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Added value of blue dye injection in sentinel node BIOPSY OF breast cancer patients: Do all patients need blue dye?

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Abstract

In the current study, we evaluated the incremental value of blue dye injection in sentinel node mapping of early breast cancer patients. We specially considered the experience of the surgeons and lymphoscintigraphy results in this regard. 605 patients with early stage breast cancer were retrospectively evaluated in the study. Patients underwent sentinel node mapping using combined radiotracer and blue dye techniques. Lymphoscintiraphy was also performed for 590 patients. Blue dye, radioisotope, and overall success rates in identifying the sentinel lymph node were evaluated in different patient groups. The benefit of blue dye and radioisotope in identifying the sentinel lymph nodes was also evaluated. Marginal benefits of both blue dye and isotope for overall sentinel node detection as well as pathologically involved sentinel nodes were statistically higher in inexperienced surgeons and in patients with sentinel node visualization failure. In the patients with sentinel node visualization on lymphoscintigraphy, 6 sentinel nodes were detected by blue dye only. All these six nodes were harvested by inexperienced surgeons. On the other hand 8 sentinel nodes were detected by dye only in the patients with sentinel node non-visualization. All these nodes were harvested by experienced surgeons. The use of blue dye should be reserved for inexperienced surgeons during their learning phase and for those patients in whom lymphoscintigraphy failed to show any uptake in the axilla.

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... Tc-99m-phytate is a radiopharmaceutical agent, which converts to particles with an average size of 150 nm upon reacting with the tissue calcium ion (6,14). In addition to regional lymph nodes, and reticuloendothelial system, biodistribution of Tc-99m-phytate includes urinary system (14), and growth plates (15). Tc-99m-phytate has been used for sentinel node mapping in various solid tumors with excellent results (16)(17)(18)(19)(20)(21). ...
... For the majority of patients with early-stage NSCLC, mediastinal lymph node dissection and sampling not only will not lead to a survival benefit but also might increase the morbidity rate (2,15). In this regard, sentinel node mapping via various tracers, such as blue dye or radioisotope tracers, has been suggested to be an effective method in reducing the possibility of lymph node dissection through the identification of the pathological sentinel node, metastases and accurate staging of solid tumors (2,8,10,15). ...
... For the majority of patients with early-stage NSCLC, mediastinal lymph node dissection and sampling not only will not lead to a survival benefit but also might increase the morbidity rate (2,15). In this regard, sentinel node mapping via various tracers, such as blue dye or radioisotope tracers, has been suggested to be an effective method in reducing the possibility of lymph node dissection through the identification of the pathological sentinel node, metastases and accurate staging of solid tumors (2,8,10,15). ...
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Objectives: Lymph node metastases are the most significant prognostic factor in localized non-small cell lung cancer (NSCLC). Identification of the first nodal drainage site (sentinel node) may improve detection of metastatic nodes. Extended surgeries, such as lobectomy or pneumonectomy with lymph node dissection, are among the therapeutic options of higher acceptability. Sentinel node biopsy can be an alternative approach to less invasive surgeries. The current study was conducted to evaluate the accuracy of sentinel node mapping in patients with NSCLC using an intraoperative radiotracer techniques. Methods: This prospective study was conducted on 21 patients with biopsy-proven NSCLC who were candidates for sentinel node mapping during 2012-2014. All patients underwent thoracoabdominal computed tomography, based on which they had no lymph node involvement. Immediately after thoracotomy and before mobilizing the tumor, peritumoral injection of 2mCi/0.4 mL Tc-99m- phytate was performed in 4 corners of tumor. After mobilization of the tumoral tissues, the sentinel nodes were searched for in the hillar and mediastinal areas using hand-held gamma probe . Any lymph node with in vivo count twice the background was considered as sentinel node and removed and sent for frozen section evaluation. All dissected nodes were evaluated by step sectioning and hematoxylin and eosin staining (H&E).The recorded data included age, gender, kind of pathology, site of lesion, number of dissected sentinel nodes, number of sentinel nodes, and site of sentinel nodes. Data analysis was performed in SPSS software (version 22). Results: The mean age of the patients was 58.52±11.46 years with a male to female ratio of 15/6. The left lower lobe was the most commonly affected site (30.09%). Squamous cell carcinoma and adenocarcinoma were detected in 11 and 10 subjects, respectively. A total of 120 lymph nodes were harvested with the mean number of 5.71±2.9 lymph nodes per patient. At least one sentinel node was identified in each patient, resulting in a detection rate of 95.2%. The mean number of sentinel nodes per patient was 3.61±2. Frozen section results showed 100% concordance with the results of hematoxylin and eosin staining. Conclusion: Based on the findings, sentinel node mapping can be considered feasible and accurate for lymph node staging and NSCLC treatment.
... However, combined, an equal amount of pathological lymph nodes was found. In line with previous studies focussing on the added value of blue dye to 99m Tc-nanocolloid, [35][36][37] it seems unlikely that the clinical relevance of the higher detection rate outweighs the clinical adverse effects of adding another tracer to ICG. 36 Moreover, other studies found that the addition of blue dye as a second tracer seemed only beneficial for inexperienced surgeons. 35,36 ICG-fluorescence to identify the SLN yields several important advantages over traditional methods. ...
... In line with previous studies focussing on the added value of blue dye to 99m Tc-nanocolloid, [35][36][37] it seems unlikely that the clinical relevance of the higher detection rate outweighs the clinical adverse effects of adding another tracer to ICG. 36 Moreover, other studies found that the addition of blue dye as a second tracer seemed only beneficial for inexperienced surgeons. 35,36 ICG-fluorescence to identify the SLN yields several important advantages over traditional methods. 38 No additional preoperative hospital visit for injection of the 99m Tc-nanocolloid and additional imaging are needed, thereby overcoming logistical challenges and patient discomfort. ...
Article
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Objective: To compare the (sentinel) lymph node detection rate of ICG-fluorescent imaging versus standard-of-care 99mTc-nanocoilloid for sentinel lymph node (SLN)-mapping. Summary background data: The current gold-standard for axillary staging in patients with breast cancer is sentinel lymph node biopsy (SLNB) using radio-guided surgery with radioisotope technetium (99mTc), sometimes combined with blue dye. A promising alternative is fluorescent imaging using indocyanine green (ICG). Methods: In this non-inferiority trial, we enrolled 102 consecutive patients with invasive early-stage, clinically node-negative breast cancer. Patients were planned for breast conserving surgery and SLNB between August 2020 and June 2021. The day or morning before surgery, patients were injected with 99mTc-nanocolloid. In each patient, SLNB was first performed using ICG-fluorescent imaging, after which excised lymph nodes were tested with the gamma-probe for 99mTc-uptake ex-vivo, and the axilla was checked for residual 99mTc-activity. Detection rate was defined as the proportion of patients in whom at least one (S)LN was detected with either tracer. Results: In total, 103 SLNBs were analysed. The detection rate of ICG-fluorescence was 96.1% (95%CI=90.4-98.9%) versus 86.4% (95%CI=78.3-92.4%) for 99mTc-nanocoilloid. The detection rate for pathological lymph nodes was 86.7% (95%CI=59.5-98.3%) for both ICG and 99mTc-nanocoilloid. A median of 2 lymph nodes were removed. ICG-fluorescent imaging did not increase detection time. No adverse events were observed. Conclusion: ICG-fluorescence showed a higher (S)LN detection rate than 99mTc-nanocoilloid, and equal detection rate for pathological (S)LNs. ICG-fluorescence may be used as a safe and effective alternative to 99mTc-nanocoilloid for SLNB in patients with early-stage breast cancer.
... Introduction of sentinel lymph node biopsy as a less aggressive approach to lymph node dissection has replaced regional lymphatic evaluation in melanoma, breast, gynecological and urological malignancies (13)(14)(15)(16)(17)(18)(19). Sentinel lymph node as the first metastatic tumor landing site through lymphatic flow, can be detected using radiotracers or dyes (20,21). The dissected sentinel lymph node reveals the pathologic status of other regional lymph nodes and there is a potential benefit of avoiding unnecessary lymph node dissection. ...
... Intraoperative injection of the mapping material has been proven to be a feasible method for sentinel node mapping, as the movement of the tracer in the lymphatics is fairly rapid and successful sentinel node harvesting can be achieved by allowing a reasonable time between injection and harvesting of the sentinel nodes (30)(31)(32). Due to reported potential complications of blue dyes, we didn't use the blue dyes in our study (20,33). ...
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Objective(s): Testicular germ cell cancers are the most common solid malignancy among young men at the age ranging between 14 and 35 years. In this study, we evaluated the feasibility of sentinel lymph node mapping using intraoperative injection of radiotracer in nonseminomatous testicular cancer patients with history of orchiectomy who were candidate for retroperitoneal lymph node dissection (RPLND) in post-chemotherapy setting. Methods: Nine consecutive cases were included in the study. Technetium-99m-labelled phytate was injected in two divided doses in the stump of the spermatic cord, through transabdominal approach. A hand-held gamma probe was used for radio-guided retroperitoneal sentinel lymph node detection intraoperatively and confirming the location of the sentinel lymph nodes. Results: Detection rate and the false negative rate were estimated as the main indices. The detection rate was 6/9 (66%) and the false negative rate was 0/2 (0%). Location of the dissected sentinel lymph nodes were interaortocaval (2 patients), internal iliac (1 patient), external iliac (1 patient), common iliac (2 patients), and paraaortic (1 patient). Conclusion: Sentinel lymph node mapping technique seems to be feasible and promising in post chemotherapy non-seminoma testis cancer patients who are candidate for RPLND; however, further larger studies are needed to increase and standardize the detection rate.
