How long the lymphoscintigraphy imaging should be continued for sentinel lymph node mapping?

A multi-institutional feasibility lead-in trial of lymphatic mapping with SPECT-CT for evaluating contralateral disease in lateralized oropharynx cancer using 99m-technetium sulfur colloid

BACKGROUND

Lymphatic mapping with SPECT-CT has been demonstrated to accurately define lymphatic drainage patterns in oropharyngeal cancer but there has yet to be a study demonstrating its feasibility across multiple institutions.

METHODS

Twelve adult patients with lateralized oropharyngeal carcinoma (T1-T3) who were planned for definitive or adjuvant radiotherapy without contralateral nodal disease underwent injection of 99-m technetium sulfur colloid followed by static planar lymphoscintigraphy to verify tracer migration, and SPECT-CT acquired at 30 ± 15 min (optional) and 3 h (±1 h) (mandatory time-point).

RESULTS

All 12 patients completed the study with 7/12 patients having the injections performed under local anesthetic and 5 patients requiring general anesthetic. There were no tracer migration failures and there were no serious adverse events or complications encountered. Four out of 12 patients (33%) showed contralateral drainage patterns.

CONCLUSIONS

Lymphatic mapping with SPECT-CT of lateralized oropharyngeal squamous cell carcinoma can be performed safely across multiple institutions.

Intra-operative lymphatic mapping and sentinel node biopsy in laryngeal carcinoma using radiotracer injection

OBJECTIVE

The purpose of this study was to determine the value of sentinel lymph node biopsy (SLNB) in the laryngeal SCC, using intra-operative peri-tumoral injection of Tc-99m-phytate.

METHODS

Patients with biopsy-proven squamous cell carcinoma of the larynx were included. On the day of surgery, after anesthesia induction, suspension laryngoscopy was performed to inject 74 MBq/0.4 ml Tc-99m-phytate in four aliquots into the sub-mucosal peri-tumoral location. After a 10-min wait, a portable gamma probe was used to locate sentinel nodes. Subsequently, all patients underwent laryngectomy and neck dissection. Both sentinel nodes and non-sentinel nodes were examined using hematoxylin and eosin (H&E) staining.

RESULTS

Twenty-six patients with a diagnosis of laryngeal carcinoma were included in the study. The SLN detection rate was 65.4%, with a 100% detection rate in the supraglottic region and a 52.6% detection rate for glottis/transglottic patients. Permanent pathology results showed lymph node involvement in four patients, but only one patient had a negative result in the SLNB, resulting in an overall false negative rate of 25%. The sensitivity of the SLN technique was 75% overall, 100% in the supraglottic region, and 67% in the glottis/transglottic region.

CONCLUSION

The accuracy and feasibility of SLNB may be related to the location of the tumors in the larynx. For supraglottic tumors, the technique seems to be feasible with a low false negative rate. For glottis/transglottic tumors, both the detection rate and false negative rate seem to be suboptimal. Further studies are needed to validate our results.

Evaluation of Preoperative and Intraoperative Mobile Gamma Camera Imaging in Sentinel Lymph Node Biopsy for Melanoma Independent of Preoperative Lymphoscintigraphy

INTRODUCTION

Sentinel lymph node biopsy (SLNB) is a standard practice for staging cutaneous melanoma. High false-negative rates have an increased interest in adjunctive techniques for localizing SLNs. Mobile gamma cameras (MGCs) represent potential tools to enhance SLNB performance.

METHODS

An institutional review board approval was obtained for this study (ClinicalTrials.gov ID NCT01531608). After obtaining informed consent, 20 eligible melanoma patients underwent 99mTc sulfur colloid injection and standard lymphoscintigraphy with a fixed gamma camera (FGC). A survey using a 20 cm square MGC, performed immediately preoperatively by the study surgeon, was used to establish an operative plan while blinded to the FGC results. Subsequently, SLNB was performed using a gamma probe and a novel 6 cm diameter handheld MGC.

RESULTS

A total of 24 SLN basins were detected by FGC. Prior to unblinding, all 24 basins were identified with the preoperative MGC and the operative plan established by preoperative MGC imaging was confirmed accurate by review of the FGC images. All individual sentinel lymph nodes were identified during intraoperative MGC imaging, and in 5/24 (21%) cases, surgeon-reported additional clinically useful information was obtained from the MGC.

