Tc-99m sulfur colloid (SC) in sentinel lymph node (SLN) detection in stage I and II breast cancer for deciding on the need for axillary dissection.. Thirty patients with stage I-II breast cancer had peritumoral injection of Tc-99m MIBI (74 MBq/0.2 mL [2 mCi/0.2 mL] at 4 different locations) and 42 different patients had peritumoral injection of filtered Tc-99m sulfur colloid (50 MBq/0.2 mL [1.3 mCi/0.2 mL] at 4 different locations). Anterior, lateral, and anterolateral spot images were acquired at 10, 30, 45, 60, and 120 minutes and 24 hours are injection in 5 patients. During surgery, counts were obtained from the injection site, affected breast tissue, internal mammary, axillary, and supraclavicular regions and the contralateral side using the gamma probe. Peritumoral blue dye was also injected during surgery. The first lymph nodes with counts at least twice the background tissue and/or with blue dye uptake were surgically isolated. Modified radical mastectomy and axillary dissection were performed.. Histopathologic evaluation was made on SLN and other excised tissues. In the Tc-99m sulfur colloid group, lymphatic drainage and lymph nodes were demonstrated with lymphoscintigraphy in 31 of 42 patients. SLN was detected by SGP in 35 of 42 patients. In the Tc-99m MIBI group, lymphatic drainage and lymph nodes were visualized with lymphoscintigraphy in 23 of 30 patients. SLN was detected in 25 of 30 patients with SGP in this group.. In patients with stage I-II breast cancer, SLN could be successfully demonstrated with lymphoscintigraphy and SGP by the peritumoral injection of filtered Tc-99m sulfur colloid and Tc-99m MIBI.

Topics: Adult; Aged; Aged, 80 and over; Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Prognosis; Radionuclide Imaging; Radiopharmaceuticals; Reproducibility of Results; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sestamibi; Technetium Tc 99m Sulfur Colloid

Lymphatic mapping with sentinel lymphadenectomy (SL) has become more widely used as an alternative to axillary dissection for the staging of breast cancer. This study was conducted to evaluate the potential associations of patient and tumor characteristics with the lymphatic mapping failure rate.. Between September 1996 and April 2003, 1,094 breast cancer patients participated in a single-institution prospective SL protocol, which was conducted using technetium 99 m sulfur colloid alone to identify sentinel lymph nodes. During the validation phase, consisting of the first 80 patients, all patients had SL followed by axillary dissection. Beginning with the 81st patient, the standard technique consisted of radiolabeled colloid injection in a peritumoral distribution 16 to 24 hours before the operation, followed by SL alone for node-negative patients.. Of 1,094 consecutive patients, 62 (5.7%) did not map. Patients having more than 10 involved lymph nodes had a significantly higher incidence of mapping failure (40.9%) than those who were node-negative (5.3%) (odds ratio = 9.19, p = 0.002). Age was a factor predictive of mapping failure for node-negative patients 70+ years of age (odds ratio = 3.14, p = 0.018). Biopsy technique, tumor size, tumor location, cell type, and surgeon experience were not predictors of mapping failure, regardless of node status.. The lymphatic mapping failure rate was associated with both anatomic and pathologic factors. Patients with extensive nodal involvement had a significantly greater chance of mapping failure. Among node-negative patients, those who were older were more likely to have mapping failure than those who were younger, suggesting that decreased breast density in postmenopausal women might provide an anatomic explanation for nonmapping.

Topics: Aged; Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Middle Aged; Neoplasm Staging; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

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

Lymphoseek is a new radiopharmaceutical that accumulates in lymphatic tissue by binding to a receptor that resides on the surface of macrophage cells. We conducted a phase I clinical trial in which Lymphoseek was compared with filtered [(99m)Tc]sulfur colloid (fTcSC) for sentinel node detection in patients with breast cancer.. Twelve women (42-71 years) with breast cancer were randomly assigned to a 3-hour imaging protocol with peritumoral/subdermal injections (.5 mCi) of either Lymphoseek (1 nmol; molecular weight, 28 kDa; diameter,.007 micro m) or.2 micro m of fTcSC. Serial images were acquired for 180 minutes. Sentinel nodes, excised within 4.2 to 7.3 hours of administration, were assayed in a dose calibrator.. The receptor-binding agent, Lymphoseek, exhibited a significantly (P =.0025) faster injection site clearance (rate,.255 +/-.147/hour; fTcSC rate,.014 +/-.018/hour); the mean Lymphoseek clearance half-time was 2.72 +/- 1.57 hours compared with 49.5 +/- 38.5 hours for fTcSC. The primary sentinel node uptake of Lymphoseek (range,.02%-1.12%; mean,.55% +/-.43%) and fTcSC (range,.00%-1.93%; mean,.65% +/-.63%) did not differ (P =.75). Lymphoseek exhibited a lower mean number of sentinel nodes per study (n = 1.3) than fTcSC (n = 1.7) and a higher concordance with Lymphazurin.. The molecular receptor-binding agent Lymphoseek demonstrated faster injection site clearance and equivalent primary sentinel node uptake when compared with fTcSC.

Topics: Adult; Aged; Breast Neoplasms; Dextrans; Female; Humans; Injections, Subcutaneous; Lymphatic Metastasis; Macrophages; Mannans; Middle Aged; Organotechnetium Compounds; Pentetic Acid; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Pentetate; Technetium Tc 99m Sulfur Colloid

The authors' purpose was to explore the association between mammographic findings and drainage patterns on lymphoscintigrams obtained during sentinel node procedures for breast carcinoma.. From July 1997 to March 2000, 132 patients with breast cancer who were included in a prospective mammography-pathology correlation and staging database were imaged 2 hours after perilesional injection of 1 mCi filtered (0. 22 microm) Tc-99m sulfur colloid (4 ml volume) before sentinel node procedures.. Sixty-four percent of the scans showed axillary drainage only, 9% showed axillary and internal mammary drainage, and 4% revealed internal mammary drainage only. Twenty-three percent of scans showed no drainage. Of the patients who showed drainage, 17% showed drainage to the internal mammary basin, and 5% showed this exclusively. Internal mammary drainage was seen in 18% (10 of 57) of lateral, 21% (6 of 29) of medial, and 14% (1 of 7) of subareolar lesions (P = NS). No drainage was seen in 22% of patients with predominantly fatty mammographic parenchymal density (>50%) compared with only 8% of patients with predominantly dense (>50%) parenchyma (P < 0.05). Failure to show drainage was more common in women older than 50 years (P < 0.05). Axillary sentinel nodes were identified surgically in 73% of patients with negative scan findings. There was no significant association between scintigraphic drainage and mammographic soft tissue tumor size and appearance, histologic findings, or axillary node status.. Dense mammographic parenchyma and age less than 50 years are associated with identification of lymphatic drainage on lymphoscintigrams performed before sentinel node procedures in 91% to 92% of patients. Internal mammary drainage, present in 18% of lateral and 21% of medial lesions, may direct therapy to include internal mammary lymph nodes.

Topics: Adolescent; Adult; Age Factors; Aged; Axilla; Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Reproducibility of Results; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Single-Blind Method; Technetium Tc 99m Sulfur Colloid

Secondary lymphedema is a localized, acquired lymphatic microcirculatory disturbance that affects large numbers of patients after breast cancer therapy. There is a paucity of objective methods to quantitate lymphatic function and to anticipate the response to therapeutic interventions. We applied radionuclide lymphoscintigraphy to evaluate lymphatic transport and axillary lymph node visualization in women following breast cancer therapy to determine the utility of these data in these patients. Lymphoscintigraphy was performed after subcutaneous injection of 0.25 mCi of Tc-filtered sulfur colloid. Subcutaneous accumulation of radiotracer ('dermal backflow') and the visualization of axillary lymph nodes were graded using our own scoring system. The ratio of radioactivity within the affected to normal axillae (ARR) was also quantified. Nineteen patients with lymphedema after breast cancer therapy were evaluated. The disease severity was documented by serial measurements of the limb volume using the truncated cone formula. Responses to therapy were quantified after completion of the therapy. There was a correlation between the ARR and the percentage reduction in edema volume. The lymphoscintigraphic score correlated with the initial arm volume excess and with the durationof lymphedema. It can be concluded that quantitative and semi-quantitative assessment by radionuclide lymphoscintigraphy represents a potentially useful tool for the clinical assessment of upper extremity lymphedema.

Topics: Aged; Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphedema; Lymphoscintigraphy; Mastectomy; Middle Aged; Physical Therapy Modalities; Postoperative Complications; Predictive Value of Tests; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid; Upper Extremity

The aim of the study was to study the influence of patient- or tumour-related factors on the lymphatic drainage patterns in breast cancer.. The study included 290 consecutive breast cancer patients with lymphatic mapping and sentinel node biopsy. Lymphoscintigraphy was performed a median of four hours after a single intratumoral injection of (99m)Tc labelled human albumin colloid with two different particle sizes.. Lymphoscintigraphy showed axillary sentinel nodes in 253 (87%) and parasternal sentinel nodes in 49 (17%) patients. The median number of nodes seen in the axilla was one (range 0-5). No sentinel nodes were visualized in 27 (9%) patients. The number of the visualized axillary nodes was influenced by the particle size of the radiocolloid, and by metastatic involvement of the axillary nodes and the age and body mass index (BMI) of the patient. Patients with parasternal sentinel nodes were younger, had a lower BMI and had more often a non-palpable tumour.. The age and BMI of the patient and the palpability of the tumour influence lymphatic drainage patterns in breast cancer. The metastatic involvement of axillary nodes seems to modify lymphatic drainage to the axilla.

Topics: Adult; Aged; Aged, 80 and over; Analysis of Variance; Breast Neoplasms; Cohort Studies; Female; Humans; Injections, Intralesional; Linear Models; Logistic Models; Lymph Nodes; Middle Aged; Neoplasm Staging; Preoperative Care; Probability; Prognosis; Prospective Studies; Radiographic Image Enhancement; Radionuclide Imaging; Radiopharmaceuticals; Sensitivity and Specificity; 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

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

Topics: Adult; Aged; Breast Neoplasms; Female; Humans; Middle Aged; Radiopharmaceuticals; 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

This prospective study was performed to ascertain the added benefit of lymphoscintigraphy to a standard method of intraoperative lymphatic mapping and sentinel node biopsy for breast cancer.. Patients with invasive breast cancer were injected with 99mTc sulfur colloid prior to sentinel node biopsy; preoperative lymphoscintigraphy was then performed in half of the patient population.. Sentinel node identification was possible in 45 of 50 patients (90%). All 14 patients (31%) with axillary nodal metastases had at least one histologically positive sentinel node (0% false negative rate). Lymphoscintigraphy revealed sentinel nodes in 17 of the 24 patients (70.8%) imaged. All 17 of these patients had one or more axillary sentinel nodes identified using intraoperative lymphatic mapping. In addition, 5 of 7 patients with a negative preoperative lymphoscintogram had an axillary sentinel lymph node(s) identified intraoperatively. None of the tumors showed drainage to the internal mammary lymph node chain by lymphoscintigraphy despite the fact that there were 5 patients with inner quadrant tumors. There was no significant advantage with respect to sentinel lymph node localization (91.7% versus 88.5%, P = not significant) or false negative rate (0%, both groups, P = not significant) in the group undergoing preoperative lymphoscintigraphy when compared with the patients in whom lymphoscintigraphy was not performed.. Preoperative lymphoscintigraphy adds little additional information to intraoperative lymphatic mapping, and its routine use is not justified.

Topics: Axilla; Biopsy; Breast Neoplasms; Female; Humans; Intraoperative Care; Lymph Nodes; Lymphatic Metastasis; Preoperative Care; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid

Evidence indicates that sentinel node (SN) biopsy can accurately predict axillary nodal status. Debate exists as to the optimal method of SN identification.. Patients with clinical T1 or T2 tumors and negative axillae were randomized to SN localization with blue dye (B) alone (n = 50) or blue dye plus radioactivity (B+R) (n = 42). Patients undergoing needle localization (n = 47) were assigned to blue dye.. The SN was identified in 110 patients (79%) and contained metastases in 28. The SN predicted the axillary nodal status in 96% of cases. The SN identification rate did not differ between B (88%) or B+R (86%) but was significantly lower in patients requiring localization (64%). The time to SN identification also did not differ between B and B+R. The number of cases done by an individual surgeon was a significant predictor of SN identification. A stepwise logistic regression analysis of factors influencing the success of SN identification identified tumor location, needle localization, number of operations, and body mass index as significant predictors.. Our study does not identify any advantage for the use of the more expensive and complex method of SN identification using B+R compared with B alone, even for surgeons learning the techniques.

Topics: Axilla; Biopsy; Breast Neoplasms; Coloring Agents; Education, Medical, Continuing; Female; Humans; Logistic Models; Lymph Nodes; Medical Staff, Hospital; Middle Aged; Palpation; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid

There are few clinical data on technical limitations and radiocolloid kinetics related to sentinel lymph node (SLN) biopsy for breast cancer.. In 70 clinical node-negative patients, unfiltered 99mTc sulfur-colloid was injected peritumorally and cutaneous hot spots were mapped with a gamma probe. SLN biopsy was performed followed by axillary lymph node dissection. Missed radioactive nodes (nodes not under hot spots) were removed from axillary lymph node dissection specimens and submitted separately.. At least one hot spot was mapped in 69 patients (98%) and SLNs were retrieved in 62 (89%). No radiolabeled nodes were found in five (7%) and only nodes not under hot spots were retrieved in three patients (4%). Residual nodes not under hot spots were retrieved in 17 patients (24%) in whom at least one SLN specimen had been found. Diffuse radioactivity around the radiocolloid injection site impeded identification of all radiolabeled nodes during SLN biopsy, and was responsible for one of two false negatives (20 node-positive patients; false-negative rate 10%). Hot spot radioactivity, number of radiolabeled nodes, and nodal radioactivity did not change with time interval from radiocolloid injection to surgery (0.75-6.25 hours).. Although SLN localization rate is high, intraparenchymal injection may predispose to failure of radiocolloid migration, failure to identify SLNs because of high radiation background, and false-negative outcomes. Alternative routes of radiocolloid administration should be explored.

Topics: Adult; Aged; Aged, 80 and over; Biopsy; Breast Neoplasms; False Negative Reactions; Humans; Lymphatic Metastasis; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid

Thirty-two patients with clinical node-negative breast cancer underwent sentinel node localization study as part of a National Cancer Institute-sponsored multicenter trial. Anatomical and histopathologic characteristics of sentinel lymph node (SLN) and a kinetic analysis of nodal uptake were studied. Patients were injected with 1 mCi/4 ml unfiltered 99mTc-sulfur colloid in four divided doses around the palpable lesion or immediately adjacent to the excision cavity if prior biopsy was performed. SLN biopsy was performed 1.5-6 hr (mean = 3 hr) postinjection. Intraoperative localization was performed using a gamma probe. All patients underwent complete axillary dissection.. SLN was identified in 30 of 32 (94%) patients. There were no false-negative SLN biopsies.. This study supports the clinical validity of SLN biopsy in breast cancer and confirms that, unlike the blue dye technique, the learning curve with unfiltered 99mTc-sulfur colloid and the gamma detection probe is short, and SLN localization is achievable in over 90% of cases by surgeons with modest experience. The use of unfiltered 99mTc-sulfur colloid (larger particle size) with larger injected volume permits effective localization of SLNs.

Topics: Adult; Aged; Axilla; Biopsy; Breast Neoplasms; Carcinoma, Ductal, Breast; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid

Axillary lymph node dissection is an important part of the surgical treatment of breast cancer as a staging procedure. Recent progressive advances in early detection have led to the treatment of small primary carcinomas; thus, a great number of axillary dissections show completely negative lymph nodes. The sentinel node (SN) concept, developed for melanoma patients, seems to be similarly valid in breast cancer and has the potential to change the standard surgical approach in these patients. To verify the accuracy of lymphoscintigraphic method associated with radioguided biopsy of the sentinel node in a large series of patients, we studied 382 patients with operable breast cancer. Lymphoscintigraphy (LS) was performed the day before surgery; three different-sized ranges of 99mTechnetium-labeled colloid particles were injected either by subdermal or peritumoral administration. Planar scans were registered in anterior and oblique projections, and a cutaneous marker was placed over the skin corresponding to the SN as visualized. SNs were localized and removed during surgery, using a gamma-detecting probe (GDP); total axillary dissection was then performed. In 54 patients, blue dye was also administrated in the tumor bed immediately after excision of the primary. LS identified at least one SN in 377 of 382 cases (98.7%). Axillary SN was localized in 371 cases (97.1%). The overall concordance between SN status and other axillary nodes was 96.8% (359 of 371). Localization of the SN was easier when large-size particles of colloidal albumin were injected in a volume of 0.4 ml. GDP successfully localized SN in 54/54 cases (100%), while blue dye identified SN in 37/54 patients (68.5%). In 33 of 37 cases (89%) the dye and LS identified the same node. LS and GDP-guided surgery provide accurate identification and removal of the SN, particularly when large-size radiolabeled colloids are injected in a small volume.

Topics: Axilla; Biopsy; Breast Neoplasms; Carcinoma in Situ; Carcinoma, Ductal, Breast; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Melanoma; Patient Selection; Radioimmunodetection; Reproducibility of Results; Technetium Tc 99m Sulfur Colloid

Recent studies have demonstrated the possibility of identifying the sentinel lymph node (sN) as a reliable predictor of axillary lymph node status in both cutaneous melanoma and breast cancer. However, some important issues need further definition: (1) optimization of the technique for intraoperative detection of the sN; (2) predictive value of the sN as regards axillary lymph node status, and (3) reliability of intraoperative histology of the sN. We report our experience in sN mapping in patients with Stage I-II breast cancer, with the aim of assessing: (1) the feasibility of lymphatic mapping with a combined approach (vital blue dye lymphatic mapping and radioguided surgery); (2) the agreement of the intraoperative histologic examination of the sN, by means of hematoxylin and eosin staining with final histology, and (3) the accuracy of sN histology as a predictor of axillary lymph node status.

Topics: Aged; Axilla; Breast Neoplasms; Coloring Agents; Female; Humans; Immunohistochemistry; Intraoperative Period; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Predictive Value of Tests; Radioimmunodetection; Sensitivity and Specificity; Technetium Tc 99m Aggregated Albumin; Technetium Tc 99m Sulfur Colloid

Determination of axillary nodal status is essential for the staging of breast cancer since nodal status is one of the most important predictors of survival. The objective of this study was to test the hypothesis that the histology of the first draining lymph node (LN) accurately predicts the histology of the rest of the axillary LNs.. Fifty-five patients with operable invasive breast carcinoma and clinically negative axillary lymph nodes were studied. Patients were injected with Technetium-99 (99Tc) sulfur colloid around the primary tumor. A hand-held gamma detector probe was used to identify the sentinel LN (SLN). After the SLN was identified and removed, a level I and II lymphadenectomy was performed.. The SLN was identified in 53 (96.3%) of the 55 patients entered into the trial. The sensitivity was 88.2% and the specificity was 100%. The positive predictive value was 100% and the negative predictive value was 94.6%. The accuracy of the study was 96.2%.. The SLN biopsy for breast cancer staging is highly accurate in our hands and has the potential to decrease the morbidity and cost of managing patients with breast cancer without compromise of staging.

Topics: Adult; Aged; Axilla; Biopsy; Breast Neoplasms; Cost-Benefit Analysis; False Negative Reactions; Female; Humans; Lymph Node Excision; Lymph Nodes; Middle Aged; Neoplasm Staging; Predictive Value of Tests; Radionuclide Imaging; Sensitivity and Specificity; Technetium Tc 99m Sulfur Colloid

We have recently reported on a technique of gamma probe localization of radiolabelled lymph nodes to identify the sentinel node in malignant melanoma. In order to determine whether this technique is applicable to assist in staging breast cancer, a pilot study was begun to address two questions: (i) can the sentinel lymph node draining a breast cancer be identified for selective resection; and (ii) is the sentinel lymph node predictive of the status of the entire axillary lymph nodes? One to four hours prior to axillary lymph node dissection, 22 consecutive patients had approximately 0.4 mCi of technetium sulfur colloid in 0.5 ml saline injected around the perimeter of the breast lesion. A hand-held gamma counter was used at surgery to locate the lymph node(s) receiving drainage from the breast. A sentinel lymph node was identified in 18 of 22 patients. Of these 18 patients, the sentinel lymph node was positive in seven of seven patients, with pathologically verified metastatic breast cancer to at least one lymph node. In three out of seven patients, the sentinel lymph node was the only lymph node with metastatic cancer. In this pilot study of breast cancer patients, we conclude that: (i) radiolocalization and selective resection of sentinel lymph nodes is possible; and (ii) the sentinel lymph node appears to predict correctly the status of the remaining axilla. These data justify a larger clinical trial to verify the value of this technique.

Topics: Adult; Aged; Aged, 80 and over; Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Pilot Projects; Prospective Studies; Scintillation Counting; Technetium Tc 99m Sulfur Colloid

Topics: Breast Neoplasms; Colloids; Cost-Benefit Analysis; Female; Humans; Lymph Nodes; Mouth; Neoplasms; Radiopharmaceuticals; Sentinel Lymph Node; Sentinel Lymph Node Biopsy; Sulfur; Technetium Tc 99m Pentetate; Technetium Tc 99m Sulfur Colloid

Breast lymphoscintigraphy with

Topics: Aged; Anesthetics, Local; Attitude of Health Personnel; Breast Neoplasms; Female; Humans; Injections; Lidocaine; Lymphoscintigraphy; Middle Aged; Pain; Patient Satisfaction; Preoperative Care; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid

A 34-year-old woman with history of bilateral saline implants, invasive ductal carcinoma of the right breast, and suspicious left breast calcifications was referred for left breast lymphoscintigraphy before bilateral mastectomy. A total of 3.2 mCi of Tc-filtered sulfur colloid was administered with 3 subdermal injections in the superior, lateral, and inferior periareolar left breast in the late afternoon preceding the day of surgery. Imaging identified radiotracer uptake within a dense, circular area deep to the injection sites within the left breast, compatible with implant puncture and radiotracer administration within the indwelling breast implant.

Topics: Adult; Breast Implants; Breast Neoplasms; Carcinoma, Ductal; Female; Humans; Lymphoscintigraphy; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid

Lymphoscintigraphy plays a vital role in sentinel lymph node (SLN) identification in oncologic breast surgery. The effectiveness of SLN localization and the degree of patient pain were compared between filtered

Topics: Breast Neoplasms; Dextrans; Female; Humans; Lymphoscintigraphy; Mannans; Middle Aged; Pain; Retrospective Studies; Sentinel Lymph Node Biopsy; Technetium Tc 99m Pentetate; Technetium Tc 99m Sulfur Colloid; Wounds and Injuries

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

Sentinel lymph node biopsy (SLNB) historically involves a separate appointment in the Radiology Department to undergo injection of the radiocolloid tracer (RT) the day of, or prior to, surgery, which can lead to disruptions in scheduling. Furthermore, the patient must endure an additional procedure. In a pilot study, intraoperative injection of the RT was previously shown to be equally as effective as preoperative injection. This study evaluates the efficacy of this method in a large cohort and examines factors associated with failure of the RT to reach the axilla.. A retrospective review of patients who underwent SLNB between June 2010 and June 2017 was performed. All patients were injected immediately following intubation with sulfur colloid and blue dye, unless contraindicated. Operative records were reviewed to determine whether sentinel nodes were identified and if gamma counts were detected. Patient and tumor characteristics were examined to identify factors related to failed RT uptake in the axilla.. In 7 years, 453 SLNBs were performed, with sentinel nodes being detected in 447 (98.7%) of these SLNBs. In the six cases where no nodes were detected, all had a prior ipsilateral axillary procedure. Sentinel nodes were undetectable with the gamma probe in 16 (3.5%) cases; a prior axillary procedure was the only statistically significant independent variable associated with this failure.. Intraoperative injection of the RT is highly effective in the detection of sentinel nodes in clinically node-negative breast cancer patients. Eliminating the need for a preoperative injection of RT can avoid scheduling conflicts and decrease patient morbidity.

Topics: Adult; Aged; Aged, 80 and over; Breast Neoplasms; Carcinoma, Ductal, Breast; Carcinoma, Intraductal, Noninfiltrating; Carcinoma, Lobular; Female; Follow-Up Studies; Humans; Intraoperative Period; Lymph Nodes; Middle Aged; Neoplasm Staging; Preoperative Care; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Traditionally lymphoscintigrams are taken after injection of peri-areolar Technetium-99m (Tc-99m) to quantify sentinel nodes before biopsy (SNB). However, recent research suggests that scintigraphy is not an essential adjunct. For service improvement, we stopped using lymphoscintigraphy so as to minimize delay to operating theater and reduce demand on the Nuclear Medicine Department. We audited early outcomes to ensure quality was maintained. 100 consecutive patients undergoing SNB with lymphoscintigrams were investigated. Lymphoscintigrams were reported by Consultant Radiologists. Reported node count (RNC) was compared to biopsied node count (BNC) using Cohen's kappa statistic. Lymphoscintigrams were then discontinued, and the results on the next 69 consecutive patients undergoing SNB were analyzed. The BNC was then compared to BNC in patients having lymphoscintigrams. Of the first 100 patients, RNC ranged from 0-5 (mean=1.84, mode=1) and BNC from 1-4 (mean=1.89, mode=1). 90% of lymphoscintigrams were performed on the day of surgery. Cohen's Kappa statistic was 0.34 (95%CI =0.195 to 0.482, i.e., Fair agreement). RNC was zero in two cases, but SNB was successful. Of 69 patients in the second group with no scan, BNC ranged from 0-4 (mean=1.80, mode=2). There were two cases of failed localization and no significant difference between BNC with or without scans (p=0.16). Sentinel node positivity rate was 36% for those with scans and 25.3% for those without scans, which was not significant (chi-squared, p=0.11). These results correlate to previously published studies. Correlation between RNC and BNC was only in fair agreement, and negative lymphoscintigrams did not result in failed SNB localization. Our study suggests that BNC without scans is safe and effective. Removing the lymphoscintigram will result in measurable cost savings, saving of clinical time (no delay to operating room while waiting for scan or multiple journeys to hospital), freeing the scanner for other scans, and allowing additional time for radiology physicians and staff.

Topics: Aged; Breast Neoplasms; Female; Humans; Lymphatic Metastasis; Lymphoscintigraphy; Middle Aged; Radiopharmaceuticals; Retrospective Studies; Rosaniline Dyes; Sentinel Lymph Node; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Performing a sentinel lymph node biopsy (SLNB) is the standard of care for axillary nodal staging in patients with invasive breast cancer and clinically negative nodes. The procedure provides valuable staging information with few complications when performed by experienced surgeons. However, variation in proficiency exists for this procedure, and a great amount of experience is required to master the technique, especially when faced with challenging cases. The purpose of this paper was to provide a troubleshooting guide for commonly encountered technical difficulties in SLNB, and offer potential solutions so that surgeons can improve their own technical performance from the collective knowledge of experienced specialists in the field.. Information was obtained from a convenience sample of six experienced breast cancer specialists, each actively involved in training surgeons and residents/fellows in SLNB. Each surgeon responded to a structured interview in order to provide salient points of the SLNB procedure.. Four of the key opinion surgical specialists provided their perspective using technetium-99 m sulfur colloid, and two shared their experience using blue dye only. Distinct categories of commonly encountered problem scenarios were presented and agreed upon by the panel of surgeons. The responses to each of these scenarios were collected and organized into a troubleshooting guide.. We present a compilation of 'tips' organized as a troubleshooting guide to be used to guide surgeons of varying levels of experience when encountering technical difficulties with SLNB.

