Comparison between periareolar and peritumoral injection of radiotracer for sentinel lymph node biopsy in patients with breast cancer

[Functional anatomy of the lymphatic drainage of the breast: contribution of sentinel lymph node biopsy]

OBJECTIVE

To make a development on the recent data of the literature concerning the functional anatomy of the lymphatic drainage of the breast, observed during interventions of sentinel lymph node biopsy; to compare the descriptive anatomy taking into consideration these new results.

METHODS

The population of our descriptive anatomical study is made-up of five patients. All the patients underwent a radical mastectomy during which, an injection of 2 ml of patented blue, realized at the periareolar area allowed to observe the glandular lymphatic vessels. Bibliographic researches were undertaken on Internet site of the National Library of Medicine and on Internet site of the library of anatomy (Faculté de médecine des Saints-Pères Paris).

RESULTS

Lymphatic anatomy of the breast was described since more than one century starting from works undertaken on anatomical subjects. Recent works, completed during sentinel lymph node biopsy, enriched these descriptive data of new functional anatomical data on the lymphatic drainage of the breast. Thus, the superficial ways of lymphatic drainage already described by Sappey, drain the surface glandular parenchyma until in the axillary lymph node. A deep plexux described more recently by Hidden drain the deep glandular parenchyma until in the internal mammary lymph nodes and the axillary lymph nodes. The results of our in vivo study corroborated the descriptive and functional data ever known.

CONCLUSION

Thanks to the sentinel lymph node biopsy technique, the descriptive anatomy described since 1885, grows rich by new functional data which make it possible on the one hand, to understand at best the descriptive anatomy, and on the other hand, to apprehend the lymphonodal metastatic risk in breast cancer. These recent data are of an interest real, as well anatomical as therapeutic, and constitute a interesting research orientation.

Use of lymphoscintigraphy defines lymphatic drainage patterns before sentinel lymph node biopsy for breast cancer

BACKGROUND

Lymphoscintigraphy (LSG) can identify lymphatic drainage patterns before sentinel lymph node (SLN) biopsy is performed in patients with early-stage breast cancer, but the importance of extraaxillary SLNs seen on LSG is unknown. We assessed whether drainage patterns seen on LSG were associated with histologic findings in axillary SLNs recovered at SLN biopsy.

STUDY DESIGN

From a prospectively maintained database, we identified 1,201 clinically node-negative patients with invasive breast cancer who underwent preoperative LSG and axillary SLN biopsy. Patient and tumor characteristics, LSG results, and final SLN pathology results were examined.

RESULTS

LSG showed drainage to internal mammary (IM) nodes in 1.6% of patients, axillary nodes in 68.1%, both IM and axillary nodes in 19.8%, and no drainage in 10.3%. Drainage to IM nodes was observed for tumors in all quadrants of the breast. Patients with IM drainage had a younger median age than patients without IM drainage (51.8 versus 58.3 years, respectively; p < 0.001). The intraoperative axillary SLN identification rate was higher when axillary drainage was observed on LSG than when it was not observed (98.7% versus 93.0%, respectively; p < 0.001), but the LSG drainage pattern was not associated with pathologic status of the SLN or number of metastatic SLNs. At a median followup of 32 months, 4 patients had regional nodal recurrence.

CONCLUSIONS

Almost one-fourth of patients had lymphatic drainage to the extraaxillary lymph nodes, particularly the IM nodes, seen on LSG. Extraaxillary drainage seen on LSG did not preclude identification of axillary SLNs at operation. Longterm followup of patients with lymphoscintigraphic evidence of extraaxillary drainage is needed to determine whether regional and systemic recurrence patterns differ in these patients.