CONCLUSIONS

Preoperative MGC images provide information consistent with FGC images for planning SLNB and in some cases provide additional information that aided in surgical decision-making.

Diagnostic Value of the Sentinel Lymph Node Technique in Patients with Muscle-Invasive Bladder Cancer

BACKGROUND

The optimal limits of the bilateral pelvic lymph node dissection (PLND) template in bladder cancer treatment remain controversial. This study aimed to investigate whether radio-guided sentinel node (SLN) detection is a reliable technique for the perioperative localisation of potential lymphatic metastasis during cystectomy for muscle-invasive bladder cancer (MIBC).

MATERIALS AND METHODS

We studied 54 patients with pT2-pT4 MIBC who underwent cystectomy with extended PLND (ePLND) augmented by the SLN technique. The identification of SLN was performed by preoperative SPECT/CT hybrid lymphoscintigraphy using peritumoral injection of nanocolloid-Tc-99m, followed by intraoperative navigation with a handheld γ-probe. All nodal specimens were collected separately and then fixed in formalin, stained with haematoxylin and eosin, and examined by an experienced uropathologist.

RESULTS

A total of 1414 LNs were resected and examined for the presence of metastases. The mean number of harvested LNs was 26 (range: 11-50) per patient. In 51 of 54 patients, 192 SLNs were resected. In addition, 20/192 (10.4%) SLNs were located outside of the ePLND area. Overall, 72 metastatic LNs (LN+) were found in 22 of 54 patients (40.7%) and in 24/192 SLNs (12.5%). The SLN technique detected LN+ in 14 of 22 (64%) patients. The SLNs were the only sites of metastasis (SLN+ = LN+) in 6 of 22 (27.3%) LN+ patients, including two cases with foci located in the pararectal region. The diagnostic values for the sensitivity, specificity, positive predictive value, and false-negative rate for the SLN technique were 66.66%, 4.16%, 28.57%, and 33.33%, respectively. Extended lymphadenectomy and its combination with the SLN technique enabled the correct assessment in 96.3 and 100% of patients, respectively.

CONCLUSIONS

The combination of ePLND and SLN provides a better pN assessment compared to ePLND alone. Although the SLN technique has restrictions that limit its diagnostic value, its use as an addition to lymphadenectomy allows for the visualisation of nonstandard lymph drainage pathways that may be potential metastatic routes.

Can late lymphoscintigraphy be omitted in the sentinel node procedure in early-stage vulvar cancer?

INTRODUCTION

In the Netherlands, the sentinel lymph node procedure protocol consists of preoperative lymphoscintigraphy combined with intraoperative blue dye for identifying sentinel lymph nodes in early vulvar squamous cell carcinoma. This study aimed at investigating the role of early and late lymphoscintigraphy.

MATERIAL AND METHODS

From January 2015 to January 2019, early and late lymphoscintigraphies of 52 women were retrospectively analyzed. Lymphoscintigraphy was performed 30 minutes (early) and 2.5-4 hours (late) after vulvar injection of ^99m Tc-labeled nanocolloid. We calculated the concordance correlation coefficient (CCC) between number of sentinel lymph nodes detected on both images using the Lins concordance coefficient and correlated with clinicopathological data.

RESULTS

Thirty-four women had a midline tumor and 18 had a lateral tumor. Detection rates with early and late scintigraphy were 88.5% and 98.1%, respectively. Median number of detected nodes was 1.0 (0-7) and 2.0 (0-7). Good statistical correlation between number of sentinel lymph nodes detected on early and late imaging was found (CCC = 0.76) in most patients. In 18 women (35%) a mismatch occurred: a higher number of nodes was detected on late imaging. In 11 of 18 women re-injection was performed because no sentinel lymph nodes were visualized on early images. Late imaging and intraoperative detection showed a good statistical correlation (CCC = 0.61). One woman showed an isolated groin recurrence despite negative sentinel lymph nodes.

CONCLUSIONS

This study showed good statistical correlations between early and late scintigraphy in most patients. However, in 35% of women late scintigraphy detected more nodes. In case of poor visualization after the first scintigraphy, re-injection should be considered. Late scintigraphy is probably helpful in confirming successful re-injection and in showing deviating lymph flow in women with failed mapping after the first injection and successful re-injection. Because missing metastatic sentinel lymph nodes often leads to a poor prognosis, we prefer optimal correlations between imaging and intraoperative identification. Hence, late scintigraphy cannot be safely omitted.