Topics: Axilla; Breast Neoplasms; Clinical Competence; Coloring Agents; Female; Humans; Interviews as Topic; Neoplasm Staging; Sentinel Lymph Node; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The efficacy of sentinel lymph node (SLN) surgery requires targeted removal of first-draining nodes; however, frequently more nodes are removed than necessary. [(99m)Tc]tilmanocept (TcTM) is a molecular-targeted radiopharmaceutical specifically designed for SLN mapping. We evaluated technical outcomes of SLN biopsy in breast cancer patients mapped with TcTM + vital blue dye (VBD) versus filtered [(99m)Tc]sulfur colloid (fTcSC) + VBD.. There were 84 versus 115 patients in the TcTM versus fTcSC cohorts, respectively. Main measures were the number of SLNs removed per patient and factors influencing number of nodes removed. We also evaluated whether the radiotracer injected affected the proportion of positive nodes removed in node-positive patients.. Fewer nodes were removed among patients mapped with TcTM compared to fTcSC (mean TcTM: 1.85 vs. fTcSC: 3.24, p < 0.001). Logistic regression analysis adjusted for tumor characteristics showed that injection of fTcSC (p < 0.001) independently predicted removal of greater than 3 nodes. A similar proportion of patients was identified as node-positive, whether mapped with TcTM or with fTcSC (TcTM: 24 % vs. fTcSC: 17 %, p = 0.3); however, TcTM detected a greater proportion of positive nodes among node-positive patients compared with fTcSC (0.73 vs. 0.43, p = 0.001).. Patients undergoing SLN biopsy with TcTM required fewer SLNs to identify the same rate of node-positive patients compared with fTcSC in breast cancer patients with similar risk of axillary metastatic disease. These data suggest that a molecularly targeted mechanism of SLN identification may reduce the total number of nodes necessary for accurate axillary staging.

Topics: Breast Neoplasms; Carcinoma, Ductal, Breast; Carcinoma, Lobular; Dextrans; Female; Follow-Up Studies; Humans; Lymph Nodes; Mannans; Middle Aged; Neoplasm Grading; Neoplasm Invasiveness; Neoplasm Staging; Prognosis; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Sentinel Lymph Node Biopsy; Technetium Tc 99m Pentetate; Technetium Tc 99m Sulfur Colloid

Preoperative sentinel node localization (SNL) using a subareolar injection of radiotracer technetium-99m-sulfur colloid (Tc(99m)SC) is associated with significant pain. Lidocaine use during SNL is not widely adopted partly due to a concern that it can obscure sentinel node identification and reduce its diagnostic accuracy. We prospectively identified women with a biopsy-proven infiltrating breast cancer who were awaiting a SNL. The women completed the McGill pain questionnaire, Visual Analog Scale, and Wong-Baker FACES Pain Rating Scale prior to and following SNL. We identified a retrospective cohort of women with similar demographic and tumor characteristics who did not receive lidocaine before SNL. We compared sentinel lymph node identification rates in the two cohorts. We used Wilcoxon rank sum tests to compare continuous measures and Fisher's exact test for categorical measures. Between January 2011 to July 2012, 110 women consented, and 105 were eligible for and received lidocaine prior to Tc(99m)SC injection. The post-lidocaine identification rate of SNL was 95 % with Tc(99m)SC, and 100 % with the addition of intraoperative methylene blue dye/saline. Pain range prior to and following the SNL was unchanged (P = 0.703). We identified 187 women from 2005 to 2009 who did not receive lidocaine during preoperative SNL. There was no significant difference in the success rate of SNL, with or without lidocaine (P = 0.194). The administration of lidocaine during SNL prevents pain related to isotope injection while maintaining the success rate. We have changed our practice at our center to incorporate the use of lidocaine during all SNL.

Topics: Adult; Aged; Aged, 80 and over; Anesthetics, Local; Breast Neoplasms; Female; Humans; Lidocaine; Middle Aged; Pain; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Treatment Outcome

This study sought to determine significance of radiocolloid injection timing for sentinel node biopsy (SNB) after neoadjuvant chemotherapy (NAC).. A retrospective comparison of intraoperative (IRCI) and preoperative (PRCI) radiocolloid injection for SNB was performed in breast cancer patients who had completed NAC. The sentinel node identification rate (SNIDR) was tested for noninferiority by a two-proportion z-test. The differences between clinical demographics, pathologic demographics, and SNIDR were evaluated by Fisher exact test. The difference in the number of sentinel nodes removed was analyzed by two-sample t-test.. In the 6-y study period, 120 SNB were performed after NAC: 84 received PRCI and 36 received IRCI. The two groups were similar except there were fewer clinical T2 and more clinical T3 and T4 with IRCI (P = 0.0008). The SNIDR was 92.9% with PRCI and 80.6% with IRCI. By two-proportion z-test, IRCI was not "noninferior" (P = 0.5179). By Fisher exact test, the SNIDR of the two groups did not differ. The SNIDR differs only in patients who experience T downstaging (100% versus 80%, P = 0.0173). The mean number of lymph nodes removed was higher with IRCI: 3.38 versus 2.49 nodes (P = 0.0068). There were more positive SNB with IRCI: 32.1% versus 55.2%, (P = 0.0432). The incidence of nontherapeutic axillary dissection was similar between the two groups (3.6% for PRCI versus 5.6% for IRCI).. IRCI for SNB after NAC may be inferior to PRCI.

Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Middle Aged; Neoadjuvant Therapy; Retrospective Studies; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Although the 2009 American Joint Committee on Cancer incorporated the internal mammary sentinel lymph node biopsy (IM-SLNB) concept, there has been little change in surgical practice patterns because of the low visualization rate of internal mammary sentinel lymph nodes (IMSLN) with the traditional radiotracer injection technique. In this study, various injection techniques were evaluated in term of the IMSLN visualization rate, and the impact of IM-SLNB on the diagnostic and prognostic value were analyzed.Clinically, axillary lymph nodes (ALN) negative patients (n = 407) were divided into group A (traditional peritumoral intraparenchymal injection) and group B (modified periareolar intraparenchymal injection). Group B was then separated into group B1 (low volume) and group B2 (high volume) according to the injection volume. Clinically, ALN-positive patients (n = 63) were managed as group B2. Internal mammary sentinel lymph node biopsy was performed for patients with IMSLN visualized.The IMSLN visualization rate was significantly higher in group B than that in group A (71.1% versus 15.5%, P < 0.001), whereas the axillary sentinel lymph nodes were reliably identified in both groups (98.9% versus 98.3%, P = 0.712). With high injection volume, group B2 was found to have higher IMSLN visualization rate than group B1 (75.1% versus 45.8%, P < 0.001). The IMSLN metastasis rate was only 8.1% (12/149) in clinically ALN-negative patients with successful IM-SLNB, and adjuvant treatment was altered in a small proportion. The IMSLN visualization rate was 69.8% (44/63) in clinically ALN-positive patients with the IMSLN metastasis rate up to 20.5% (9/44), and individual radiotherapy strategy could be guided with the IM-SLNB results.The modified injection technique (periareolar intraparenchymal, high volume, and ultrasound guidance) significantly improved the IMSLN visualization rate, making the routine IM-SLNB possible in daily practice. Internal mammary sentinel lymph node biopsy could provide individual minimally invasive staging, prognosis, and decision making of the internal mammary radiotherapy, especially for clinically ALN-positive patients.

Topics: Adult; Aged; Aged, 80 and over; Axilla; Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Lymphoscintigraphy; Middle Aged; Neoplasm Staging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Lymphedema is a common complication in breast carcinoma patients undergoing axillary lymph node dissection. Although there is a significant reduction in the lymphedema rate with sentinel lymph node biopsy compared to axillary lymph node dissection, there is some risk after sentinel lymph node biopsy. Axillary reverse mapping, an emerging concept aims at identifying and preserving the draining lymph node of the arm that is invariably devoid of malignancy. This concept if validated may prevent lymphedema in breast carcinoma patients. Axillary reverse mapping node can be identified using a radiotracer or blue dye. We describe the procedure using filtered Tc-SC.

Topics: Aged; Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphedema; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid; Tomography, Emission-Computed

The aim of this study was to evaluate the axillary reverse lymphatic mapping (ARM) procedure for reducing the risk of arm lymphedema after breast cancer surgery.. The ARM procedure was carried out with a subareolar injection of technetium-99 sulfur colloid the morning of surgery, and a patent blue dye injection into the upper inner arm after anesthesia.. Fifty-two women made up our study population. Thirty-seven patients underwent sentinel lymph node biopsy (SLNB) and 15 patients underwent an axillary lymph node dissection (ALND) for known nodal metastasis. The sentinel lymph node was identified in 36 of the 37 cases who underwent SLNB alone and in 12 of 15 patients who underwent on ALND. In 13 patients, both blue and radioactive lymph nodes or lymphatics were clearly identified (25%) and 5 patients had a clear crossover with nodes being both blue and hot. Only a single patient with crossover lymphatics had metastases present in their sentinel node.. The ARM technique did not prevent identification of the SLN and we identified much greater crossover than reported. We had a single patient, who underwent a sentinel node biopsy, with mild arm lymphedema (1.9%) after 2 years of follow up.

Topics: Adult; Aged; Arm; Axilla; Breast Neoplasms; Female; Follow-Up Studies; Humans; Lymph Node Excision; Lymph Nodes; Lymphedema; Mastectomy; Middle Aged; Neoplasm Staging; Prognosis; Prospective Studies; Radionuclide Imaging; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

A few studies about lymphoscintigraphy in breast cancer patients have reported a correlation between decreased sentinel lymph node (LN) uptake and increased risk of axillary involvement with the hypothesis of blocked lymphatic passage of radiotracers by metastatic burden. This study is designed to investigate whether the visible internal mammary LN of lymphoscintigraphy (IM-LPS) is related to axillary LN metastasis, rather than identifying sentinel LN in the internal mammary area.. We retrospectively reviewed medical records of 401 breast cancer patients who underwent sentinel lymphoscintigraphy using Tc-99m phytate and subsequent axillary LN dissection. The IM-LPS was divided into positive or negative groups, and axillary lymphoscintigraphy (A-LPS) was visually graded into four groups according to the method suggested by Lee et al. (1) To evaluate the relation of positive IM-LPS and A-LPS pattern with axillary LN metastasis, multivariate logistic regression analysis was done with covariates of Memorial Sloan-Kettering Cancer Center model.. Positive IM-LPS was found in 32 patients. On the univariate logistic regression analysis, positive IM-LPS (p=0.01) and A-LPS pattern (p<0.05) successfully predicted the axillary LN status. On the multivariate logistic regression model, positive IM-LPS (OR 2.6362; 95% CI 1.0382-6.6938; p=0.04) and group II A-LPS (OR 1.9773; 95% CI 1.1336-3.4491; p=0.01) remained statistically significant variables for the predictor of axillary LN metastasis.. This study suggests that IM-LPS and A-LPS pattern might be useful to show the burden of axillary LN metastasis in breast cancer patients, as an indicator of altered lymphatic pathway.

Topics: Adult; Aged; Aged, 80 and over; Axilla; Breast Neoplasms; Carcinoma, Ductal, Breast; Carcinoma, Lobular; Female; Follow-Up Studies; Humans; Lymph Nodes; Lymphatic Metastasis; Lymphoscintigraphy; Mammary Glands, Human; Middle Aged; Neoplasm Grading; Neoplasm Invasiveness; Neoplasm Staging; Prognosis; Radiopharmaceuticals; Retrospective Studies; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

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 purpose of this study was to determine whether certain factors in the preparation and use of (99m)Tc-sulfur colloid affected the number of sentinel lymph nodes (SLNs) detected during SLN mapping and during intraoperative SLN identification. The factors that were investigated included the use of a dry heat block versus a hot water bath to heat the (99m)Tc-sulfur colloid bulk vial, amount of (99m)TcOH4(-) added to form the sulfur colloid particles, time between the unit dose calibration and the injection of the dose, and breast quadrant in which the injection occurred.. Data were collected retrospectively and quantitatively analyzed from images and reports of 488 patients with breast cancer who had undergone SLN mapping and intraoperative SLN identification from January 1, 2008, to June 30, 2011, inclusive. The dependent variables assessed were the number of SLNs visualized during lymphoscintigraphy, number of radioactive SLNs removed during surgery, and total number of lymph nodes removed intraoperatively.. There was no significant difference in outcomes when comparing the amount of (99m)TcOH4(-) added during the preparation process to form the sulfur colloid particles, time between the unit dose calibration time and the time that the unit doses were injected, or location in the breast tissue in which the unit dose was administered. Initially, there were observed significant differences in outcomes when the heating methods used to prepare the (99m)Tc-sulfur colloid were compared. When the increased number of patients who were administered a calibrated unit dose activity of 74 MBq in the group using a dry heat block preparation method was taken into account, however, the findings were not significant.. The use of a dry heat block versus a hot water bath to heat the (99m)Tc-sulfur colloid bulk vial, amount of (99m)TcOH4(-) added to form sulfur colloid particles, time between the unit dose calibration and the injection of the dose, and breast quadrant in which the injection occurred do not affect the number of SLNs detected during SLN mapping and during intraoperative SLN identification.

Topics: Breast; Breast Neoplasms; Humans; Lymph Nodes; Lymphatic Metastasis; Lymphoscintigraphy; Radiation Dosage; Retrospective Studies; Technetium Tc 99m Sulfur Colloid

To test the hypothesis that sub-areolar (SA) lymphoscintigraphy (LSG) identifies the same sentinel node as peri-tumoural (PT) injections.. It is commonly believed that all LSG techniques will identify the same sentinel lymph nodes (SLN) draining the breast. Hybrid imaging technology (SPECT/CT) allows accurate identification of the exact location of SLNs. Using SPECT/CT SA and PT LSG techniques were compared.. In a multi-centre trial 39 patients sequentially underwent LSG (SA followed by PT) separated by 2-7 days. Patients were referred by 4 surgeons to 3 LSG centres, with standardization of isotope (99mTc-antimony sulfide colloid), LSG and SPECT/CT evaluation techniques. LSG were evaluated for SLN concordance and degree of discordance in the axilla and internal mammary nodes (IMN).. 39 eligible patients, median age 62 years, were recruited. Successful axillary SLN mapping for SA and PT injection techniques was 87% and 95% respectively. Successful internal mammary SLN mapping occurred with SA and PT LSG in 5% and 36% respectively. Discordance was identified in the IMN (39%) and axilla (21%), with an overall rate of discordance between SA and PT LSG of 56%.. There is a high level of discordance in the localization of SLN by these commonly used LSG injection techniques. This discordance has implications for accuracy of axillary and extra-axillary staging and could impact on patient outcome.

Topics: Adult; Aged; Axilla; Breast Neoplasms; Female; Humans; Lymphoscintigraphy; Middle Aged; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Tomography, Emission-Computed, Single-Photon

To explore the effects of different injection techniques of radiotracer on the visualization rate of internal mammary sentinel lymph nodes (IMSLN) in breast cancer patients.. A series of 137 consecutive breast cancer patients was included in this prospective study. Fifty-eight patients (group A) received the radiotracer (99)Tc(m)-sulphur colloid injected only into 1-2 points in the breast parenchyma in one quadrant, and seventy-nine patients (group B) received the radiotracer injection into the breast parenchyma in two quadrants of the breast. The differences of IMSLN visualization rates of the two groups were compared and the relevant affecting factors were analyzed.. The IMSLN visualization rate of the group B (70.9%, 56/79) was significantly higher than that of the group A (13.8%, 8/58) (P < 0.001). Both techniques seemed to be reliable to identify sentinel lymph node in the axilla (98.7% vs. 98.3%, P = 0.825). In addition, the visualization rate of internal mammary hotspots (82.2%) was more commonly seen in patients receiving injection of a larger volume of radiotracer ( ≥ 0.5 ml/point) than those receiving a smaller volume of radiotracer (<0.5 ml/point, 55.9%, P = 0.011).. The modified injection technique (two quadrants, large volume radiotraver, and ultrasound guidance) can significantly improve the visualization rate of IMSLN. Our findings should make the biopsy of IMSLN widely implemented and provide an effective and minimally invasive technique to evaluate the internal mammary lymph node status.

Topics: Adult; Aged; Axilla; Breast Neoplasms; Female; Humans; Injections; Lymph Nodes; Middle Aged; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

We compared histological patterns after lumpectomy for non-palpable breast cancers preoperatively localized by radioguided occult lesion localization plus sentinel node localization (SNOLL) versus wire-guided localization.. To ensure a homogeneously treated cohort and rigorous comparisons, only patients with invasive cancer and measurable opacity by imaging were included. Exclusion criteria were one or more parameters that could interfere with localization and/or the surgical procedure. Forty-three SNOLL were compared with 86 WGL plus sentinel node (SN) localization. Cancer localization effectiveness was based on careful assessment of histological data from only the first resected glandular specimen, as any additional resection specimens were guided by intraoperative histological examination.. Reexcisions to ensure free tissue margins were performed during the same procedure in 13.9% of SNOLL versus 31.3% of WGL; p = 0.02. Significantly more women in SNOLL (53.4%) also had free nearest margins of >9 mm after the first procedure compared with WGL (33.7%); p = 0.03. The median centricity ratio after the first procedure was better in SNOLL (2.8, range 1.3-14) than WGL (5, range 1-50); p = 0.008. The median number of SN detected by lymphoscintigraphy was the same in SNOLL and WGL (1, range 0-9, vs. 1, range 0-8). Intraoperative SN detection by blue dye and/or gamma probe was successful for 97.6% of SNOLL versus 93% of WGL.. In this study, SNOLL was effective and safe, and this procedure significantly improved the rate of negative margins in the first specimen and the rate of reexcision for positive margins compared with WGL.

Topics: Breast Neoplasms; Case-Control Studies; Chi-Square Distribution; Coloring Agents; Female; Humans; Lymphatic Metastasis; Lymphoscintigraphy; Mastectomy, Segmental; Middle Aged; Multimodal Imaging; Neoplasm Invasiveness; Positron-Emission Tomography; Radiopharmaceuticals; Reoperation; Retrospective Studies; Sentinel Lymph Node Biopsy; Statistics, Nonparametric; Technetium Tc 99m Sulfur Colloid; Tomography, X-Ray Computed

Involvement of internal mammary (IM) lymph nodes is associated with a poor prognosis for patients with breast cancer. This study examined the effect of drainage to IM nodes identified by lymphoscintigraphy on oncologic outcomes.. A prospectively maintained breast cancer patient database at the University of Texas MD Anderson Cancer Center was used to identify patients with stage I to III breast cancer who underwent preoperative lymphoscintigraphy with peritumoral injection of colloid and intraoperative lymphatic mapping from 1996 to 2005. Medical records were reviewed of 1772 patients who had drainage to any lymph node basin on lymphoscintigraphy but who did not undergo IM nodal biopsy. Patients with IM drainage, with or without axillary drainage, were compared with patients without IM drainage. Local-regional recurrence, distant disease-free survival (DDFS), and overall survival were evaluated.. We identified IM drainage in 334 patients (18.8%). Patients with IM drainage were significantly younger, less likely to have upper outer quadrant tumors, and more likely to have smaller and medial tumors than patients without IM drainage. Rates of IM irradiation did not differ between the 2 groups. The median follow-up time was 7.4 years. On multivariate analysis, IM drainage was significantly associated with a worse DDFS (hazard ratio, 1.6; 95% confidence interval, 1.03-2.6; P = .04) but not local-regional recurrence or overall survival.. IM drainage on preoperative lymphoscintigraphy was found to be significantly associated with worse DDFS. Further study is needed to determine the role of lymphoscintigraphy in the personalization of breast cancer staging and therapy.

Topics: Adult; Aged; Aged, 80 and over; Axilla; Breast Neoplasms; Carcinoma, Ductal, Breast; Carcinoma, Lobular; Drainage; Female; Follow-Up Studies; Humans; Lymph Nodes; Lymphatic Metastasis; Lymphoscintigraphy; Middle Aged; Neoplasm Invasiveness; Neoplasm Recurrence, Local; Neoplasm Staging; Preoperative Care; Prognosis; Prospective Studies; Retrospective Studies; Sentinel Lymph Node Biopsy; Survival Rate; Technetium Tc 99m Sulfur Colloid; Young Adult

The Danish national mammography screening programme leads to identification of an increased number of small non-palpable breast tumours, suitable for breast-conserving surgery. Accurate lesion localization is therefore important. The current standard is wire-guided localization and although effective it involves a risk of high rates of positive margin and re-operations. New methods are emerging and radioactive seed localization (RSL) seems promising with regards to re-operation rates and logistics. In RSL a small titanium seed containing radioactive iodine is used to mark the lesion.

Topics: Biopsy, Needle; Breast Neoplasms; Denmark; Female; Gamma Rays; Humans; Iodine Radioisotopes; Mammography; Mass Screening; Mastectomy, Segmental; Monitoring, Intraoperative; Palpation; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Ultrasonography, Mammary

Topics: Breast Neoplasms; Decision Making; Female; Humans; Lymph Nodes; Lymphoscintigraphy; Mammary Glands, Human; Radiography; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

When Carl Langer described the aberrant axillary arch in 1846 its relevance in sentinel node biopsy (SNB) surgery could not have been contemplated. The authors define an incidence and elucidate relevance of the arch in SNB of the axilla.. A review of a database for breast and melanoma axillary SNB was carried out. The sample was 1 year at Princess Margaret Hospital, Toronto.. Of 319 axillary SNB, 3 (0.9%) had axillary arches noted. Two were in the melanoma group (n = 59) and one in the breast (n = 260). Interestingly one arch case had an ipsilateral 'idiopathic' axillary vein thrombosis as a child.. The authors see no reason to deviate from the practice of division of the arch at the highest level when recognised at SNB. This would abrogate the risk of concealed nodes and possible future neurovascular compression.

Topics: Adult; Axilla; Breast Neoplasms; Female; Humans; Lymphatic Metastasis; Male; Melanoma; Middle Aged; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The hook-wire technique is used to guide surgical excision of nonpalpable breast lesions. Recently, isotope has been used to guide the excision, and when sentinel node biopsy is performed during the same operation, the procedure is termed Sentinel Node and Occult Lesion Localization (SNOLL). We evaluated the use of this procedure for nonpalpable cancers in Chinese women.. Seventy-four patients underwent SNOLL before breast-conserving surgery. Intratumoral injection of sulfur colloid and lymphoscintigraphy (LSG) were performed. A gamma probe was used for resection planning and localization of the sentinel node (SN). Blue dye mapping was used in patients with negative LSG. Complete excision was defined as a tumor-free margin greater than 1 mm.. The primary breast lesion was successfully removed in 73 patients (99%). Complete excision was achieved in 61 patients (82%). Drainage to axilla was detected by LSG in 53 patients (72%). The gamma probe was more sensitive than LSG and had an 82% SN identification rate. Patients with a positive LSG had a higher chance of SN localization by gamma probe than patients with a negative LSG (100% vs. 38%, p < 0.001). In patients with a negative LSG, supplementary blue dye mapping increased the SN localization rate from 38 to 90%. The SN identification rate was 97% in the whole series.. Isotope-guided surgery was reliable, with a 99% localization rate for nonpalpable breast lesions and an 82% SN localization rate. The success rate of SN identification could be improved to 97% with the addition of blue dye mapping for patients with negative drainage on lymphoscintigraphy.

Topics: Axilla; Breast Neoplasms; Calcinosis; China; Coloring Agents; Female; Humans; Immunohistochemistry; Mastectomy, Segmental; Middle Aged; Neoplasm Invasiveness; Palpation; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

With regard to the sentinel lymph node (SLN) procedure in breast cancer, the study analyzed the impact of discrepancies between the number of clinically and histologically identified SLN, the impact of removing additional non-hot/non-blue but clinically conspicuous lymph nodes (LN), and whether the application of blue dye for mapping is necessary.. We analyzed 391 SLN procedures in which 928 SLN were removed. In all cases, radiolabeled colloid and blue dye were used for SLN mapping.. In 60 cases (15.3%), additional LN that were not identified by the surgeon were found by histological examination. In 22 cases (5.3%), tissue which clinically resembled an SLN but was histologically connective tissue, was removed. In 76 cases (19.4%), 133 non-hot/non-blue but clinically conspicuous LN were removed. These additionally removed LN, however, did not alter the axillary staging. In 50.8% of the cases (n = 471), the SLN were marked only by radiolabeled colloid. In 27 cases (2.9%), the surgeon identified the LN through blue coloration alone; however, in all of the latter cases, these SLN were not deciding for axillary staging.. The mapping agents may accumulate in axillary tissue and mimic the existence of an SLN. The radiolabeled colloid method alone gives excellent mapping results. The additional application of blue dye is avoidable. Exact surgical preparation enables removal of the SLN only and avoids removal of LN-containing adjacent tissue. The removal of further clinically identifiable enlarged non-hot LN should only be done if there is strong suspicion of metastatic involvement.

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

Regional lymph node status is the most important prognostic factor in breast cancer. Sentinel lymph node biopsy is the standard method of axillary staging in early breast cancer patients with clinically negative nodes. Preoperative lymphoscintigraphy might support refining biopsy findings by determining the number and location of sentinel lymph nodes. In aged or overweight patients, in the presence of atypical or extra-axillary lymphatic drainage, non-visualized lymph nodes, or sentinel lymph nodes close to the isotope injection site, detection could be aided by a new, hybrid imaging tool: the single-photon emission computed tomography combined with computed tomography (3D SPECT/CT). For the first time in Hungarian language, authors overview the literature: all 14 English-language articles on the implementation of 3D SPECT/CT in sentinel lymph node detection in breast cancer are included. It is concluded that 3D SPECT/CT increases the success rate and quality of preoperative sentinel node identification, and is capable of providing a more accurate staging of breast cancer patients in routine clinical practice.

Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Nodes; Neoplasm Staging; Organotechnetium Compounds; Phytic Acid; Radiopharmaceuticals; Rhenium; Sentinel Lymph Node Biopsy; Technetium Compounds; Technetium Tc 99m Aggregated Albumin; Technetium Tc 99m Sulfur Colloid; Tomography, Emission-Computed, Single-Photon; Tomography, X-Ray Computed

Leakiness of angiogenic tumor vessels results in elevated pressure in primary breast cancers and increased lymphatic flow to sentinel lymph node(s) (SLNs). We hypothesized that a similar pathophysiology in metastatic axillary SLNs would result in increased intranodal pressure (INP).. SLNs were "hot" and "blue" after intramammary injection of dilute methylene blue and filtered Tc99 sulfur colloid. Intraoperative pressure was measured in SLNs by a noncoring needle and recording device in 114 breast cancer patients. Excised axillary SLNs were examined by standard pathological techniques and metastases measured, recorded, and compared with INP measurements for SLN #1 and sometimes #2.. INP in 131 SLNs with no tumor (SLN #1, n = 93; SLN #2, n = 38) was 9.1 ± 6.2 (SD; range -2, 35) mmHg and 21.4 ± 15.4 mmHg (range 0-50) in 35 tumor-containing SLNs (SLN #1, n = 29; SLN #2, n = 6) (P = 0.0066). Elevated INPs significantly correlated with SLN tumor metastasis sizes (P = 0.0038; r = 0.4904). In two patients, tumor-laden SLNs with high INP were not blue or "hot" while a blue lymphatic bypassed these nodes and was traced to the next echelon tumor-free blue and "hot" nodes with low INP.. Breast cancer metastasis in axillary SLNs was associated with significantly higher INP than in tumor-free lymph nodes. When "true" SLNs were replaced by tumor, and the INP levels were very high, lymph flow direction changed; lymphophilic particles (blue dye and radiocolloid) were redirected to the next echelon of nodes, where the pressures were much lower. Mechanical factors may increase the likelihood of metastasis to neighboring lymph nodes with lower INP.