... 22,23 Surgeon experience with the procedure is important, as it significantly affects SLN identification and accuracy rates. 24,25 One study recommends the combined approach but only for inexperienced surgeons. 25 Although reports conflict, several publications continue to support the dual method for improved accuracy. ...
... 24,25 One study recommends the combined approach but only for inexperienced surgeons. 25 Although reports conflict, several publications continue to support the dual method for improved accuracy. 26 A review of the literature on the use of blue dye only for SLNB in early breast cancer notes the lack of reliably reproduced data showing that single-agent mapping with radiocolloid only is comparable or superior to the dual method of SLNB. ...
Article
Allergic reactions including anaphylaxis resulting from isosulfan blue dye are rare but warrant a thorough review given that lymph node mapping has become an increasingly common procedure, putting more patients at risk. Our patient was an 82-year-old female who underwent elective excision of a right forearm melanoma and right axillary sentinel lymph node mapping and suffered an anaphylactic reaction approximately 15 minutes after injection of isosulfan blue dye. The procedure was aborted. She was intubated; diphenhydramine and dexamethasone were administered; her blood pressure was stabilized with phenylephrine, epinephrine, and intravenous fluids; and she was transferred to the intensive care unit. She was extubated on postoperative day 1 and discharged home on postoperative day 2. Sentinel lymph node biopsy is the standard of care for staging several cancers, and isosulfan blue is the dye most commonly used for this procedure. Reactions to the dye occur in some patients; however, we recommend the continued use of isosulfan blue dye for lymph node mapping given the low incidence of adverse effects, with no reported mortalities. Physicians should be prepared for the potential risk of anaphylactic shock.
... Studies excluded due to being narrative review article, letter to editors, and original articles n=5 However, for intra-thoracic tumors, the anthracosis of the mediastinal lymph nodes makes the SN mapping by blue dye very hard if not impossible. Therefore, it seems that the complication risks of blue dye use (for example anaphylactic reactions) do outweigh the benefits of blue dye addition to SN mapping of intra-thoracic tumors (14,15). ...
... The experience of the surgeon has been evaluated in detail for SN mapping in breast cancer. The more experienced surgeons would have less false negative results (14,20). Limited studies also showed the same findings in EC and NSCLC; however, larger studies are needed to be able to draw any definite conclusion in this regard. ...
Article
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Introduction: Sentinel node mapping is a new technique of lymph nodal staging in solid tumors, which can decrease the morbidity of regional lymph node dissection considerably. Intra-thoracic tumors including non-small cell lung cancer (NSCLC) and esophageal carcinoma (EC) are among the solid tumors in which sentinel node (SN) mapping has been applied. In the current systematic review, we gathered the best available evidence (systematic reviews) in this regard and presented the results in a systematic review format. Material and methods: We searched MEDLINE and SCOPUS since the inception till 13 December 2014 using the following keywords: (lung OR esophagus OR esophageal) AND sentinel AND (" systematic review " OR meta-analysis OR metaanalysis). No language limit was imposed on the search strategy. Systematic reviews and meta-analyses on SN mapping in EC or NSCLC were included in the current study. Narrative review articles were excluded from the study. Results: Overall five systematic review were included. One of the included studies was on SN mapping in NSCLC and four were on EC. Overall detection rate and sensitivity for EC and NSCLC were high and both were related to mapping technique, pathological involvement of the mediastinal nodes, size and location of the tumors. Conclusion: SN mapping is feasible and highly accurate in EC and NSCLC. Attention to the technique (using radiotracers, peri-tumoral injection) and restriction of the patients to less advanced cases (cN0 and T1, 2) would ensure the best results with high detection rate and sensitivity.
... İki yöntemin birlikte kullanılması ile yöntemin başarı şansı daha da artmaktadır. Ancak SLNB tekniğinin başarısında deneyimin önemli rol oynadığı unutulmamalıdır (16)(17)(18)(19). Çalışmamızda tek merkezde meme kanseri nedeniyle sentinel lenf nodu biyopsisi yapılan hastalarda sentinel lenf nodunu tespit etmede mavi boya kullanımı ile mavi boya ve radyoaktif maddenin birlikte kullanımı karşılaştırarak sentinel lenf nodu saptamadaki etkinliklerini değerlendirmeyi amaçladık. ...
Article
Amaç: 1990’lı yılların ortalarında sentinel lenf nodu biyopsisi , meme kanserli hastalarda aksiller lenf nodu durumunun değerlendirilmesinde kullanılmaya başlanmış ve günümüzde klinik olarak aksillası negatif meme kanserli hastalarda aksiller evreleme için tercih edilen bir prosedür haline gelmiştir. Sentinel lenf nodu tespitinde sadece mavi boya yöntemi veya sadece radyokolloid madde yöntemi ve her ikisinin birlikte kullanıldığı kombine yöntem uygulanmaktadır. Gereç ve Yöntemler: 01/07/2013-01/07/2014 tarihleri arasında meme kanseri nedeniyle opere edilen hastaların dosyaları retrospektif olarak incelendi. Klinik olarak aksilla negatif erken evre meme kanseri nedeniyle sentinel lenf nodu biyopsisi yapılan hastalar çalışmaya dahil edildi. Klinik olarak aksillası pozitif olan, lokal ileri ve ileri evre meme kanseri olan, neoadjuvan tedavi alan hastalar çalışmaya dahil edilmedi. Klinik olarak aksilla negatif erken evre meme kanseri nedeniyle sentinel lenf nodu biyopisi yapılan toplam 68 hasta çalışmaya dahil edildi. Hastalar sentinel lenf nodu biyopsisi mavi boya yöntemi ile yapılanlar ve kombine yöntemle (mavi boya+ radyokolloid) yapılanlar olmak üzere iki gruba ayrıldı. Mavi boya grubunda 41 hasta, kombine grupta 27 hasta mevcuttu. Çıkartılan sentinel lenf nodları intraoperatif frozen inceleme ile değerlendirildi ve metastaz görülen hastalara aksiller lenf nodu diseksiyonu yapıldı. Bulgular: Metilen mavi grubundaki 41 hastanın 6 tanesinde sentinel lenf nodu bulunamamış ve sentinel lenf nodu %85 oranında tespit edilmiştir. On hastanın sentinel lenf nodunda metastaz görülmüş ve pozitiflik oranı %24 olarak bulunmuştur. Kombine gruptaki 27 hastanın tamamında sentinel nodu bulunmuş ve sentinel lenf nodu %100 oranında tespit edilmiştir. On hastada sentinel lenf nodunda metastaz görülmüş ve pozitiflik oranı %37 olarak bulunmuştur. Sonuç: Bu çalışmada klinik olarak aksilla negatif erken evre meme kanserinde perop sentinel lenf nodu tespitinde kombine yöntemin sadece mavi boya yönteminden anlamlı olarak üstün olduğu tespit edilmiştir.
... Studies are almost consistent regarding the clinical importance of sentinel node nonvisualization on preoperative lymphoscintigraphy. Several studies reported that sentinel node nonvisualization is strongly correlated with pathological involvement of the axilla (11,12,15,(29)(30)(31)(32). The current study also showed the same findings. ...
Article
Aim: Sentinel node biopsy is considered the standard of care in early-stage breast cancer patients. In the current study, we evaluated the effect of radiotracer reinjection in the case of sentinel node nonvisualization on preoperative lymphoscintigraphy. Materials and methods: Between March 2017 and March 2020, 1850 early-stage breast cancer patients were referred for sentinel node mapping. All patients received a single injected activity of Tc-99m Phytate intradermally in the periareolar area of the index lesion using an insulin syringe. Lymphoscintigraphy images of the patients were done 1-2 h postinjection. Between March 2017 and September 2017, sentinel node nonvisualization was reported to the surgeon, and for the rest of the study period, the patients received another injected activity of the radiotracer, and immediately, other lymphoscintigraphy images were taken (with the same parameters). Results: A total of 255 patients entered our study. Fifty-five patients were in group I without any reinjection. The remainder of the patients were in group II. In 155 out of 200 patients of group II, a sentinel node could be visualized following reinjection of the radiotracer. The detection rate was 15 out of 45 and 15 out of 55 in group I and patients without sentinel node visualization even after reinjection, respectively. Axilla was involved in 5 out of 40 (12.5%) patients in group I with intraoperative sentinel node mapping failure. On the other hand, axilla was involved in 27 out of 30 (90%) group II patients with sentinel node nonvisualization. Conclusion: Reinjection of the tracer in cases of no sentinel node visualization in lymphoscintigraphy for breast cancer increases the detection rate of sentinel nodes, and therefore a high number of unnecessary axillary lymph node dissections can be avoided.