Results of preoperative lymphoscintigraphy for breast cancer are predictive of identification of axillary sentinel lymph nodes

The aim of this study was to identify the variables associated with successful peroperative sentinel lymph node (SLN) localization. We studied 201 patients with T1, T2, N0 invasive breast cancer who underwent a SLN procedure from 1999 to 2003. Of these 201 patients, 55 underwent peritumoral and 146 underwent periareolar radioisotope injection before the blue dye injection. All patients were operated on by breast conservative surgery and axillary dissection after SLN biopsy. Age, weight, menopausal status, previous biopsy, localization of the tumor, results of lymphoscintigraphy, site of radiotracer injection, tumor size, tumor grade, experience of surgeons, and the number of invaded axillary nodes were analyzed to determine whether they had any significant correlation with successful identification of SLN. Variables found to have a statistically significant influence on the SLN identification rate and on preoperative lymphoscintigraphy identification were introduced into a univariate and multivariate logistic regression model. In multivariate analysis, successful lymphoscintigraphy (P < 0.0001) and the absence of metastatic axillary nodes (P < 0.005) were associated with successful identification of SLNs. The peritumoral injection of radiotracer (P < 0.001), patient age > 60 years (P < 0.003), and localization of the tumor in the upper outer quadrant (P < 0.004) were associated with failure of lymphoscintigraphic visualization of SLN. The technique of SLN detection thus appears to be better for patients with low risk of invaded axillary lymph nodes.

Factors predicting failure to identify a sentinel lymph node in breast cancer

BACKGROUND

Although sentinel lymph node (SLN) biopsy is widely accepted as a minimally invasive method of nodal staging, failure to identify an SLN mandates a level I/II axillary node dissection. The purpose of this study was to elucidate factors that independently predict failure to identify an SLN.

METHODS

Using a large multicenter prospective study of SLN biopsy for patients with invasive breast cancer, we performed univariate and multivariate regression analyses to determine clinicopathologic factors predictive of failure to identify an SLN.

RESULTS

Of the total 4131 patients in the study, an SLN was not identified in 249 (6.0%). Tumor location (P = .409), biopsy type (P = .079), surgery type (P = .380), and histologic subtype (P = .999) were not significant predictors of failure to identify an SLN. On multivariate analysis, age greater than 60 years (OR = 1.469; 95% CI, 1.116-1.934, P = .006), nonpalpable tumors (OR = 0.639; 95% CI, 0.479-0.852, P = .002), injection technique with blue dye alone (OR = 0.389, 95% CI, 0.259-5.86, P < .001), and surgical experience of less than 10 SLN biopsy cases (OR = 1.886; 1.428-2.492, P < .001) were significant independent predictors of failure to identify an SLN. Optimal SLN biopsy technique using an intradermal and/or subareolar injection of radioactive colloid and blue dye can improve SLN identification rates regardless of patient and tumor characteristics.

CONCLUSIONS

Patient age and tumor palpability significantly affect the ability to identify an SLN in patients with breast cancer. Optimal injection technique can significantly improve sentinel node identification rate regardless of these factors.

A critical review of variables affecting the accuracy and false-negative rate of sentinel node biopsy procedures in early breast cancer

Radionuclide sentinel lymph node localization and biopsy is a staging procedure that is being increasingly used to evaluate patients with invasive breast cancer who have clinically normal axillary nodes. The most important prognostic indicator in patients with invasive breast cancer is the axillary node status, which must also be known for correct staging, and influences the selection of adjuvant therapies. The accuracy of sentinel lymph node localization depends on a number of factors, including the injection method, the operating surgeon's experience and the hospital setting. The efficacy of sentinel lymph node mapping can be determined by two measures: the sentinel lymph node identification rate and the false-negative rate. Of these, the false-negative rate is the most important, based on a review of 92 studies. As sentinel lymph node procedures vary widely, nuclear medicine physicians and radiologists must be acquainted with the advantages and disadvantages of the various techniques. In this review, the factors that influence the success of different techniques are examined, and studies which have investigated false-negative rates and/or sentinel lymph node identification rates are summarized.

Factors of importance for scintigraphic non-visualisation of sentinel nodes in breast cancer

PURPOSE

The aim of this study was to analyse different factors of possible significance for non-visualisation of sentinel nodes (SNs) by preoperative lymphoscintigraphy, in order to enable improvement of the success rate of SN visualisation through modification or alteration of some of the factors.

METHODS

Between March 1998 and January 2003 we analysed a series of 442 women with unilateral stage T1 and clinical N0 breast cancer. Lymphoscintigraphy was performed after periareolar or peritumoural injection of 99mTc-albumin nanocolloid, with image acquisition after 2-6 h or 18-24 h. Until January 2001, all patients received around 20 MBq tracer, irrespective of time to operation. From January 2001, patients injected on the day before surgery received at least 100 MBq while patients injected on the day of surgery received around 50 MBq.