Topics: Adult; Aged; Breast Neoplasms; Carcinoma, Ductal, Breast; Carcinoma, Intraductal, Noninfiltrating; Carcinoma, Lobular; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Pressure; Prognosis; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Our objective is to prove that injection of technetium-99m (Tc99) sulfur colloid in a subareolar manner, after induction of anesthesia, is a safe and effective technique for sentinel lymph node identification in breast cancer patients.. Preoperative injection of Tc99 and lymphoscintigraphy is standardly performed before sentinel lymph node biopsy (SLNB) for breast cancer. Blue dye is often used to help guide and confirm the localization but tattoos the breast. This method is limited because of painful injections, variable identification rates, added costs and unnecessary scheduling delays. We hypothesized that intraoperative injection alone by the surgeon of dermal or subareolar Tc99 is practical for the identification of sentinel lymph node in breast cancer.. This is a prospective single institution study that was approved by our institutional review board. All patients with operable breast cancer that were eligible for a SLNB from October 2002 to October 2010 were included in our study population. After induction and before sterile preparation of the operative field 1 mCi of Tc-99 unfiltered was administered by a subareolar injection. In patients where the scar was in the periareolar region or in the upper outer quadrant a dermal injection using 0.25mCi was used. Confirmatory Lymphazurin was also injected early on in this series but became unnecessary later in the study. Site and type of injection, injection time, incision time, and extraction time along with other factors for the purposes of the study were recorded. Data comparing injection preoperative and intraoperative were collected.. Six hundred ninty-nine patients were accrued for a SLNB with an average age 57.1 ± 12.8 (range 24-92). Seventy-six patients underwent 2 SLNB procedures for a total of 775 intraoperative Tc-99 injections. Six patients underwent intraoperative dermal injection with Tc-99. The average dose of Tc-99 administered was 1.157 ± 0.230 mCi. The sentinel node was localized in 98.6% of the cases (419/425) of subareolar radiotracer alone, 94.8% (326/344) in dual injection and 100% (6/6) in dermal injection. Average time from injection to incision was 41.20 ± 29.56 minutes for radiotracer injection in subareolar region only. For dermal injections it was 40.83 ± 39.64 minutes. For patients with dual injection of Lymphazurin and radiotracer it was 31.74 ± 24.86 minutes. The average ex vivo count was 6474 ± 8395 for dermal injection, 28,250 ± 69,932 for Tc-99 subareolar injection, and 35,501 ± 97,753 for dual subareolar injection. Intraoperative radiotracer alone incurred a charge of $189.00; Lymphazurin blue dye added $591.40, whereas preoperative injection had a charge of $1257.06 associated with imaging, injection, and interpretation of images.. Intraoperative injection of Tc99 alone with a subareolar or dermal injection technique rapidly localizes the sentinel node in breast cancer, is an oncologically sound procedure, is cost effective and facilitates operative room time management.

Topics: Adult; Aged; Aged, 80 and over; Breast Neoplasms; Female; Humans; Injections, Intradermal; Intraoperative Care; Middle Aged; Nipples; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Young Adult

Controversy exists in the literature regarding the optimal site for lymphatic mapping in breast cancer. This study was designed to characterize lymphatic drainage patterns within the same patient after subareolar (SA) and peritumoral (PT) radiopharmaceutical injections and examine the impact of reader interpretation on reported drainage.. In this prospective trial, 27 women with breast cancer underwent sequential preoperative SA and PT injections of 0.5 to 2.7 mCi of technetium-99 m filtered sulfur colloid 3 days or more apart. Patterns of radiopharmaceutical uptake were reviewed independently by two nuclear medicine physicians. Inter-reader agreement and injection success were assessed in conjunction with observed drainage patterns.. There was near perfect inter-reader agreement observed on identification of axillary LN drainage after PT injection (P = 0.0004) and substantial agreement with SA injection (P = 0.0344). SA injection was more likely to drain to only axillary LNs, whereas PT injection appeared more likely to drain to both axillary and extra-axillary LNs, although no statistically significant differences were found. All patients with extra-axillary drainage after PT injection (n = 6 patients) had only axillary drainage after SA injection. Dual drainage was observed for six patients with PT injection and one patient with SA injection.. Our findings suggest that radiopharmaceutical injected in the SA location has a high propensity to drain to axillary LNs only. After controlling for patient factors and demonstrating inter-reader agreement, the inability to demonstrate statistically significant differences in drainage based on injection site suggests that lymphatic drainage patterns may be a function of patient and tumor-specific features.

Topics: Adult; Aged; Aged, 80 and over; Breast Neoplasms; Carcinoma, Ductal, Breast; Female; Humans; Injections; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Survival Rate; Technetium Tc 99m Sulfur Colloid; Treatment Outcome

Image-guided treatment planning that minimizes irradiation of critical lymph nodes (LNs) may reduce the incidence and severity of long term complications following breast cancer treatment. This localization cannot be obtained with conventional imaging techniques and we undertook this proof of concept study to determine whether a coordinated use of SPECT and CT has sufficient precision to inform radiation planning and potentially lessen the incidental exposure of critical LNs. Thirty-two consecutive women with breast cancer were injected in the arm ipsilateral to their breast cancers prior to radiation treatment with 0.5 mCi of filtered (99m)Tc-sulfur colloid and underwent scanning with a hybrid device which combined a dual-head SPECT camera and a low-dose, single slice CT scanner. The number of visualized LNs as well as their locations, maximum counts, and total uptake were recorded. Coordinates derived from the SPECT/CT fusion images were used to map LN locations onto the 3D radiation treatment planning system. A mean of 3.4 (SD 2.0) lymph nodes were detected in each subject. Level I and II LNs were detected more often in patients who had sentinel node biopsies, and more supraclavicular nodes were detected in patients who had undergone axillary dissection (P < 0.001). SPECT-CT derived LN coordinates were successfully mapped onto radiation simulation CT scans for all patients. SPECT/CT fusion images localize the LNs draining the arm after breast cancer surgery. These finding suggest that SPECT/CT may be helpful in minimizing incidental LN irradiation and in directing breast cancer therapy to reduce long-term morbidity.

Topics: Arm; Breast Neoplasms; Diagnostic Imaging; Drainage; Female; Humans; Image Processing, Computer-Assisted; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Pilot Projects; Prognosis; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Tomography, Emission-Computed, Single-Photon; Tomography, X-Ray Computed

Preoperative injection of radiocolloid before a sentinel lymph node (SLN) biopsy is painful for patients with breast cancer. Injection after anesthesia eliminates this discomfort but allows less time for radiocolloid migration. Our goal was to validate the efficacy of intraoperative injection.. In this retrospective study of prospectively collected data, patients underwent periareolar dermal injection of technetium sulfur colloid. Patients in the preoperative injection (PO) group were injected by radiologists in the breast imaging center. Patients in the intraoperative injection (IO) group were injected by surgeons after induction of anesthesia. Consecutive cases were evaluated for radioactive "hotspots," time elapsed before incision, number of SLNs removed, number of positive SLNs, and percentage of positive biopsies.. Two hundred fourteen breasts were evaluated (PO = 102; IO = 112). The mean time from injection to incision was significantly shorter by 107 minutes for the IO group. There were no differences in the percentage of positive biopsies (PO: 20.6%; IO: 19.6%; P = 0.863), the number of SLNs removed (PO: 3.3; IO: 3.0; P = 0.091), or the number of positive SLNs (PO: 1.4; IO: 1.4; P = 0.657).. There are no significant differences in the principal results of SLN biopsy between PO and IO injection methods. Dermal radiocolloid injection after induction of anesthesia seems to be an oncologically sound procedure and may be a preferable technique.

Topics: Adenocarcinoma; Adenocarcinoma, Mucinous; Breast Neoplasms; Carcinoma, Ductal, Breast; Carcinoma, Intraductal, Noninfiltrating; Carcinoma, Lobular; Female; Humans; Intraoperative Period; Lymph Nodes; Middle Aged; Neoplasm Invasiveness; Preoperative Care; Prognosis; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Topics: Anesthetics, Local; Breast Neoplasms; Drug Combinations; Female; Humans; Injections, Intradermal; Lidocaine; Pain; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The aim of this prospective study was to analyze the safety of methylene blue dye (MBD) and compare its efficacy with that of isotopic mapping for sentinel lymph node (SLN) identification in breast cancer.. The SLN procedure, involving isotopic mapping and MBD (subareolar intraparenchymal injections of 2 mL, 10 mg/mL), was performed on 100 patients with early breast cancer.. The procedure was safe with a success rate of 99%; SLNs were, respectively, found in 65% by MBD, in 73% by lymphoscintigraphy and in 94% by gamma-probe. Out of 40 metastatic SLNs, 37 were "hot" and 32 stained. Digital examination allowed the detection of 2 additional metastatic LNs.. MBD is safe and combination mapping associated with digital examination is the superior method. Modification of the procedure, favouring injections of dilute MBD (4 mL, 1.25 mg/mL) increases MBD efficiency (90%) and maintains low rates of complications.

Topics: Breast Neoplasms; Carcinoma in Situ; Carcinoma, Ductal, Breast; Female; Humans; Lymph Nodes; Methylene Blue; Middle Aged; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Sulfur; Technetium Tc 99m Sulfur Colloid

The objective of axillary reverse mapping (ARM) is to preserve the main lymphatic chain-with both the nodes and the ducts-in relation to lymphatic arm drainage (LAD) during an axillary dissection (AD).. From July 2006 to March 2008, 23 patients with stage II or III breast carcinoma requiring an AD underwent an ARM procedure. Identification of the ARM nodes relied on an isotope injection into the web space of the ipsilateral hand. During AD, the radioactive ARM node was localized above the second intercostal brachial nerve, and blue dye was directly injected inside the node to visualize the efferent ducts, constituting the lymphatic ARM chain. The blue and radioactive nodes constituted the ARM sampling, while other nodes were considered part of the AD.. Metastatic lymph node involvement was identified in the AD in 20 of 23 patients, with an average of 4.4 (1-11) nodes involved and an average of 10.7 (7-20) lymph nodes removed. The ARM sampling was performed in 21 of 23 patients (91%), with an average of 1.6 ARM nodes removed. In 18 of these 21 patients (86%), the nodes relating to ARM sampling had no metastatic involvement. There were 3 patients (14%) who demonstrated metastatic involvement of the ARM sampling, and all had pN3a (N+ > 9) involvement of the axilla.. This technique of combined isotopic and blue dye ARM and findings must now be validated. A multicentric study is planned to confirm this data.

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

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

In breast cancer patients with only extra-axillary sentinel nodes, surgeons typically perform axillary node dissection. The purpose of this study was to evaluate our approach to spare such patients further dissection based on the hypothesis that a sentinel node is not necessarily located in the axilla.. Between March 11, 1999 and March 5, 2008, 1,949 breast cancer patients underwent lymphatic mapping with preoperative lymphoscintigraphy and intraoperative use of a gamma-ray detection probe and patent blue dye. The tracers were injected into the tumors.. Eighty-two of the 1,949 patients had only extra-axillary drainage on their lymphoscintigrams. A sentinel node was harvested from the axilla in 62 patients but not in the remaining 20 patients. No axillary lymph nodes were removed in 4 of these 20 patients, suspicious palpable nodes were excised in another 4 patients, and node sampling was done in the remaining 12. These nodes were all free of disease. All sentinel nodes outside the axilla were removed. Two patients had a metastasis in an internal mammary chain node. No lymph node recurrences were detected in or outside the axilla in any of the 20 patients with a median follow-up time of 49 months.. 4% of the patients have only extra-axillary drainage on preoperative lymphoscintigrams. It is worthwhile to explore the axilla since a sentinel node can be found in three-quarters. In the remaining 1% without axillary sentinel nodes, axillary sampling seems unnecessary and the approach to refrain from axillary dissection appears valid.

Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Mastectomy; Neoplasm Recurrence, Local; Prognosis; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Preoperative injection of technetium-99 m sulfur colloid (Tc-99) in the Nuclear Medicine Department for localizing sentinel lymph nodes (SLNs) can be extremely painful for the patient. The difficulties in scheduling and the delay in starting surgery can be frustrating for the patient and the surgeon. We hypothesized that intraoperative injection facilitated by the subareolar technique would obviate the problems associated with preoperative injection.. We performed an institutional review board-approved prospective study of patients with operable breast cancer who were candidates for an SLN biopsy from October 2002 to January 2006 at our institution. After induction of general anesthesia, patients underwent a subareolar injection of 1 mCi Tc-99 unfiltered and blue dye. Data comparing preoperative cost were collected.. A total of 236 patients had 252 intraoperative SLN procedures. The mean patient age was 57.3 (range, 24-88) years. The mean +/- standard deviation time from injection to incision was 25.5 +/- 16.2 minutes. Identification rate was 96%, and the number of SLNs identified per patient was 1.6 +/- .8. The count of SLN was 60,313 +/- 134,692 with 20% SLN positivity. Tumor staging distribution was standard staging terminology for an in situ cancer (Tis) = 17 with 0% (+) SLN, T1 = 115 with 11% (+) SLN, T2 = 56 with 29% (+) SLN, T3 = 19 with 37% (+) SLN, and T4 = 4 with 50% (+) SLN. Maximum exposure to the surgeon was well below maximum, at 100 microSV/mo. Preoperative injection had an additive charge of $1325 associated with it for imaging, injection, and interpretation of images by physician.. Intraoperative subareolar injection of Tc-99 localizes the SLN and avoids the pain, vasovagal events, delays, and cost associated with preoperative procedure.

Topics: Adult; Aged; Aged, 80 and over; Biopsy, Needle; Breast Neoplasms; Cost-Benefit Analysis; Female; Follow-Up Studies; Humans; Injections, Intralesional; Lymph Nodes; Lymphatic Metastasis; Mastectomy; Middle Aged; Monitoring, Intraoperative; Neoplasm Staging; Positron-Emission Tomography; Prospective Studies; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Some preparations of 99mTc-colloidal rhenium sulfide (Nanocis) contain excess free pertechnetate (99mTcO4) impurity (>5%).. To improve the radiochemical purity of Nanocis preparations and the quality of preoperative lymphoscintigraphy in sentinel node localization of breast cancer patients, we investigated the effects of temperature on the presence of free 99mTcO4 and nanocolloid size modification.. A Nanocis kit was reconstituted with sodium pertechnetate (650-850 MBq) in a final volume of 3.5 ml and heated for 30 min at 100, 115, or 130 degrees C. The radiochemical purity was determined by paper chromatography, in triplicate. The particle size was evaluated by membrane filtration through a 200-nm and 100-nm filter. The preoperative lymphoscintigraphy images were acquired about 2 h after tracer administration.. Significantly higher radiochemical purity values were observed with 28 Nanocis preparations heated at 130 degrees C (median: 99.8%, min-max: 97.0-99.9%) compared with values from 37 Nanocis preparations heated at 100 degrees C (median: 96.3%, min-max: 85.2-99.5%) or 26 Nanocis preparations heated at 115 degrees C (median: 95.1%, min-max: 85.7-99.8%). The interbatch variations of the radiochemical purity were reduced at 130 degrees C. A high temperature level (130 degrees C) did not modify the particle size. In lymphoscintigraphy, free 99mTcO4 uptake by the thyroid or stomach, which was sometimes observed with a Nanocis preparation heated at 100 or 115 degrees C, was never visualized with a Nanocis preparation heated at 130 degrees C.. These results indicate that increasing temperature from 100 to 130 degrees C can be used in routine clinical practice to improve the radiochemical purity of the Nanocis preparation.

Topics: Breast Neoplasms; Chlorides; Chromatography, Paper; Female; Filtration; Humans; Lymph Nodes; Lymphatic Metastasis; Particle Size; Radionuclide Imaging; Radiopharmaceuticals; Rhenium; Sodium Pertechnetate Tc 99m; Sulfides; Technetium Tc 99m Sulfur Colloid; Temperature

Although sentinel lymph node (SLN) biopsy is the standard technique for staging the axilla of clinically node-negative breast cancer, the optimal number of radioactive SLNs to remove to ensure accuracy and minimize morbidity is still actively debated. The purpose of this study was to determine the minimum number of SLNs to excise to ensure accurate axillary staging of SLN-positive patients.. A total of 126 patients with invasive breast cancer underwent SLN biopsy by periareolar injection of radiolabeled technetium sulfur colloid on the day of surgery. The sequence in which SLNs were removed and the corresponding ex vivo radioactive counts were recorded. SLNs were removed until radioactive counts in the axilla were less than 10% of the ex vivo counts of the hottest SLN.. A radioactive SLN was identified in every patient. The mean number of SLNs identified was 2.86 (range, 1-8). Clinicopathologic features associated with a positive SLN included a palpable tumor (P = .0035), increasing tumor size (P = .0039), increasing histologic grade (P = .0234), and angiolymphatic invasion (P < .001). The highest radioactive counts were found in the first node in 100 patients (79.4%), the second node in 15 (11.9%), and the third or later node in 11 patients (8.7%). Among the 38 patients with a positive SLN (30.2%), the hottest node was the first positive SLN in 27 patients (71.1%). The first positive SLN was the first node removed in 31 patients (81.6%) and after the second node in 37 patients (97.4%); it was removed in all patients by the third SLN.. These data support the trend of limiting SLN biopsy to 3 lymph nodes. Removing all SLNs with radioactive counts greater than 10% of the ex vivo counts of the hottest SLN did not increase accuracy.

Topics: Adult; Aged; Analysis of Variance; Axilla; Biopsy, Fine-Needle; Breast Neoplasms; Cohort Studies; Female; Humans; Lymph Nodes; Middle Aged; Neoplasm Invasiveness; Neoplasm Staging; Probability; Radionuclide Imaging; Retrospective Studies; Risk Assessment; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The gold standard of axillary sentinel lymph node biopsy (SLNB) in breast cancer is the combination of radioactive colloid and blue dye injection. Worldwide, numerous hospitals without access to radioactive tracers still perform a routine complete axillary lymph node dissection (ALND). We retrospectively analyzed the false negative rate and identification rate of SLNB with injection of blue dye in the absence of radioactive colloid and compared the subareolar (SA) and the peritumoral (PT) injection.. Two hundred and fourteen patients with clinically node negative unifocal breast cancer of up to 3 cm in size who underwent SLNB followed by ALND were included. Patent Blue V was injected at the SA site in 120 patients or at the PT site in 94 patients.. Thirty-seven (31%) patients in the SA group and 28 (29.8%) in the PT group were node-positive by ALND. The mean number of SLNs identified was 3.1 in the SA group and 1.6 in the PT group. The SLN identification rate was 91.7% for the SA group and 80.9% for the PT group (P = 0.017). The false negative rate was 3.6% in the SA group and 11.8% in the PT group (P = 0.032).. Our study shows an acceptable low false negative rate for the SA blue dye only injection and confirms the higher identification rate of SA versus PT localisation. This technique could have spared 67.5% (81 out of 120) of our patients the ALND and could replace ALND of early breast cancer patients in environments without access to nuclear medicine.

Topics: Adult; Aged; Aged, 80 and over; Axilla; Breast Neoplasms; Coloring Agents; False Negative Reactions; Female; Humans; Injections; Lymph Node Excision; Mastectomy; Middle Aged; Radiopharmaceuticals; Retrospective Studies; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Sentinel lymph node biopsy is an accepted standard of care for staging the axilla in patients with early-stage breast cancer. Little attention has been placed to the presence of intramammary sentinel lymph nodes (intraMSLNs) on preoperative lymphoscintigraphy.. Between December 2001 and September 2006, in 9632 breast cancer patients with clinically uninvolved axillary nodes, lymphoscintigraphy was performed at the European Institute of Oncology (EIO). An axillary SLN (axSLN) was identified in 99.4% of cases. An intraMSLN was identified in association with the axillary sentinel lymph node in 22 patients (0.2%). In 15 cases both the axSLN and the intraMSLN were excised.. The intraMSLN was positive in six patients (micrometastatic in three cases). The axSLNs were negative in all 15 cases. Two patients with positive intraMSLNs and one patient with a negative intraMSLN underwent axillary dissection; all three cases had negative axillary nodes. At a median follow-up of 24 months, no locoregional or systemic recurrences were observed.. Positive intraMSLNs can improve disease staging but do not necessarily portend axillary lymph node metastasis. When intraMSLNs and axSLNs are present, we advocate biopsy of both sites and that management of the axilla should rely on axSLN status. In cases with intraMSLNs as the only draining site on lymphoscintigraphy, decisions on axillary management should be made on individualized basis.

Topics: Adult; Aged; Axilla; Breast Neoplasms; Female; Follow-Up Studies; Humans; Lymph Nodes; Male; Mammary Glands, Human; Medical Records; Middle Aged; Neoplasm Staging; Prognosis; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

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

The injection techniques and use of lymphoscintigraphy for sentinel lymph node (SLN) biopsy in breast cancer patients vary. Some do not advocate routine use of lymphoscintigraphy. The purpose of this case report is to illustrate when lymphoscintigraphy should be used.. At our institution, we use periareolar intradermal injections of 0.6 mCi Tc-99m sulfur colloid followed by lymphoscintigraphy with reported identification rates greater than 99%. The only patient in our series who did not have a SLN identified had presented after excisional biopsy of an upper outer quadrant cancer. We report the case of another patient who presented after excision of an upper outer quadrant invasive ductal carcinoma and had no evidence of lymphatic drainage on lymphoscintigraphy after the periareolar injections of radioisotope.. Additional injections of 0.4 mCi Tc-99m sulfur colloid were performed lateral to the incision in the upper outer quadrant. On lymphoscintigraphy a SLN was visualized and was subsequently successfully identified intraoperatively.. This case report supports the value of lymphoscintigraphy for successful identification of a SLN in a patient with prior surgery. We therefore recommend imaging patients who have had prior breast surgery, particularly excisions in the upper outer quadrant.

Topics: Adult; Breast Neoplasms; False Negative Reactions; Female; Humans; Image Enhancement; Injections, Intralesional; Lymph Nodes; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

We report 2 cases demonstrating that localization of internal mammary (IM) sentinel lymph nodes with lymphoscintigraphy using peritumoral injection of Tc-99m antimony sulfide colloid, followed by resection using minimal access surgery, can reveal nodal metastatic disease in patients with clinically node-negative breast cancer when axillary sentinel nodes are not affected by metastatic disease. When this is found, it changes staging and can affect prognosis and treatment. These cases confirm that the technique used is sampling true sentinel IM nodes, that is nodes that receive direct lymph flow from the breast cancer, and confirm the importance of sampling IM sentinel lymph nodes. Unless techniques are used that are specifically designed to identify IM node drainage from the breast cancer site itself, with subsequent directed surgical removal of sentinel IM nodes, some patients with breast cancer will not be staged correctly.

Topics: Adult; Breast Neoplasms; False Negative Reactions; Female; Humans; Image Enhancement; Injections, Intralesional; Lymph Nodes; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Immediate dynamic imaging enables accurate definition of sentinel lymph nodes, whereas imaging 3 hr after tracer injection may lead to overestimation of the number of sentinel lymph nodes. A study was performed to define the value of lymphoscintigraphy immediately versus 3 hr after tracer injection in sentinel lymph node biopsy for breast cancer management.. In 165 sentinel lymph node biopsy procedures preoperative immediate and 3 hr post-injection lymphoscintigraphy was performed after intraparenchymal tracer administration.. Lymph node visualization occurred in 63 immediate procedures (38%) versus in 163 procedures 3 hr post-injection (99%). In 17 procedures (10%) in which immediate lymphoscintigraphy had visualized sentinel lymph nodes, additional nodes had been seen on 3 hr post-injection lymphoscintigraphy. In eight of these procedures (5%) all nodes were detected in the same draining lymph node basin. Non-axillary sentinel lymph nodes were identified by preoperative lymphoscintigraphy in 28 procedures (17%) and improved staging in three patients (5%).. The only impact of immediate lymphoscintigraphy was the possible omission of removal of 1-2 sec-echelon nodes per patient in 5% of patients. We consider this yield too low to continue immediate lymphoscintigraphy in breast cancer patients.

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

The aim of this study was to test a new strategy for radioguided management of malignant or suspicious nonpalpable breast lesions, with a combination of radioguided occult lesion localization (ROLL), sentinel lymph node (SLN) mapping, and, if necessary, immediate local surgery and SLN biopsy with a single injection of (99m)Tc-labeled dextran for the whole procedure.. A total of 115 nonpalpable lesions were studied: 101 with high suspicion of malignancy from which frozen sections had been produced, and 14 carcinomas diagnosed by mammotomy. On the day before surgery, 0.2 mL of solution of dextran labeled with 15 MBq of (99m)Tc was injected into the center of the lesions under imaging guidance. All patients underwent lymphoscintigraphy and open-surgery biopsy guided by gamma probe, followed by radiographic verification of the specimen. If malignancy was detected, in cases of infiltrating or ductal carcinoma-in-situ with comedonecrosis or high nuclear grade, breast-conserving surgery and SLN biopsy were performed during the same operation.. The combination of ROLL and SLN biopsy was feasible and practical. The rate of simultaneous SLN mapping by lymphoscintigraphy was 97.4% (112 of 115), and the confirmation rate for breast lesion removal by specimen radiography was 100%. It was known that 57 cases were malignant at the time of surgery. After segmental breast resection, SLN immediately underwent biopsy in 50 cases (34 infiltrating carcinomas and 16 ductal carcinoma-in-situ) with probe monitoring. Three were cytologically positive for metastasis and required full axillary dissection.. ROLL and SLN biopsy are emerging procedures that can be used simultaneously. They permit exact breast lesion excision, immediate local breast surgery, and intraoperative SLN biopsy in a single procedure. The combination of radioguided nonpalpable lesion localization and SLN biopsy is a suitable alternative to working up subclinical imaging-detected breast carcinomas.