Sentinel Lymph Node Identification in Cutaneous Head & Neck Cancer - Lymphoscintigraphy Late Phase

OBJECTIVE

Sentinel node (SN) biopsy following lymphoscintography is recommended for high-risk cutaneous malignancies. Herein, we investigate different lymphoscintography phases, focusing on the importance of the late static phase and the resultant discovery of distal echelon solitary positive sentinel nodes that would otherwise have been overlooked.

METHODS

In this retrospective cohort study, conducted in a tertiary referral medical center, we assessed SN localization and time from tracer injection to SN identification on lymphoscintigraphy. Findings on scan were compared with SN found in the surgical field, and with the final pathological investigation.

RESULTS

Seventy-three patients, undergoing SN biopsy for head and neck skin malignancies, were investigated. Most patients were male (n = 50). The average age was 65.7 (±15.7) years and the average follow-up time was 29.1 (±22.4) months. Overall, 101 SNs were histologically investigated, demonstrating 7 positive SN. Eleven patients (15%) benefited from the late lymphoscintigraphy phase. In four studies, an SN was identified only in the late static phase, one of which was positive for the disease. In seven patients, SN was identified in the early phase with additional, different, SN on the late phase, one of which was positive for the disease. Comparing the yield (positive SNs) of early versus late phases, demonstrated the same importance (p = 0.275).

CONCLUSIONS

The late lymphoscintigraphy phase has a crucial role in high-risk HN cutaneous cancer.

LEVEL OF EVIDENCE

3 Laryngoscope, 132:2164-2168, 2022.

Repeat injection following sentinel node nonvisualization on lymphoscintigraphy images can decrease axillary dissection rate in breast cancer patients

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.

Lymphoscintigraphy in the Time of COVID-19: Effect of Molybdenum-99 Shortage on Feasibility of Sentinel Node Mapping

Background: In the current study, we reported our experience on sentinel node mapping of breast cancer patients during the extreme shortage of Mo99-Tc99m generators using Tc-99m phytate. Methods and Results: During the period from March 7, 2019, to April 18, 2020, due to disruption of molybdenum supply chain, we used low specific activity Tc-99m pertechnetate elute (0.5-2 mCi of 99mTcO4 in 5 mL) for each kit preparation. Two or three intradermal periareolar injections were done for each patient (0.02-0.1 mCi/0.2 mL for each injection). Immediately following injection, dynamic lymphoscintigraphy was done. Surgery was done the same day of injection and the axillary sentinel node was sought using a gamma probe. Overall, 35 patients were included in the study. The specific activity of the Tc-99m elute (in 5 mL) used for kit preparation was 2 mCi/10 mg in four, 1.5 mCi/10 mg in eight, 1.25 mCi/10 mg in eight, 1 mCi/10 mg in three, 0.75 mCi/10 mg in five, and 0.5 mCi/10 mg of 99mTc-Phytate in seven patients. For the first four groups of patients, we used two 0.2 mL injections, while in the latter two groups, three 0.2 mL injections were used. At least one sentinel node was detected in all patients but three in whom axilla was involved. Conclusion: Sentinel node biopsy can be achieved with low specific activity of Tc-99m elute at the time of Mo99-Tc-99m generator shortage. If special personal protection is used, sentinel node mapping can be done in nuclear medicine departments with excellent results despite the COVID-19 pandemic and disruption of generator shipment.

Sentinel lymph node biopsy in muscle-invasive bladder cancer: single-center experience

OBJECTIVE

In this study, the validity of sentinel node biopsy procedure as our index test was assessed and compared with bilateral pelvic lymphadenectomy for staging and detecting the regional lymph nodes metastasis in patients with muscle-invasive bladder cancer (MIBC).

METHODS

Consecutive series of cases with T1-T4 urothelial MIBC were included. Following the injection of radiotracer, sentinel nodes were sought using a handheld gamma probe and all hot nodes were harvested. Bilateral pelvic lymphadenectomy was done for all patients following sentinel node biopsy. The tumor specimen, sentinel nodes, and excised lymph nodes were evaluated histopathologically. Same as the other midline tumors, detection rate and false negative rates were calculated using patient basis and side basis methods.