... Five out of 8 included studies applied the intraoperative blue dye detection technique [16,17,19,22,23] and utilized 1 mL patent blue dye peritumorally into detrusor muscle for SLN detection, but only 3 of them reported the data related to the blue dye detection rate [17,22,23]. According to these reports, applying dye is easy and cost effective, and nodes and lymphatic channels containing blue dye could be observed visually intraoperatively; however, blue dye application was associated with a low detection rate of SLNs compared to radiotracers, which might be due to the short time interval between the injection of blue dye and performance of nodal mapping [17], which is also in accordance with the previous studies of sentinel node mapping in other tumors [34][35][36][37]. This was also evident in our meta-analysis based on these 3 studies used blue dye. ...
Article
Objectives: To determine the application of sentinel node biopsy in urothelial carcinoma of the bladder, we performed a systematic review and meta-analysis. Methods: Pooled false negative rate and detection rate were presented using Meta-Disc (version 1.4), and comprehensive meta-analysis (version 2). Publication bias and heterogeneity were assessed using funnel plot, Cochrane Q test, and I2 index. Results: The pooled detection rate was 91% (95% CI 87-93%) and pooled sensitivity was 79% (95% CI 0.69-0.86%). When the neoadjuvant chemotherapy group of patients was omitted, the pooled sensitivity changed to 82% (95% CI 74-88%), and the Cochrane Q and I2 statistics were 15.44 and 48.2%, respectively. The pooled sensitivity of studies that included > 50% of pT 3 or 4 patients was 70% (59-80), by omitting studies that enrolled > 50% of patients at pT stage of 3 or 4, the pooled sensitivity increased to 93% (81-98). Conclusions: Although the studies on SN biopsy of muscle invasive bladder cancer patients resulted in a high detection rate and sensitivity, further validated multicenter trials with larger sample size are essential to confirm the reliability and accuracy of this approach and obtain a standardized method. We showed that pT1 or pT2 bladder cancer patients with clinically negative lymph nodes are the most appropriated group for sentinel lymph node mapping.
... Moreover, blue dyes rapidly diffuse to LNs adjacent to SLN due to small size (<2 nm), thereby posing difficulty in detection. Radiotracers such as 99m Tc-sulfur colloid may effectively identify the localization of SLN 5-7 but necessitates the requirement of experienced surgeons to increase SLN detection rate and accuracy 8,9 . In addition, the portion of radiocolloids entering the lymphatic system is very low and the majority remains in the interstitial tissue of the injected site due to large particle size (~100 nm). ...
Article
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99mTc-labeled mannosylated human serum albumin (MSA) has been reported as a sentinel lymph node (SLN)-imaging agent by binding to macrophages in the LNs. By conjugating it with blue dye, we developed a new multimodal radio-nanocarrier by visual investigation, fluorescence imaging, and single photon emission computed tomography (SPECT)/computed tomography (CT). Binding affinities of seven blue dyes to MSA were tested. According to the spectroscopic study and visual inspection of MSA-bound dyes, naphthol blue black (NBB) was selected as the best candidate of multimodal agent. Thus, 99mTc-MSA-NBB conjugate was prepared and further investigated using mice. After footpad injection, it showed high popliteal LN accumulation at 1 h. SPECT/CT also showed high popliteal as well as inguinal LN uptakes at 10 min that sustained until 2 h. In conclusion, we prepared a multimodal SLN imaging radio-nanocarrier, 99mTc-MSA-NBB conjugate, and confirmed its excellency as a multimodal probe for SLN mapping.
... However, the use of a radiotracer alone is now a frequent issue in clinical practice due to the inferior performance of 123 blue dyes and their cumbersome staining of the resection margins [9][10][11]. Although this procedure is straightforward in the SN identification of single SNs that are clearly separated from the injection site, the limited spatial resolution of gamma tracing may complicate nodal identifications in other cases. ...
Article
Introduction: Guidelines advocate the use of combined detection techniques to achieve optimal results for sentinel node (SN) biopsy. The fluorescent and radioactive (dual-) tracer ICG-99mTc-nanocolloid has been shown to facilitate SN biopsy in several indications. It was reported that an opto-nuclear probe permitted the detection of near-infrared fluorescence and gamma-rays. The aim of the current study was to evaluate this device in a large patient group and to test it in both open and laparoscopic surgery implications. Methods: Thirty-three patients scheduled for SN biopsy with the dual-tracer were retrospectively analyzed. Pre-operative lymphoscintigraphy was performed in all patients; in 18 patients (55%), a SPECT/CT scan was also performed. Radioactive and fluorescent signatures in the SNs were assessed in vivo and ex vivo using the opto-nuclear probe. Results: One or more SNs were identified in all patients (identification rate 100%). Planar lymphoscintigraphic images revealed 95 hot spots that were considered as SNs. This number increased to 103 SNs when SPECT/CT was used. During surgery, 106 SNs were excised. In vivo, the fluorescence mode of the opto-nuclear probe was able to locate 79 SNs (74.5%). When the gamma-ray detection option of the same probe was used, this number increased to 99 SNs (93.3%). Ex vivo analysis revealed fluorescence in 93.3% of the excised nodes and radioactivity in 95.2%. Conclusions: This study underlines the feasibility of using the dual-tracer/opto-nuclear probe combination for SN resections. The use of the opto-nuclear technology has been extended to laparoscopic surgery. This study also underlines the fluorescence tracing can complement traditional radio-tracing approaches.
... In addition to the location of the sentinel nodes, lymphoscintigraphy can predict intra-operative sentinel node mapping failure [15,16]. In case of sentinel node non-visualization on lymphoscintigraphy images, intra-operative blue dye injection should also be strongly considered [17,18]. One of the major problems of lymphoscintigraphy is the time of patient presence in the nuclear medicine wards. ...
Article
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Introduction: One of the major problems of lymphoscintigraphy is the time of patient presence in the nuclear medicine wards. The operating room schedule can be compromised if the patients stay longer than usual in the nuclear medicine departments. However, too early imaging can be falsely negative for sentinel node visualization and delayed imaging may be required. The aim of the current study is to determine a time beyond which lymphoscintigraphy imaging does not yield more information and imaging can be terminated. Methods: One hundred and fifty women with proven clinically axillary node negative breast cancer entered the study For each patient 0.5 mCi Tc-99m phytate in the 0.2 cc volume was intradermally injected in periareolar region to raise a wheal. Lymphoscintigraphy imaging was done in the following time intervals: 5, 10, 30, 45, 60, 90 minutes post injection. In case of sentinel node visualization at any time, the imaging was terminated.
... Sentinel node mapping is an alternative method for surgical lymph node staging of solid tumors [1][2][3]. Lymphoscintigraphy is considered an integral part of sentinel node mapping as imaging can be very useful for pre-operative localization of the sentinel nodes as well as identifying a group of patients with sentinel node non-visualization [4][5][6][7][8][9]. Some groups have proposed a radiotracer re-injection in patients with sentinel node non-visualization on lymphoscintigraphy of breast cancer patients [10,11]. ...
Article
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We reported a 35 year old breast cancer patient who was referred to our nuclear medicine department for sentinel node mapping. She was planned to undergo mastectomy and lymphatic mapping. A dose of Tc-99m Phytate was injection in the peri-areolar region in an intra-dermal fashion. Two hours post-injection no sentinel node was visible in the axilla. Due to a high liver uptake, inadvertent intra-vascular injection was suspected and another dose of the radiotracer was injected in the breast. Lymphoscintigraphy two minutes post-injection showed an axillary sentinel node. Our case underscores the importance of second radiotracer injection in case of sentinel node non-visualization.
... We used a combination method (blue dye/radiotracer) in four patients and all four patients had blue paraaortic sentinel nodes. Adding blue dye to radiotracer (dual mapping method) has been shown to be an effective method for decreasing sentinel node detection failure as well as false negative cases in many tumors [31][32][33]. However, Kleppe et al. showed that blue dye was successful only in 2 patients out of 6 with retro-peritoneal exploration and ascribed it to the long time between blue dye injection and exploration [17]. ...
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Background Experience on sentinel node mapping in ovarian tumors is very limited. We evaluated the sentinel node concept in ovarian tumors using intra-operativeTc-99m-Phytate injection and lymphoscintigraphy imaging. Methods Thirty-five patients with a pelvic mass due to an ovarian pathology were included in the study. The radiotracer was injected just after laparotomy and before removal of the tumor either beneath the normal cortex (10 patients) or in the utero-ovarian and suspensory ligaments of the ovary just beneath the peritoneum two injections of the radiotracer (25 patients). For malignant masses, the sentinel nodes were identified using a hand held gamma probe. Then standard pelvic and para-aortic lymphadenectomy was performed. In case of benign pathologies or borderline ovarian tumors on frozen section, lymphadenectomy was not performed. The morning after surgery, all patients were sent for lymphoscintigraphy imaging of the abdomen and pelvis. Results Sentinel node was identified only in 4 patients of the cortical injection group. At least one sentinel node could be identified in 21 patients of the sub-peritoneal group. Sentinel nodes were identified only in the para-aortic area in 21, pelvic/para-aortic areas in 2, and pelvic only area in 2 patients. Three patients had lymph node involvement and all had involved sentinel nodes (no false negative case). Conclusion Sentinel node mapping using intra-operative injection of the radiotracer (in the utero-ovarian and suspensory ligaments of the ovary just beneath the peritoneum) is feasible in ovarian tumors. Technical aspects of this method should be explored in larger multicenter studies in the future.