Topics: Adult; Aged; Aged, 80 and over; Breast Neoplasms; Carcinoma, Ductal, Breast; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Monitoring, Intraoperative; Palpation; Radiography; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Surgery, Computer-Assisted; Technetium Tc 99m Sulfur Colloid

This study set out to determine the impact of different criteria for radioactive sentinel lymph nodes (SLNs) on sentinel lymph node biopsy (SLNB), and the optimal criteria for radioactive SLNs.. Eighty-four breast cancer patients with cT1-2N0M0 were studied prospectively. Filtered technetium 99 m sulfur colloid was injected in peritumor parenchyma. Three different definitions of SLNs were adopted in each patient: (1) the lymph node with the highest radioactivity. (2) Any lymph node with an in vivo hot spot-to-background activity ratio of at least 3:1 or an ex vivo SLN-to-non-SLN ratio of at least 10:1. (3) All radioactive hot nodes.. With three different definitions, the success rate of sentinel node biopsy were all 96.4%, the sensitivity was 78.9%, 92.1%, 97.4% respectively; false negative rate 21.1%, 7.9%, 2.6% respectively; predicting accuracy 90.1%, 96.3%, 98.8% respectively (P < 0.05). The first, the first two, the first three, and the first four highest radioactive sentinel nodes identified 81.1%, 89.2%, 94.6%, 100% of the positive-SLN patients, respectively.. The different criteria for radioactive SLNs had different impact on the accuracy, sensitivity, and false negative rate, but not on the success rate, during sentinel node biopsy using radioactive sulfur colloid in breast cancer patients. The first four highest radioactive sentinel nodes could accurately predict the status of axillary metastases. J. Surg. Oncol. 2007;95:635-639. (c) 2007 Wiley-Liss, Inc.

Topics: Breast Neoplasms; False Negative Reactions; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Sensitivity and Specificity; 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

Sentinel lymph node (LN) biopsy has been widely adopted in the axillary staging of clinical node-negative breast cancer patients. This study aimed to evaluate the accuracy of radio-guided sentinel LN (SLN) biopsy (SLNB) using the periareolar injection technique for predicting the histopathologic status of axillary LNs in early breast cancer patients.. Between November 2003 and November 2004 in the National Taiwan University Hospital, radio-guided SLNB using the periareolar injection technique was consecutively performed in 213 female patients with early breast cancer (stage T1 and T2) but without clinically palpable axillary LN and previous chemotherapy. Two mCi of filtered (0.22 microm) (99m)Tc-sulfur colloid were injected in the afternoon 1 day before surgery (2-day protocol) or 1 mCi of the same radiopharmaceutical was injected on the morning of the surgery (1-day protocol). During surgery, a handheld gamma probe was used to identify the LNs with radioactivity in the axilla. A node was deemed a SLN if its radioactivity was >10% of the hottest node. All the SLNs identified were removed for histology.. Radioactive SLN was identified at surgery in 207 patients. The SLN identification rate was 97.2% (207/213). Of these 207 patients, 163 patients had received both SLNB and axillary LN dissection. Among these 163 patients, 77 patients had LN metastases and four had negative SLN but positive non-SLN. The false-negative rate of SLNB for the detection of axillary LN metastases was 5.2% (4/77). There were no statistical differences between false-negative and SLN positive groups for all factors.. Our study suggests that SLNB with periareolar injection of radiocolloid provides valuable information on the axillary nodal status in patients with early breast cancer.

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

Internal mammary node (IMN) is an important lymphatic metastasis pathway in breast cancer. Its status may affect the staging, treatment, prognosis, and outcome evaluation of breast cancer. This study was to discuss the significance of internal mammary sentinel node biopsy (IMSNB), IMN dissection via intercostal spaces, and IMN micro-metastasis detection in breast cancer.. A total of 38 consecutive patients with primary breast cancer received mastectomy in Cancer Center of Sun Yat-sen University from Dec. 2004 to May 2006. IMSNB was guided by radionuclide tracking method, followed by IMN dissection via the first to forth intercostal spaces. After routine pathologic examination for all the removed IMNs, the negative ones were submitted to further micro-metastasis detection by immunohistochemistry (IHC) combined with multilayer section technique.. Of the 38 patients, 17 (44.7%) had internal mammary sentinel nodes (IMSNs). Of the 17 patients, 4 had IMSN metastasis detected by routine pathology, 1 had IMSN micro-metastasis, and 2 had isolated tumor cells in IMSNs, while the remaining 10 had no metastasis. The results of IMSNB were accordant to the results of IMN dissection. Of the 21 (55.3%) patients had no IMSN identified, 5 had IMN metastasis by routine pathology after IMN dissection, and 16 had no metastasis.. When IMSNs are identified, they can predict the IMN status well. While for the patients had no IMSN identified, IMN dissection should be performed, especially for those more likely to have metastasis, to decrease the false negative rate. IHC combined with multilayer section technique tends to search out micro-metastasis.

Topics: Adult; Aged; Breast; Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Mastectomy, Radical; Middle Aged; Radionuclide Imaging; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

As sentinel lymph node (SLN) experience rises, it is important to identify factors that can limit lymphoscintigraphic mapping.. A prospective study was conducted with breast cancer patients that were submitted to sentinel node mapping by lymphoscintigraphy between October 2003 and January 2005. The analyzed factors were: patients' age, body mass index, tumor size, previous breast surgeries, time between a previous biopsy and the radiotracer injection and their impact on preoperative SLN identification.. Two hundred and three breast cancer patients were injected with (99m)Technetium-sulfur colloid and submitted to lymphoscintigraphy scan for SLN biopsy. One hundred and eighty-four of these patients (90.64%) had a successfully identified SLN and 19 (9.36%) had a mapping failure. The median age of the successful group was 55.6 years and in the failure group was 57.1 years (P=0.002). The median body mass index was 25.3 and 27.6, respectively (P=0.024). The tumor size did not show any significant difference between the patients with successful mapping and failure (P=0.07). Previous breast surgery was an important limiting factor for SLN mapping (P=0.017). The mean time from biopsy to SLN detection was 23.6 days on the successfully marked patients and 17.4 days in the failure group (P<0.0001). All the 184 successfully mapped patients had the SLN identified. Only one patient of the failure group had the SLN identified using blue dye.. Advanced age, elevated body mass index, previous breast surgery and a shorter period of time after a breast biopsy are causes for SLN identification failure. The tumor size was not a limiting factor.

Topics: Adult; Aged; Aged, 80 and over; Breast Neoplasms; Diagnostic Errors; Female; Humans; Injections, Intralesional; Lymph Nodes; Lymphatic Metastasis; Male; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Reproducibility of Results; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Variations in arm lymphatic drainage put the arm lymphatics at risk for disruption during axillary lymph node surgery. Mapping the drainage of the arm with blue dye (axillary reverse mapping, ARM) decreases the likelihood of disruption of lymphatics and subsequent lymphedema.. This institutional review board (IRB)-approved study from May to October 2006 involved patients undergoing SLNB and/or ALND. Technetium sulfur colloid (4 mL) was injected in the subareolar plexus and 2-5 mL of blue dye intradermally was injected in the ipsilateral upper extremity (ARM). Data were collected on variations in lymphatic drainage that impacted SLNB or ALND, successful identification and protection of the arm lymphatics, any crossover between a hot breast node and a blue arm node, and occurrence of lymphedema.. Of the 40 patients undergoing surgery for breast cancer, 18 required an ALND, with a median age of 49.7 years old. Fourteen patients had a SLNB + ALND, and four patients had ALND alone. In 100% of patients, all breast SLNs were hot but not blue, and the false negative rate was 0. In 11 of 18 ALNDs (61%) blue lymphatics or blue nodes were identified in the axilla. In the initial seven cases with positive lymph nodes in the axilla, the blue node draining from the arm was biopsied and all were negative.. ARM identified significant lymphatic variations draining the upper extremities and facilitated preservation in all but one case. ARM added to present-day ALND and SLNB further defines the axilla and may be useful to prevent lymphedema.

Topics: Adult; Aged; Axilla; Breast Neoplasms; Coloring Agents; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Lymphatic Vessels; Lymphedema; Middle Aged; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Although preoperative lymphoscintigraphy in sentinel lymph node biopsy (SLNB) for breast cancer patients is undergone commonly, its clinical significance remains controversial.. We retrospectively analyzed our database that contained 636 consecutive breast cancer patients who received preoperative lymphoscintigraphy before SLNB.. The sentinel lymph nodes (SLNs) of 86.5% of patients were well imaged by lymphoscintigraphy, and SLN were located extra-axilla in 5.3% patients. The visualization of SLN in lymphoscintigraphy was not associated with histopathologic type, location, and stage of primary tumor, as well as the time interval from injection of radiocolloid to surgery. The negative lymphoscintigraphy results were associated with excision ;biopsy before injection of radiocolloid and positive axillary node statues. The SLN was successfully detected in 625 (98.3%) enrolled patients. Failure of surgical identification of axillary SLN was associated with whether hot spot was imaged by lymphoscintigraphy. However, we identified axillary SLN in 90 (90.9%) out of 99 patients with negative axillary findings in lymphoscintigram. The false negative rate of SLNB in our study was 16.0% (15 of 94) among patients of training group, and there was no significant difference in the false negative rate between patients who had axillary hot spot in lymphoscintigram and those who had not (P = .273).. Visualization of SLN in preoperative lymphoscintigraphy predicted the successful SLN identification. However, it was less informative for the location of SLN during operation. Considering the complexity, time consumed, and cost, lymphoscintigraphy should at present be undergone for investigation purposes only.

Topics: Breast Neoplasms; False Negative Reactions; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Predictive Value of Tests; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Internal mammary (IM) nodes are a potential site of breast lymphatic drainage. We examined the relationship between lymphoscintigraphic evidence of IM drainage and survival in early-stage breast cancer patients (pts).. From a prospective database of 855 consecutive sentinel node mapping procedures using peritumoral radiocolloid injection from 1996-2004, we analyzed the 604 cases with stage I-III breast cancer. Overall survival and recurrence-free survival (OS, RFS) rates were compared in pts with (IM+) and without (IM-) IM drainage on lymphoscintigraphy using Kaplan-Meier plots and Cox proportional hazards models.. 100 of 604 pts (17%) showed IM drainage. Five-year OS and RFS were 92% vs 88% and 88% vs 85% in IM- vs IM+ pts. In the 186 pts with axillary metastases (node+), 5-year OS and RFS were 91% vs 71% and 84% vs 69% in IM- vs IM+ pts. Univariate analysis of node+ pts estimated increased mortality risk for IM+ (hazard ratio, HR 2.9, P = .04), >or=4 positive nodes (HR 3.2, P = .02), tumors that were ER-negative (HR 3.4, P = .02), or had high Ki-67 (HR 6.8, P = .01). Multivariate analysis estimated similar increased risks [>or=4 nodes (HR 4.0, P = .02), IM+ (HR 3.3, P = .06), and ER negativity (HR 2.6, P = .09)].. IM nodal drainage predicted a nearly 3-fold increased mortality risk in node+ pts. Peritumoral radiocolloid injection provides a clinically relevant assessment of IM drainage and should be prospectively tested for its value in tailoring treatment strategies for axillary node-positive pts.

Topics: Adult; Aged; Axilla; Breast; Breast Neoplasms; Carcinoma, Ductal; Disease-Free Survival; Female; Follow-Up Studies; Humans; Kaplan-Meier Estimate; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Multivariate Analysis; Neoplasm Recurrence, Local; Neoplasm Staging; Predictive Value of Tests; Prognosis; Proportional Hazards Models; Prospective Studies; Radionuclide Imaging; Risk Assessment; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Topics: Adult; Axilla; Breast Neoplasms; Carcinoma, Ductal, Breast; Carcinoma, Intraductal, Noninfiltrating; False Negative Reactions; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Mastectomy; Reproducibility of Results; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

According to the concept of sentinel node (SN), the lymphatic pathway leading to SN should be regarded as the main and the most important lymphatic route from primary tumor to regional lymph nodes. We performed ex vivo blue-dye SN mapping in postmastectomy specimens to assess whether the main lymphatic tract leading to SN is completely removed during mastectomy. We assumed that ex vivo identification of SN may be possible only if the entire lymphatic tract leading to sentinel node is removed from within the postmastectomy specimen.. Blue dye (1 mL) was injected intracutaenously, periareolary into each of 28 postmastectomy specimens. In 13 cases mastectomy was performed with the use of transverse skin incision; in 15 cases oblique incision was used.. The use of transverse skin incision during modified radical mastectomy allowed identification of the sentinel node and removal of the entire lymphatic pathway leading to sentinel node only in 4 of 15 cases (31%). Conversely, the use of oblique skin incision during modified radical mastectomy allowed identification of the sentinel node and removal of the entire lymphatic pathway leading to sentinel node in 12 of 15 cases (80%).. Our experiment revealed that the use of transverse skin incision during modified radical mastectomy may not be the best choice for breast cancer patients. In our opinion, this observation may be especially important for patients not irradiated postoperatively.

Topics: Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Mastectomy, Radical; Neoplasm Recurrence, Local; Prospective Studies; Radionuclide Imaging; Retrospective Studies; Rosaniline Dyes; 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

Extra-axillary sentinel lymph nodes can only be detected if radioactive tracer is used and pre-operative scans are carried out. The presence of metastatic sentinel lymph nodes in most extra-axillary sites will upstage patients if the ipsilateral axillary sentinel lymph node is normal. Paradoxically, the presence of metastatic sentinel lymph nodes in the contralateral axilla has the potential to prevent upstaging to stage IV, but only if detected as a sentinel node at the initial surgery rather than as a systemic recurrence at some later time. We describe a case of bilateral axillary sentinel lymph nodes detected by pre-operative lymphoscintigraphy in a patient with a medial quadrant breast cancer and discuss the possible implications of such a finding.

Topics: Axilla; Breast Neoplasms; Diagnosis, Differential; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Radionuclide Imaging; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Combined use of blue dye and radiocolloid is considered to be useful for sentinel lymph node (SLN) biopsy of breast cancer. Whether both techniques together is superior to either alone was analyzed.. A consecutive series of 308 cases of breast cancer who underwent SLN biopsy using the combination technique was used. The frequency of a blue node or hot node was analyzed in all cases and only node-positive cases. Furthermore, the frequency of a blue node and hot node together, or either alone, and the highest radiocount of the SLNs in each case were examined for correlation with 8 clinicopathologic features. Three types of SLN containing both blue dye and radioactivity (blue-hot node), blue dye alone (blue-only node) and radioactivity alone (hot-only node), and the SLN radiocounts were analyzed for correlation with metastatic tumor.. Of 308 cases, a blue node was present in 298 (97%), a hot node in 295 (96%), and either a blue or hot node in 306 (99%). The presence of a blue node or hot node was similarly affected by previous surgical biopsy and body mass index (BMI), and the presence of a hot node was also affected by age and tumor location. However, the presence of either a blue node or hot node was not affected by any of these characteristics. Of 77 node-positive cases, 8 (10%), 15 (19%) and 6 (8%) were considered to be node-negative based on blue node, hot node and either blue node or hot node positivity, respectively. The frequency of positivity for SLN metastasis decreased in order from blue-hot, blue-only to hot-only nodes. Of 62 cases with metastatic hot nodes, six (10%) were negative when the hottest node was examined, but the second-hottest node was positive.. The added value of the presence of blue node or hot node was confirmed in the SLN biopsy using the combination technique, which suggests that all blue nodes and hot nodes need to be harvested.

Topics: Adult; Aged; Biopsy, Needle; Breast Neoplasms; Cohort Studies; Female; Humans; Immunohistochemistry; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Predictive Value of Tests; Probability; Prognosis; Radionuclide Imaging; Radiopharmaceuticals; Risk Factors; Rosaniline Dyes; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Sentinel node (SN) biopsy for breast cancer is becoming more common owing to its lower morbidity when compared with full axillary dissection. However, the optimal method of finding and the number of SN to be dissected are still subject to conjecture. The aim of this study was to determine the optimal number of SN required to accurately stage an axilla after the i.d. injection of isotope and blue dye.. Prospective data from all patients undergoing SN biopsy from April 2000 to September 2004 were analysed. For positive SN, the order in which they became positive was then tabulated.. During the 4 years, 113 patients who fulfilled the selection criteria had undergone SN biopsy with 216 SN harvested. Of these, 33 patients had positive SN results. If only the first SN was analysed, 87.9% of those positive biopsies would have been discovered. Two SN raised the predictive value to 97.0%.. Two SN would seem to be the optimal number to harvest after i.d. injection of both isotope and blue dye.

Topics: Adult; Aged; Aged, 80 and over; Axilla; Breast Neoplasms; Coloring Agents; Female; Humans; Injections, Intradermal; Middle Aged; Neoplasm Staging; Predictive Value of Tests; Radiopharmaceuticals; Rosaniline Dyes; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Topics: Breast Neoplasms; Carcinoma, Ductal, Breast; Female; Humans; Hyperthyroidism; Iodine Radioisotopes; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid; Thyroid Nodule

Most centers perform lymphoscintigraphy for the detection of sentinel lymph node (SLN) in patients with breast cancer within 2 hours after radiotracer injection. However, the interval between the injection of the radiotracer and surgery may not be long enough. In this study, we evaluated the effectiveness of delayed imaging (more than 15 hours) for SLN detection in patients with negative early images.. We retrospectively analyzed a database of 401 patients with breast cancer referred for SLN detection. On the day before surgery, lymphoscintigrams were obtained at 30-minute intervals until SLN was detected or 120 minutes. In those patients who failed to localize SLN on the early images, delayed imaging was performed the next morning.. Twenty-seven (6.7%) patients failed to show SLN on the early images. In the 27 patients, delayed imaging was available for 14 patients but not for 13 patients resulting from the tight time schedule for surgery. Of the 14 patients with delayed images, SLNs were successfully harvested in 10 patients (71.4%) at surgery. In contrast, in the 13 patients who lacked delayed images, SLN was only harvested in one case (7.7%) at surgery. The intraoperative detection rate for SLN was significantly higher in the 14 patients with delayed images than that in the 13 patients without delayed images.. Two-day delayed imaging is significantly useful to increase the rate of localizing SLN at surgery in patients with a negative early image.

Topics: Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Predictive Value of Tests; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Time Factors

In an effort to optimize sentinel lymph node (SLN) mapping for breast cancer, sites of mapping agent administration and types of mapping agents used continue to be evaluated. This study compares SLN mapping using peritumoral (PT) or subareolar (SA) injection of radiolabeled colloid and examines the relative contributions of radiotracer and blue dye to SLN identification.. A retrospective review was performed of 456 patients with breast cancer and clinically negative axillae who underwent SLN mapping. Sequential groups of patients were injected with filtered Tc-99m SC, 326 peritumorally (group 1) and 130 subareolarly (group 2). All patients had intraoperative SA injection of 1% isosulfan blue dye.. The SLN identification and isotope success rates were 97% and 96% in group 1 and 98% and 98% in group 2, respectively. Eighty-one patients (25%) in group 1 and 44 patients (34%) in group 2 had positive SLNs. Of these patients, 15% from group 1 and 14% from group 2 had only positive nodes detected by radiotracer, and 9 of these patients (6 from group 1 and 3 from group 2) had other nodes identified by both radiotracer and blue dye that were negative for metastases. Six percent of patients with positive SLNs were upstaged because of use of radiotracer.. PT and SA injection of radiotracer have comparable success rates for axillary SLN identification. Given that 15% of patients in group 1 and 14% in group 2 had only positive SLNs detected by radiotracer, independent of site of administration, radiotracer remains essential for optimizing breast SLN mapping.

Topics: Adult; Aged; Aged, 80 and over; Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Our objective was to determine if intraoperative injection of technetium-99m-labeled sulfur colloid is as effective as preoperative injection in the detection of sentinel lymph nodes (SLNs).. Two hundred consecutive patients with breast cancer underwent SLN biopsy examination. Radiocolloid was injected in the preoperative area (group A) or immediately after induction of anesthesia in the operating room (group B).. The SLN detection rate was similar for groups A (96%) and B (100%; P = .2). Radioactive SLNs were detected in 95% of patients in group A and in 97% of patients in group B (P = .1). The mean number of SLNs harvested was 1.6 and 2.1 for groups A and B, respectively. There was no significant difference in positive SLNs between groups (P = .11).. Intraoperative injection of sulfur colloid is highly effective in the detection of SLNs, avoiding patient discomfort and surgical schedule delays.

Topics: Breast Neoplasms; Cohort Studies; Drug Administration Schedule; Female; Humans; Intraoperative Care; Lymph Nodes; Middle Aged; Neoplasm Staging; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The aim of this study was to evaluate the success rate of combined peritumoral and subdermal injection techniques based on our previous experience on different injection techniques for lymphoscintigraphy.. Fifty-nine women with early breast cancer (mean tumor size, 20.5 mm) were prospectively studied. On the morning of the operation, each patient had 2 injections, one peritumoral (PT) medial to the lesion and one subdermal (SD) into the skin over the tumor quadrant. Each injection consisted of 20 MBq (540 mCi) Tc-99m rhenium sulfide colloid. Early dynamic and delayed static images were obtained up to 4 hours after injections. An intraoperative gamma probe was used to explore the axillary sentinel lymph nodes (SLN). All surgical specimens were evaluated histopathologically.. Forty patients had breast-preserving surgery and 19 had modified radical mastectomy. Thirty-eight patients had axillary dissection. All but 4 patients showed axillary lymphatic drainage. Twelve of 59 patients (20%) showed extraaxillary drainage with lymphoscintigraphy. Combined injection technique yielded a 93.2% success rate in detecting axillary SLN. In 2 of 4 patients with no drainage on lymphoscintigraphy, intraoperative gamma probe revealed SLN during the surgery. Twenty patients (33%) had positive axillary lymph nodes. In 14 of them, the SLN was the only positive node. A false-negative rate was found 1.6% (one of 59 patients).. This results suggest that a combination of both PT and SD techniques increases the success rate of visualization SLN and enhances the visualization of extraaxillary nodes for further treatment planning.

Topics: Adult; Breast Neoplasms; Carcinoma, Ductal; Female; Humans; Injections, Intralesional; Injections, Subcutaneous; Lymph Nodes; Lymphatic Metastasis; Positron-Emission Tomography; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Radiation to the internal mammary chain (IMC) may be indicated for breast carcinoma patients with positive axillary sentinel lymph nodes (SLNs) and lymphoscintigraphic evidence of drainage to the IMC. The purpose of this study was to identify predictors of IMC drainage in patients with positive axillary SLNs.. The records of 297 breast carcinoma patients with positive axillary SLNs and preoperative lymphoscintigraphy were reviewed between 1995 and 2002. Radiolabeled colloid was injected peritumorally with lymphoscintigraphy performed 30-60 minutes later. Drainage to the regional nodes of 279 patients was seen on lymphoscintigraphy. Associations among patient and tumor-related factors and drainage to the IMC were examined.. Drainage to the IMC on lymphoscintigraphy was seen in 63 patients (21%). IMC drainage only occurred in 4 patients, and 59 patients had both axillary and IMC drainage. The only variable that correlated with IMC drainage was tumor location (P = 0.017). Rates of drainage to the IMC were 14.1% for upper outer quadrant (n = 128), 16.7% for upper inner quadrant (n = 30), 31.6% for lower outer quadrant (n = 19), 42.9% for lower inner quadrant (n = 14), and 28.4% for central tumors (n = 88). IMC drainage rates differed significantly between upper and lower tumors (lower 36.4% vs. central 28.4% vs. upper 14.6%, P = 0.003) but not between medial and lateral tumors (medial 25.0% vs. central 28.4% vs. lateral 16.3%, P = 0.077).. Patients with tumors in the lower or central breast and positive axillary SLNs have increased incidence of drainage to the IMC. Preoperative lymphoscintigraphy can help to define the nodal basins at risk for harboring disease.

Topics: Adult; Aged; Breast Neoplasms; Carcinoma; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

The recent American Joint Committee on Cancer revision of the staging system for breast cancer classifies sentinel node metastases < 0.2 mm (pN0[i+]) as node negative and those > 0.2 mm but < 2 mm are designated pN1(mi). We examined the association between size of sentinel node metastases and rate of nonsentinel node metastases, specifically in the subgroup of patients with micrometastases.. We examined the nonsentinel nodes of 124 patients with positive sentinel nodes and correlated the likelihood of nonsentinel node involvement with the size of the metastasis in the sentinel node and primary tumor characteristics.. Nonsentinel node metastases were found in 19% (6 of 31) of patients with sentinel node metastases 2 mm. Multivariate analysis found that involvement of the majority of sentinel nodes (p = 0.01) and sentinel metastases > 2 mm (p = 0.001) were significantly related to presence of metastases in nonsentinel nodes. Age, tumor size, pathology, multifocality, satellites, and lymphovascular invasion were not significantly related to nonsentinel node metastases in multivariate analysis.. These findings indicate that frequency of nonsentinel node metastases with sentinel node metastases 0.2 to 2 mm. Omitting complete axillary dissection in pN1(mi) and pN0(i+) patients may leave residual disease in up to 20% of these patients.

Topics: Adult; Aged; Axilla; Breast Neoplasms; Carcinoma in Situ; Carcinoma, Ductal, Breast; Carcinoma, Lobular; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Multivariate Analysis; Neoplasm Invasiveness; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The combination of concurrently administered perilesional radiotracer injections and areolar-cutaneous junction radiotracer injections during one imaging session in the detection of sentinel nodes (SN) in breast cancer is new. A case is presented where the perilesional injections of radiotracer produced a faint node. Subsequently, 45 minutes later, the same patient received an injection of radiotracer at the areolar-cutaneous junction, which "boosted" the activity in the original SN by more than 50 times. This case illustrates the marked improvement in SN counts that can occur with the addition of areolar-cutaneous junction injections to perilesional injections. The perilesional component of this hybrid injection technique maintains the ability to visualize internal mammary and extra-axillary SN. Even more importantly, these "hotter" nodes have significant implications for morbidity reduction, the main goal of sentinel lymph node biopsy in itself.

Topics: Adult; Breast Neoplasms; Carcinoma, Lobular; Female; Humans; Injections, Intradermal; Injections, Intralesional; Lymph Nodes; Lymphatic Metastasis; Radionuclide Imaging; Radiopharmaceuticals; Reproducibility of Results; 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

Axillary lymph node dissection (ALND) is routinely performed during surgery for breast cancer, but whether ALND could increase survival rate of early stage breast cancer patients remains controversial. Recently, replacing ALND with sentinel lymph node (SLN) biopsy has became a hotspot in breast cancer research. This study aimed to evaluate the reliability and accuracy of SLN biopsy for early stage breast cancer, and to discover the significance of multiple step section level cytokeratin immunohistochemistry in identifying micrometastatic disease.. SLN biopsy was performed on 121 patients with T1 or T2 breast cancer: methylene blue-labeling was used in 38 patients (methylene blue group), double-labeling of (99m)Tc sulfur colloid and methylene blue was used in 83 patients (combination group). Lymphoscintigraphy and hand-hold gamma detector were used to localize SLNs before operation. All SLNs and ALND lymph nodes were pathologically examined. The tumor-negative SLNs were cut at three levels, and detected by immunohistochemistry.. Success rates were 81.6% in methylene blue group, and 95.2% in combination group; accurate detection rates of axillary lymph nodes were 93.5% in methylene blue group, and 97.5% in combination group. SLNs were found in 19 patients (23%) by lymphoscintigraphy, and 76 patients (92%) by hand-hold gamma detector, respectively (P=0.04). A total of 194 negative SLNs, detected by routine pathologic examination, were re-examined by multiple step section level cytokeratin immunohistochemistry; micrometastatic diseases were identified in 21 SLNs of 13 patients. The accuracy rate of combined examinations was 98.7%, and the false-negative rate was 3.2%.. The axillary node status can be predicted by SLN biopsy; double-staining is better than methylene blue-labeling. The role of lymphoscintigraphy in SLN biopsy needs further explore. Multiple step section level cytokeratin immunohistochemistry can improve detection rate of micrometastatic diseases.