RESULTS

By evaluating each patient as a unit of analysis, sentinel nodes were detected in 35 of 41 patients (85%), 13/16 (81%) of the neoadjuvant chemotherapy (NAC) and 22/25 (88%) of the no-neoadjuvant chemotherapy (No-NAC) participants. The false negative rate was 3/7 (42%): 1/3 (33%) for NAC, and 2/4 (50%) for No-NAC patients. By evaluating each hemipelvis as a unit of analysis, sentinel nodes were detected in 53 of 82 hemipelves (65%), 19/32 (66%) of the NAC, and 34/50 (68%) of the No-NAC hemipelves. No false-negative result was found by assessing each hemipelvis as a unit of analysis.

CONCLUSIONS

Sentinel node biopsy is a feasible method for lymph node staging in MIBC, including patients with a history of NAC. To optimize the sensitivity, the decision regarding the lymphadenectomy is best to be based on the pathological status of sentinel node harvested from each hemipelvis separately as the unilateral finding of a sentinel node, does not rule out the possibility of metastatic involvement of contralateral pelvic lymph nodes.

Optimal imaging time for Tc-99m phytate lymphoscintigraphy for sentinel lymph node mapping in patients with breast cancer

OBJECTIVES

Sentinel lymph node (SLN) sampling has become a standard practice in managing early-stage breast cancer. Lymphoscintigraphy is one of the major methods used. The radioactive tracer used in Taiwan is Tc-99m phytate. However, this agent is not commonly used around the world and the optimal imaging time has not been studied. Thus, we investigated the optimal imaging time of Tc-99m phytate lymphoscintigraphy for SLN mapping in patients with breast cancer.

MATERIALS AND METHODS

We retrospectively reviewed SLN Tc-99m phytate lymphoscintigraphies in 135 patients with breast cancer between August 2013 and November 2017. The time for the first SLN to be visualized after radiotracer injection was recorded to determine the optimal imaging time. If no SLN was identified on imaging, the scan was continued to 60 min. We also recorded the presurgical technical and clinical factors to analyze the risk factors for nonvisualization of SLN. Each patient's postoperative axillary lymph node status was also recorded.

RESULTS

Axillary SLNs were identified on imaging in 94.8% of the patients. All first SLNs presented within 30 min. In 6 of 7 patients with negative imaging, SLNs were identified during surgery using either blue dye or a hand-held gamma probe. Nonvisualization of SLNs on lymphoscintigraphy was significantly associated with a lower injection dose (1.0 mCi vs. 2.0 mCi), 4-injection protocol (compared to 2-injection), and injection around an outer upper quadrant tumor. In addition, patients with axillary lymph node metastasis had a higher percentage of SLN image mapping failure, with a marginally significant difference.

CONCLUSION

Based on our study, 30 min after Tc-99m phytate injection is the optimal time for lymphoscintigraphy and delayed imaging beyond 30 min is not necessary. In addition, a lower injection dose, the 4-injection method, and an injection near the outer upper quadrant tumor should be avoided to minimize nonvisualization of SLNs.

Lymphoscintigraphy for Sentinel Lymph Node Biopsy in Breast Cancer: Do We Need a Delayed Image?

Background

Sentinel lymph node biopsy has become a standard of care in the treatment of patients with early breast cancer, but clinical guidelines continue to be vague on details of the procedure. We were interested in the results of our 2-day protocol, which includes delayed lymphoscintigraphy at 18 h.

Methods

We reviewed the results of preoperative lymphoscintigrams in patients undergoing surgery for breast cancer. Lymphoscintigraphy was performed 2 h after periareolar injection of 4 × 37 MBq ^99mTc nanocolloid (early lymphoscintigraphy) and 18 h following injection (delayed lymphoscintigraphy). The early results were compared with the late results.

Results

A total of 238 lymphoscintigraphies were performed in 232 patients (6 bilateral). At 2 h, ≥1 sentinel nodes were visualized in 154/238 (65%) cases; in 84 (35%), no sentinel node was visualized. Delayed lymphoscintigraphy visualized a sentinel node in 40 of 76 (53%) cases with no visualization at 2 h and failed to show a sentinel node in 36 (47%) of these cases (in 8 cases, no delayed lymphoscintigram was obtained).

Conclusions

Delayed lymphoscintigraphy was useful in about 50% of the breast cancer patients in whom immediate scintigraphy failed to demonstrate a sentinel lymph node.