RESULTS

An SN was visualised in 87% of the patients, and at surgery the SN was detected with the hand-held gamma probe in 42% of the remaining patients. By multiple logistic regression analysis, statistically significant independent variables that increased the risk for non-visualisation were increasing age (p=0.0007), increasing body weight (p=0.0189) and peritumoural injection (p<0.0001). Significant interaction was found for imaging time and injected activity (p=0.0017).

CONCLUSION

This study conclusively shows that the risk of unsuccessful SN imaging increases with age and body weight. Our findings suggest that the scintigraphic success rate may be improved by periareolar (rather than peritumoural) injection. Early and late imaging procedures are equally efficient, but if a late imaging procedure is used, activity (adjusted for physical decay) in the patient on day 2 should be more than 10 MBq.

Sentinel lymph node biopsy in breast cancer: results of intradermal periareolar tracer injection and follow-up of sentinel lymph node-negative patients

Several methods are in use for identification of the sentinel lymph node (SLN) in breast cancer. We set up the hypothesis that intradermal (i.d.) infra-areolar injection of technetium-99m in combination with i.d. injection of patent blue dye lateral to the areola can identify the same lymph node as peritumoral injection, regardless of the location of the tumour. Each of 50 patients with breast cancer (group I) received an i.d. injection of technetium-99m 1cm caudal to the areola. After induction, blue dye was injected intradermally 1cm lateral to the areola. These patients underwent axillary dissection regardless of their lymph node status. The SLN was identified in 96% of these patients. One of them had axillary lymph node metastases even though the SLN was negative (6%). Further 82 patients (group II) underwent SLN identification and removal without further axillary dissection. The duration of mean follow-up for these patients was 28 months (16-39 months). One patient developed axillary recurrence (1%) 24 months after the initial operation. Intradermal periareolar tracer injection is an accurate method of locating the sentinel node. Long-term follow-up of patients who had negative sentinel nodes and did not undergo axillary dissection revealed a low axillary recurrence rate.

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

PURPOSE

The purpose of this study was to evaluate 2 different injection techniques for lymphoscintigraphy to determine the axillary sentinel lymph node (SLN) in patients with breast cancer.

METHODS

Thirty-six patients with early breast cancer were studied prospectively. Both peritumoral (PT) and subdermal (SD) injections were performed on each patient with Tc-99m rhenium sulfide colloid. PT injections were done 1 to 8 days before surgery and SD injections were done on the day of operation. An intraoperative gamma probe was used to explore the axillary SLNs prior to tumor excision and axillary dissection. All surgical specimens were evaluated histopathologically.

RESULTS

In 19 of 36 patients, the same lymphatic drainage sites were observed with both techniques. Of these, 17 patients showed only axillary, 1 showed axillary and internal mammary (IM), and 1 showed axillary and subclavicular drainage sites. With PT injections 26 of 36 patients (72%), and with SD injections 33 of 36 patients (92%), showed axillary drainage and axillary SLNs. With PT injections 9 patients, and with SD injections only 2 patients, did not show any drainage site. During the operation with a gamma probe, axillary SLNs were excised in 35 patients (success rate, 97%). IM drainage was seen in 8 of 36 patients who underwent PT injections and in 3 of 36 with SD injections.

CONCLUSION

The success rate was found to be higher with the SD injection technique than with PT injections to visualize the axillary SLN. To increase the visualization of both axillary and IM SLNs, it may be useful to perform lymphoscintigraphy with SD and PT injections together.