Topics: Adult; Aged; Axilla; Breast Neoplasms; Carcinoma, Ductal, Breast; Carcinoma, Intraductal, Noninfiltrating; Female; Gamma Cameras; Humans; Keratins; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Tomography, Emission-Computed, Single-Photon

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

Since its introduction in the early 1990s, the sentinel node (SN) concept in breast cancer has been validated by many studies. Because SN biopsy in breast cancer enables the identification of node-negative axillae, the potential morbidity of an axillary lymph node dissection (ALND) can be avoided. The SN procedure is still surrounded by many variables and uncertainties, such as the clinical relevance of micrometastases. However, the main goal is to avoid unnecessary ALND in node-negative breast cancer patients. Sufficient clinical data are available to achieve this goal by incorporating the SN procedure into routine clinical practice. The ultimate safety of the applied technique will be determined by the number of axillary recurrences during long-term follow-up. Preoperative lymphoscintigraphy and intraoperative use of both blue dye and a hand-held gamma probe-the triple technique-has been applied at our institute since early 1994.

Topics: Breast Neoplasms; Female; Humans; Lymph Nodes; Radionuclide Imaging; Radiopharmaceuticals; Recurrence; 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

To determine the identification of sentinel lymph node biopsy (SLNB) in breast cancer patients after intraoperative injection of unfiltered technetium-99m sulfur colloid (Tc-99) and blue dye.. SLNB guided by a combination of radioisotope and blue dye injection yields the best identification rates in breast cancer patients. Radioisotope is given preoperatively, without local anesthesia, whereas blue dye is given intraoperatively. We hypothesized that, because of the rapid drainage noted with the subareolar injection technique of radioisotope, intraoperative injection would be feasible and less painful for SLN localization in breast cancer patients.. Intraoperative injection of Tc-99 and confirmation blue dye was performed using the subareolar technique for SLNB in patients with operable breast cancer. The time lapse between injection and axillary incision, the background count, the preincision and ex vivo counts of the hot nodes, and the axillary bed counts were documented. The identification rate was recorded.. Ninety-six SLNB procedures were done in 88 patients with breast cancer employing intraoperative subareolar injection technique for both radioisotope (all 96 procedures) and blue dye (93 procedures) injections. Ninety-three (97%) procedures had successful identification; all SLNs were hot; 91 (of 93 procedures with blue dye) were blue and hot. The mean time from radioisotope injection to incision was 19.9 minutes (SD 8.5 minutes). The mean highest 10 second count was 88,544 (SD 55,954). Three of 96 (3%) patients with failure of localization had previous excisional biopsies: 1 circumareolar and 2 upper outer quadrant incisions that may have disrupted the lymphatic flow.. Intraoperative subareolar injection of radioisotope rapidly drains to the SLNs and allows immediate staging of the axilla, avoiding the need to coordinate diagnostic services and a painful preoperative procedure.

Topics: Aged; Aged, 80 and over; Biopsy, Needle; Breast Neoplasms; Coloring Agents; Female; Follow-Up Studies; Humans; Injections, Intralesional; Lymph Nodes; Mastectomy; Middle Aged; Monitoring, Intraoperative; Neoplasm Staging; Nipples; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Risk Assessment; Sampling Studies; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Since the introduction of sentinel node (SN) mapping in breast cancer, extra-axillary lymph node sites of breast tumor drainage are discovered in about one-quarter of cases, especially after intraparenchymal injection. In most such cases, an ipsilateral axillary SN is associated with an extra-axillary SN. Non visualization of ipsilateral axillary SN and extra-axillary SN drainage are often associated with an increased risk of axillary involvement.. We report a case of contralateral axillary SN drainage on lymphoscintigraphy in a breast cancer patient with a history of bilateral reduction mammoplasty and no ipsilateral axillary lymph node involvement.

Topics: Aged; Axilla; Breast Neoplasms; Carcinoma, Ductal, Breast; Drainage; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Topics: Adult; Artifacts; Breast Implants; Breast Neoplasms; Carcinoma, Ductal; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid

To evaluate the performance and feasibility of sentinel lymph node biopsy in breast cancer patients using technetium-99m (99mTc) sulphur colloid and gamma probe.. From May 2000 to March 2001, 70 patients with a tumour less than 5 cm with clinically negative axillary lymph nodes underwent sentinel node biopsy followed by standard axillary dissection. 99mTc sulphur colloid was injected around the primary tumour the day before surgery and a gamma probe was used to detect the sentinel lymph node during the surgical procedure. Sentinel lymph node biopsy was compared with standard axillary dissection for its ability to accurately reflect the final pathological status of the axillary nodes.. The sentinel lymph node was successfully identified in 67 of 70 patients (95.71%). The number of sentinel lymph nodes ranged from 1-5 (mean 1.5) and non-sentinel nodes ranged from 5-22 (mean 13.3). Of the 67 patients with successfully identified sentinel lymph nodes, 43.28% (29/67) were histologically positive. Sensitivity of the sentinel lymph node to predict axilla was 82.75%; specificity was 100%. Positive and negative predictive values were 100% and 88.3% respectively. The sentinel lymph node was falsely negative in five patients, yielding an accuracy of 92.53%. Sentinel lymph node biopsy was more accurate for T1 tumours than for T2 tumours.. The gamma probe guided method after overnight migration of 99mTc sulphur colloid is technically feasible for detecting sentinel lymph nodes in most breast cancer patients, accurately predicting the axillary lymph node status, and appears more accurate for T1 lesions than for larger lesions. This minimally invasive axillary staging procedure represents a major advance in the surgical treatment of breast cancer.

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

The sentinel lymph node approach has almost become the standard procedure of choice in the management of patients with early breast cancer. The status of sentinel nodes, whether or not pathologically involved by cancer cells, represents those of the axillary nodes with a negative predictive value of almost 100%. If the axillary lymphatic nodal drainage is altered, alternative lymphatic pathways and accordingly sentinel node location will be changed.. In this article, 4 patients are presented, 3 with recurrent breast cancer who had already undergone lumpectomy, axillary node dissection, and radiotherapy in the past and 1 with primary breast cancer after surgical removal of a malignant melanoma on her back and had axillary node dissection on the same side as the breast cancer. These patients underwent lymphoscintigraphy followed by sentinel node localization using the gamma probe and also blue dye injection during surgery.. All patients showed alternate lymphatic pathways, 1 had an ipsilateral internal mammary node and crossed lymphatics to a contralateral axillary node, 2 had intramammary sentinel nodes, and 1 had an internal mammary on the same side. Pathologic examination of the intramammary and contralateral sentinel nodes were negative for metastases. Internal mammary sentinel nodes were not biopsied.. We feel that sentinel node lymphoscintigraphy should be done even in patients who have altered lymphatic pathways resulting from previous axillary node dissection. It allows identifying and biopsy of the sentinel node at its new unpredicted location.

Topics: Aged; Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymphatic System; Lymphoscintigraphy; Mastectomy, Segmental; Middle Aged; Neoplasm Recurrence, Local; 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, along with triangulated patient body marking, can serve as a guide for surgeons during sentinel lymph node harvesting. Unique drainage patterns have been noted, especially with areolar or intradermal based injections, which are becoming increasingly popular. The images lymphoscintigraphy provide have been invaluable in delineating these patterns. The authors present a case that simultaneously illustrates two separate points in the same patient, a reverse echelon node and a lymphatic ectasia. To our knowledge, this combination has never been described in the same patient. Perilesional and areolar-cutaneous junction injections were performed sequentially and generated these patterns that could potentially have resulted in added morbidity and a false-negative sentinel node if not realised before surgery. Lymphoscintigraphy added valuable information in the management of this patient, which can occasionally present with complex patterns of activity during sentinel node harvesting.

Topics: Adult; Breast Neoplasms; Dilatation, Pathologic; Female; Humans; Injections; Lymph Nodes; Lymphatic Metastasis; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid

We set out to measure the reduction in exposure attained by using a weak 57Co sheet source with optimal energy windows.. Two groups of 10 lymphoscintigraphy studies were analyzed. Group 1 consisted of 10 studies obtained with a stronger source of 57Co, 59 MBq (1.6 mCi) at the time of data acquisition, with transmission images acquired at 3 energy windows of 115-129, 130-134, and 135-150 keV. Group 2 consisted of 10 studies with a weaker sheet source of 57Co, 11 MBq (0.3 mCi). Transmission images were acquired at 3 energy windows of 112-132, 130-134, and 135-150 keV. Same-sized regions of interest (ROIs) were drawn on the patient's torso (PT) and on the nonattenuated image of the transmission source itself (TS), all 1-min images. The counts in each ROI obtained over 1 min and the ratios between the TS ROI and the PT ROI were calculated for all of the energies. Dosimetry calculations based on measured exposure rates and the activity of the sheet sources were used to calculate the patient equivalent dose at 30 cm.. For the 57Co energy window, group 1 had an average ROI count of 1,955 in the TS region and 135 counts in the PT region. The average ratio of TS/PT was 15.4. Similarly, group 2 had an average ROI count of 646.4 in the TS region and 91.2 counts in the PT region. The average ratio of TS/PT was 8.6. The relative "outlining performance," when comparing the 57Co and 99mTc windows, showed an average improvement when using the 57Co window of 4.4 and 5.8 times for group 1 and group 2, respectively (TS/PT at 57Co window)/(TS/PT at 99mTc window). Estimates of the patient equivalent dose per study were 2.30 microSv for the stronger 57Co flood source and 0.46 microSv for the weaker 57Co flood source, a 5-fold reduction in equivalent dose. Technologists received less than half of the above doses.. Use of expanded, separate energy windows optimized for the primary 122-keV photon of 57Co greatly improves transmission scan image quality compared with the standard 140-keV 99mTc windows used for the delineation of the sentinel node. This markedly reduces exposure for all, by allowing the use of a weaker source, and can save time.

Topics: Breast; Breast Neoplasms; Cobalt Radioisotopes; Female; Gamma Cameras; Gamma Rays; Humans; Image Enhancement; Lymph Nodes; Mammography; Radiation Dosage; Signal Processing, Computer-Assisted; Technetium Tc 99m Sulfur Colloid; Tomography, Emission-Computed, Single-Photon

We investigated whether the timing of injection of (99m)Tc-labeled sulfur colloid (radiocolloid) significantly influenced the success of breast cancer sentinel lymph node (SLN) mapping.. Review of a prospective SLN database. Five hundred forty-six consecutive breast SLN mapping patients were analyzed. A dual radiocolloid/blue dye technique was used in all patients.. The SLN identification rate was similar among those patients injected the day prior (100%) and those injected the day of operation (99%, P = 0.14). A "hot" SLN was identified in 99% of patients injected the day prior and in 97% (P = 0.17) injected the day of operation. The mean number of SLNs was greater among those injected the day prior (2.71) than among those injected the day of operation (2.33, P = 0.01). There were no differences in the rates of SLN metastases.. Radiocolloid injection the day before operation is an acceptable and logistically advantageous technique for breast cancer SLN mapping.

Topics: Adult; Aged; Breast Neoplasms; Cohort Studies; Female; Humans; Injections, Intravenous; Lymph Nodes; Mastectomy; Middle Aged; Neoplasm Invasiveness; Neoplasm Staging; Preoperative Care; Probability; Prospective Studies; Radionuclide Imaging; Risk Assessment; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Time Factors

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

The authors report on a modified lymphoscintigraphy protocol for increasing activity in the sentinel node (SN) through a specific technique (LymphoBoost). It consists of an areolar-cutaneous "junction" injection, using a very shallow, high-volume, high-specific-activity injection of 100% filtered Tc-99m sulfur colloid, as an adjunct to their standard protocol.. Results from a previously optimized protocol (group 1, n = 28) were compared with those from their new protocol (group 2, n = 85), which consisted of two sets of consecutively applied (within 12 to 20 minutes) injections: group 2A composed of perilesional and intradermal injections (similar to the previous group 1) followed by group 2B LymphoBoost injections within 12 to 20 minutes in the same patients. Regions of interest were drawn around the SN and the injection sites (IS) at the end of the studies to calculate the end-of-study SN:IS ratio for both group 1 and group 2 studies. The SN:IS ratio is generally independent of dose and is a measurement of the "efficiency" of getting activity from the IS to the SN.. The mean SN:IS ratio in group 2 was 3.34 times greater than that in group 1 studies (P < 0.0005). The median SN:IS ratio was 3.53 times greater in the group 2 studies. Many cases showed a dramatic increase in SN counts before the LymphoBoost injection was even completed, with more than 5% of injected activity reaching nodes at the end of the study in some patients. Multiple different lymphatic pathways were noted, but all led to the same node(s). No significant disagreement between group 2A and group 2B results was noted.. Areolar-cutaneous junction injections, performed under these conditions, augment SN activity dramatically in most patients. Hotter nodes provide several benefits, especially when next-day surgery is contemplated, and should also reduce the extent of dissection needed to remove the sentinel node.

Topics: Breast; Breast Neoplasms; Female; Humans; Injections, Intradermal; Injections, Intralesional; Lymph Nodes; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Data from a recent study support the hypothesis that axillary lymph node metastases frequently localize near the inflow junction of the afferent lymphatic vessel. Our goal was to evaluate the microscopic location of axillary sentinel lymph node metastases in a prospective study of breast cancer patients. A total of 305 axillary sentinel lymph nodes from 213 breast cancer patients undergoing surgery at our institution were evaluated. Preoperative lymphoscintigraphy using technetium-labeled sulfur colloid and intraoperative isosulfan blue dye injection were used for identifying the sentinel lymph node. Intraoperatively, the surgeon placed a suture either at the point of entry of isosulfan blue dye or at the area with the highest radioactive counts, and this area was inked at the grossing bench before processing. Metastases were identified in 55 of the 305 lymph nodes examined. Thirty-four nodes contained metastases in both the inked half and the opposite half. Metastatic tumor was identified in the inked half alone in 18 lymph nodes. Only three nodes contained metastatic tumor in the opposite half with no tumor in the inked half (p <0.001). Similar results were found when nodes tagged at the point of blue dye entry and nodes tagged at the area with the highest radioactive counts were analyzed separately. Our findings suggest that metastatic tumor has a higher probability of being present in the region of the inflow junction of the afferent lymphatic vessel. This information may be useful in determining the optimal method for evaluating axillary sentinel lymph node specimens from breast cancer patients.

Topics: Axilla; Breast Neoplasms; Carcinoma, Ductal, Breast; Carcinoma, Lobular; Female; Humans; Lymph Nodes; Prospective Studies; Radionuclide Imaging; 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

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

Sentinel-node biopsy is becoming widely accepted in breast cancer treatment. Using the radioisotope technique, a lower risk of identification failure is related to the amount of radiocolloid in the sentinel nodes. The aim of this study was to identify the factors associated with the colloidal uptake of the sentinel nodes.. Technetium-labeled colloid was injected peritumorally, with or without subdermal injection. According to the maximum radioactivity of the sentinel nodes, patients were divided into high (>/=100 counts/s) or low (<100 counts/s) uptake groups. The uptake was compared in relation to the clinicopathologic and technical features.. The sentinel node was identified in 183 of 186 patients (98.4%), with 60 and 123 patients in the low- and high-uptake groups (mean: 39 and 1003 counts/s), respectively. Multivariate analysis showed that an age of 65 years or older and a sentinel-node size of 8 mm or more were significantly more predominant in the low-uptake group.. Care must be taken when performing sentinel-node biopsy, especially for aged patients and for those with large sentinel nodes. The optimal technique should be determined on the basis of these results.

Topics: Adult; Aged; Aged, 80 and over; Breast Neoplasms; Female; Humans; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; 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

Topics: Breast Neoplasms; Female; Humans; Lymphatic Vessels; Middle Aged; Radionuclide Imaging; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The aim of this study was to define the factors associated with nonvisualization of a sentinel node (SN) in the axilla area during preoperative lymphoscintigraphy.. We retrospectively studied 332 women with T0, T1, or T2 <3-cm, N0 invasive breast cancer who underwent a sentinel lymph node biopsy procedure. All patients had intradermal and intraparenchymal injection of 37 MBq (99m)Tc-sulfur colloid in a total volume of 4 x 0.1 mL, above and around the tumor. Anterior and lateral static views were obtained a few minutes and 2-4 h after injection. Surgery was performed the next day. The SNs were localized intraoperatively with the aid of patent blue dye and using a hand-held gamma-probe. SNs were analyzed by serial sections stained with hematoxylin-eosin, with the adjacent section stained with anticytokeratin antibodies. Different parameters, such as the number of positive lymph nodes, presence of lymphovascular invasion, tumor size, tumor grade, histology (invasive vs. in situ), prior excisional biopsy, and patient age were analyzed to determine whether they had any significant correlation with nonvisualization of SNs in the axillary area.. An axillary SN was successfully visualized on the preoperative lymphoscintigraphy in 302 of 332 patients (90.7%). No axillary drainage was found in 30 patients on the delayed images, even after a second injection of radiocolloid, and 5 of 30 patients showed uptake outside the axillary area. Positive nodes were identified in 86 of 302 patients (28.5%) with successful axillary drainage and in 19 of 30 patients (63.3%) with unsuccessful axillary drainage. More than 4 invaded axillary nodes (P < 0.0001) and the presence of lymphovascular invasion in the breast tumor (P = 0.004) were the only significant variables on univariate analysis, although multivariate analysis showed that only the increased number of invaded nodes was statistically significant.. Patients with unsuccessful axillary mapping have an increased risk for axillary involvement.

Topics: Adult; Aged; Aged, 80 and over; Axilla; Breast Neoplasms; Carcinoma, Ductal, Breast; Carcinoma, Lobular; Carcinoma, Transitional Cell; False Negative Reactions; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Preoperative Care; Radionuclide Imaging; Radiopharmaceuticals; Reproducibility of Results; Retrospective Studies; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The graded shield technique was developed to increase the sentinel node detection rate by improving lymphoscintigraphic image contrast. In a 6-month period, 50 women with clinical suspicion of early stage breast cancer (T1 and T2 tumors) were enrolled in this study. The patients had a mean age of 47.2 +/- 10.3 years. A composite graded shield was constructed using three concentric layers of leaded plastic measuring 3 cm, 5 cm, and 7 cm each in diameter. The graded shield was designed with a movable Velcro backing for accurate positioning over the injection site. Images were acquired with a vertical angle dual-head gamma camera using an established injection procedure developed at our institution. The rate of detection of sentinel lymph nodes using lymphoscintigraphic mapping improved from 74% (37/50 patients) to 96% (48/50) using the graded shield (p < 0.05). In addition to the increased detection rate, our technique also increased the number of nodes detected and improved visualization of the adjacent lymphatic basin. By enhancing nodal contrast, we have demonstrated that the graded shield technique is an effective method for improving the rate of sentinel node detection.

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

There is great variation in the reported frequency of internal mammary (IM) sentinel node (SN) visualization. We observed a marked increase in our IM SN detection rate after 2 factors were changed simultaneously: depth of perilesional injection and dose.. A retrospective review of 82 consecutive patients (group 1) was compared with 61 consecutive patients (group 2) after changing the depth of perilesional injections and dose. Both groups had perilesional injections of (99m)Tc-sulfur colloid followed by intradermal injections at the areolar cutaneous junction. For group 2, activity was increased in all patients scheduled for next-day surgery. Group 2 had perilesional injections on top of, beside, and just below the estimated level of the tumor in an infiltrative manner, versus injections just on top of and beside the tumor as performed for group 1.. The rates of IM SN visualization were 4.9% (4/82) for group 1 and 23.0% (14/61) for group 2 (P < 0.003). IM SNs were hotter in group 2 than in group 1. The total number of IM SNs detected per patient was also higher for group 2 than for group 1: 2.1 and 1.2, respectively. In group 2, patients with small breasts had an IM SN visualization rate of 46.2%; those with medium breasts, 21.1%; and those with large breasts, 0% (P < 0.017). In group 2, primary lesions located medially had a higher rate of IM SN visualization than did lesions located laterally: 38.9% (7/18) and 16.2% (6/37), respectively (P = 0.066). Dose was not a statistically significant factor within group 2 or group 1 when comparing IM SN visualization rate for doses above or below the mean or median.. Modification of just these 2 factors resulted in a striking change in our IM SN detection rates. The injection depth was the most important factor. Breast size had a marked effect on the probability of detecting IM SNs. This suggests that the variation in detection rates reported in the literature could be at least partly dependent on variations in these factors, among others. Many surgeons do not routinely harvest IM SNs, but information about their presence can potentially alter treatment decisions.

Topics: Axilla; Breast Neoplasms; Dose-Response Relationship, Drug; Female; Humans; Injections, Subcutaneous; Lymph Nodes; Lymphatic Metastasis; Predictive Value of Tests; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Tissue Distribution

The preoperative lymphoscintigraphy to the Sentinel Node Biopsy (SNB) can reproduce the lymphatic drainage of the tumour in breast cancer.. To establish the pattern of lymphatic drainage of the mammary tumors by means of isotopic lymphoscintigraphy and determine the factors that could influence the negativity of the scintigraphy.. 121 patients with breast cancer who were going to undergo mammary surgery were studied with SNB. One day before the operation, 37 MBq 99mTc-colloidal sulphide colloid in a volume of 2 ml was injected in peritumoral tissue. Mammary lymphoscintigraphies were performed at 30 minutes and 18 hours P.I., in ANT and OA projections of the corresponding chest. After, the clinical-biological parameters and their influence on the result of the lymphoscintigraphy were analyzed.. The scintigraphy were positive in 85 % of the patients. The axillary chain was observed in 97 % and the internal mammary chain in 11 %. The factors associated to the absence of visualization of the sentinel node were: older than 50 years (94 %), menopause (89 %), tumoral size > or = 2 cm (67 %), axillary metastases (67 %), the overexpression of C-erbB-2 oncoprotein (44 %) and proliferative activity > 10 % (67 %).. The peritumoral injection of the radiocolloid establishes the lymphatic drainage pattern in the patients with breast cancer. Its absence of visualization can be associated to circumstances like: age > or = 50 years, menopause, tumoral size > or = 2 cm, axillary metastases, tumoral overexpression of the C-erbB-2 oncoprotein and high proliferative activity of the mammary tumor.

Topics: Adult; Aged; Aged, 80 and over; Axilla; Breast Neoplasms; Female; Humans; Lymphatic Metastasis; Lymphoscintigraphy; Middle Aged; Preoperative Care; Radiopharmaceuticals; Risk Factors; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Topics: Breast Neoplasms; Female; Humans; Melanoma; Sentinel Lymph Node Biopsy; Suture Techniques; Sutures; Technetium Tc 99m Sulfur Colloid

Sentinel lymph node (SLN) biopsy, primary used as an alternative to elective lymph node dissection in melanoma, is being applied successfully in management of patients with breast cancer. The aim of this method in breast cancer is to determine the presence of axillary node involvement while clinically normal axilla. The validity of the sentinel node concept in breast cancer is demonstrated in various studies. The results of identification rates, sensitivity, overall accuracy and false negative rate are so encouraging in most publications, as to implement this concept to every-day surgical practice. There is lack, however, of many fundamental answers pertaining relationship between tumor-size and the results of SLN Biopsy or related surgical standards.. 36 females at the age 33-66, with breast cancer underwent primary surgical treatment with SLN Biopsy in Department of Gynaecology and Oncology Jagiellonian University between 2001-2002. The study inclusion criteria were tumour size-T1, T2. The day before surgery the static scanning was performed after injection of Tc radiolabelled nannocolloid. SLN(s) were identified intraoperatively using a handheld gamma detection probe (Navigator GPS) and intraoperative lymphatic mapping with blue dye (Patent Blau V). After localization and excision of SLN(s), axillary's lymph node dissection (ALND) was performed.. In 34 patients SLN Biopsy revealed accumulation of the tracer in axilla, which was classified as SLN. Detection rate was 94.4% (34/36). Overall sensitivity of the procedure was 81%, whereas negative predictive value 92%. False negative rate was 2.2%. Detection rate for T1 tumors was 100% (15/15 cases), and for T2 tumors was 90.4% (19/21 cases). Sensitivity for tumor classified as T1 was 100% (3/3 cases), whereas for tumor T2 was 75% (6/8 cases).. SLN Biopsy seems to be very interesting alternative to ALND in patients with small tumor's dimension.

Topics: Adult; Aged; Breast Neoplasms; Diagnosis, Differential; Female; Gamma Rays; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

To study intra-operative radionuclide lymphatic mapping in sentinel lymph node (SLN) biopsy of breast cancer.. Forty-two breast cancer (diameter 98%, size of colloid granule 100 approximately 200 nm) was injected into the mammary tissue around the tumor or biopsy site at four points. SLN in breast cancer was detected and dissected with the help of lymphoscintigraphy and intra-operative gamma probe. Routine lymph node dissection was performed for all patients.. The detection rate was 88.1% in lymphoscintigraphy and 97.6% in intra-operative gamma probe detection for SLN in breast cancer. The sensitivity, accuracy, false negative and specificity of SLN biopsy were 93.3% (14 in 15), 97.6% (40 in 41), 6.7% (1 in 15) and 100% (26 in 26).. Sentinel lymph node in breast cancer, detected by preoperative lymphoscintigraphy combined with intra-operative gamma probe, is able to predict regional lymph node metastasis. The successful rate of SLN biopsy can be raised by improvement in the quality of nuclear imaging agent, technic of injection and method of measurement.

Topics: Adult; Aged; Breast Neoplasms; Female; Humans; Lymph Nodes; Middle Aged; Radionuclide Imaging; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

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

Topics: Aged; Breast Neoplasms; Female; Humans; Injections, Intradermal; Injections, Intralesional; Middle Aged; Radiopharmaceuticals; Retrospective Studies; 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

The radioisotope technique has been used to identify sentinel nodes in patients with breast cancer. However, quantitative analysis of the radioactivity for detecting the sentinel nodes was not previously examined. In this study, we considered a clinically useful criterion for detecting sentinel nodes by a detailed analysis of 312 sentinel nodes using the radioisotope technique.. Patients with T1-2, N0 breast cancer were eligible for this study. The nodes with the highest radioactivity after injection of technetium-labeled tin colloids were identified as hot nodes. The radioactivities of the hot nodes and the background counts of the axillary basin were examined in order to establish new criteria for detecting the sentinel nodes.. Between May 1997 and December 2001, 312 hot nodes were detected in 183 of 186 patients (98.4%). Since the false-negative rate for metastasis in hot nodes was only 2.1% (1/48), they could serve as sentinel nodes to predict the nodal status. However, there was a wide distribution of the hot nodes and the background in terms of absolute counts and a criterion for the sentinel nodes could not be established in terms of the absolute counts. When we adopted the criterion of sentinel nodes with a >/=100 count ratio in relation to the background, only 169 hot nodes (54.3%) met our definition. When the criterion of a >or=10 count ratio was adopted, all hot nodes met our definition and all other nodes remained non-sentinel nodes.. The criterion for defining sentinel nodes in our method is a node with a >or=10 count ratio with respect to the background. It is recommended that an analysis based on such objective data should be investigated in order to provide surgeons with more accurate and clinically useful criteria for detecting sentinel nodes.

