Comparison of Subdermal and Peritumoral Injection Techniques of Lymphoscintigraphy to Determine the Sentinel Lymph Node in Breast Cancer

Improved False-Negative Rates with Intraoperative Identification of Clipped Nodes in Patients Undergoing Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy

BACKGROUND

Identification and resection of a clipped node was shown to decrease the false-negative rate (FNR) of sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NAC) for patients presenting with initially node-positive breast cancer.

METHODS

Between March 2014 and March 2016, a prospective trial analyzed 98 patients with axilla-positive locally advanced breast cancer (T1-4, N1-3) to assess the feasibility and efficacy of placing clips into most suspicious biopsy-proven node. The study considered blue, radioisotope active, and suspiciously palpable nodes as sentinel lymph nodes (SLNs).

RESULTS

The SLN identification rate was 87.8%. The median age of the patients with an SLNB (n = 86) was 44 years (range 28-66 years). Of these patients, 77 (88.4%) had cT1-3 disease, and 10 (11.6%) had cT4 disease. The majority of the patients (n = 66, 76.7%) had cN1, whereas 21 patients (23.3%) had cN2 and cN3. A combined method was used for 37 patients (43%), whereas blue dye alone was used for the remaining patients (57%). The clipped node was the SLN in 70 patients (81.4%). For the patients with cN1 before NAC, the FNR was found to be 4.2% (1/24) when the clipped node was identified as an SLN. However, the FNR was estimated to be as high as 16.7% (1/6) for the patients with cN1 before NAC when the clipped node was found to be a non-SLN.

CONCLUSIONS

The study results also suggest that axillary dissection could be omitted for patients presenting initially with N1 disease and with a negative clipped node as the SLN after NAC due to the low FNR.

Meta-analysis of superficial versus deep injection of radioactive tracer and blue dye for lymphatic mapping and detection of sentinel lymph nodes in breast cancer

BACKGROUND

Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in early breast cancer. Currently, no consensus exists on the optimal site of injection of the radioactive tracer or blue dye.

METHODS

A systematic review and meta-analysis of studies comparing superficial and deep injections of radioactive tracer or blue dye for lymphatic mapping and SLNB was performed. The axillary and extra-axillary sentinel lymph node (SLN) identification rates obtained by lymphoscintigraphy and intraoperative SLNB were evaluated. Pooled odds ratios (ORs) and 95 per cent c.i. were estimated using fixed-effect analyses, or random-effects analyses if there was statistically significant heterogeneity (P < 0·050).

RESULTS

Thirteen studies were included in the meta-analysis. There was no significant difference between superficial and deep injections of radioactive tracer for axillary SLN identification on lymphoscintigraphy (OR 1·59, 95 per cent c.i. 0·79 to 3·17), during surgery (OR 1·27, 0·60 to 2·68) and for SLN identification using blue dye (OR 1·40, 0·83 to 2·35). The rate of extra-axillary SLN identification was significantly greater when deep rather than superficial injection was used (OR 3·00, 1·92 to 4·67). The discordance rate between superficial and deep injections ranged from 4 to 73 per cent for axillary and from 0 to 61 per cent for internal mammary node mapping.

CONCLUSION

Both superficial and deep injections of radioactive tracer and blue dye are effective for axillary SLN identification. Clinical consequences of discordance rates between the two injection techniques are unclear. Deep injections are associated with significantly greater extra-axillary SLN identification; however, this may not have a significant impact on clinical management.

Status of sentinel lymph node for breast cancer

Long-awaited results from randomized clinical trials designed to test the validity of sentinel lymph node biopsy (SLNB) as replacement of axillary lymph node dissection (ALND) in management of early breast cancer have recently been published. All the trials conclude SLNB has survival rates comparable to those of ALND (up to 10 years in one study) and conclude SLNB has less morbidity than ALND. All the trials support replacing ALND with SLNB for staging in early breast cancer; all support SLNB as the standard of care for such cancer. The SLNB protocols used in the trials varied, and no consensus that would suggest a standard protocol exists. The results of the trials and of other peer-reviewed research do, however, suggest a framework for including some specific methodologies in accepted practice. This article highlights the overall survival and disease-free survival data as reported from the clinical trials. This article also reviews the status of SLN procedures and the following: male breast cancer, the roles of various imaging modalities (single-photon emission computed tomography/computed tomography, positron emission tomography/computed tomography, and ultrasound), ductal carcinoma in situ, extra-axillary SLNs, SLNB after neoadjuvant chemotherapy, radiation exposure to patients and medical personnel, and a new radiotracer that is the first to label SLNs not by particle trapping but by specific macrophage receptor binding. The proper Current Procedural Terminology (CPT) code for lymphoscintigraphy and SLN localization prior to surgery is 78195.