Current controversies in sentinel lymph node biopsy for breast cancer

Despite the widespread use of sentinel lymph node biopsy (SLNBx) in the surgical management of breast cancer patients, several areas remain controversial. The following controversies are reviewed: Learning curves and validation studies. There clearly is a learning curve, and a completion ALND should be done until adequate proficiency is exhibited, both in terms of identification and false-negative rates. Location of injection. Intradermal injection offers superior identification rates compared with peritumoral injection, with comparable false-negative rates. Subareolar injection is as accurate as peritumoral injection. The value of scintigraphy. Routine scintigraphy does not enhance identification or false-negative rates. Mapping agents. Blue dye and radioactive tracer combined to provide a higher identification rate than either used alone.SLNBx in DCIS. In patients with a high risk of microinvasion, such as large tumors, a mass or high-grade DCIS-SLNBx is justified.SLNBx following neoadjuvant chemotherapy. Although there is evidence that SLNBx after neoadjuvant chemotherapy may be accurate, these data should be applied cautiously. Implications of non axillary SLN, especially internal mammary nodes. Data do not support routine resection of internal mammary sentinel lymph nodes outside a clinical trial. Implications of micrometastases in the sentinel lymph node seen only on immunohistochemistry. Since the significance of such metastases is unclear, decisions regarding treatment of these patients should be individualized. The value of completion axillary lymph node dissection. Is being addressed in clinical trials. Until those studies mature, completion ALND should be performed for patients with SLN metastases, but may be abandoned for patients with a negative SLN.

Localización del ganglio centinela en cáncer de mama. Inyección periareolar del radiocoloide

Traditional lymphadenectomy is being replaced by sentinel node biopsy in initial management of early stage breast cancer. The aim of this study was to validate the technique in our center, where we perform preoperative lymphoscintigraphy and intraoperative detection of sentinel node, after periareolar radiotracer and peritumoral blue dye injection. Sixty patients, breast cancer stages I and II, were included. Lymphatic mapping was performed the day before surgery, after the administration of 74 MBq 99mTc sulfur colloid in periareolar subdermal tissue. Surgical detection of sentinel node through gamma probe was followed by intraoperative and occasionally delayed biopsies. Finally, full axillary node dissection was completed. Lymphoscintigraphy identified sentinel node in 78% of the patients (47/60): 43 in axilla, 4 in internal mammary chain. Probe guided axillary detection was achieved in 88% (53/60): in every patient with axillar migration in scan, in 9/13 without imaged drainage and in 1/4 with internal mammary chain migration. Sensitivity of blue dye technique was 75% (45/60), the concordance between both procedures being high. Considering both, the overall success rate of surgical detection was 90% (54/60); if we exclude those patients who showed exclusive extraaxillar drainage, the success rate reaches 95%. Malignancy was found in 24% of sentinel nodes removed (13/54); it being the only metastatic axillary node in 4/13. No false negative sentinel nodes were found. Therefore, negative predictive value and accuracy were 100%. These results allow us to validate the technique in our center.

Sentinel lymph node biopsy using periareolar injection of radiocolloid for patients with neoadjuvant chemotherapy-treated breast carcinoma

BACKGROUND

The feasibility and accuracy of sentinel lymph node (SLN) biopsy after neoadjuvant chemotherapy (NAC) for patients with breast carcinoma have been investigated primarily for the situation in which the radiocolloid imaging agent is injected peritumorally. No such study has involved periareolar injection of radiocolloid, although the usefulness of this injection technique has been demonstrated in patients with early-stage breast carcinoma who have not been treated with NAC. The objective of the current study was to determine the feasibility and accuracy of SLN biopsy using periareolar injection of radiocolloid for patients with breast carcinoma who were treated with NAC.

METHODS

Forty-seven patients with AJCC Stage II or III breast carcinoma who were treated with NAC were enrolled in the study. All patients underwent SLN biopsy, which involved a combination of periareolar injection of radiocolloid (technetium 99m tin colloid) and peritumoral injection of isosulfan blue dye, followed by backup axillary lymph node dissection. SLN metastases were examined by hematoxylin and eosin staining and immunohistochemical analysis using an anticytokeratin antibody.

RESULTS

An SLN was identified successfully in 44 patients (94%). Twenty-nine patients (66%) had positive SLNs. Fifteen patients had negative SLNs, and 4 patients had positive non-SLNs. Thus, the false-negative rate was 12.1% (4 of 33 patients). The false-negative rate tended to be higher, although not statistically significantly so, among patients who had clinically positive axillary lymph nodes before and/or after NAC (15.8%; 3 of 19 patients) compared with patients who had clinically negative axillary lymph nodes both before and after NAC (7.1%; 1 of 14 patients).

CONCLUSIONS

SLN biopsy using periareolar injection of radiocolloid is feasible after NAC. In patients with clinically negative axillary lymph nodes both before and after NAC, SLN biopsy was capable of predicting axillary lymph node status with an accuracy comparable to the accuracy associated with SLN biopsy for patients with early-stage carcinoma who have not been treated with NAC.