Topics: Adult; Aged; Aged, 80 and over; Axilla; Background Radiation; Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Radioactivity; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; 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

Preliminary results by other investigators suggest that increasing the specific activity of Tc-99m nanocolloid preparations increases the measured counts in sentinel nodes compared with lower specific-activity (SA) preparations using the same initial injected dose. The authors set out to determine whether a similar result could be perceived with Tc-99m sulfur colloid (SC) preparations.. Twenty-three consecutive patients (low SA group) with successful visualization of sentinel nodes by lymphoscintigraphy before our standard protocol was changed to a higher SA preparation were compared with 28 patients (high SA group) just after the switch. Injection techniques were similar in both groups: peritumoral injections at two to four points of a mixture of half-filtered (0.22 microm filter) and unfiltered Tc-99m sulfur colloid in 6 ml followed immediately by intradermal injections of filtered sulfur colloid above the tumor. Activity levels for both types of injections ranged from 3.7 to 11.1 mBq (100 to 300 microCi). Preparation of the higher SA mixture of sulfur colloid was achieved by using only one eighth of the sulfur colloid vial contents when the same activity (125 mCi) of Tc-99 was added. Regions of interest were drawn around the images of sentinel nodes and the initial injection site in the anterior and lateral projections. Ratios of sentinel node to initial injection site count were calculated for both groups.. The mean ratio of sentinel node to injection site count in the high SA group was 2.9 times greater than that in the low SA group. The median ratio value was 2.7 times greater in the high SA group.. These preliminary results suggest higher counts in the sentinel node are possible with a higher SA preparation.

Topics: Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid

The present study was undertaken to find out if ageing and lateralization might influence the results of lymphoscintigraphic investigations. Axillary lymphoscintigrams obtained in 756 women after subcutaneous intercostal (IC) injection of 99mTc-labelled colloids at the level of the chest wall were reviewed and analysed according to age (<41 years, 41-50 years, 51-60 years, 61-70 years, 71-80 years, >80 years) and the side injected (right or left). No axillary nodes were visualized (IC-) in 34% of the population, and IC- cases were somewhat, but not significantly (0.1080 years, four out of seven), and the absence of drainage was more common in patients over 50 years old (overall, 38.2%; right, 36%; left, 40.2%) than in younger cases (overall, 27.9%; right, 24.1%; left, 30.3%). From a statistical point of view, the differences between these two age-discriminated populations were significant both when considering the series of injections as a whole (0.01>2P>0.001) and injections in the right side only (0.01<2P<0.02). In conclusion, ageing and lateralization influence lymphoscintigraphic investigations and have to be taken into account when analysing results.

Topics: Adult; Aged; Aged, 80 and over; Aging; Axilla; Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphography; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Aggregated Albumin; 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 optimal technique for intraoperative pathologic examination of sentinel lymph nodes (SLNs) is still controversial. Recent small series report sensitivity between 60% and 100% for various techniques. The aim of this study was to evaluate our long-term experience with touch preparation cytology (TPC) and frozen section (FS) in the intraoperative examination of SLNs for breast cancer.. A total of 247 patients with operable breast cancer underwent an SLN biopsy for staging of the axilla. The SLN was identified by (99m)Tc-labeled sulfur colloid unfiltered dye, blue dye, or both and dissected, and then intraoperative TPC or FS and permanent section, or both, were performed.. A total of 479 SLNs were submitted for TPC and permanent hematoxylin and eosin. A total of 68 SLNs were positive by hematoxylin and eosin; 65 SLNs were positive by TPC, with a false-negative rate of 5.8%. The sensitivity for TPC was 94.2%, with a false-positive rate of 0.2%. A total of 165 SLNs were submitted for FS, with a sensitivity of 85.7% and a specificity of 98.6%. The false-positive rate was 1.4%, with a false-negative rate of 15.8%.. In a large series, TPC is as accurate as FS but is simpler and faster in the detection of intraoperative metastasis in SLNs for breast cancer.

Topics: Adult; Aged; Aged, 80 and over; Axilla; Breast Neoplasms; Confidence Intervals; Female; Humans; Intraoperative Care; Lymph Node Excision; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Predictive Value of Tests; Radiopharmaceuticals; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Recent data suggests that intradermal (ID) injection for sentinel lymph node (SLN) mapping and biopsy in breast cancer is as effective and reproducible as intraparenchymal (IP) injection. The aim of this study was to review our initial experience with IP and ID injection for SLN mapping and biopsy at our rural-based university medical center.. From January 4, 1999 to January 5, 2001, 113 of 165 patients with breast cancer underwent attempted SLN mapping and biopsy by either IP (n=63) or ID (n=50) injection. Selection of the IP versus ID injection route was non-randomized and based on surgeon preference. Success of SLN localization was examined.. SLN localization was successful in 82% of IP and 100% of ID for radioisotope (p=0.001), 69% of IP and 92% of ID for blue dye (p=0.002), and 90% of IP and 100% of ID (p=0.024) for radioisotope and blue dye. Identical comparisons made after excluding the first 10 cases, 20 cases, and 30 cases from each injection group showed that the percentage of cases in each group in which the SLN localized changed minimally; however, some of the resultant p values eventually lost statistical significance.. SLN localization was more successful by ID injection than by IP injection, thus favoring utilization of the ID injection route. The eventual loss of statistical power in some of the comparisons with increasing numbers of initial cases excluded may reflect differential learning curves of the two injection techniques; however, this may simply be a reflection of decreasing sample size used in each subsequent analysis. A prospective randomized trial comparing the IP and ID injection route may be warranted.

Topics: Academic Medical Centers; Adult; Aged; Aged, 80 and over; Breast Neoplasms; Female; Humans; Injections, Intradermal; Injections, Intralesional; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Prognosis; Prospective Studies; Rural Population; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The evolution of sentinel node biopsy has placed new emphasis on the biology of lymphatic metastases in breast cancer. If radiocolloid mimics the migration of tumor cells, the nodes with the most uptake should also be the most likely to harbor metastatic cells. We attempted to correlate the frequency of metastatic disease to the greatest gamma uptake and to clarify the physiology of breast lymphatic drainage.. Data were collected from 152 patients undergoing sentinel node biopsy from January 1997 to June 1999. Localization was by injection of unfiltered (99m)Tc-labeled sulfur colloid. Sentinel nodes were identified with an intraoperative gamma counter and the 10% rule. A completion level I/II axillary dissection was performed in all patients.. Fifty-four of 152 patients were positive for metastatic disease. There were no false-negative sentinel nodes. In 46 (85%) of 54 cases, the node with the highest uptake was positive for metastatic disease. In the remaining eight (15%) cases, another node with a lower gamma count was positive.. The sentinel node with the highest uptake is not the one that contains metastatic disease in 15% of cases. This may reflect variations in lymphatic channels or technical variations in colloid properties and injection technique.

Topics: Adult; Aged; Breast Neoplasms; Cell Movement; Female; Humans; Lymphatic Metastasis; Middle Aged; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

A 62-year-old woman with right breast carcinoma who had a breast biopsy 3 weeks earlier was referred for a whole-body Tc-99m MDP bone scan to identify possible osseous metastases. Twenty-four hours later, she underwent lymphoscintigraphy using four peritumoral injections of 250 microCi filtered Tc-99m sulfur colloid of 0.22 microm each. The lymphoscintigraphic images showed good delineation of three right axillary lymph nodes in relation to the rib cage. Performing a bone scan just before lymphoscintigraphy for sentinel node detection may help the surgeon to identify sentinel lymph nodes. This is more anatomically precise than using a flood source to delineate body contour. A Tc-99m MDP bone scan followed by lymphoscintigraphy should be considered in patients with breast carcinoma who will have both bone imaging and lymphoscintigraphy.

Topics: Bone and Bones; Bone Neoplasms; Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Medronate; 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

Histological evaluation of the first draining lymph node (sentinel node) in the axilla of patients with breast cancer has dramatically altered the surgical approach to these patients, with sparing of the axilla if no tumour cells are identified. In a fraction of patients imaged after peri-tumoural injection of the breast, there is no visualization of the sentinel node. We retrospectively analysed the status of patients whose nodes were visualized and of patients whose nodes failed to visualize, to define the variables associated with non-visualization of the sentinel node. Seventy-four breast cancer patients were imaged following peri-tumoural injection of filtered 99Tc(m)-sulfur colloid, immediately and up to 5.5 h post-injection. The scintigraphic data were analysed with reference to the patient's age, histology, grade, site and size of tumour, previous diagnostic procedure and time interval to scan, using univariate analysis and a logistic regression model. A sentinel node was visualized in 53 of 74 women (72%). Comparison of patients with non-visualized versus visualized sentinel nodes disclosed no statistically significant univariate relation to age of the patients (P = 0.10), size of tumour (P = 0.46), site (P = 0.26), histology [invasive ductal carcinoma in 16 of 20 (80%) non-visualized cases, and in 43 of 53 (81%) visualized patients], prior excision biopsy (P = 0.36) and time interval to surgery (P = 0.29). Tumour grade was the only significant variable on univariate analysis (P = 0.03), though multivariate analysis showed that none of the independent parameters were statistically significant. In 39 patients with an upper outer quadrant tumour, the location of the sentinel node was not limited to the axilla and even crossed the midline of the breast. Our results show that none of the independent variables is associated with non-visualization of sentinel lymph node on preoperative lymphoscintigraphy of patients with breast cancer, though the tumour grade may have contributed to non-visualization of this node. The non-axillary drainage from upper outer quadrant tumours suggests the routine use of lymphoscintigraphy prior to axillary dissection.

Topics: Adult; Aged; Aged, 80 and over; Analysis of Variance; Breast Neoplasms; Female; Humans; Logistic Models; Lymph Nodes; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

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

Dermal and intraparenchymal (IP) injections of radiocolloid have been used for lymphoscintigraphic identification of the sentinel node (SN) in breast cancer. Because of our institute's extensive experience with dermal and IP lymphoscintigraphy for melanoma and breast cancer, we compared patterns of lymphatic migration after both types of injections to identify any differences in drainage patterns or SN identification.. Lymphoscintigrams (n = 31) after dermal injections in 30 patients with primary cutaneous melanoma on the breast were compared with lymphoscintigrams after IP injections in 97 consecutive patients with breast cancer. In each case, 400 microCi of filtered 99mTc-sulfur colloid was injected in four quadrants around the tumor or in the biopsy cavity. All lymphoscintigrams were reviewed for patterns of migration and SN location.. Five of 31 (16%) dermal injections demonstrated bilateral axillary migration (n = 3) or a suprasternal SN (n = 2), neither of which was found with IP injections. Conversely, 3 of 97 (3%) IP injections demonstrated direct supraclavicular (n = 2) or costal margin (n = 1) nodes (P = .006), neither of which was found with dermal injections. Low axillary SNs were noted after 26 (84%) dermal and 93 (96%) IP injections (P = .037). The incidence of extra-axillary SNs was 26% (8 of 31) in the dermal group but only 5% (5 of 97) in the IP group (P = .0027).. There is a significant difference in lymphatic drainage and SN localization between dermal and IP lymphoscintigraphy. This finding has implications for injection techniques when lymphatic mapping of the SN is undertaken to stage a breast carcinoma.

Topics: Axilla; Breast Neoplasms; Carcinoma; Chi-Square Distribution; Female; Humans; Lymph Nodes; Male; Melanoma; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Skin Neoplasms; Technetium Tc 99m Sulfur Colloid

The purpose of this study was to map the lymphatic drainage patterns of breast cancer with lymphoscintigraphy to evaluate the variability of drainage and to determine whether lymphatic mapping can help to increase the certainty of breast cancer staging.. Fifty women with breast cancer (mean age, 49 years) were included in the study. Lymphoscintigraphy was performed with 1 mCi Tc-99m rhenium sulfide colloid in a 2-ml volume injected into the four quadrants of the peritumoral area using a 25-gauge needle. Ten-minute dynamic images and 2-hour delayed static images were obtained in the anterior and lateral positions using a gamma camera with a high-resolution collimator. All patients had a modified radical mastectomy and axillary dissection. The results were evaluated with histopathologic findings of the axilla.. Six patients had excision biopsies before surgery. Of 13 patients with centrally located tumors, 84% had axillary lymphatic drainage, whereas 53% drained to internal mammary lymphatics. Of 23 patients with outer quadrant tumors, 4 showed no lymphatic drainage and all of them had metastatic tumor in the axillary lymph nodes. Axillary drainage was seen in 82% of patients and internal mammary lymphatic drainage in 23%. Of eight patients with inner quadrant tumors, one patient with no lymphatic drainage was found to have metastases in the axilla. In this group, 62% had axillary and 50% had internal mammary lymphatic drainage, and one patient had supraclavicular drainage.. Lymphoscintigraphy indicates that drainage routes may vary, and thus it may play a guiding role in patients with breast cancer who need radiotherapy. In patients with internal mammary lymphatic drainage, the accuracy of radiotherapy planning may increase if internal mammary lymphoscintigraphy is added to the protocol. In patients with internal mammary drainage, obtaining an internal mammary lymphatic biopsy during surgery will also increase the accuracy of staging.

Topics: Adult; Aged; Axilla; Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Preoperative Care; Radionuclide Imaging; Radiopharmaceuticals; 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

Sentinel node biopsy is emerging as a technique to replace routine axillary lymph node dissection. The lymphatic mapping technique is still at a developmental stage and no standard technique exists. This study used technetium-99m colloidal rhenium sulphide with a mean particle size of 100 (range 50-200) nm for sentinel node mapping.. Eighty-seven patients with breast cancer, but no clinical evidence of axillary metastasis, were studied. One day before operation technetium-99m colloidal rhenium sulphide was injected at four points into breast tissue surrounding the tumour. Lymphoscintigraphy was performed 2 h after injection, and surgery was usually performed after 20 h. A hand-held gamma probe guided sentinel node biopsy.. Lymphoscintigraphy revealed axillary hot spots in all patients. During operation, the sentinel node was identified in all 87 patients (100 per cent). The number of sentinel nodes per patient ranged from 1 to 5 (mean 2). Metastatic sentinel nodes were identified in 37 of 87 patients. There were no false negatives.. This study suggests that technetium-99m rhenium sulphide is a suitable agent for sentinel node mapping in patients with breast cancer.

Topics: Adult; Aged; Breast Neoplasms; Female; Humans; Lymphatic Metastasis; Middle Aged; Radionuclide Imaging; Rhenium; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

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

Topics: Breast Neoplasms; Humans; Injections, Intradermal; Injections, Intralesional; Middle Aged; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The objective of this study was to maximize the success rate of sentinel node (SN) localization in breast cancer patients with the tracer that demonstrated the highest initial success during a preliminary evaluation. Altogether, 145 patients with operable invasive breast cancer and clinically negative lymph nodes were studied. Technetium 99m (99mTc)-sulfur colloid was injected into the breast parenchyma surrounding the invasive cancer or the biopsy cavity. Variable volumes of tracer, amounts of 99mTc, and duration of time between injection and surgery were evaluated. A hand-held gamma detector was used at surgery to locate and guide resection of all radioactive sentinel nodes (SNs), including those that were extraaxillary. A conventional lymphadenectomy was then performed in all cases. Based on previous studies, unfiltered sulfur colloid provided a higher success rate of SN identification than the other tracer types. Further evaluation with 99mTc-sulfur colloid demonstrated that increased volume increased the success rate of SN identification. An injection volume of 8 ml resulted in a success rate of 98%. SNs were not exclusively located in the axilla: In 8.6% of cases SNs were removed from an internal mammary location. The overall accuracy of patients with SNs resected was 98.4%, and the false-negative rate was 4.4%. It was concluded that (1) unfiltered 99mTc-sulfur colloid at a volume of 8 ml resulted in a high success rate for SN identification; (2) a significant number of the SNs were extraaxillary in location; and (3) the accuracy of the SNs for determining whether regional metastases had occurred was high. The U.S. National Cancer Institute is funding a randomized phase III clinical trial to evaluate SN resection compared to conventional axillary lymphadenectomy in clinical node-negative breast cancer patients. Major endpoints of this trial include long-term regional control and survival.

Topics: Breast Neoplasms; Clinical Trials as Topic; Female; Humans; Lymph Nodes; Predictive Value of Tests; Prognosis; Radionuclide Imaging; Radiopharmaceuticals; Research Support as Topic; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

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

The authors compared the supine and standing positions for lymphoscintigraphy in breast cancer patients to identify any changes in the number of affected lymph nodes detected and the quality of images.. Twenty-three patients were examined using lymphoscintigraphy in both positions. Sequential supine, standing, and supine oblique images were acquired in each patient.. The number of lymph nodes detected or the quality of the images acquired was improved in 20 of the 23 patients in the standing position compared with the supine position. The remaining three patients' images were judged to be equal in lymph node number and image quality in both positions.. Lymphoscintigraphy in patients with breast cancer appears to be more sensitive in the standing than in the supine position.

Topics: Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Posture; Radionuclide Imaging; Radiopharmaceuticals; 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

Radioguided surgery can also be used for the simultaneous guidance to a nonpalpable primary tumor and sentinel lymph nodes.. Retrospective review of a prospective database. The surgeon used a gamma probe for guidance to an iodine-125 labeled titanium seed at the primary lesion and technetium-99 labeled sulfur colloid at the sentinel lymph node.. Forty-three patients with nonpalpable breast carcinoma underwent dual isotope radioguided surgery. The radioactive seed and primary lesion were retrieved in the first excision in all 44 patients (100%). Eleven patients (25%) had pathologically involved margins. Sentinel lymph node mapping was successful in 42 patients (98%). A mean of 2.4 sentinel nodes were excised and metastatic carcinoma was present in four patients (10%).. Dual isotopes can be effectively used in breast cancer patients for simultaneous radioguidance to both a nonpalpable primary lesion and sentinel lymph node and allows for improved logistics.

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

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

Injection of Technetium 99m sulfur colloid (Tc-99m-SC) into the subareolar lymphatic plexus provides a rapid and reliable method of identifying breast sentinel lymph nodes and their lymphatic connections to the areola, termed sentinel lymphatic channels (SLCs). The objective of this study was to define the anatomic origin, number, and direction of the SLC in relation to the areola after subareolar injection of Tc-99m-SC.. Using a hand-held goniometer, the exit angle (theta(e)) and direction from the vertical (to the patient's right or left) of SLCs were determined in 87 successful preoperative lymphoscintigrams (46 left breast and 41 right breast).. One major lymphatic trunk was identified in 91% of cases (n = 79), and two lymphatic trunks were identified in 9% of cases (n = 8). Overall, 24% (n = 21) of major lymphatic trunks exited the areola vertically (theta(e) = 0 degrees), 33% (n = 29) exited the areola with theta(e) = right or left 1 to 30 degrees, and 32% (n = 28) exited with a theta(e) = right or left 31 to 60 degrees. In total, 90% (n = 78) of SLCs exited the areola with a theta(e) = right or left 0 to 60 degrees, equivalent to 10 to 12 o'clock in the right breast, and 12 to 2 o'clock in the left breast.. Radial angular measurements of SLCs from preoperative lymphoscintigrams performed by SA injection confirm that the origin of the majority of SLCs is within the upper, outer edge of the areola, and that all SLCs ultimatelytraverse the upper, outer quadrant of the breast and terminate on axillary sentinel nodes.

Topics: Breast; Breast Neoplasms; Female; Humans; Lymphatic System; Lymphoscintigraphy; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

In sentinel lymph node (SLN) biopsy for breast cancer, many centers use same-day preoperative injection of technetium 99mTc-labeled sulfur colloid and intraoperative injection of blue dye for localization of SLNs. Same-day sulfur colloid injections can be problematic because of the variability in sulfur colloid migration times, which can lead to ineffective use of operating room time, and low SLN-to-background radioactivity ratios. We examined the utility of day-before-surgery injections of high dose 99mTc-labeled sulfur colloid injections.. The day before surgery, high-dose 99mTc-labeled sulfur colloid was injected peritumorally, and a lymphoscintigram was obtained. Intraoperatively, after injection of blue dye, a gamma probe was used to localize SLNs. Nodes that were stained blue or were highly radioactive were considered SLNs and were removed.. Lymphoscintigraphy demonstrated drainage in 107 patients (91%). Transcutaneous localization of the SLN was possible in 104 patients (89%). In three patients, all of whom had no drainage demonstrated on lymphoscintigraphy, no SLN was identified at surgery (97.5% success rate for SLN identification). A mean of 2.3 SLNs per patient were identified. Twenty-five patients (21%) had at least one histologically positive SLN. In 23 of these patients, the positive SLN was the SLN with the most radioactivity, and in the remaining two patients, the positive SLN was both blue-stained and hot.. Day-before-surgery injection of high-dose 99mTc-labeled sulfur colloid results in high rates of transcutaneous and intraoperative identification of SLNs. The delay between injection and surgery did not appear to promote significant passage of sulfur colloid to second-echelon nodes.

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

The current standard for obtaining accurate sentinel lymph node (SLN) mapping is intraparenchymal lymphophilic dye/radiocolloid injection close to the breast tumor. We hypothesized that common lymphatic trunks drain both a large volume of breast parenchyma and skin and that intradermal or intraparenchymal routes flow to the same axillary node.. 99mTc-labeled filtered sulfur colloid was injected intradermally directly over the breast tumor in 119 patients. Blue dye was injected intraparenchymally in the same quadrant as the primary tumor (concordant quadrant) in 66 and in a discordant quadrant in 53 patients. During axillary exploration, both blue and gamma-emitting (hot) nodes were found. End points were SLNs that were hot and blue, either the same node or different nodes.. In 62 (93.9%) of 66 of concordant quadrant and in 49 (92.5%) of 53 of discordant quadrant patients, the same SLN was both hot and blue (P = .99; Fisher's exact test). In eight cases in which two distinct nodes were blue and not hot and hot but not blue, the lymph nodes were very close to each other.. The dermal and parenchymal lymphatics of the breast seemed to drain to the same axillary lymph nodes. Lymph from the entire breast seemed to drain through a small number of lymphatic trunks to one or two lymph nodes.

Topics: Aged; Axilla; Breast Neoplasms; Coloring Agents; Female; Humans; Lymph Nodes; Lymphoscintigraphy; Middle Aged; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

The lymphoscintigraphy is a widely accepted procedure to detect the sentinel node in breast cancer. This is a case report of a 45 year old woman diagnosed of breast cancer who was referred to the nuclear medicine facility to perform the sentinel node detection procedure. The lymphoscintigraphy prior to surgery shows a double pathway in the tracer migration: one going to the axillary area and the second to the internal mammary chain and shows hot spots that represent the sentinel nodes. After surgical removal of those nodes, the pathological analysis report indicated tumor infiltration in the internal mammary chain sentinel node with all axillary nodes free of malignant cells. The aim of this report is to emphasize the importance of performing a pathological analysis of all the sentinel nodes detected in lymphoscintigraphy.

Topics: Axilla; Breast; Breast Neoplasms; Carcinoma, Ductal, Breast; False Positive Reactions; Female; Humans; Intraoperative Care; Lymph Node Excision; Lymphatic Metastasis; Mastectomy, Radical; Middle Aged; Neoplasm Staging; Neoplasms, Multiple Primary; Particle Size; Radiometry; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Uterine Cervical Dysplasia; Uterine Cervical Neoplasms

Lymphoscintigraphy along with a gamma-detecting probe has been applied successfully to breast cancer patients to localize the sentinel node during surgery, with a 5% false-negative rate. The authors report a case of stage II breast cancer. The sentinel node was not visualized on the initial lymphoscintigraphy with peritumoral injection of 37 MBq (1 mCi) 10 ml Tc-99m colloidal rhenium sulfide (Tc-99m ReS colloid; average particle size, 100 nm). However, the sentinel node was visualized in the left lateral view of the second lymphoscintigraphy with peritumoral injection of 37 MBq (1 mCi) 10 ml Tc-99m ReS colloid (average particle size, 500 nm). Lymphoscintigraphy using the larger colloid particles may enhance visualization of a sentinel node in breast cancer.

Topics: Adult; Breast Neoplasms; Colloids; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Particle Size; Radionuclide Imaging; Radiopharmaceuticals; Rhenium; 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

Topics: Breast Neoplasms; Coloring Agents; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Radionuclide Imaging; 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

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

Although sentinel lymph node biopsy is likely to be offered as a method of assessing nodal status in primary breast cancer, the inability to identify the sentinel node at the time of surgery will limit the number of patients who may benefit from the procedure. The purpose of the present study was to identify factors that are associated with intraoperative identification of the sentinel node(s).. Between September 1995 and May 1999, lymphatic mapping using a combination of preoperative lymphoscintigraphy and/or blue dye was performed on 169 consecutive patients with clinically lymph node-negative primary operable breast cancer. Clinical and histological factors were assessed using univariate and multivariate analysis to determine those that were associated with intraoperative identification of the sentinel node.. The sentinel node was identified at the time of surgery in 142 cases (84%). Of the clinical factors assessed, preoperative identification of the sentinel node on lymphoscintigraphy (P < 0.0001), use of blue dye in combination with isotope (P = 0.001), symptomatic palpable tumours (P < 0.05) and the experience of the surgeon (P = 0.03) were significant in identifying the sentinel node at operation. No histological factor was associated with intraoperative identification of the sentinel node. Using multivariate analysis, positive identification of the sentinel node on lymphoscintigram, the experience of the surgeon and the use of both blue dye and isotope for sentinel node mapping were independent factors associated with intraoperative sentinel node identification. The lymphoscintigram result was the strongest independent factor according to its beta value, a measure of the weight of significance.. Patients undergoing sentinel lymph node mapping and biopsy should be warned of the possibility of failure of sentinel node identification at operation. Our results suggest that the best predictor of intraoperative sentinel node identification is the visualization of the sentinel node on preoperative lymphoscintigraphy. The result of the lymhoscintigram may allow for additional preoperative counselling of the patient regarding the success or failure of sentinel node biopsy. Technical factors such as the experience and diligence of the surgeon, as well as the sentinel node mapping technique, are also important in determining the success of the procedure.

Topics: Adult; Aged; Aged, 80 and over; Analysis of Variance; Axilla; Biopsy; Breast Neoplasms; Coloring Agents; Female; Forecasting; Humans; Intraoperative Care; Logistic Models; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Multivariate Analysis; Palpation; Preoperative Care; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Technetium Tc 99m Sulfur Colloid; Treatment Outcome

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

Currently outer quadrant breast tumors are not felt to have significant drainage to the internal mammary nodal chain. We evaluated the incidence of internal mammary sentinel nodes (IMSN) found with lymphoscintigraphy for all breast quadrants.. Eighty women were prospectively studied by technitium-sulfur colloid injection, nuclear medicine imaging, and intraoperative gamma probe identification of sentinel nodes. IMSN detected were surgically removed.. Ten of 80 ( 12%) patients had IMSN identified in addition to axillary sentinel nodes (AXSN). Four tumors were located medially, 6 (60%) were in the outer quadrants. Metastatic disease was present in 3 of 10 women. Patients with positive IMSN also had positive AXSN.. Patients undergoing lymphatic mapping for the management of breast cancer should have radiolabelled tracer and gamma probe sentinel node identification regardless of tumor location in the breast.