... By identifying subgroup of patients with regional lymph node involvement in clinically node negative patients, sentinel node mapping can help planning treatment in MCC patients. Our department has an extensive experience in sentinel node mapping in different solid tumors since ten years ago [15]. The current case was the first MCC patient who underwent sentinel node mapping in our department. ...
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Sentinel node mapping is an integral part of regional lymph node staging in many solid tumors and plays an important role in surgical oncology. This technique has been used with excellent results for non-melanoma skin cancers including Merkel Cell Carcinoma (MCC). In the current study, we reported our first MCC patient who underwent successful sentinel node mapping. We also reviewed the available literature regarding the prognostic significance of sentinel node mapping in cN0 MCC patients.
... Contrary to the previous cases, the authors in this study identified sentinel nodes in only 2 out of 10 included patients (a 20% detection rate) which is not a promising result. The clinicians at the Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran, have 10 years experience in sentinel node mapping in various malignancies, 17,28,38,39 so the poor results of lymphatic mapping in Marjolin's ulcers should not be attributed to the learning curve effect. ...
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This study evaluated the feasibility of sentinel node biopsy in Marjolin's ulcers using peritumoral injection of the radiotracer and blue dye. Ten patients with Marjolin's ulcers (5 male and 5 females) ranging in age from 39-65 years, and who were candidates for surgical removal of their tumors, were included in this study. The patients received 2 mCi technetium 99m (99mTc) antimony sulfide colloid in 2 divided doses subcutaneously in the peritumoral region. Immediately after anesthesia induction, 1 cc patent blue V in 2 divided doses was also injected in the same fashion as the radiotracer. Lymphatic mapping and sentinel node biopsy was performed using a gamma probe. Any hot and/or blue lymph nodes were harvested as a sentinel node. Primary lesions were then excised and wounds grafted with a splitthickness skin graft. A sentinel node could be identified on the lymphoscintigraphy images in only 2 patients. Sentinel node mapping was successful during surgery in these 2 patients. None of the harvested sentinel nodes were blue. Lymphatic mapping and sentinel node biopsy do not seem feasible in Marjolin's ulcers located in areas of extensive burn scarring due to a low detection rate. Larger studies are needed to validate the results of this study.
... Both of the detectors had good sensitivity that did not influence the detection rate. [11] In addition, if the node was just hot with no blue staining or was not hot but had blue staining, it was recorded separately on a checklist. Then we examined the frozen section to detect SLN metastasis. ...
Article
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Sentinel lymph node biopsy (SLNB) is standard care to evaluate axillary involvement in early breast cancer. It has fewer complications than complete lymph node dissection; however, using blue dye in SLNB is controversial. We have evaluated the detection rate and local complications associated with methylene blue dye (MBD) used in SLNB in early breast cancer patients and compared these results to patent blue dye (PBD). In a cohort prospective study, 312 patients with early breast cancer without axillary lymph node involvement were divided into two groups according to dye type. All of the patients received radiotracer and one type of blue dye. We filled out a checklist for the patients that contained demographic data, size of tumor, stage, detection of sentinel lymph node, and complications and then analyzed the data. Demographic and histopathologic characteristics were not significantly different in both groups. Mean (standard deviation [SD]) tumor size in all patients was 2.4 (0.8) cm. Detection rate in the MBD group was 77.5% with dye alone and 94.2% with dye and radioisotope; and in the PBD group it was 80.1% and 92.9% respectively (P > 0.05). We had blue discoloration of the skin in 23.7% in the PBD and 14.1% in the MBD group (P < 0.05) local inflammation was detected in one patient in the PBD and five in the MBD group (P < 0.05). Skin necrosis and systemic complications were not observed. Methylene blue has an acceptable detection rate, which may be a good alternative in SLNB. Complication such as blue discoloration of the skin was also lower with MBD.
Chapter
The concept of sentinel node (SN) is an important aspect of surgical oncology that has revolutionized the treatment of solid tumors. The concept of sentinel node mapping suggests that lymphatic basin involvement starts from the sentinel nodes, and if sentinel nodes are pathologically clear from tumor cells, the other lymph nodes of the basin are clear either. In the current chapter, general aspects of sentinel node mapping have been discussed, including various mapping materials and radiopharmaceuticals; injection site, time, dose, and volume; imaging (lymphoscintigraphy); and gamma-probe-related issues. Special considerations for sentinel node mapping in breast cancer, melanoma, and uterine cervix, endometrial, vulvar, penile, colorectal, and head and neck cancers were also discussed.
Article
Background: Although morbidity is reduced when sentinel lymph node (SLN) biopsy is performed with dual isotopic and blue dye identification, the effectiveness of adding blue dye to radioisotope remains debated because side effects including anaphylactic reactions. Patients and methods: Using data from a prospectively maintained database, 1884 lymph node-negative breast cancer patients who underwent partial mastectomy with SLN mapping by a dual-tracer using patent blue dye (PBD) and radioisotope were retrospectively studied between January 2000 and July 2013. Patients with tumors <3 cm and with >1 node detected by one of the two techniques (N = 1024) were included in this real-life cross-sectional study. Results: Among the 1024 patients, 274 had positive SLN detected by isotopic and/or PBD staining. Only 4 patients having no detectable radioactivity in the axilla had SLN identified only by PBD staining (blue-only) while 26 patients had SLN only identified by isotopic detection (hot-only) illustrating failure rates of 9.5% (26/274) and 1.5% (4/274), respectively. Among these four patients, two had negative lymphoscintigraphy. Therefore, the contribution of PBD to metastatic nodes identification was relevant for only 2/274 patients (0.8%). Three patients (0.3%) had an allergic reaction with PBD, and anaphylactic shock occurred in two cases (0.2%). Conclusions: The added-value of PBD to reduce the false-negative rate of SLN mapping is only limited to the rare cases in which no radioactivity is detectable in the axilla (<1%). When a radioisotope mapping agent is available, the use of PBD should be avoided, because it can induce anaphylaxis.
Article
Background and objectives: The French Sentimag feasibility trial evaluated a new method for the localization of breast cancer sentinel lymph node (SLN) using Sienna+®, superparamagnetic iron oxide particles, and Sentimag® detection in comparison to the standard technique (isotopes ± blue dye). Methods: We conducted a prospective multicentric paired comparison trial on 115 patients. SLN localization was performed using both the magnetic technique and the standard method. Detection rate and concordance between magnetic and standard tracers were calculated. Post-operative complications were assessed after 30 days. Results: Results are based on 108 patients. SLN identification rate was 98.1% [93.5-99.8] for both methods, 97.2% [92.1-99.4] for Sienna+® and 95.4% [89.5-98.5] for standard technique. A mean of 2.1 SLNs per patient was removed. The concordance rate was 99.0% [94.7-100.0%] per patient and 97.4% [94.1-99.2] per node. Forty-six patients (43.4%) had nodal involvement. Among involved SLNs, concordance rate was 97.7% [88.0-99.9] per patient and 98.1% [90.1-100.0] per node. Conclusions: This new magnetic tracer is a feasible method and a promising alternative to the isotope. It could offer benefits for ambulatory surgery or sites without nuclear medicine departments. J. Surg. Oncol. 2016;9999:XX-XX. © 2016 Wiley Periodicals, Inc.
Article
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Herein, we report a case of sentinel lymph node mapping in a uterine cervix cancer patient, referring to the nuclear medicine department of our institute. Lymphoscintigraphy images showed inappropriate intra‐cervical injection of radiotracer. Blue dye technique was applied for sentinel lymph node mapping, using intra‐cervical injection of methylene blue. Two blue/cold sentinel lymph nodes, with no pathological involvement, were intra‐operatively identified, and the patient was spared pelvic lymph node dissection. The present case underscores the importance of lymphoscintigraphy imaging in sentinel lymph node mapping and demonstrates the added value of blue dye injection in selected patients. It is suggested that preoperative lymphoscintigraphy imaging be considered as an integral part of sentinel lymph node mapping in surgical oncology. Detailed results of lymphoscintigraphy images should be provided for surgeons prior to surgery, and in case the sentinel lymph nodes are not visualized, use of blue dye for sentinel node mapping should be encouraged.