3-Dimensional Computed Tomography Lymphography–Guided Identification of Sentinel Lymph Nodes in Breast Cancer Patients Using Subcutaneous Injection of Nonionic Contrast Medium

OBJECTIVE

Simple and reliable identification methods for sentinel lymph nodes (SLNs) which do not use radioisotope are essential for early breast cancer patients in community hospitals in Japan. The purpose of this paper is to demonstrate the feasibility and efficacy of computed tomography (CT) lymphography for SLN detection.

METHODS

The study included 15 cases with T1 or T2 breast cancer. After subcutaneous injection of 1 mL of iopamidol in 1 subareolar area of the affected breast, CT scanning was carried out and 3-dimensional (3D) CT images were created. SLNs predicted from images and CT values were assessed as to whether they were identical to those identified by the dye method.

RESULTS

An enhanced lymph vessel draining into SLN was demonstrated in 11 cases (73%) and an enhanced SLN in 10 cases (67%). 3D images clearly revealed the anatomic relationship between lymph vessels, SLN, and the surrounding structures. In addition, SLN could be predicted by the change of CT value in the time-course in another case. In total, SLN in 13 cases (87%) could be predicted. All SLNs suggested from CT lymphography were identified by the dye method. No significant adverse effect was noted in any case.

CONCLUSIONS

The present clinical trial indicated that subcutaneous injection of nonionic contrast medium with CT scanning seems to be a promising method for the demonstration of a draining lymph vessel and SLN. The CT value time-course may also provide some important information. Further trials will be needed for the successful establishment of this CT lymphography-guided method for SLN identification.

The evolving role of sentinel lymph node biopsy for breast cancer

Recent studies have demonstrated that the sentinal node biopsy (SNB), which utilizes a simple principle, is a reliable and minimally invasive method for determining the status of the regional lymph nodes in patients with clinically node-negative breast cancer. The technique has been widely used in the management of patients with early breast cancer despite the lack of long-term data from randomised controlled trials which are currently in progress. The present article reviews the role of the SNB in the context of axillary node sampling and determines the requirements for its safe clinical application. It also highlights the need for further research to clarify the role of the SNB in high risk DCIS, the value of preoperative lymphascintigraphy, and the clinical relevance of internal mammary node dissection and focused examination of the sentinal node by immunohistochemistry and polymerase chain reaction.

Combination of subareolar blue dye and peritumoral RI for sentinel lymph node biopsy

BACKGROUND

The identification rate of sentinel lymph nodes (SLNs) is variable because numerous different methods employing different tracers have been used for sentinel lymph node detection. The aim of this study was to determine the optimal technique for sentinel lymph node biopsy (SLNB).

METHODS

From May 1999 to December 2001, SLNB was performed for 376 patients with T1-3 and N0-1 primary breast cancer using blue dye alone, radioisotope (RI) alone and combination of RI and blue dye. Two hundred sixty-eight patients underwent SLNB using blue dye alone. They were divided into 4 groups (Group A: n=50; peritumoral injection, Group B: n=83; the first half to receive subareolar injection, Group C: n=83; the second half to receive subareolar injection, and Group D: n=52; small incision according to an axillary skin landmark). One hundred eight patients underwent SLNB using RI. Tin colloid was used in 49 cases (Tin Colloid Group) and phytate in 59 cases (Phytate Group). Among them, 29 patients underwent injection of RI alone and 79 patients received a combination of RI and blue dye.

RESULTS

The identification rates of SLN using blue dye alone were 60%, 82%, 92% and 79% in Groups A, B, C and D, respectively. The identification rates of SLN in patients receiving RI alone and in those receiving combination of RI and blue dye were 40% and 89%, respectively, in Tin Colloid Group, and 92% and 94%, respectively, in Phytate Group.

CONCLUSION

When using blue dye alone, subareolar injection provided a better identification rate than peritumoral injection. The combination of peritumoral phytate and subareolar blue dye provided the best identification rate (94%) in all the groups. The combination of intraparenchymal phytate and subareolar blue dye was the most efficient technique for sentinel node biopsy in breast cancer patients.