Topics: Biopsy; Breast Neoplasms; Female; Gamma Cameras; Humans; Incidence; Lymph Node Excision; Lymphatic Metastasis; Mammary Arteries; Monitoring, Intraoperative; Neoplasm Staging; Predictive Value of Tests; Prospective Studies; Radionuclide Imaging; Reproducibility of Results; Technetium Tc 99m Sulfur Colloid; Ultrasonography, Interventional

Variable success rates for identifying axillary (AX) sentinel nodes in breast cancer patients using preoperative lymphoscintigraphy have been reported. We evaluated the effects of age, weight, breast size, method of biopsy, interval after biopsy, and imaging view on the success of sentinel node identification and on the kinetics of radiopharmaceutical migration.. Preoperative breast lymphoscintigraphy was performed in consecutive breast cancer patients from February 1998 to December 1998. The ipsilateral shoulder was elevated on a foam wedge and the arm was abducted and elevated overhead. Imaging using this modified oblique view of the axilla (MOVA) started immediately after peritumoral injection of Millipore-filtered 99mTc-sulfur colloid and continued until AX sentinel nodes were identified. Anterior views were obtained after MOVA. AX, internal mammary (IM), and clavicular (CL) basins were monitored in all patients. MOVA was compared with the anterior view for sentinel node identification. Age, weight, breast size, method of biopsy, interval after biopsy, and primary tumor location were evaluated for their effects on sentinel node localization and transit times from injection to arrival at the sentinel nodes.. Seventy-six lymphoscintigrams were obtained for 75 patients. AX sentinel nodes were revealed in 75 (99%) cases. IM or CL sentinel nodes were found in 19 (25%) cases and were not related to tumor location; exclusive IM drainage was present in 1 (1%) case. Identification of AX sentinel nodes was equivalent with MOVA and anterior views in 18 (24%) patients, was better with MOVA in 20 (26%) patients, and was accomplished only with MOVA in 38 (50%) patients. Median transit time was 17.5 min (range, 1 min to 18 h) after injection, and larger breast size was associated with increased transit time. No effect of age, weight, biopsy method, interval from biopsy, or tumor location on transit time was found.. Use of MOVA can improve identification of AX sentinel nodes. Although AX drainage is the predominant pattern, a tumor in any portion of the breast can drain to IM sentinel nodes. Transit time was influenced by breast size. Overall short arrival times with this technique allow sentinel lymph node dissection to be performed on the same day as lymphoscintigraphy.

Topics: Axilla; Breast Neoplasms; Female; Humans; Logistic Models; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Preoperative Care; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid; Time Factors

The sentinel node biopsy appears to offer an alternative to routine axillary lymph node dissection for staging patients with breast cancer. Various techniques have been studied for identifying the sentinel node, using vital blue or radioactive colloid. This study aimed to evaluate our preliminary results with these techniques.. In this work carried out in the Valencian Institute of Oncology, 21 women with T1- T2 breast cancer with an average age of 52 years (range: 42-73) underwent the sentinel node biopsy, which was immediately followed by standard axillary dissection. Both blue dye and radioisotope were used to identify the sentinel node. The radioactive axillary of sentinel node was localized by the gamma probe.. The sentinel node was successfully identified by lymph node scintigraphy in 100%. It was localized by blue dye in 33% and by combination of blue dye and isotope in 95%. Of the 21 patients in this study in whom sentinel nodes were identified, 7 (35%) were histologically positive; in 6 cases, the sentinel was the only site of the metastases (86%). The histology of the sentinel node accurately predicted axillary node status in 95% of cases.. The sentinel node biopsy technique is a promising and feasible procedure in patients with clinically T1-T2 N0M0 breast cancer, providing valuable axillary staging information.

Topics: Adult; Aged; Axilla; Breast Neoplasms; Coloring Agents; Female; Humans; Lymph Node Excision; Lymphatic Metastasis; Mastectomy, Modified Radical; Middle Aged; Neoplasm Staging; Radiometry; Radionuclide Imaging; Radiopharmaceuticals; Rosaniline Dyes; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Technetium Tc 99m Sulfur Colloid

Preoperative lymphoscintigraphy has been recommended to confirm the successful uptake and direction of migration of radiotracer into sentinel nodes during lymphatic mapping for breast cancer. In addition, preoperative lymphatic mapping may provide a visually useful aid to the relative location of sentinel nodes within a nodal basin. One common method of breast lymphoscintigraphy involves injections of unfiltered technetium 99m sulfur colloid (Tc-99m-SC) directly into parenchymal tissues surrounding a tumor or biopsy cavity (IP injection). Because of the many imaging failures and prolonged imaging times of IP lymphoscintigraphy, the procedure has fallen into disfavor by oncologic surgeons. The purpose of this study is to document the increased success rate of preoperative breast lymphoscintigraphy using a new anatomic site of injection, the subareolar lymphatic plexus (SA injection).. In the 12 months between December 1, 1998, and December 29, 1999, 42 women with stage I and II breast cancer underwent preoperative lymphoscintigraphy by either the IP (n = 12, December 1998 to May 1999) or SA (n = 30, May 1999 to December 1999) route of injection. Both groups were injected with 1 mCi (37 MBq) of unfiltered Tc-99m-SC followed immediately by external gamma-camera imaging. The success rate for preoperative sentinel node imaging and the total imaging time were recorded in both groups.. The success rate of identifying a sentinel node by SA lymphoscintigraphy was 90% (n = 27 of 30 patients), compared with 50% (n = 6 of 12 patients) for IP lymphoscintigraphy (p = 0.009). The imaging time in the SA injection group was 34 +/- 16 minutes, which was 59% shorter than the imaging time in the IP injection group of 82 +/- 48 minutes (p < 0.001). No uptake into internal mammary nodes was seen in either group.. Moving the site of injection ofunfiltered Tc-99m-SC to the subareolar lymphatic plexus (SA injection) increased the success rate of preoperative lymphoscintigraphy to 90%, compared with 50% using IP injections. Preoperative SA lymphoscintigraphy resulted in the rapid visualization of axillary sentinel nodes within 30 minutes of SA injection, enabling a visual determination of the approximate number of sentinel nodes and their relative locations within the axilla. We conclude SA injection of unfiltered Tc-99m-SC is superior to IP injections when performing preoperative breast lymphoscintigraphy and is a visually useful aid to lymphatic mapping for breast cancer.

Topics: Adult; Aged; Aged, 80 and over; Axilla; Breast Neoplasms; Carcinoma, Intraductal, Noninfiltrating; Female; Humans; Injections; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid

Sentinel node detection is an important part of the clinical management of newly diagnosed melanoma. Now there is a similar or even greater enthusiasm for sentinel node evaluation in patients with breast carcinoma. However, controversies exist regarding the dose, volume, and route of administration. Even the role of lymphoscintigraphy itself, in contrast to using only a hand-held gamma probe during surgery for sentinel node detection, is being debated. Nevertheless, many centers and surgeons find that lymphoscintigraphy images are valuable in the treatment of patients and they use lymphoscintigraphy as a guide during surgery and to confirm the results obtained with the hand-held probe. Centers just beginning to use lymphoscintigraphy may find the images especially useful. Given this fact, the authors wanted to define the practical and technical aspects of performing lymphoscintigraphy in patients with breast cancer and examined various methods for the optimization of the technique of image acquisition. The suggested technique is generally free of the controversies noted above and applies to most patients. It includes various maneuvers that aim to improve the rate of sentinel node visualization using the gamma camera and the accuracy of node detection. The recommendations presented here should prove useful for both those experienced and for those centers just beginning to use the technique of lymphoscintigraphy.

Topics: Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Posture; Radionuclide Imaging; Radiopharmaceuticals; Sentinel Lymph Node Biopsy; 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

The significance of the sentinel lymph node (SLN) was examined in 58 Chinese breast cancer patients. The method of technetium-99m sulfur colloid injection and the intraoperative gamma probe was found to be very useful for identifying the SLN. The positive predictive value was 64.5%, and the negative predictive value was 93.2%. Findings suggest that lymph node dissection is not necessary in breast cancer patients with a negative SLN.

Topics: Adult; Aged; Breast Neoplasms; Chi-Square Distribution; Female; Gamma Cameras; Humans; Lymph Node Excision; Lymphatic Metastasis; Middle Aged; Patient Selection; Predictive Value of Tests; Radionuclide Imaging; Sentinel Lymph Node Biopsy; Taiwan; Technetium Tc 99m Sulfur Colloid

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

Topics: Biopsy; Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Male; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Technetium Tc 99m Sulfur Colloid

To determine the technical success rate of sentinel lymph node biopsy in women with nonpalpable infiltrating breast cancer diagnosed by using percutaneous core biopsy and to determine the frequency with which sentinel lymph node biopsy obviated axillary dissection.. Retrospective review revealed 33 women who underwent sentinel node biopsy after percutaneous core biopsy diagnosis of nonpalpable infiltrating breast cancer. Sentinel nodes were identified with radioisotope and blue dye; the procedure was technically successful if sentinel nodes were found at surgery. All sentinel nodes were excised. Axillary dissection was performed if tumor was present in sentinel nodes.. Sentinel nodes were found at surgery in 30 women (91%). Sentinel nodes were identified with both radioisotope and blue dye in 22 (73%) of these women, with only radioisotope in six (20%), and with only blue dye in two (7%). Sentinel nodes were found in 12 (80%) of 15 women in the first half of the study versus all 18 (100%) women in the second half (P = .08). Sentinel nodes were free of tumor in 23 (77%) of 30 women. In six (86%) of seven women with tumor in sentinel nodes, the sentinel nodes were the only nodes with tumor.. Sentinel node biopsy was successful in 30 women (91%) with nonpalpable infiltrating carcinoma diagnosed with percutaneous core biopsy and obviated axillary dissection in 23 women (70%). Using both radioisotope and blue dye may increase the success rate. A learning curve exists, and success improves with experience.

Topics: Adult; Aged; Aged, 80 and over; Biopsy; Biopsy, Needle; Breast Neoplasms; Coloring Agents; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Technetium Tc 99m Sulfur Colloid

A significant morbidity risk is associated with axillary nodal dissections for breast cancer. Many treatment decisions are based on axillary nodal status. Lymphatic mapping and sentinel node biopsy have been investigated to determine if the histology of the sentinel node reflects the remaining lymph node basin. We describe the technical aspects of sentinel node lymphoscintigraphy for breast cancer.. Ninety-three patients had lymphoscintigraphy for breast cancer. Patients with palpable lesions had 4 concentric injections around the site and lesions requiring localization had injections made through tubing connected to the localizing wire introducer needle. Immediate static images were acquired and the sentinel node was marked for surgery. Marks were reverified using a handheld gamma probe.. Lymph nodes were visualized by lymphoscintigraphy in 87% of cases. Time to visualization of lymph nodes ranged from 1-120 min with a mean of 28 min. An average of 1.5 nodes were visualized. The overall success rate for identifying the sentinel node at time of surgery was 85%.. We conclude that lymphoscintigraphy for breast cancer is a detailed procedure that requires coordination with radiology and surgery teams to ensure proper identification of sentinel lymph nodes.

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

Axillary node status remains the most important prognostic indicator of survival in breast cancer patients. Only 25% to 35% of patients having standard level I/II axillary dissection have involved nodes, yet all accept the potential for morbidity after the operation. This study was conducted to assess whether status of the sentinel node(s) was an accurate predictor of the presence of metastatic disease in axillary or internal mammary nodes.. In 180 patients, technetium 99m sulphur colloid was injected in a 4-quadrant peritumoral distribution. During the first phase of the study, 72 patients had sentinel node excision followed by a level I/II axillary dissection. During the second phase of the study, 108 patients had sentinel node excision and only those with positive nodes had completion axillary dissection. Nodes were examined after formalin fixation by taking 10 sections at 20-microm intervals and staining with hematoxylin-eosin.. Sentinel nodes were found in 162 (90%) of 180 patients. The mean number of sentinel nodes examined was 3.1. Of the 162 patients with successful lymphatic mapping, positive sentinel nodes were found in 44 (27%). In 23 (66%) of 35 patients with positive sentinel nodes who had a completion level I/II axillary dissection, the sentinel nodes were the only positive nodes. The concurrent negative predictive value was 4% in the first 72 patients who had completion axillary dissection after sentinel node excision, and 2% for the entire series. With evolution of technique, identification of sentinel nodes with radiolabeled colloid was successful in 97% of the last 100 patients.. Because the concurrent negative predictive value was low, sentinel node excision appeared to accurately identify node status, potentially avoiding the need for standard level I/II axillary dissection in sentinel node-negative patients.

Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Predictive Value of Tests; Prognosis; Radionuclide Imaging; Radiopharmaceuticals; 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

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

The objective were to study the relevance of the subareolar injection for sentinel node [SN] detection in multiple foci breast cancer. Seventy-nine patients with infiltrative breast carcinoma (diagnosed pre-operatively by core biopsy) and a mean age of 55 (31-78) years were enrolled. All patients were free of previous homolateral surgery, chemotherapy, locoregional radiotherapy or prevalent axillary lymph node. Using four 0.1 ml injections of 1.8 MBq, the technetium-99m 100 nm filtered sulfur colloid was injected by subareolar way (group I) in 16 cases of radiologically cancer with multiple invasive foci and 31 cases of radiologically unifocal cancer, and by peritumoral way (group II) in 32 cases of radiologically unifocal cancer. Scintigrams were obtained 2 to 4 hours after the injections and radioactive nodes were detected peroperatively 18 hours after the injection by intraoperative detection probe. Individual removal of all radioactive nodes was followed by axillary dissection at levels I and II of Berg including Rotter area control. All sentinel nodes were submitted to standard histopathological analysis on serial sections at 500 mu intervals completed by immunohistochemistry for cytokeratin on negative SN. SN were detected by scintigrams in 85% and 88% of the cases of group I and group II respectively, but in 98% and 97% of the cases of respectively both groups by intraoperative probe. Group I was composed of 69% ductal, 22% lobular and 9% tubular carcinomas, and group II of 87% ductal, 10% lobular and 3% tubular carcinomas. Seven and 5 radiologically unifocal tumors were in fact with multiple invasive foci at histology in groups I and II respectively. The complete scintigraphic procedure permitted the detection of a mean number of 2.7 (1-7) SN in group I and 2.3 (1-4) in group II (NS). In group I, the SN were metastatic in 22 patients (48%), 15 of them with the metastases being restricted to the SN, whereas in group II, the SN were metastatic in 9 patients (28%), 5 of them with the positivity restricted to the SN. No false negative result (SN negative and other axillary nodes positive) was observed in group I and only one false negative result in group II which was related to a cancer with histological multiple invasive foci. Sensitivities were 100% and 90%, and negative predictive values were 100% and 95%, for groups I and II respectively. Subareolar injection of radiocolloid allows identification of SN in cases of unifocal and multiple cancer. Th

Topics: Adenocarcinoma; Adult; Aged; Breast Neoplasms; Carcinoma, Ductal, Breast; Carcinoma, Lobular; Female; Humans; Injections; Lymph Nodes; Middle Aged; Neoplasms, Multiple Primary; Nipples; Radionuclide Imaging; Radiopharmaceuticals; Sensitivity and Specificity; Technetium Tc 99m Sulfur Colloid

Sentinel lymph node biopsy with Technetium 99m sulfur colloid (Tc99m) is an evolving technique that offers the potential for improved staging of breast cancer with decreased morbidity. However, the use of radioactive materials in the operating room generates significant concern about radiation exposure. The purpose of this study was to evaluate radiation exposure to operating room personnel, pathologist, and equipment from specimens during breast sentinel lymph node biopsy.. Twenty patients were injected with 0.7 to 1.1 mCi of Tc99m sulfur colloid 1.5 to 3 hours before sentinel lymph node biopsy. A calibrated Geiger counter was used to measure dose rates from the breast injection site before skin incision (n = 20), lumpectomy specimens (n = 8), and sentinel nodes (n = 20) at distances of 3, 30, and 300 cm. This represented exposure to the surgeon's hands, surgeon's torso, and scrub nurse, respectively. Exposure to the pathologist's hands and torso was represented as dose-rate measurements from lumpectomy and nodal specimens. The operative instruments, trash receptacles, suction canisters, pathology slides, and cryostat machines were measured at 3 cm at the conclusion of each procedure. Specimens or equipment emitting radiation doses equal to background levels (0.04 mRem/h) were exempt from special handling and disposal.. The highest exposure rate was to the surgeon's hands from the breast injection site before skin incision (34.25 mRem/h). Exposure to the surgeon's torso measured 1.33 mRem/h, and exposure to the scrub nurse's torso measured 0.15 mRem/h from the injection site. Exposure to the pathologist's hands was 18.62 and 0.06 mRem/h from the lumpectomy specimen and sentinel node, respectively. Exposure to the pathologist's torso measured 0.34 and 0.04 mRem/h from the lumpectomy specimen and sentinel node, respectively. One hundred percent of lumpectomy specimens measured above the exempt level. Thirty-two of 46 (70%) sentinel lymph nodes emitted radiation equal to the exempt background level. Seventeen of 20 trash receptacles (85%) and 4 of 12 (33%) suction canisters measured equal to background levels. All operative instruments, pathology slides, and cryostat machines were equal to background levels.. Radiation exposure to operating room personnel, pathologists, and operative equipment during a breast sentinel node biopsy using Tc99m is minimal. A primary surgeon can perform 2,190 hours, a scrub nurse 33,333 hours, and a pathologist 14,705 hours of procedural work before surpassing Occupational Safety and Health Administration limits. Operative instruments, pathology slides, and cryostat machines do not require special handling. All lumpectomy specimens should be stored for decontamination until the dose rate equals background levels. Intraoperative dose-rate monitoring allows selective decontamination of nodal specimens, trash receptacles, and suction canisters, which decreases disposal time and cost.

Topics: Air Pollutants, Radioactive; Biopsy; Breast Neoplasms; Female; Humans; Lymph Nodes; Male; Mastectomy, Segmental; Occupational Exposure; Operating Rooms; Radiation Dosage; Radiation Protection; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid

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

Sentinel node biopsy (SNB) has emerged as a potential alternative to routine axillary dissection in clinically node-negative breast cancer.. From September 1995 to June 1996 at Memorial Sloan-Kettering Cancer Center, 60 patients with clinically node-negative cancer underwent SNB, which was immediately followed by standard axillary dissection. Both blue dye and radioisotope were used to identify the sentinel node. SNB was compared with standard axillary dissection for its ability to accurately reflect the final pathologic status of the axillary nodes.. The sentinel node was successfully identified by lymphoscintigraphy in 75% (42 of 56), by blue dye in 75% (44 of 59), by isotope in 88% (52 of 59), and by the combination of blue dye and isotope in 93% (55 of 59) of all 59 evaluable patients. Of the 55 patients in this study where sentinel nodes were identified, 20 (36%) were histologically positive. The sentinel node was falsely negative in three patients, yielding an accuracy of 95%. SNB was more accurate for T1 (98%) than for T2-T3 tumors (82%).. Lymphatic mapping is technically feasible, reliably identifies a sentinel node in most cases, and appears more accurate for T1 tumors than for larger lesions. Blue dye and radioisotope are complementary techniques, and the overall success of the procedure is maximized when the two are used together.

Topics: Biopsy; Breast Neoplasms; Coloring Agents; Feasibility Studies; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid

To define preliminary guidelines for the use of lymphatic mapping techniques in patients with breast cancer.. Lymphatic mapping techniques have the potential of changing the standard of surgical care of patients with breast cancer.. Four hundred sixty-six consecutive patients with newly diagnosed breast cancer underwent a prospective trial of intraoperative lymphatic mapping using a combination of vital blue dye and filtered technetium-labeled sulfur colloid. A sentinel lymph node (SLN) was defined as a blue node and/or a hot node with a 10:1 ex vivo gamma probe ratio of SLN to non-SLN. All SLNs were bivalved, step-sectioned, and examined with routine hematoxylin and eosin (H&E) stains and immunohistochemical stains for cytokeratin. A cytokeratin-positive SLN was defined as any SLN with a defined cluster of positive-staining cells that could be confirmed histologically on H&E sections.. Fine-needle aspiration (FNA) or stereotactic core biopsy was used to diagnose 195 of the 422 patients (46.2%) with breast cancer; 227 of 422 patients (53.8%) were diagnosed by excisional biopsy. The SLN was successfully identified in 440 of 466 patients (94.4%). Failure to identify an SLN to the axilla intraoperatively occurred in 26 of 466 patients (5.6%). In all patients who failed lymphatic mappings, a complete axillary dissection was performed, and metastatic disease was documented in 4 of 26 (15.4%) of these patients. Of the 26 patients who failed lymphatic mapping, 11 of 227 (4.8%) were diagnosed by excisional biopsy and 15 of 195 (7.7%) were diagnosed by FNA or stereotactic core biopsy. Of interest, there was only one skip metastasis (defined as a negative SLN with higher nodes in the chain being positive) in a patient with prior excisional biopsy. A mean of 1.92 SLNs were harvested per patient. Twenty percent of the SLNs removed were positive for metastatic disease in 105 of 440 (23.8%) of the patients. Descriptive information on 844 SLNs was evaluated: 339 of 844 (40.2%) were hot, 272 of 844 (32.2%) were blue, and 233 of 844 (27.6%) were both hot and blue. At least one positive SLN was found in 4 of 87 patients (4.6%) with noninvasive (ductal carcinoma in situ) tumors. A greater incidence of positive SLNs was found in patients who had invasive tumors of increasing size: 18 of 112 patients (16%) with tumor size between 0.1 mm and 1 cm had positive SLNs. However, a significantly greater percentage of patients (43 of 131 [32.8%] with tumor size between 1 and 2 cm and 31 of 76 [40.8%] with tumor size between 2 and 5 cm) had positive SLNs. The highest incidence of positive SLNs was seen with patients of tumor size greater than 5 cm; in this group, 9 of 12 (75%) had a positive SLN (p < 0.001).. This study demonstrates that accurate SLN identification was obtained when all blue and hot lymph nodes were harvested as SLNs. Therefore, lymphatic mapping and SLN biopsy is most effective when a combination of vital blue dye and radiolabeled sulfur colloid is used. Furthermore, these data demonstrate that patients with ductal carcinoma in situ or small tumors exhibit a low but significant incidence of metastatic disease to the axillary lymph nodes and may benefit most from selective lymphadenectomy, avoiding the unnecessary complications of a complete axillary lymph node dissection.

Topics: Biopsy; Breast Neoplasms; Carcinoma in Situ; Carcinoma, Ductal, Breast; Coloring Agents; Female; Humans; Immunohistochemistry; Lymph Nodes; Lymphatic Metastasis; Prospective Studies; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

Recent reports indicate that the sentinel node, defined as the first regional lymph node to receive lymphatic fluid from the breast, accurately represents the metastatic status of the primary breast cancer. However, routine single section examination of the regional nodes, including the sentinel node, underestimates the true incidence of metastases. The goal of this study is to determine whether multiple sectioning of sentinel nodes will detect occult metastases in operable breast cancer.. Nineteen patients with invasive breast cancers were injected with technetium-99m sulfur colloid solution around the tumor or at the biopsy site before lumpectomy and axillary lymph node dissection (ALND) or mastectomy. The labeled sentinel lymph nodes (SLND) were bivalved, and a central section was taken for hematoxylin and eosin (H & E) examination. The sentinel nodes of 13 patients, which were reported to be negative for metastases, were serially sectioned at 0.5-mm intervals and stained with H & E and a cytokeratin stain, CAM 5.2.. In the 13 node-negative patients, occult metastases were found in the sentinel nodes of 3 patients (23%). Two were seen on H & E and one by cytokeratin stain. The mean numbers of SLND and ALND in this series were 2.6 and 12.5, respectively, and the average number of sections for the two groups was 14 and 1, respectively.. Multiple sectioning of the sentinel node or nodes detects occult metastases and changes the staging of breast cancer.

Topics: Adult; Aged; Axilla; Breast Neoplasms; Histocytochemistry; Humans; Lymph Node Excision; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Pilot Projects; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid

Several reports have demonstrated the accurate prediction of axillary nodal status (ANS) with radiolocalization and selective resection of sentinel lymph nodes (SLN) in breast cancer. To date, no technique has proven to be superior in localizing the SLN.. 1.0 mCi of clear unfiltered 99mtechnetium sulfur colloid was injected under ultrasonographic (US) guidance around the perimeter of the breast lesion (palpable and nonpalpable) or previous biopsy site. Resection of the radiolocalized nodes was performed, followed by complete axillary lymph node dissection (AXLND).. Forty-two breast cancer patients underwent SLN biopsy after US-guided radiopharmaceutical injection. The SLN was localized in 41 patients (98%). The type of previously performed diagnostic biopsy did not influence the ability to localize the sentinel lymph node. Pathology revealed nodal metastasis in 7 of the 41 evaluable patients (17%). ANS was accurately predicted in 40 of 41 patients (98%).. Early experience with radiolocalization and selective resection of SLN in breast cancer remains promising. Use of US-guided injection facilitates localization of the SLN, perhaps as a result of more accurate placement of the radionuclide marker. Use of this technique allowed for effective management of patients regardless of tumor size or the extent of prior biopsy, thereby expanding the potential number of eligible patients for SLN biopsy.

Topics: Analysis of Variance; Axilla; Biopsy, Needle; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid; Ultrasonography

Regional lymph node metastases in patients with breast cancer have fundamental staging, prognostic, and treatment implications. Classically, axillary lymph node sampling requires a dissection under general anesthesia. The concept that a primary, or sentinel, lymph node is the first node to receive drainage from a tumor has been established in patients with malignant melanomas using radiolabeled tracers and vital dyes. This study proposed two hypotheses: (1) radiolabeled sentinel lymph nodes can be identified in most patients with breast cancer, and (2) radiolabeled sentinel lymph node biopsy accurately predicts axillary lymph node metastases in those patients. Patients with operable breast cancer had Tc-99 sulphur colloid injected around their breast tumors 1-6 hours preoperatively. Patients underwent gamma probe identification of sentinel lymph nodes that were biopsied. All patients underwent axillary lymphadenectomy in conjunction with lumpectomy or mastectomy. Fifty female patients ages 26 to 90 years underwent lumpectomies with axillary dissections (40 patients) or modified radical mastectomies (10 patients). Sentinel lymph nodes were identified in 42 of 50 patients (84%). Eight patients (16%) had metastases to the axillary lymph nodes. In 7 patients, sentinel lymph nodes correctly predicted the status of the axillary nodes. There was one false negative result. A total of 550 lymph nodes were resected for an average of 11.2 nodes per patient. Sentinel lymph node scintigraphy and biopsy accurately predicted the axillary lymph node status in 41 of 42 patients (98%). Scintigraphy can identify sentinel lymph nodes in a large majority of patients. Sentinel lymph node biopsy is an accurate predictor of axillary lymphatic metastases.