Intra-individual comparison of lymphatic drainage patterns using subareolar and peritumoral isotope injection for breast cancer

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Factors affecting false-negative breast sentinel node biopsy in Chinese patients

BACKGROUND

The objective of the research was to validate our results on sentinel lymph node biopsy (SLNB) and to determine factors affecting false-negative (FN) rates of SLNB in Chinese patients with invasive breast cancers.

METHODS

A retrospective study of patients with clinically node-negative invasive breast cancer was carried out from May 1999 to April 2006. A combination of radioisotope (99m)technetium(Tc)-albumin sulfur colloid and Patent Blue V dye was used to identify the sentinel lymph node. Sentinel lymph node biopsy was followed by standard level I and II axillary dissection in all patients. Various clinicopathologic variables were analysed to determine factors associated with FN SLNB.

RESULTS

Three hundred and sixty-five Chinese patients received SLNB consecutively during the study period. Seventy-eight patients with neoadjuvant chemotherapy and 56 patients with in situ carcinoma were excluded. A total of 231 patients were studied. Sentinel lymph nodes were identified in 221 patients (95.7%). There were 10 FN, resulting in a FN rate of 12.5% and accuracy rate of 95.5%. Only the number of sentinel lymph node harvested was found to be a significant factor affecting FN rates on univariate (P < 0.009) and multivariate logistic regression (odds ratio: 2.65; 95% confidence interval: 2.57-2.73; P < 0.000).

CONCLUSIONS

In Chinese women, after this retrospective analysis of available findings, at least should sentinel nodes should be removed to reduce risk of false negativity.

Aspectos técnicos de interés en la localización de drenajes linfáticos en la biopsia del ganglio centinela del cáncer de mama

OBJECTIVES

The sentinel node is defined as the node with the highest probability of being involved in the case of lymphatic spread from a tumor. Accurate identification and biopsy of this node can avoid unnecessary lymphadenectomies. The aim of this study was to determine if there are differences in the number of isolated sentinel lymph nodes in breast cancer according to whether a mixed technique (vital dye plus isotopic tracer) or radiotracer alone is used and if there are differences in the detection of more than one lymphatic basin and in the number of lymphatic nodes depending on the site of tracer injection.

PATIENTS AND METHOD

A total of 173 sentinel lymph node biopsies in 173 women with breast cancer were studied taking into account the technique (mixed [n = 109] or radiotracer alone [n = 64]) and the location of tracer injection (periareolar [n = 81], intra and/or peritumoral [n = 92]). The number of lymphatic basins and the number of sentinel nodes were compared among the distinct groups resulting from the combination of the 2 parameters.

RESULTS

Simultaneous drainage to both the axilla and internal mammary chain was more frequent with the intra-periareolar technique. The number of identified nodes was significantly higher when mixed techniques were compared, and was higher with periareolar injection than with the intra-peritumoral route.

CONCLUSIONS

In breast cancer sentinel lymph node biopsy, the number of identified nodes is not influenced by the use of a mixed technique or radiotracer alone. However, the number of identified nodes is higher with the periareolar route than with the intra-peritumoral route. Intra-peritumoral injection of the tracer shows a higher frequency of internal mammary chain drainage than periareolar injection, although this difference was not statistically significant.

The presentation of contralateral axillary lymph node metastases from breast carcinoma: a clinical management dilemma

Metastases to the contralateral axillary lymph nodes in breast cancer patients are uncommon. Involvement of the contralateral axilla is a manifestation of systemic disease (stage IV) or a regional metastasis from a new occult primary (T0N1, stage II). The uncertain laterality of the cancer responsible for these metastases complicates overall disease staging and is a management dilemma for clinicians. Seven women who developed contralateral axillary metastases (CAM), but did not have evidence of systemic disease were identified. Patient demographics, histopathologic tumor characteristics, treatment and outcome were examined. The median age was 49 years. A family history of breast cancer was present in six (86%). The initial breast cancers were located in all quadrants. They were generally hormone receptor negative, HER-2/neu overexpressing and associated with lymphovascular invasion. There was a median interval of 71 months between initial breast cancer diagnosis and CAM presentation. Surgical management of the CAM included simple excision in one (14%) and axillary lymph node dissection in five (71%). Adjuvant treatment consisted of chemotherapy in seven (100%) and hormonal therapy in one (14%). The median follow-up from the diagnosis of CAM was 35 months and three women were alive without disease, two were alive with disease and two had died of disease. With surgical treatment, there were no axillary recurrences in this series. When patients present with CAM and no evidence of systemic disease or a new primary in the contralateral breast, surgical treatment should be considered for local control and possibly improved relapse-free survival.