Lymphatic mapping and sentinel node biopsy in ovarian tumors: a study using intra-operative Tc-99m-Phytate and lymphoscintigraphy imaging

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.

Manual Lymphatic Drainage after Subepidermal Tracer Injection Optimizes Results of Sentinel Lymph Node Labeling in Primary Breast Cancer

INTRODUCTION

Our aim was to assess the practicability and reliability of a novel labeling regime for axillary sentinel lymph nodes (SLNs) in early breast cancer.

METHODS

362 patients with early breast cancer (bilateral in 9 cases, giving a total of 371 cases) underwent intradermal radio tracer injection with simultaneous manual lymphatic drainage. SLN biopsy was performed within 24 h. For retrospective analysis, data were extracted from patient's records.

RESULTS

At least 1 SLN was detected intraoperatively in 369 cases (99.5%, range 1-9 nodes). This node was metastatic in 88 and unaffected in 281 cases. Coincidentally removed but unlabeled lymph nodes were affected in 3 cases in which the SLN was unaffected (3/153 = 2%). In all cases, on histological evaluation, tissue removed as SLN contained lymph nodes. After a period of 69.5 months (median 1.7-115.8 months), no axillary recurrences were observed in 213 patients.

CONCLUSION

Manual lymphatic drainage is a simple technique that leads to an extremely high pick-up rate of axillary SLNs after subepidermal radio tracer injection. If unaffected, this node correctly predicts nodal-negative disease in 98% of cases studied.

Evaluating One Day versus Two Days Preoperative Lymphoscintigraphy Protocols for Sentinel Lymph Node Biopsy in Breast Cancer

Sentinel lymph node biopsy (SLNB) is used to detect axillary lymph node metastases in breast cancer. Preoperative radiocolloid injection with lymphoscintigraphy (PL) is performed before SLNB. Few comparisons between 1- and 2-day PL protocols exist. Opponents of a 2-day protocol have expressed concerns of radiotracer washout to nonsentinel nodes. Proponents cite lack of scheduling conflicts between PL and surgery. A total of 387 consecutive patients with clinically node-negative breast cancer underwent SLNB with PL. Lymphoscintigraphy images were obtained within 30 minutes of radio-colloid injection. Axillary lymph node dissection was performed if the sentinel lymph node (SLN) could not be identified. Data were collected regarding PL technique and results. In all, 212 patients were included in the 2-day PL group and 175 patients in the 1-day PL group. Lymphoscintigraphy identified an axillary sentinel node in 143/212 (67.5%) of patients in the 2-day group and 127/175 (72.5%) in the 1-day group ( P = 0.28). SLN was identified at surgery in 209/212 (98.6%) patients in the 2-day group and 174/175 (99.4%) in the 1-day group ( P = 0.41). An average of 3 SLN was found at surgery in the 2-day group compared with 3.15 in the 1-day group ( P = 0.43). SLN was positive for metastatic disease in 54/212 (25.5%) patients in the 2-day group compared with 40/175 (22.9%) in the 1-day group ( P = 0.55). A 2-day lymphoscintigraphy protocol allows reliable detection of the SLN, of positive SLN and equivalent SLN harvest compared with a 1-day protocol. The timing of radiocolloid injection before SLNB can be left at the discretion of the surgeon.

Sentinel node biopsy for lymph nodal staging of uterine cervix cancer: a systematic review and meta-analysis of the pertinent literature

BACKGROUND

We reviewed the available literature on the accuracy of sentinel node mapping in the lymph nodal staging of uterine cervical cancers.

METHODS

MEDLINE and Scopus were searched by using "sentinel AND (cervix OR cervical)" as key words. Studies evaluating the accuracy of sentinel node mapping in the lymph nodal staging of uterine cervical cancers were included if enough data could be extracted for calculation of detection rate and/or sensitivity.

RESULTS

Sixty-seven studies were included in the systematic review. Pooled detection rate was 89.2% [95% CI: 86.3-91.6]. Pooled sensitivity was 90% [95% CI: 88-92]. Sentinel node detection rate and sensitivity were related to mapping method (blue dye, radiotracer, or both) and history of pre-operative neoadjuvant chemotherapy. Sensitivity was higher in patients with bilaterally detected pelvic sentinel nodes compared to those with unilateral sentinel nodes. Lymphatic mapping could identify sentinel nodes outside the routine lymphadenectomy limits.