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BACKGROUND: New Start, a structured, validated, multidisciplinary training programme in sentinel lymph node biopsy (SLNB), was established to allow the introduction and rapid transfer of appropriate knowledge and technical skills to ensure safe and competent practice across the UK. METHODS: Multidisciplinary teams attended a theory/skills laboratory course, following which they performed 30 consecutive SLNBs, either concurrently with their standard axillary staging procedure (training model A) or as stand-alone SLNB (training model B). SLNB was performed according to a standard protocol using the combined technique of isotope (Tc-99m labelled albumin colloid) and blue dye. An accredited New Start trainer mentored the first five procedures in the participant's hospital, or all 30 if stand-alone. Validation standards for model A and B were a localisation rate of at least 90 per cent. In addition, for model A only, in which a minimum of ten patients were required to be node-positive, a false-negative rate (FNR) of 10 per cent or less was required. RESULTS: From October 2004 to December 2008, 210 SLNB-naive surgeons, in 103 centres, performed 6685 SLNB procedures. The overall sentinel lymph node (SLN) localization rate was 98.9 (95 per cent confidence interval 98.6 to 99.1) per cent (6610 of 6685) and the FNR 9.1 (7.9 to 10.5) per cent (160 of 1757). The FNR was related to nodal yield, ranging from 14.8 per cent for one node and declining to 9.7, 6.6, 4.7 and 4.1 per cent for two, three, four and more than four SLNs respectively. No learning curve was identified for localisation or FNR. CONCLUSION: The programme successfully trained a wide range of UK breast teams to perform safe SLNB and suggested that a standard injection protocol and structured multidisciplinary training can abolish learning curves.
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Introduction: Several radiotracers are being used for sentinel node mapping in patients with breast cancer. In the current study, we reported our experience with 99m-Tc Phytate for sentinel node mapping in Mashhad University of Medical Sciences. Methods: All breast cancer patients who underwent sentinel node mapping using 99m-Tc Phytate were included. All patients received intradermal peri-areolar injection of 0.5 mCi/0.1cc 99m-Tc Phytate. Lymphoscintiraphy was performed for 145 patients 5-10 minutes post-injection. The sentinel nodes were found during surgery using a hand-held gamma probe as well as blue dye technique. Results: In total 165 patients were evaluated. Lymphoscintigraphy showed axillary sentinel nodes in 135 out of 145 patients (93%) following imaging. At least one sentinel node could be detected in all these 135 patients during surgery. In the remaining 10 patients with sentinel node non-visualization, 5 had sentinel node harvesting failure during surgery. Median number of sentinel nodes on the lymphoscintigraphy images was 1. Sentinel node detection rate was 95% (157/165). In the 8 patients with sentinel node harvesting failure, 7 had pathologically involved axilla. Median number of harvested sentinel nodes was 1. Mean sentinel node to background count ratio was 10±2. Conclusions: 99m-Tc Phytate is an effective and highly successful radiotracer for sentinel node mapping. Sentinel node can be visualized in a short time after 99m-Tc Phytate injection on the lymphoscintigraphy images. The sentinel to background count during surgery is high which results in more convenient sentinel node harvesting and high detection rate.
Article
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Background: Not all patients with non-small cell lung carcinoma (NSCLC) have mediastinal lymph node involvement and development of less invasive methods for evaluating mediastinal lymph nodes is important. Sentinel node biopsy has been used for NSCLC since 1999 to decrease the need for mediastinal lymph node dissection. In this review, we searched the literature in this regard and reported the results in a meta-analysis format. Methods: Medline, SCOPUS, and ISI web of knowledge were searched using: "(lung AND sentinel)" with no date or language limit. Any study with more than 5 patients and enough information to calculate detection rate and sensitivity was included. Results: Overall 47 and 43 studies (including subgroups) had the criteria for detection rate and sensitivity pooling respectively. Pooled detection rate was 80.6% [76.8-84%] and pooled sensitivity was 87% [83-90%]. Using radiotracers or both radiotracers and dyes had higher detection rate and sensitivity compared to dye alone. Among studies using radiotracers, highest detection rate was in intra-operative peri-tumoral injection group and highest sensitivity was in peri-tumoral pre-operative injection group. Emerging methods of sentinel node surgery including magnetic materials, fluorescent dyes, CT contrast agents, and carbon nano-particles had promising results. Conclusions: Sentinel node mapping using radiotracers is a feasible technique for mediastinal lymph node staging of N0 NSCLC patients. Alternative methods of sentinel node mapping are promising and warrant further studies.
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We evaluated the feasibility of outlining the body with scattered photons using a low dose intradermal injection of the radiotracer. PATIENTS AND METHODS.: Sixty breast cancer patients were included into the study. 30 minutes post radiotracer injection static lymphoscintigraphy images were acquired using low energy high resolution collimator in anterior and lateral views. For patients with 2-day protocol another set of images was taken 20 hours post-injection. Two photopeaks were used during imaging: 1-Tc-99m (130-150 keV) and 2- Scatter photons (60-120). The fusion image of these two images was constructed by NM-NM fusion workflow of the workstation. The usual body outline of the patients was also acquired in 20 cases using the external flood source without moving the patients from their positions. The early (30 minute image) scatterograms of the patients clearly showed the contour of the body. The 20 hour scatterograms were not as high quality as the corresponding early images. The constructed overlaid images showed the location of the axillary sentinel nodes and the body contours clearly for early scatterograms but not the delayed (20 hour) ones. The processing of the images for the reconstruction of overlaid scatterograms took the mean time of 10±5 seconds. Imaging the scattered photons is feasible for the intradermal low dose injection of the radiotracers in order to outline the body contour. This imaging method does not increase the radiation exposure of the patients or operators and does not extend the time of imaging either.
Article
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Sentinel node (SN) biopsy is becoming a standard procedure in the management of several malignancies. Several groups have evaluated the feasibility and value of this procedure in prostate cancer patients. In the current meta-analysis, we comprehensively and quantitatively summarized the results of these studies. Several databases including Medline, SCOPUS, Google Scholar, Ovid, Springer, and Science direct were systematically searched for the relevant studies regarding SL biopsy in the prostate cancer ("prostate" AND "sentinel" as search keywords). The outcomes of interest were sensitivity and detection rate of the procedure. For detection rate and sensitivity 21 and 16 studies met the criteria of inclusion respectively. Pooled detection rate was 93.8% (95% CI 89-96.6%). Cochrane Q value was 216.077 (I2 = 89.81% and p < 0.001). Pooled sensitivity was 94% (95% CI 91-96%). Cochrane Q value was 14.12 (I2 = 0.0 and p = 0.516). SL biopsy can prevent unnecessary pelvic lymph node dissection in prostate cancer patients. This procedure is feasible with low false negative rate and high detection rate.
Article
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Sentinel lymph node biopsy (SLNB) is commonly performed using radioisotopes and/or blue dye. However, it is still undefined which reagent is more suitable for identifying sentinel lymph nodes (SLN). A consecutive series of 640 breast cancer patients who had undergone SLNB at the Keio University Hospital from 2001 to 2006 was analyzed. The SLN was identified by a combination of technetium-99m tin colloid and isosulfan blue dye. The correlation between clinicopathological factors and the distribution of radioisotopes and blue dye was analyzed. The single metastatic lymph node revealed by axillary lymph node dissection (ALND) is the 'true SLN', and the distribution of radioisotopes and blue dye to the 'true SLN' was also analyzed. Blue-dye- and radioisotope-positive SLN were identified in 79.6 and 94.7% of the patients, respectively. Taken together, SLN were identified in 625 patients (97.7%) by radioisotope and/or blue dye. No significant correlation was observed between clinicopathological features and the distribution of the reagents. ALND found 73 patients with single lymph node metastasis, and 73 'true SLN' were identified by blue dye in 65.7% (48/73), and by radioisotope in 95.9% (70/73) of the cases. These data suggest that radioisotopes are superior to blue dye in detecting SLN in breast cancer.
Article
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We assessed the need for delayed lymphoscintigraphy imaging for sentinel lymph node (SLN) biopsy in stage I and II breast cancer patients using intradermal injection of (99m)Tc-antimony sulfide colloid. Seventy-five patients with early-stage breast cancer were included in our study. Periareolar intradermal injections of 0.5 mCi/0.2 mL (99m)Tc-antimony sulfide colloid was used for the patients without previous excisional biopsy (45 patients). Two intradermal injection of 0.5 mCi/0.2 mL (99m)Tc-antimony sulfide colloid was used on each side of the dermal incision in patients with the history of excisional biopsy (30 patients). Anterior and lateral static images were taken at 2 min. If SLN was not visualized, delayed imaging at 5, 10, 30, 60, 90, 150, and 180 min was done (till the visualization of the SLN or 180 min). SLN was performed by the combination of gamma probe and blue dye during surgery. Sentinel lymph node detection rate was 96% (72/75). SLNs were detected on the immediate (2 min) images in 55 (73.33%) patients. In the remaining patients, the SLNs were detected first on the 5-, 10-, and 30-min images in 10 (13/33%), 5 (6.66%), and 2 (2.66%) patients, respectively. In three patients (4%), SLN was not detected by lymphoscintigraphy even on 180-min images. During surgery, SLN was not detected in these three patients either. Considering the rapid flow of (99m)Tc-antimony sulfide colloid in our study, lymphoscintigraphy imaging can be completed in the nuclear medicine department without any delay in sending the patient back to the surgery department. Thirty minutes after radiotracer injection seems to be the optimal time for lymphoscintigraphy and delayed imaging beyond 30 min would not be necessary.