The Value of Combined Peritumoral and Subdermal Injection Techniques for Lymphoscintigraphy in Detection of Sentinel Lymph Node in Breast Cancer

PURPOSE

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.

PATIENTS AND METHODS

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.

RESULTS

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).

CONCLUSION

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.

Sentinel Lymph Node Biopsy for Breast Cancer: Current Controversies

Sentinel lymph node biopsy (SLNB) has replaced the routine level I and II axillary lymph node dissection (ALND) for women with clinically node-negative T1 and T2 breast cancer. Studies have shown that SLNB is highly predictive of axillary nodal status with a false-negative of rate less than 10%. Our purpose was to address some of the ongoing controversies about this procedure, including technical issues, use of preoperative lymphoscintigraphy, internal mammary lymph node biopsy, criteria for patient selection (in intraductal carcinoma?), its staging accuracy, and the clinical approach when a SLNB was found to be negative or positive on pathologic examination. After the revision of the American Joint Committee on Cancer (AJCC) staging system for breast cancer in 2002, the evaluation of internal mammary lymph nodes and determination of micrometastases by hematoxylin-eosin or by immunohistochemistry have become increasingly important in staging of patients. Recent guideline recommendations developed by the American Society of Clinical Oncology (ASCO) Expert Panel in 2005 are also discussed. Long-term follow-up results of ongoing studies will provide more accurate assessment of the prognostic significance of SLNB and its value in the prevention of breast cancer-related morbidity in axillary staging compared to ALND.

Clinical implications of sentinel nodes outside the axilla and internal mammary chain in patients with breast cancer

PURPOSE

The aim of this study was to determine the incidence, location, surgical identification rate, tumor status, and clinical implications of sentinel nodes outside the axilla and internal mammary chain.

PATIENTS AND METHODS

In 785 breast cancer patients, pre-operative lymphoscintigraphy was performed after intratumoral injection of 116 MBq 99mTc-labeled nanocolloid (0.2 ml; 3.1 mCi). Sentinel nodes were pursued using a gamma-ray detection probe and vital blue dye.

RESULTS

Lymphoscintigraphy visualized sentinel nodes outside the axilla and internal mammary chain in 91 of the 785 patients (12%). Sentinel nodes (106) were identified in 80 patients. These nodes were found in the following locations: 50 in the breast, 31 in the infraclavicular fossa, 19 between the pectoral muscles, and 6 within the supraclavicular bed. Eighteen nodes contained a metastasis (17%) and were removed from 16 patients. The treatment strategy was adjusted in 12 of them with the addition of adjuvant local or systemic therapy. Two additional patients with an unusually situated tumor-negative sentinel node were spared an axillary node dissection that would otherwise have been performed.

CONCLUSION

Unusually situated sentinel nodes were visualized in 12% of the patients. The treatment was adjusted in 18% of patients in whom these nodes were identified.

Factors predicting the sentinel and non-sentinel lymph node metastases in breast cancer