Topics: Adult; Aged; Aged, 80 and over; Axilla; Biopsy; Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Mastectomy, Modified Radical; Mastectomy, Segmental; Middle Aged; Predictive Value of Tests; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid

Pilot studies indicate that probe-guided resection of radioactive sentinel nodes (the first nodes that receive drainage from tumors) can identify regional metastases in patients with breast cancer. To confirm this finding, we conducted a multicenter study of the method as used by 11 surgeons in a variety of practice settings.. We enrolled 443 patients with breast cancer. The technique involved the injection of 4 ml of technetium-99m sulfur colloid (1 mCi [37 MBq]) into the breast around the tumor or biopsy cavity. "Hot spots" representing underlying sentinel nodes were identified with a gamma probe. Sentinel nodes subjacent to hot spots were removed. All patients underwent a complete axillary lymphadenectomy.. The overall rate of identification of hot spots was 93 percent (in 413 of 443 patients). The pathological status of the sentinel nodes was compared with that of the remaining axillary nodes. The accuracy of the sentinel nodes with respect to the positive or negative status of the axillary nodes was 97 percent (392 of 405); the specificity of the method was 100 percent, the positive predictive value was 100 percent, the negative predictive value was 96 percent (291 of 304), and the sensitivity was 89 percent (101 of 114). The sentinel nodes were outside the axilla in 8 percent of cases and outside of level 1 nodes in 11 percent of cases. Three percent of positive sentinel nodes were in nonaxillary locations.. Biopsy of sentinel nodes can predict the presence or absence of axillary-node metastases in patients with breast cancer. However, the procedure can be technically challenging, and the success rate varies according to the surgeon and the characteristics of the patient.

Topics: Axilla; Breast Neoplasms; Carcinoma, Ductal, Breast; Carcinoma, Lobular; False Negative Reactions; Female; Humans; Logistic Models; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Radionuclide Imaging; Radiopharmaceuticals; Sensitivity and Specificity; Technetium Tc 99m Sulfur Colloid

The role of axillary lymph node dissection (ALND) in breast cancer is currently being reevaluated. Sentinel node biopsy (SNB) holds promise for replacing full dissection in a large number of patients with breast cancer.. We evaluated SNB utilizing an intraoperative gamma probe localization technique following injection of technetium sulfur colloid in 80 patients with primary breast cancer and clinically negative axillae. Forty-eight patients were evaluated at Baptist Medical Center, Montgomery, Alabama, and 32 at Rush-Presbyterian-St. Luke's Medical Center in Chicago, Illinois.. At least one sentinel node was found in 70 of the 80 patients (88%). One patient had a sentinel node in both the axilla and internal mammary chain. The remainder had axillary sentinel nodes only. The sentinel nodes accurately predicted the status of the axilla in 69 of the 70 patients (99%). One of 14 node-positive patients would have been missed with sentinel node biopsy alone, for a false negative rate of 7%. Four node-positive patients would have been missed with routine ALND without serial sectioning (SS) and immunohistochemical staining (IH) of the sentinel node.. Sentinel node biopsy with SS and IH more precisely predicted the status of the axilla than routine ALND in this group of patients. SNB will likely replace full axillary dissection in the majority of patients with breast cancer.

Topics: Adult; Aged; Aged, 80 and over; Axilla; Biopsy; Breast Neoplasms; False Negative Reactions; Female; Humans; Immunohistochemistry; Lymph Node Excision; Lymph Nodes; Middle Aged; Neoplasm Staging; Predictive Value of Tests; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

Topics: Breast Neoplasms; Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Nuclear Medicine; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid

Axillary metastases remain an important prognostic indicator in breast cancer. Axillary lymphadenectomy (ALND) carries significant morbidity and is unnecessary in most patients with early breast cancer; thus, sentinel lymph node (SLN) biopsy has been advocated for axillary staging. We studied the SLN identification rate and its accuracy in predicting axillary metastases.. One hundred nineteen women with breast carcinoma underwent SLN and ALND. Lymphoscintigraphy was performed using Technetium99 sulfur colloid supplemented by Isosulfan blue dye. Hematoxylin/eosin-stained lymph node sections were examined by light microscopy.. The SLN identification rate was 81%. One SLN was negative (1%) in a patient with axillary disease. SLN histology correctly predicted the absence of axillary disease in 98.6%. Sensitivity, specificity, and positive and negative predictive values were 96%, 100%, 100%, and 99%, respectively.. Sentinel lymph node biopsy accurately predicts total axillary status and is valuable in the surgical staging of breast cancer.

Topics: Adult; Aged; Aged, 80 and over; Axilla; Biopsy; Breast Neoplasms; Eosine Yellowish-(YS); Feasibility Studies; Female; Hematoxylin; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Predictive Value of Tests; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

LL1, a monoclonal antibody (MAb) to HLA Class-II-like antigen (li determinant) on the surface of B-lymphocytes, monocytes and histiocytes, was evaluated as an agent for bone marrow imaging. Six patients with diverse diseases (non-Hodgkin's lymphoma, n = 2; multiple myeloma, n = 1; polycythaemia vera, n = 1; lung cancer, n = 1; breast cancer, n = 1) were given low protein doses (< 1 mg) of 99Tcm (30 mCi) labelled Fab' of LL1. 99Tcm-sulphur colloid (SC) imaging was performed in three patients for comparison. Both planar and single photon emission tomographic images were acquired using Sopha gamma cameras. As early as 2 h post-MAb injection, excellent bone marrow images were achieved in all patients, demonstrating both normal or hyperproliferative marrow, as well as 'cold' bone marrow abnormalities such as radiation defects or cancer metastases. Similar to SC, relatively high uptake of LL1 was found in the liver and spleen. However, the bone marrow-to-liver and -spleen uptake ratios were approximately 19-fold higher (0.75 vs 0.04) and 6-fold higher (1.23 vs 0.22), respectively, with LL1 than with SC. The higher bone marrow uptake allowed clearly superior visualization of the thoracic spine when compared to SC. The mean T1/2 of blood and whole-body clearance were 0.4 and 66 h, respectively. The highest radiation absorbed doses (in cGy mCi-1) were observed in the spleen (0.47 +/- 0.24), kidneys (0.25 +/- 0.09) and liver (0.14 +/- 0.04). The bone marrow dose was only 0.05 +/- 0.02 cGy mCi-1. These results indicate that bone marrow imaging with 99Tcm-LL1 is feasible, and that LL1 may be a suitable alternative to SC because of better visualization of the lower thoracic spine. Potential applications include the improved detection of bone marrow metastases of solid tumours and the assessment of haematological disorders.

Topics: Animals; Antibodies, Monoclonal; Bone Marrow; Breast Neoplasms; Female; Humans; Lung Neoplasms; Lymphoma, Non-Hodgkin; Mice; Multiple Myeloma; Neoplasms; Polycythemia Vera; Radioimmunodetection; Technetium; Technetium Tc 99m Sulfur Colloid; Tissue Distribution; Tomography, Emission-Computed

To identify the sentinel lymph node(s) (SLN[s]) (the first node[s] draining the primary tumor in the regional lymphatic basin) in patients with invasive breast cancer and to test the hypothesis that the histologic characteristics of the SLN predict the histologic characteristics of the remaining lymph nodes in the axilla.. A prospective trial.. Sixty-two patients with newly diagnosed invasive breast cancers.. Patients underwent intraoperative lymphatic mapping using a combination of a vital blue dye and filtered technetium-labeled sulfur colloid. The SLN was identified and removed, followed by a definitive cancer operation, including a complete axillary node dissection.. The metastatic distribution in the axilla was determined in patients with occult nodal disease.. The SLN was successfully identified in 57 (92%) of 62 patients using the 2 lymphatic mapping procedures. After localization, 18 patients (32%) were found to have metastatic disease, and the SLN tested positive in all 18 patients. There were no "skip" metastases, defined as an SLN that tested negative with higher nodes that tested positive. In 12 (67%) of 18 patients with metastatic disease, the SLN was the only site of disease. The metastatic distribution significantly favored SLN involvement. Among subjects with discordant nodal involvement, the probability of observing the distribution of SLN involvement by chance is very small (P<.001).. This study confirms that lymphatic mapping is technically possible in the patient with breast cancer and that the histologic characteristics of the SLN probably reflect the histologic characteristics of the rest of the axillary lymph nodes. The procedure also allows the pathologist to focus the histologic examination on 1 or 2 nodes, potentially increasing the yield of positive dissections and the accuracy of staging.

Topics: Axilla; Biopsy; Breast Neoplasms; Carcinoma, Ductal, Breast; Carcinoma, Lobular; Coloring Agents; Female; Humans; Intraoperative Period; Lymph Node Excision; Lymphatic Metastasis; Probability; Prospective Studies; Sensitivity and Specificity; Technetium Tc 99m Sulfur Colloid

The distribution of 99Tcm-sulphur colloid (99Tcm-SC) in 15 patients receiving human recombinant granulocyte colony-stimulating factor (G-CSF) following high-dose combination chemotherapy and autologous bone marrow transplantation (ABMT) for treatment of solid tumours was prospectively determined. 99Tcm-SC imaging was performed before treatment and at the time of leukocyte recovery during G-CSF administration. On the baseline 99Tcm-SC study, lung and bone marrow radiocolloid activity were not detected. The study performed during G-CSF infusion demonstrated lung colloid activity in 12 of 15 patients and bone marrow colloid activity in 11 of 15 patients. The average background corrected region of interest counts significantly increased for lung (P < 0.008), bone marrow (P < 0.0001) and cardiac blood pool (P < 0.05), and significantly decreased for liver (P < 0.0005) during G-CSF compared to the baseline study. No relationship between the distribution of 99Tcm-SC and response to therapy or patient outcome could be established. In conclusion, these data demonstrate a shift of 99Tcm-SC to lung, bone marrow and cardiac blood pool, and away from liver following high-dose combination chemotherapy and ABMT and during G-CSF administration in patients undergoing treatment for solid tumours.

Topics: Antineoplastic Combined Chemotherapy Protocols; Bone Marrow Transplantation; Breast Neoplasms; Female; Granulocyte Colony-Stimulating Factor; Humans; Male; Melanoma; Prospective Studies; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

Clinically significant lesions originating within a Riedel's lobe are extremely rare. Characteristic findings from a Tc-99m SC liver-spleen scan of metastatic breast carcinoma arising in a Riedel's lobe are described.

Topics: Breast Neoplasms; Carcinoma, Intraductal, Noninfiltrating; Female; Humans; Liver; Liver Neoplasms; Middle Aged; Radionuclide Imaging; Spleen; Technetium Tc 99m Sulfur Colloid

Topics: Breast Neoplasms; Carcinoma, Intraductal, Noninfiltrating; Female; Humans; Liver; Middle Aged; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

Lymphoscintigraphy was performed in 50 cases of breast cancer using 99mTc-colloid as a tracer. The results indicated that 277 lymph nodes, 128 on the right side and 149 on the left, were imaged. Most of the lymph nodes were located in the second and third intercostal spaces. The mean distance between these lymph nodes and mid line was 1.93 +/- 1.05 cm-2.70 +/- 0.93 cm. The mean depth was 2.42 +/- 0.52 cm-3.07 +/- 0.72 cm. It was over 4.0 cm in isolated cases. The lymph nodes which were not showed after repeated examination could have been involved by the cancer. Radionuclide lymphoscintigraphy, being safe, easily repeated and having low radiation dose and good image, is very useful for radiotherapy.

Topics: Adult; Aged; Breast Neoplasms; Female; Gamma Cameras; Humans; Lymph Nodes; Middle Aged; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

The pathological status of the axillary nodes remains the single most determining factor for survival, local recurrence and disease-free interval in operable breast cancer. Radical axillary dissection results in better local control with or without systemic disease in all operable cases. In pathologically negative cases, radical axillary dissection decreases local recurrence rates and perhaps prolongs disease-free survival. In pathologically positive cases, radical axillary dissection improves local control only. Radical axillary dissection avoids axillary irradiation and so decreases the risk and the importance of lymphoedema. Perfect axillary dissection does not show a decisive advantage over less complete axillary dissection when the 'quality' of surgery is measured by lymphoscintigraphy, but it should be kept in mind that only total control of the local situation can ensure a patient free of distal spread at the time of first therapy.

Topics: Axilla; Breast Neoplasms; Female; Follow-Up Studies; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Mastectomy, Modified Radical; Neoplasm Recurrence, Local; Neoplasm Staging; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

Fatty infiltration of the liver may cause a range of focal abnormalities on hepatic sonography which may simulate hepatic nodular lesions. Discrete deposits of fat or islands of normal tissue which are uninvolved by fatty infiltration may stand out as potential space-occupying lesions on the sonograms. Twelve patients with such focally abnormal ultrasound images were referred for liver scintigraphy with 133Xe and 99mTc colloidal SPECT studies to clarify the issue. These examinations helped identify, in nine of 12 patients, the innocent nature of the sonographic abnormalities which were simply related to the fat deposition process. Further, [99mTc]RBC scans defined the additional pathologic process in three patients in whom actual space-occupying lesions were indeed present in the liver. Scintigraphy has an important role to play in the understanding of focal hepatic ultrasound abnormalities particularly in unsuspected hepatic steatosis.

Topics: Aged; Aged, 80 and over; Breast Neoplasms; Erythrocytes; Fatty Liver; Female; Hemangioma; Humans; Liver; Liver Neoplasms; Male; Middle Aged; Technetium; Technetium Tc 99m Sulfur Colloid; Tomography, Emission-Computed; Ultrasonography; Xenon Radioisotopes

Conservative surgery combined with radiation therapy for the treatment of early breast carcinoma has been shown to achieve both a high rate of local tumor control and good cosmetic results with a minimum of complications. Whether the internal mammary lymph nodes (IMNs) should be included in the treatment volume is a topic of considerable controversy. Radionuclide internal mammary node lymphoscintigraphy (IMN-LS) can locate these nodes in three dimensions. We have analyzed the results of IMN-LS in 167 patients imaged at the Dana-Farber Cancer Institute and treated at the Joint Center for Radiation Therapy between 1977 and 1980. The location of the IMNs was found variable from patient to patient. At least one IMN was not included within tangential fields arbitrarily arranged to have a medial entrance point 3.0 cm across the midline in 17% of evaluable patients. However, 48% and 66% of patients had IMNs that could be adequately treated with fields positioned only 1.0 cm or 2.0 cm across midline, respectively. We conclude that when treatment of the IMNs is warranted, IMN-LS not only assures their complete coverage in the majority of patients but also may help reduce the amount of heart and lung irradiated.

Topics: Breast; Breast Neoplasms; Female; Humans; Lymph Nodes; Radionuclide Imaging; Radiotherapy Planning, Computer-Assisted; Technetium Tc 99m Sulfur Colloid

The objective of this study is to correlate the presence of bone and liver metastases in patients with breast cancer with respect to the results of bone and liver scans, axillary nodal status, and serum alkaline phosphatase levels. One hundred ninety-seven patients with breast cancer treated by modified radical mastectomy between the years 1978 and 1981 were studied. Fifty-nine (30%) of the total group had distant metastases during the course of observation of 60 to 96 months; of 35 patients in whom bone metastases developed, 30 had normal preoperative bone scan results. Of 21 patients who had liver metastases, 19 had normal preoperative liver scans. Nineteen (70%) of the 27 patients with abnormal bone scans had normal alkaline phosphatase levels. Seven (63%) of the 11 patients who had abnormal liver scans had a normal alkaline phosphatase. The study supports the concept that preoperative bone and liver scans are ineffective indicators of metastatic involvement. Selection of patients for screening by bone and liver scans according to alkaline phosphatase determinations was not supported by this study. The appropriate use of bone scans for screening in patients with breast carcinoma is suggested as a follow-up device in patients with positive lymph nodes.

Topics: Alkaline Phosphatase; Bone Neoplasms; Breast Neoplasms; Diphosphates; Female; Humans; Liver Neoplasms; Mastectomy; Radionuclide Imaging; Technetium; Technetium Tc 99m Pyrophosphate; Technetium Tc 99m Sulfur Colloid

The authors report their studies of 39 lymphoscintigraphies performed on patients with breast cancer. They point out that interpretation of scintigraphic imaging must take into account the morphologic variations of the lymph nodes of the internal mammary chains (i.e. single central chain, single central lymph node) and the morphological difference in the symmetry of lymph nodes considered non-pathologic to avoid false positives. The authors retain that lack of visualization of a chain, conspicuous increase in size of a lymph node, asymmetry of pathologic development, or reduced uptake by one or more lymph nodes of the internal mammary chains must be interpreted as a sign of metastatic spread. The authors recommend lymphoscintigraphy as an effective technique in the screening of breast cancer patients for staging, follow-up, restaging, and planning of radiotherapy.

Topics: Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Methods; Middle Aged; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

Preoperative detection of metastases in regional lymph nodes should constitute a fundamental step towards a better management of breast cancer. The National Cancer Institute of Milan has traditionally been engaged in this particular problem, that is, the search for a new imaging technique for detecting lymph nodal metastases from breast cancer. In 1984 axillary lymphoscintigraphy was performed on 26 patients with operable breast cancer by periareolar injection of 100 mu Ci of 99mTc sulphur microcolloid. The regional lymph nodes were identified as spot areas and a comparison was made between the number of primary draining axillary lymph nodes and their pathological examination. In only 2 of the 26 patients have more than 3 spot areas been revealed by axillary scintiscan, but this finding did not correspond to metastatic invasion. The lymphoscintigraphy pattern of the other 24 patients did not suggest any pathological condition. From our experience the method does not appear to help either a precise diagnosis of breast disease or the definition of the extent of mammary cancer.

Topics: Adult; Aged; Axilla; Breast Neoplasms; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

Three clinically unsuspected malignant pericardial effusions were discovered during routine dynamic hepatic scintigraphy. The only common clinical feature shared by the patients was dyspnea. Static scintigrams alone would not have detected these effusions, which points out again the importance of including dynamic scintigraphy in routine radionuclide evaluations of the liver.

Topics: Aged; Breast Neoplasms; Female; Humans; Liver; Lung Neoplasms; Lymphoma; Male; Middle Aged; Pericardial Effusion; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

To determine the accuracy of liver sonography in the diagnosis of liver metastases, the results of 99 patients with breast or lung cancer were compared with liver scintigraphy, physical examination, laboratory tests, histological examination and clinical follow-up. Liver sonography proved to be an accurate method to demonstrate or exclude liver metastases, with a sensitivity of 78.6% and a specificity of 90.0%. The highest accuracy was achieved if the sonographic examination of the liver was performed while there was a clinical suspicion of liver metastases and if compoundscan sonography was supplemented by real-time sonography.

Topics: Breast Neoplasms; Carcinoma, Bronchogenic; Humans; Liver Function Tests; Liver Neoplasms; Lung Neoplasms; Physical Examination; Retrospective Studies; Technetium Tc 99m Sulfur Colloid; Ultrasonography

Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Nodes; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

Recent studies suggest that 99mTc-labeled radiocolloid (SC) compounded with hydrogen sulfide can be used to visualize lymph channels and nodes. Our study prospectively compared SC with 99mTc antimony sulfide (SbS) colloid, in 28 patients undergoing internal mammary lymphoscintigraphy. Images were recorded on a scintillation camera and computer at 0.5, 1.0, and 3.0 hr. Quantitative analysis included assessment of percent (%) injected dose in nodes, the percent remaining at the injection site, and the relative intensity of the most cephalad node compared to a 57Co standard. The mean (means) % injected dose of both radiocolloids within visualized nodes was less than 1% at each time interval, with no significant differences between means's. The means % injected dose remaining at the injection site at 3.0 hr was 83 for SbS and 76 for SC not statistically significant (N.S.). The means of the ratio of counts within the most cephalad node at 3.0 hr to counts within a 57Co standard was 0.98 for SbS and 1.03 for SC (N.S.). Clinical assessment of number of nodes visualized and extent of radiocolloid migration showed no difference between the two agents. The biological and clinical parameters for the two colloids appear similar when used for internal mammary lymphoscintigraphy.

Topics: Adult; Aged; Antimony; Breast Neoplasms; Colloids; Female; Humans; Lymphatic Metastasis; Lymphoscintigraphy; Middle Aged; Prospective Studies; Technetium; Technetium Compounds; Technetium Tc 99m Sulfur Colloid

Indium is generally presumed to localize in the bone marrow within the erythroid cell line. Fibrosis, inflammation, lymphoma, extended field radiation, chemotherapy, or combinations of both treatment modalities generally depress the uptake of indium by the marrow a complex fashion. We report a case of metastatic breast carcinoma and pancytopenia in which the In-111 scan appeared qualitatively similar to a Tc-99m MDP bone scan. Findings were confirmed by bone marrow biopsy.

Topics: Bone Marrow; Bone Neoplasms; Breast Neoplasms; Diphosphonates; Female; Humans; Indium; Middle Aged; Pancytopenia; Radioisotopes; Radionuclide Imaging; Technetium; Technetium Tc 99m Medronate; Technetium Tc 99m Sulfur Colloid

The concentration of granulocyte-macrophage colonies in culture (CFU-c) in bone marrow cells was estimated, and bone marrow radionuclide scans were performed in a group of 15 cancer patients prior to bone marrow harvest for autologous transplantation. Preharvest CFU-c counts on iliac-crest bone marrow aspirates correlated very well with CFU-c counts from fresh and frozen-thawed bone marrows. Technetium-99m-sulfur colloid radionuclide scans showed that the distribution of total-body bone marrow and increased peripheral radionuclide uptake correlated with higher preharvest and harvest CFU-c counts. Bone marrow scan results were available in 1 h, whereas CFU-c counts took 14 days to obtain. Bone marrow scans may facilitate the clinical estimation of hemopoietic activity in patients under consideration for autologous bone marrow transplantation.

Topics: Bone Marrow; Breast Neoplasms; Carcinoma, Small Cell; Colony-Forming Units Assay; Hematopoiesis; Humans; Leukemia; Lung Neoplasms; Lymphoma; Male; Neoplasms; Radionuclide Imaging; Sulfur; Technetium; Technetium Tc 99m Sulfur Colloid; Testicular Neoplasms

The purpose of this study was to determine what effect further improvement in an Anger camera's intrinsic resolution has on lesion detection. We studied 52 patients undergoing bone imaging and 58 undergoing liver imaging. All patients had images performed in rapid sequence on ZLC -75 and ZLC -37 Anger cameras, both by Siemens. The two imaging systems are virtually identical except for the number of photomultiplier tubes and crystal thickness; these resulted in differences in intrinsic resolution ( ZLC -75 less than 3.8 mm FWHM at 140 keV, ZLC -37 less than 4.9 mm) and sensitivity ( ZLC -75 approximately 0.91 of ZLC -37 at 140 keV). Observer performance, measured by ROC curves, for detection of abnormalities was virtually identical with the two instruments. Subjectively, there was a trend toward preference of the ZLC -75 images, but this was not associated with any significant improvement in lesion detectability even in the subgroup in which a preference for one or the other instrument was noted.

Topics: Bone and Bones; Breast Neoplasms; Female; Humans; Image Enhancement; Liver; Lung Neoplasms; Male; Prostatic Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Sulfur; Technetium; Technetium Tc 99m Sulfur Colloid

A prospective evaluation of computed tomography (CT), ultrasonography (US), and Tc-99m sulfur colloid scintigraphy of the liver was performed in 189 patients who had either colon (n = 129) or breast (n = 60) carcinoma. Imaging was performed with fourth-generation CT scanners, gray-scale or phased array ultrasound scanners, and 37-tube gamma cameras. Studies were evaluated independently and receiver operating characteristic (ROC) curves were constructed. In addition, a standard 2 X 2 matrix analysis was performed. In patients who had all three examinations (n = 122), the matrix analysis showed that CT had a slightly higher sensitivity (0.93) than scintigraphy (0.86) or US (0.82); specificities were 0.88, 0.83, and 0.85, respectively. These differences were not statistically significant. However, ROC curves showed that CT had the highest true-positive ratio at every false-positive ratio, and that US had the lowest. The performance of CT did not differ significantly from that of scintigraphy, but was better than that of US (p less than .05), especially in patients with breast carcinoma. Overall, CT provided the most accurate means for detecting liver metastases from both primary lesions.

Topics: Breast Neoplasms; Carcinoma; Colloids; Colonic Neoplasms; Diatrizoate; Diatrizoate Meglumine; False Positive Reactions; Female; Humans; Liver; Liver Neoplasms; Male; Prospective Studies; Radionuclide Imaging; Sulfur; Technetium; Technetium Tc 99m Sulfur Colloid; Tomography, X-Ray Computed; Ultrasonography

The authors have reviewed their experiences in determining the presence of liver metastases in 103 patients by radiocolloid scanning. The sensitivity of liver scanning proved to be quite low if the presence of focal defects in the distribution of the tracer was chosen as the diagnostic criterion. The inclusion of less restrictive criteria such as liver enlargement or irregular distribution of the tracer, resulted in a higher sensitivity without lowering the predictive value of a negative scan. Using the latter diagnostic criterion, sensitivity, specificity and accuracy were in the range of 90%. Abnormal liver scans are common in patients classified at T3-T4 or N+ and their chances of being "true positive" are high. Conversely, abnormal scans are seldom found in patients classified at T1-T2 or N0 and probabilities of "false positive" results are high.

Topics: Breast Neoplasms; Decision Theory; Female; Gold Colloid, Radioactive; Humans; Liver Neoplasms; Organotechnetium Compounds; Phytic Acid; Radionuclide Imaging; Sulfur; Technetium; Technetium Tc 99m Sulfur Colloid

The authors have reviewed their experiences in determining the presence of liver metastases in 103 patients by radiocolloid scanning. The sensitivity of liver scanning proved to be quite low if the presence of focal defects of tracer's distribution was chosen as the diagnostic criterion. The inclusion of less restrictive criteria, such as liver enlargement or irregular distribution of the tracer, resulted in an higher sensitivity without lowering the predictive value of a negative scan. Using the more extensive diagnostic criterion, sensitivity, specificity and accuracy were in the range of 90%. Abnormal liver scans are common in patients classified as T3-T4 or N+ and their chances of to be "true positives" are high. Conversely, abnormal scans are seldom found in patients classified as T1-T2 or N0 and chances of "false positives" are high.

Topics: Breast Neoplasms; False Negative Reactions; False Positive Reactions; Female; Gold Colloid, Radioactive; Humans; Liver; Liver Neoplasms; Lymphatic Metastasis; Neoplasm Staging; Organotechnetium Compounds; Phytic Acid; Radionuclide Imaging; Sulfur; Technetium; Technetium Tc 99m Sulfur Colloid

Topics: Aged; Bone Marrow; Bone Neoplasms; Breast Neoplasms; Female; Gallium Radioisotopes; Humans; Liver; Liver Neoplasms; Male; Neoplastic Cells, Circulating; Prostatic Neoplasms; Radionuclide Imaging; Sulfur; Technetium; Technetium Tc 99m Sulfur Colloid

Topics: Axilla; Breast Neoplasms; Colloids; Evaluation Studies as Topic; Humans; Lymph Nodes; Mammography; Radionuclide Imaging; Sulfur; Technetium; Technetium Tc 99m Sulfur Colloid

Topics: Antimony; Axilla; Breast Neoplasms; Female; Humans; Lymph Nodes; Organotechnetium Compounds; Phytic Acid; Radionuclide Imaging; Sulfur; Technetium; Technetium Compounds; Technetium Tc 99m Sulfur Colloid

Topics: Breast Neoplasms; Colloids; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Radionuclide Imaging; Sulfur; Technetium; Technetium Tc 99m Sulfur Colloid