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Sentinel node biopsy (SNB) is rapidly emerging as the preferred technique for nodal staging in breast cancer. When radioactive colloid is used, a preoperative lymphoscintiscan is obtained to ease sentinel lymph node (SN) identification. This study evaluates whether preoperative lymphoscintigraphy adds diagnostic accuracy to offset the additional time and cost required. 823 breast cancer patients underwent SNB based on lymphoscintigraphy, intraoperative gamma probe detection, and blue dye mapping using 99 mTc-nanocolloid and Patent Blue V injected peritumourally. The SNB was followed by standard axillary treatment at the same operation. Preoperative lymphoscintigraphy was performed around 3 h after the radioisotope injection. Preoperative lymphoscintigraphy revealed SNs in 593 (72%) of the 823 patients imaged. SN visualisation on lymphoscintigraphy was less successful in large tumours and tumours involving the upper outer quadrant of the breast (P=0.046, P<0.001, respectively). Lymphoscintigraphy showed internal mammary sentinel nodes in 9% (62/707) patients. The SN was identified intraoperatively in 98% (581) patients who had SN visualised on preoperative lymphoscintigraphy, with a false-negative rate of 7%. In patients who did not have SN visualised on preoperative lymphoscintigraphy, the SN was identified at operation in 90% (204) patients, with a false-negative rate of 7%. The SN identification rate was significantly higher in patients with SN visualised on preoperative lymphoscintigraphy (P<0.001). SN identification rate intraoperatively using the gamma probe was significantly higher in the SN visualised group compared with the SN non-visualised group (95% vs. 68%; chi square (1 degrees of freedom (df)) P<0.001. There was no statistically significant difference in the false-negative rate and the operative time between the two groups. A mean of 2.3 (standard deviation (SD) 1.3) SNs per patient were removed in patients with SN visualised on preoperative lymphoscintigraphy compared with 1.8 (SD 1.2) in patients with no SN visualised on lymphoscintigraphy (P<0.001). Although SN visualisation on preoperative lymphoscintigraphy significantly improved the intraoperative SN localisation rate, SN was successfully identified in 90% of patients with no SN visualisation on lymphoscintigraphy. Given the time and cost required to perform routine preoperative lymphoscintigraphy, these data suggest that it may not be necessary in all cases. It may be valuable for surgeons in the learning phase to shorten the learning curve and in patients who have increased risk of intraoperative failed localisation (obese or old patients). A negative preoperative lymphoscintiscan predicts the inability to localise with the hand-held gamma probe. Therefore, if the SN is not visualised on lymphoscintigraphy then the addition of intraoperative blue dye is recommended to increase the likelihood of SN identification.
Article
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The use of isosulfan blue dye in sentinel node biopsy for breast cancer has been questioned because of its risk of allergic reaction. We hypothesized that blue dye could be safely omitted in the subgroup of patients who have evidence of successful sentinel node localization by lymphoscintigraphy. A retrospective review of patients with breast cancer and sentinel node biopsy was conducted. Information was collected on lymphoscintigraphy results, use of blue dye, and intraoperative and pathologic findings of sentinel nodes. We identified 475 patients with breast cancer who underwent 478 sentinel node biopsies. Both dye and isotope were given in 418 cases, of which 380 had a positive lymphoscintigram. In 5 of the 380 cases with a positive lymphoscintigram, the sentinel nodes obtained were blue but not hot, for a 1.3% marginal benefit of dye in the technical success of the procedure. Sentinel nodes positive for metastasis were found in 102 of 380 cases; in 3 cases, the only positive sentinel node was blue but not hot. Omission of the blue dye tracer would have increased the false-negative rate of the sentinel node procedure by approximately 2.5%. Even in sentinel node biopsy cases with a positive lymphoscintigram, the use of blue dye is beneficial for both improving the technical success of the procedure and reducing the false-negative rate of the procedure. Because the marginal benefits of dye justify its routine use, strategies to minimize the toxicity of blue dye are warranted.
Article
Anal squamous cell carcinoma with lymph node metastases carries a poor outcome. There remains a need for a better method to diagnose inguinal lymph node metastases which is minimally invasive, accurate and avoids unnecessary irradiation to the groin with its associated significant co-morbidity. The aim of this study was to evaluate the role of sentinel lymph node (SLN) biopsy in anal squamous cell carcinoma. The systematic review was conducted in accordance with PRISMA guidelines. The Medline, Central and Embase databases were searched using the terms 'sentinel lymph node' and 'anus neoplasms'. The systematic review identified 17 studies, containing 270 patients. SLN detection rate varied from 47%-100%. The presence of nodal metastases varied from 0-44%. The complication rate varied from 0-59%.The rate of development of subsequent inguinal lymph node metastases in those previously SLN biopsy-negative (a surrogate marker for false negative rate) ranged from 0-18.75%. SLN biopsy is a feasible method of assessing lymph node status in patients with anal squamous cell carcinoma. Longer follow up is required to evaluate the proportion of patients who are SLN biopsy-negative and subsequently develop nodal metastases. More studies are required to ascertain whether SLN biopsy should be the main method of assessing inguinal lymph node involvement in patients with anal squamous cell carcinoma.
Article
Background: Current guidelines for breast cancer treatment recommend completion axillary lymph node dissection (CALND) following in case of positive sentinel lymph node (SLN) metastasis, which only in 35%-70% shows additional nodal metastases. Several nomograms and scoring systems have been created to predict the risk of metastasis in non-SLNs. The aim of the study was to identify individual patient risk for non-sentinel lymph node metastasis by validating with MSKCC nomogram and to evaluate the variability within a group of SLN-positive breast cancer patients with the final goal of avoiding unnecessary CALND. Patients and methods: We retrospectively evaluated 1496 primary breast cancer patients. 324 women with a positive SLN who underwent CALND were identified. The predictive accuracy was measured and compared with the MSKCC nomogram by the area under the receiver operating characteristic curve. Receiver operating characteristic (ROC) curve was drawn on the basis of the sensitivity and specificity, and the area under the curve (AUC) was calculated. Results: At least one metastatic non-SLN were identified in 88/324 (27.2%) patients. Tumor size, tumor type, tumor grade, number of positive SLNs and number of negative SLNs were significantly associated with non-SLN status in multivariate analyses. The MSKCC nomogram showed an AUC value of 0.738 (95% confidence interval = 0.682-0.793) after the validation for our collectives. Conclusions: The MSKCC nomogram showed a good prediction for the non-SLN metastasis and performed adequately in our patient collective. Therefore, for the use of nomogram, validation with other populations of patients is strongly suggested.
Article
Background: New Start, a structured, validated, multidisciplinary training programme in sentinel lymph node biopsy (SLNB), was established to allow the introduction and rapid transfer of appropriate knowledge and technical skills to ensure safe and competent practice across the UK. Methods: Multidisciplinary teams attended a theory/skills laboratory course, following which they performed 30 consecutive SLNBs, either concurrently with their standard axillary staging procedure (training model A) or as stand-alone SLNB (training model B). SLNB was performed according to a standard protocol using the combined technique of isotope ((99m) Tc-labelled albumin colloid) and blue dye. An accredited New Start trainer mentored the first five procedures in the participant's hospital, or all 30 if stand-alone. Validation standards for model A and B were a localization rate of at least 90 per cent. In addition, for model A only, in which a minimum of ten patients were required to be node-positive, a false-negative rate (FNR) of 10 per cent or less was required. Results: From October 2004 to December 2008, 210 SLNB-naive surgeons, in 103 centres, performed 6685 SLNB procedures. The overall sentinel lymph node (SLN) localization rate was 98·9 (95 per cent confidence interval 98·6 to 99·1) per cent (6610 of 6685) and the FNR 9·1 (7·9 to 10·5) per cent (160 of 1757). The FNR was related to nodal yield, ranging from 14·8 per cent for one node and declining to 9·7, 6·6, 4·7 and 4·1 per cent for two, three, four and more than four SLNs respectively. No learning curve was identified for localization or FNR. Conclusion: The programme successfully trained a wide range of UK breast teams to perform safe SLNB and suggested that a standard injection protocol and structured multidisciplinary training can abolish learning curves.
Article
Sentinel node biopsy has replaced axillary lymph node dissection as the standard of care in early breast cancers. Sentinel node biopsy represents a highly accurate and less-morbid axillary staging, which allows most patients to avoid unnecessary axillary lymph node dissection and its morbidity. This review provides information including several issues which are still under debate, such as clinical significance of micrometastases, avoidance of axillary lymph node dissection for patients with positive sentinel nodes, accuracy and timing of sentinel node biopsy in patients undergoing neoadjuvant chemotherapy, and how many sentinel nodes are sufficient for removal. Finally, a new topic is introduced: superparamagnetic iron oxide (SPIO)-enhanced magnetic resonance (MR) imaging for the detection of metastases in sentinel nodes localized by computed tomography (CT)-lymphography (CT-LG) in patients with breast cancer. SPIO-enhanced MR imaging is a useful method of detecting metastases in sentinel nodes localized by CT-LG in patients with breast cancer. Patients with clinically negative nodes may be spared even sentinel node biopsy when the sentinel node is diagnosed as disease free using SPIO-enhanced MR imaging.