The sentinel lymph node (SLN) is the only focus of axillary metastasis in a significant proportion of patients. In this single institutional study, clinicopathologic characteristics were investigated to determine the factors predicting the status of a SLN biopsy and the metastatic involvement of non-SLNs. Data were retrospectively reveiwed for 400 consecutive patients with clinical T1/T2 N0 breast cancer who underwent a SLN biopsy including axillary and/or internal mammary lymph nodes. The SLNs were evaluated by using the new AJCC staging criteria following multiple sectioning and immunohistochemical (IHC) analyses of nodes. The SLN contained metastases in 148 patients (38.5%) including 18 patients (12.2%) with micrometastases (<or=0.2 mm) and 130 patients (87.8%) with macrometastases (>0.2 cm). Five patients had isolated tumor cells detected by IHC (<or=0.2 mm, N(0i)). Patients with tumor size more than 2 cm (T1, 29.8% versus T2, 51.6%; OR=2.31, 95% CI, 1.50-3.56) and lymphovascular invasion (LVI-, 30.3% versus LVI+, 51.3%; OR=2.07, 95% CI, 1.34-3.19) were more likely to have positive SLNs in both univariate and multivariate analyses. Among patients with a positive SLN biopsy, those with T2 tumors (versus T1; 63.1% versus 36.9; OR=2.93, 95% CI, 1.43-6.04), macrometastases in SLNs (versus micrometastases; 88.9% versus 11.1%; OR=8.83; 95% CI, 1.82-42.87) and extracapsular node extension (versus without extracapsular node extension; 65.4% versus 34.6%; OR, 2.23; 95% CI, 1.05-4.72) were more likely to have non-SLN metastases in both univariate and multivarite analyses. These results indicate that clinicopathologic factors might be helpful to select patients who were less likely to have negative SLN or non-SLNs. However, additional factors are still needed to be identified to omit surgical axillary staging.

Subdermal re-injection: a method to increase surgical detection of the sentinel node in breast cancer without increasing the false-negative rate

PURPOSE

The aim of this study was to evaluate in breast cancer whether subdermal (SB) re-injection improves surgical detection (SD) of the sentinel node (SN) in patients with negative lymphoscintigraphy on peritumoral (PT) injection, without increasing the false-negative (FN) rate.

METHODS

Group I comprised 261 patients with invasive breast cancer >3 cm and clinically negative axilla treated with primary chemotherapy. Axillary lymphadenectomy was performed in all of these patients. Group IA comprised 201 patients with PT injection, while group IB comprised 60 patients with SB injection in the tumour quadrant. Group II comprised 652 patients with breast cancer <3 cm; in 73 of these patients with negative lymphoscintigraphy, SB re-injection was performed. For lymphoscintigraphy, 37-55 MBq (99m)Tc-albumin nanocolloid in 1 ml was used for PT injection, and 18 MBq in 0.2 ml for SB injection. Five-minute images were obtained 2 h p.i. for PT injection and 20-30 min p.i. for SB injection. SD was performed 4 or 24 h p.i. Lymphoscintigraphic (LD), surgical and internal mammary (IM) detection rates were calculated. In group I, FN, negative predictive value (NPV) and accuracy (A) were calculated. Statistical analysis was performed using the chi-square test.

RESULTS

In percentages, results were as follows: Group IA: SD: 84.1, FN: 13.6, NPV: 88.9, A: 78.6, IM: 14.5*. Group IB: SD: 90, FN: 0, NPV: 100, A: 90, IM: 1.7* (*p<0.025). Group II: PT injection only: LD: 82.4, SD: 94; PT injection+SB re-injection: LD: 90, SD: 98.5. SD was 97.8** in patients with positive lymphoscintigraphy and 58.5** when lymphoscintigraphy was negative (**p<0.001).

CONCLUSION

For correct staging, including extra-axillary drainage, peritumoural injection should first be performed. When the SN is not visualised, and only in those cases, SB re-injection should be performed, which increases the SD rate without increasing the FN rate.

Extra-axillary sentinel node biopsy in the management of early breast cancer

AIM

To document of our experience with EAS SNB and evaluate its impact on the staging, management and the associated morbidities of patients with early breast cancer.

METHOD

A review of two prospective breast cancer databases identifying all SNB procedures performed at two affiliated breast units from 1998 to 2003.

RESULTS

A series of 979 patients underwent lymphatic mapping. Sentinel nodes were successfully identified in 903 patients. There were 142 cases in which lymphoscintigraphy identified EAS. In 17 cases extraaxillary sentinel nodes were identified with lymphoscintigraphy but could not be removed. There were 138 cases where internal mammary nodes (IMN) were removed. Of those IMN removed 25 were positive for metastases and in six of these cases only the IMN was positive. Of the 21 cases where other EAS were identified there was one case in which a supraclavicular sentinel node was positive. Twenty-five of the 26 positive sentinel nodes in EAS were macrometastases and one was a micrometastasis. No significant morbidity resulted from biopsy of EAS SNB. During IMN SNB there were eight pleural breeches, which did not result in pneumothoraces, and one case in which bleeding was difficult to control.