Lymphoscintigraphic visualization of internal mammary nodes with subtumoral injection of radiocolloid in patients with breast cancer

OBJECTIVE

To determine whether subtumoral injection of radiocolloid is useful for lymphoscintigraphic visualization of the internal mammary node and in sentinel lymph node (SLN) biopsy of the axilla in breast cancer patients.

SUMMARY BACKGROUND DATA

The presence of retromammary lymphatics connecting to the axillary and internal mammary basins has been demonstrated by early anatomic studies. Thus, it is hypothesized that some lymph, especially that from the parenchyma under the tumor, may drain into both the axillary and internal mammary basins.

METHODS

Patients (n = 196) with T1-2, N0 breast cancer underwent preoperative lymphoscintigraphy with radiocolloid (technetium 99m tin colloid) injection into various sites of the breast, followed by SLN biopsy using the combined method with blue dye. Patients were divided into four groups: group A (n = 41), peritumoral injection of both radiocolloid and blue dye; group B (n = 70), periareolar radiocolloid and peritumoral blue dye; group C (n = 45), intradermal radiocolloid and periareolar blue dye; and group D (n = 40), subtumoral radiocolloid and intradermal blue dye. A retrospective analysis of 1,297 breast cancer patients who underwent extended radical mastectomy with internal mammary node dissection was also conducted to determine the relationship between vertical tumor location (superficial or deep) and frequency of axillary and internal mammary node metastases.

RESULTS

One patient (2%) in group A, 3 (4%) in group B, 0 (0%) in group C, and 15 (38%) in group D exhibited hot spots in the internal mammary region on lymphoscintigraphy (P <.001, group D vs. the other groups). The concordance rate of radiocolloid and blue dye methods in detection of SLNs in the axillary basin was significantly lower in group D than in the other groups. In contrast, the mismatch rate (some SLNs were identified by radiocolloid and other SLNs were identified by blue dye, but no SLN was identified by both in the same patient) was significantly higher in group D than in the other groups. In patients treated with extended radical mastectomy, positivity of axillary and internal mammary metastases was significantly higher in patients (n = 215) with deep tumors than those (n = 368) with superficial tumors.

CONCLUSIONS

These results suggest the presence of a retromammary lymphatic pathway from the deep portion of the breast to both axillary and internal mammary basins, which is distinct from the superficial pathway. Therefore, SLN biopsy with a combination of subtumoral and other (peritumoral, dermal, or areolar) injections of radiocolloid will improve both axillary and internal mammary nodal staging.

Areolar-cutaneous "junction" injections to augment sentinel node count activity

PURPOSE

The authors report on a modified lymphoscintigraphy protocol for increasing activity in the sentinel node (SN) through a specific technique (LymphoBoost). It consists of an areolar-cutaneous "junction" injection, using a very shallow, high-volume, high-specific-activity injection of 100% filtered Tc-99m sulfur colloid, as an adjunct to their standard protocol.

MATERIALS AND METHODS

Results from a previously optimized protocol (group 1, n = 28) were compared with those from their new protocol (group 2, n = 85), which consisted of two sets of consecutively applied (within 12 to 20 minutes) injections: group 2A composed of perilesional and intradermal injections (similar to the previous group 1) followed by group 2B LymphoBoost injections within 12 to 20 minutes in the same patients. Regions of interest were drawn around the SN and the injection sites (IS) at the end of the studies to calculate the end-of-study SN:IS ratio for both group 1 and group 2 studies. The SN:IS ratio is generally independent of dose and is a measurement of the "efficiency" of getting activity from the IS to the SN.

RESULTS

The mean SN:IS ratio in group 2 was 3.34 times greater than that in group 1 studies (P < 0.0005). The median SN:IS ratio was 3.53 times greater in the group 2 studies. Many cases showed a dramatic increase in SN counts before the LymphoBoost injection was even completed, with more than 5% of injected activity reaching nodes at the end of the study in some patients. Multiple different lymphatic pathways were noted, but all led to the same node(s). No significant disagreement between group 2A and group 2B results was noted.

CONCLUSIONS

Areolar-cutaneous junction injections, performed under these conditions, augment SN activity dramatically in most patients. Hotter nodes provide several benefits, especially when next-day surgery is contemplated, and should also reduce the extent of dissection needed to remove the sentinel node.