Article
In sentinel node surgery for breast cancer, procedural accuracy is assessed by calculating the false-negative rate. It is important to measure this since there are potential adverse outcomes from missing node metastases. We performed a meta-analysis of published data to assess which method has achieved the lowest false-negative rate. We found 3,588 articles concerning sentinel nodes and breast cancer published from 1993 through mid-2011; 183 articles met our inclusion criteria. The studies described in these 183 articles included a total of 9,306 patients. We grouped the studies by injection material and injection location. The false-negative rates were analyzed according to these groupings and also by the year in which the articles were published. There was significant variation related to injection material. The use of blue dye alone was associated with the highest false-negative rate. Inclusion of a radioactive tracer along with blue dye resulted in a significantly lower false-negative rate. Although there were variations in the false-negative rate according to injection location, none were significant. The use of blue dye should be accompanied by a radioactive tracer to achieve a significantly lower false-negative rate. Location of injection did not have a significant impact on the false-negative rate. Given the limitations of acquiring appropriate data, the false-negative rate should not be used as a metric for training or quality control.
Article
Sentinel lymph node biopsy is emerging as a promising method for inguinal lymph node staging of penile squamous cell carcinoma. In the current systematic review we evaluated the accuracy of sentinel lymph node biopsy for inguinal lymph node staging of penile squamous cell carcinoma and studied possible influential factors. MEDLINE®, Scopus®, ISI®, Ovid SP®, Springer, ScienceDirect® and Google™ Scholar were searched by the key words "(penile OR penis) AND sentinel". No date or language limitation was imposed on the search and meeting abstracts were not excluded from analysis. A random effects model was used for statistical pooling. A total of 17 studies suitable for meta-analysis were detected. Three articles had 2 different subgroups of patients and each subgroup was considered as a separate study. Overall 18 studies (including the subgroups) were used for detection rate meta-analysis and 19 for sensitivity meta-analysis. The pooled detection rate was 88.3% (95% CI 81.9-92.6). Pooled detection rate of 90.1% (95% CI 83.6-94.1) was calculated for the studies using blue dye and radiotracer. The pooled sensitivity was 88% (95% CI 83-92). The highest pooled sensitivity (92% [95% CI 86-96]) was in the studies using radiotracer and blue dye, and recruiting only cN0 cases. Sentinel lymph node mapping in penile squamous cell carcinoma is a method with a high detection rate and sensitivity. Using radiotracer and blue dye for sentinel lymph node mapping and including only cN0 disease ensures the highest detection rate and sensitivity.
Article
Sentinel lymph node biopsy (SLNB) has become the standard of care for early breast cancer. Its use in breast cancer has been evaluated in several randomized controlled trials and validated in multiple prospective studies. Additionally, it has been verified that SLNB has decreased morbidity when compared to axillary lymph node dissection (ALND). The technique used to perform sentinel lymph node mapping was also evaluated in multiple studies and the accuracy rate increases when radiocolloid and blue dye are used in combination. As SLNB became more accepted, contraindications were delineated and are still debated. Patients who have clinically positive lymph nodes or core biopsy-proven positive lymph nodes should not have SLNB, but should have an ALND as their staging procedure. The safety of SLNB in pregnant patients is not fully established. However, patients with multifocal or multicentric breast cancer and patients having neoadjuvant chemotherapy are considered candidates for SLNB. However, the details of which specific neoadjuvant patients should have SLNB are currently being evaluated in a randomized controlled trial. Patients with ductal carcinoma in situ (DCIS) benefit from SLNB when mastectomy is planned and when there is a high clinical suspicion of invasion. With the advent of SLNB, pathologic review of breast cancer lymph nodes has evolved. The significance of occult metastasis in SLNB patients is currently being debated. Additionally, the most controversial subject with regards to SLNB is determining which patients with positive SLNs benefit from further axillary dissection.
Article
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.
Article
Sentinel lymph node biopsy (SLNB) is an important method of staging early breast cancer because of the inherent benefits it confers on patients in terms of arm function and quality of life. Its success depends on a high level of accuracy in detecting the sentinel node. This is achieved by a dual mapping technique that employs a radio-labelled nanocolloid and a vital blue dye. The vital dyes however carry the risk of anaphylaxis, and as more surgeons employ SLNB in their daily practice, a proportionate rise in the number of anaphylactic reactions can be expected. A comprehensive review of risks and benefits associated with using vital blues dyes has not been published and therefore a retrospective review was undertaken of the different levels of anaphylaxis associated with vital dyes as well as their benefits in SLNB. An OVID MEDLINE search was performed of the English published literature using appropriate search terms to find published trial data and case series that focused on adverse reactions to vital blue dyes. The risk of severe anaphylaxis (grade 3) can be as low as 0.06%, and up to 0.4% for patients undergoing SLNB when data is analysed from large trials. Furthermore, adverse reactions associated with blue dyes are reversible with appropriate management. Surgeons should continue to use vital dyes to ensure that SLNB remains a highly sensitive procedure.
Article
The sentinel lymph node (SLN) procedure is now used routinely for the staging of clinically node-negative patients with early breast cancer. Two identification techniques exist: colorimetric and isotopic. These can be used alone or in combination. The combined method is associated with an increased identification rate. However, allergic and adverse reactions to blue dyes have been reported. The objective of this review was to determine the incidence of such events and to discuss alternative approaches. The authors conducted a search of the MEDLINE and EMBASE databases for reports of anaphylactic responses to isosulfan blue dye and patent blue V dye. Allergic reaction to the dyes isosulfan blue and patent blue V is rare and the reported incidence varies between 0.07% and 2.7%. Methylene blue dye appears to be safer, with no cases of allergic events having been reported. However, allergy tests in some patients have proven that there is cross-reactivity between isosulfan blue dye and methylene blue dye. Even though the risk of an anaphylactic response is low, this raises questions about the usefulness of colorimetric detection of SLN and whether alternatives to the use of the isosulfan and patent blue V dyes, such as methylene blue, exist.
Article
We sought to evaluate the utilization of blue dye in addition to radioisotope and its relative contribution to sentinel lymph node (SLN) mapping at a high-volume institution. Using a prospectively maintained database, 3,402 breast cancer patients undergoing SLN mapping between 2002 and 2006 were identified. Trends in utilization of blue dye and results of SLN mapping were assessed through retrospective review. Statistical analysis was performed with Student t test and chi-square analysis. 2,049 (60.2%) patients underwent mapping with dual technique, and 1,353 (39.8%) with radioisotope only. Blue dye use decreased gradually over time (69.8% in 2002 to 48.3% in 2006, p < 0.0001). Blue dye was used significantly more frequently in patients with lower axillary counts, higher body mass index (BMI), African-American race, and higher T stage, and in patients not undergoing skin-sparing mastectomy. There was no difference in SLN identification rates between patients who had dual technique versus radiocolloid alone (both 98.4%). Four (0.8%) of 496 patients who had dual mapping and a positive SLN had a blue but not hot node as the only involved SLN. None of these four had significant counts detected in the axilla intraoperatively. Nine (0.4%) of 2,049 patients who had dual mapping had allergic reactions attributed to blue dye. Blue dye use has decreased with increasing institutional experience with SLN mapping. In patients with adequate radioactive counts in the axilla, blue dye is unlikely to improve the success of sentinel node mapping.
Article
We compared early and delayed lymphoscintigraphy images using intradermal injection of (99m)Tc-antimony sulfide colloid, which has small particles. Eighty patients with early-stage breast cancer were included into the study. Intradermal injection of (99m)Tc-antimony sulfide colloid was used for sentinel node mapping. After radiotracer injection, 30 min and 20 h later, lymphoscitigraphy images were obtained in lateral and anterior views. After the completion of each image sets, the location of the visible nodes in the axilla was marked on the skin. Two nuclear medicine specialists reviewed the images independently and the number and location of detected nodes were recorded. At least one hotspot was detected in the axillary region in 78 (97.5%) and 79 (98.75%) patients on the early and delayed images, respectively. No extra-axillary drainage was noted in the patients. The number and location of detected hot spots were the same in 77 patients on both image sets. In one patient the early image did not show any axillary hot spot despite its visualization on the delayed image set and in one patient no hot spot was noted on either images. In one patient an additional axillary hot spot was noted on the delayed image, which was not apparent on the early image. Our study showed that a delay of up to 20 h in sentinel lymph node biopsy using intradermal injection of (99m)Tc-antimony sulfide colloid does not result in washout of the tracer from the true sentinel node or migration of the radiotracer into second-echelon nodes.