CONCLUSION

EAS SNB is technically feasible in the majority of cases. Minimal morbidity occurs after an initial learning phase. IMN SNB was shown to have significant impact on the staging and management in 18% of patients when IMNs were identified with lymphoscintigraphy. The impact of other extraaxillary lymph nodes is more difficult to assess due to small numbers. As there is little morbidity and valuable information is gained in a significant percentage of cases we strongly advocate EAS SNB.

Le ganglion sentinelle sans curage systématique dans le cancer du sein : bilan d'une expérience de 1000 interventions

OBJECTIVE

To assess daily practice of 1000 sentinel node (SN) biopsies in breast cancer.

PATIENTS AND METHOD

Prospective review of 1000 consecutive sentinel node biopsies between February 2001 and June 2004. Analyses concerned technical aspects of sentinel node detection, pathologic results of the tumor and sentinel node, treatment and follow-up.

RESULTS

Nine hundred and seventy-eight SN were detected (98.7%). In univariate analyses, age, pathologic tumor size (20 mm) and method of detection (blue dye or isotopic vs. combined) were statistically significant. One hundred and fifty-six cases (16%) underwent immediate axillary dissection (AD), whereas 116 (12%) had a delayed AD. There were 923 invasive or micro-invasive carcinoma with detected SN: 282 SN (30.5%) were involved, either with macrometastases (166) or with micrometastases (116), 34% had positive non-sentinel node. Age and metastasis size were predictive for AD involvement. Sixteen percent of micrometastatic SN had positive AD, there was no predictive factor for axillary involvement. After a median follow-up of 20 months, there were 4 axillary recurrences: 1 (0.1%) after negative SN without AD, 1 (0.1%) after positive SN with positive AD, 1 (4.3%) after micrometatastatic SN without AD, and 1 (8.3%) after macrometastatic SN without AD. There were 55 ductal carcinoma in situ and 54 micro-invasive cancer: positive SN (with negative AD) were detected in only 2 cases (2.3%). There were initially 112 ductal carcinoma in situ diagnosed by percutaneaous biopsy, 25 of them (22%) had invasive disease on definitive histology. Among there, 12 had involved SN (with 4 positive AD).

DISCUSSION AND CONCLUSION

With a high detection rate and low recurrence rate, SN biopsy is considered in our institute as a reliable procedure and is used to evaluate regional nodal status of early breast cancer. Thus, 70% of AD can be omitted.

Drug concentrations in axillary lymph nodes after lymphatic chemotherapy on patients with breast cancer

Background

Lymph node status is one of the decisive prognostic factors in breast cancer. Chemotherapy targeting regional lymphatic tissues has emerged as a promising therapy for the treatment of malignancies with a high tendency to disseminate lymphatically. The present study determined the drug concentrations in axillary lymph nodes after lymphatic chemotherapy (LC) in patients with breast cancer and compared the results with those receiving intravenous chemotherapy (VC) to investigate whether LC could improve the accumulation of anticancer drug in regional lymph nodes.

Methods

Sixty patients with breast carcinoma confirmed by preoperative puncture-biopsy were divided into two groups at random. The LC group (n = 30) received a subcutaneous injection of 4 ml of carboplatin-activated carbon suspension, containing 20 mg of carboplatin, adjacent to the primary tumour. The VC group (n = 30) received an intravenous administration of an equal dose of aqueous carboplatin. At 1, 12, 24, 36 and 48 hours after administration, modified radical mammectomies were performed on 12 patients at each time point, with 6 from each group. Axillary lymph nodes were removed for pathological examination. The platinum concentrations in nodes were determined by Zeeman atomic absorption spectrometry.

Results

A total of 275 axillary lymph nodes were resected, with 154 in the LC group and 121 in the VC group. Of the 275 lymph nodes, 136 (49.5%) from 23 patients (38.3%) had histopathologically detected metastases. At 1, 12, 24, 36 and 48 hours after injection, the carboplatin concentrations in the LC group were 11.82 ± 3.50, 23.58 ± 7.34, 18.22 ± 4.93, 16.70 ± 5.15 and 14.62 ± 4.29 μg/g (means ± SD), respectively, whereas those in the VC group were 0.06 ± 0.02, 0.11 ± 0.05, 0.10 ± 0.02, 0.05 ± 0.02 and 0 μg/g, respectively. Significant differences were found in each corresponding comparison (P < 0.001). Lymph node metastasis was uncorrelated with drug concentration (P > 0.05).

Conclusion

LC can effectively and continuously improve the drug concentrations in axillary lymph nodes in patients with breast cancer, in comparison with VC.