Article
The UK National training programme (NEWSTART) for SLNB in breast cancer was established in 2004, aimed at providing structured, standardised training with a focus on multidisciplinary team (MDT) delivery. A questionnaire was devised and after approval by the Association of Breast Surgeons (ABS) executive committee they were sent to all full members of the ABS. Most (97%) of breast surgeons are convinced by the evidence for SLNB as standard of care for early breast cancer. 64% use SLNB to stage clinically node negative patients, of whom 23% use it as a standalone procedure. 38% of surgeons were dissatisfied with the time it takes to complete the in house training, and 87% with the time it takes to complete the validation phase. Logistical and funding issues were the main problems cited. The majority of surgeons (86%) use the recommended combined technique, with 47% continuing to use the dual localisation method. 14% use either blue dye or isotope alone, without scintiscan. Only 10% offer intra operative diagnosis, of which the majority (6%) use touch imprint cytology. 31% included their results in their most recent surgical appraisal. The majority of breast surgeons in the UK are convinced by the evidence for SLNB, and most use SLNB in their practice for staging. Reasons for not conducting SLNB are logistical rather than lack of belief in the procedure. The majority of respondents completed their training within the anticipated time line. The majority of centres do not perform intra-operative assessment.
Article
The standard method for axillary lymph node staging in early breast cancer is sentinel lymph node biopsy. In some patients the sentinel lymph node can not be localized during surgery and these patients have to undergo standard axillary lymph node dissection. In this study we have evaluated the predictors of sentinel lymph node localization failure using (99m)Tc-antimony sulfide colloid and intradermal injection combined with blue dye technique. 202 consecutive patients with early stage breast cancer (clinically stage I or II) were retrospectively evaluated. Patients whose sentinel lymph node was localized during surgery were compared to those with localization failure considering several variables. Sentinel lymph node was successfully located on the pre-operative lymphoscintigraphy images in 180 patients (89%). Both univariate and multivariate analyses showed that only sentinel lymph node non-visualization by pre-operative lymphoscintigraphy, experience of the surgeon, and axillary lymph node involvement are associated with sentinel node localization failure during surgery. This study shows the importance of pre-operative lymphoscintigraphy in order to identify the group of patients with possible localization failure during surgery and warning the surgeon beforehand. We also recommend that all surgeons pass the learning curve of sentinel lymph node biopsy before routinely performing this procedure.
Article
Isosulfan Blue dye (BD) allergic drug reactions (ADR) occur in up to 2% of patients undergoing SLN biopsy (SLNB). We sought to determine if BD enhances the performance of SLNB such that this risk is justified. A retrospective review of 392 breast cancer patients undergoing SLNB between 8/99 and 8/04 was performed; 208 patients had radioisotope (ISO) alone, 167 had ISO+BD. Total SLN and positive SLN in each group were compared. We examined the ISO+BD group for concordance and the presence of blue only nodes. The effect of tumor location, injection site, angiolymphatic invasion, Her2/neu expression, and the presence of a noninvasive component were studied. Chi-square, linear regression, Fisher t tests, and ANOVA were performed. SLN were identified in 94% of ISO and 96% of ISO+BD patients. The mean number SLN from the ISO group was 2.01, 1.93 for ISO+BD; 27% of ISO and 21% of ISO+BD patients had positive nodes. These differences were not significant. No difference for tumor location, injection site, angiolymphatic invasion, Her2/neu expression, or the presence of a noninvasive component was found. The addition of BD to ISO in patients with invasive breast cancer does not significantly enhance the performance of SLNB.
Article
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.
Article
Selective sentinel lymphadenectomy dissection has been demonstrated to have high predictive value for axillary staging in breast cancer patients. Preoperative lymphoscintigraphy can localize and facilitate the harvesting of sentinel lymph nodes (SNLs) with a high success rate. The failure rate of selective sentinel lymphadenectomy ranges between 2% and 8%. Details of the failures were seldom addressed. This study analyzes the causes of failure to harvest SLNs in spite of positive preoperative lymphoscintigraphy. From November 1997 through November 2000, 201 female patients with histologically confirmed and operable breast carcinoma underwent selective sentinel lymphadenectomy at the University of California, San Francisco (UCSF) Carol Franc Buck Breast Care Center. Among these patients, 183 (91%) received preoperative lymphoscintigraphy to identify axillary lymph nodes. The causes of failure to harvest the SLNs in this group of patients despite successful preoperative lymphoscintigraphy were analyzed. In our series, the failure rate of SLN identification was 7.0% (14/201). The failure rate for our first year was 11.1% (6/54), second year 9.1% (7/77), and third year 1.4% (1/70). The incidence of failure in spite of positive preoperative lymphoscintigraphy was 3.5% (6/170). The shine-through effect of the primary injection site and failure to visualize a blue lymph node were the main reasons for technical failure. Most of these cases occurred during our learning curve of the procedure. The possibility of failure to get the SLN should be explained to patients before surgery. Axillary lymph node dissection (ALND) should be done if selective SLN dissection is not successful.
Article
Sentinel node biopsy (SNB) is a minimally invasive procedure to stage the axilla in patients with breast cancer. Like any new surgical procedure, it is associated with a learning curve. This article describes the learning curve as part of the ALMANAC trial. The first phase of this trial is a validation phase in which surgeons perform SNB followed by an immediate axillary dissection in a consecutive series of 40 patients with invasive breast cancer. Each surgeon completes a mandatory program of proctored training during this phase. Surgeons who achieve a localization rate of 90% or more and a false-negative rate of 5% or less are eligible to proceed to the randomized phase. All 13 surgeons who completed 40 procedures as part of the validation phase of the ALMANAC trial achieved the set target. This study shows that a standardized training program allows surgeons to achieve a satisfactory localization rate and an acceptable false-negative rate after 40 SNBs.
Article
Sentinel node biopsy in breast cancer is a new rapidly advancing minimal invasive procedure which enables nodal staging of clinically node negative breast cancer patients without performing complete axillary dissection. There are still controversies over the added value of Blue Dye when lymphoscintigraphy and gamma probe are used. In our series, 91 consecutive patients with invasive breast carcinoma were operated by a single surgeon, using lymphoscintigraphy, gamma probe and Blue Dye. The sentinel nodes (SLN) were histologically examined by HE and immunohistochemistry. Lymphoscintigraphy was succesful in 81 patients (89%). After the injection of Blue Dye, SLN could be identified in all 91 patients. Metastases in the SLN were present in 35 patients. We retrieved 128 SLN, of these 93 were hot and blue, 19 only hot and 16 only blue. The distribution of metastatic and nonmetastatic SLN between these three labeling groups was not different (P = 0.9361). We could not show any difference in the metastatic involvement of SLN in patients in whom preoperative lymphoscintigraphy could visualise the SLN preoperatively compared to those in whom it could not (P = 0.7315). False negativity calculated in our initial series of 36 patients was 0%. Our study showed added value of Blue Dye in detection of metastatic and nonmetastatic SLN.
Article
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.
Article
The techniques for performing sentinel lymph node biopsy (SLNB) vary from institution to institution. Some advocate blue dye only, others radioisotope only, and many utilize a combination of both. The purpose of this study is to evaluate the additional benefit that blue dye provides when used in combination with a radioisotope. From October 2001 to June 2004, 102 SLNBs were attempted in 99 patients with breast cancer using a combination of blue dye and radioisotope. A lymph node was considered a sentinel lymph node (SLN) when it was stained with blue dye, had a blue lymphatic afferent, or had increased radioactivity. Ninety-eight patients had 101 successful identifications of SLNs, for an identification rate of 99%. Twenty-eight patients had positive SLNs. In three of those patients, although there were SLNs identified by both techniques, the positive SLNs were identified with only blue dye. Of the 102 SLNB procedures, there were two patients whose only SLN was identified by blue dye only. Although blue dye did not improve the identification rate, there was a definite benefit in improving the false-negative rate.
Article
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.
Article
The study compared the accuracy and success rate of two techniques, methylene blue alone versus combined methylene blue and radioactive colloid in sentinel lymph node localisation in the management early breast cancer. Three hundred and twenty-nine patients with tumours less than 2 cm on ultrasound assessment were prospectively evaluated. One hundred and seventy-three patients (Group A) underwent sentinel lymph node localisation using 1 ml of 1% methylene blue. A combined technique of both methylene blue and radioactive colloid was used in 156 patients (Group B). Application of both was subdermal and subareolar. Sentinel lymph nodes were examined by standard microscopy. Patients underwent breast conservation surgery or mastectomy and sentinel node guided four node axillary sampling+/-clearance. In Group A, the sentinel lymph node identification rate was 96.5%. The negative predictive value was 96.3%, with false negative of 3.7% and accuracy of 87.4%. In group B the identification rate for sentinel lymph node was 98.7%, with false negative of 4.1%, negative predictive value of 96%, and accuracy of 83.8%. Sentinel lymph node localisation using methylene blue or combined dye and radioactive tracer technique predicts the axillary lymph node status in early breast cancer with comparable success rates, accuracy and false negative rates. The combined technique facilitates quicker identification of sentinel lymph node; however the dye technique alone can be used successfully in centres without nuclear medicine facilities.
Combined methylene blue dye and radioactive tracer technique for sentinel lymph node localization in early breast cancer
  • S Tahmasebi
  • M Haghighifard
  • A Talei
S. Tahmasebi, M. Haghighifard, A. Talei, Combined methylene blue dye and radioactive tracer technique for sentinel lymph node localization in early breast cancer, Middle East J. Cancer 1 (2010) 155e158.