CONCLUSION

Sentinel node mapping is an accurate method for the assessment of lymph nodal involvement in uterine cervical cancers. Selection of a population with small tumor size and lower stage will ensure the lowest false negative rate. Lymphatic mapping can also detect sentinel nodes outside of routine lymphadenectomy areas providing additional histological information which can improve the staging. Further studies are needed to explore the impact of sentinel node mapping in fertility sparing surgery and in patients with history of neoadjuvant chemotherapy.

Added value of blue dye injection in sentinel node biopsy of breast cancer patients: do all patients need blue dye?

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Efficacy of high-energy collimator for sentinel node lymphoscintigraphy of early breast cancer patients

INTRODUCTION

Lymphoscintigraphy is an important part of sentinel node mapping in breast cancer patients. Sometimes star shaped artefacts due to septal penetration can be problematic during imaging. In the current study, we evaluated the possibility of high energy (HE) collimators use for lymphoscintigraphy.

PATIENTS AND METHODS

Twenty patients with early breast carcinoma were included. Thirty minutes after radiotracer injection (99mTc-antimony sulphide colloid), anterior and lateral images were acquired using a dual head gamma camera equipped with a parallel hole low energy high resolution (LEHR) collimator on one head and HE collimator on another head. All images were reviewed by two nuclear medicine specialists regarding detectability and number of axillary sentinel nodes and presence of star artefact.

RESULTS

All images taken by LEHR collimators showed star artefact of the injection site. No image taken by HE collimator showed this effect. In two patients the sentinel node was visible only by HE collimator. Tumour location in both of these patients was in the upper lateral quadrant and both had history of excisional biopsy. In two patients additional sentinel node was visible adjacent to the first one only on the LEHR images.

CONCLUSIONS

HE collimators can be used for sentinel lymph node mapping and lymphoscintigraphy of the breast cancer patients. This collimator can almost eliminate star-shaped artefacts due to septal penetration which can be advantageous in some cases. However, to separate two adjacent sentinel nodes from each other LEHR collimators perform better.

Factors influencing the time of sentinel node visualization in breast cancer patients using intradermal injection of the radiotracer

BACKGROUND

The objective of our study was to determine the important factors that have influence on the time of sentinel node visualization using intradermal injection of (99m)Tc-antimony sulfide colloid.

METHODS

Two hundred fifty consecutive patients with the diagnosis of early-stage breast cancer were evaluated. Anterior and lateral views were acquired in various intervals after intradermal injection of the tracer until 180 minutes or visualization of the sentinel node. The effect of several variables on the time of sentinel node visualization was evaluated by univariate and multivariate analyses.

RESULTS

The time of sentinel node visualization was significantly correlated with age, body mass index (BMI), and interval between biopsy and sentinel node mapping. Standardized beta values for these variables were .1, .3, -.55 respectively.

CONCLUSIONS

Older age and higher BMI can result in slow sentinel node visualization. Longer interval between biopsy and sentinel node mapping can be associated with rapid sentinel node detection.

Current controversies in the management of patients with early-stage vulvar cancer

PURPOSE OF REVIEW

The purpose of this review is to outline current controversies in management of early-stage vulvar cancer. The main focus will be on the procedures for assessing the sentinel node and the treatment of those with evidence of metastatic involvement.

RECENT FINDINGS

Assessment of the sentinel node has recently been introduced into the standard treatment of early-stage squamous cell vulvar cancer. The combination of a radioactive tracer and blue dye is the most accurate technique for sentinel node detection. Preoperative imaging is recommended to rule out gross nodal involvement and ultrasound with fine needle aspiration cytology by an experienced radiologist appears to have the highest sensitivity/specificity for detecting metastases, although large comparative studies are not available. All patients with sentinel node metastases require additional treatment to the groin, independent of the size of metastasis in the sentinel node and currently this involves inguinofemoral lymphadenectomy. Further research is ongoing to investigate the role of radiotherapy instead of lymphadenectomy. The little experience there is of sentinel node biopsy in vulvar melanoma suggests that the procedure is feasible and inclusion criteria should follow those of cutaneous melanoma.

SUMMARY

Sentinel node biopsy is safe in treatment of early-stage vulvar cancer. Ongoing studies are investigating the optimal additional treatment for patients with a positive sentinel node in terms of efficacy and morbidity.

The Effect of Excisional Biopsy on the Accuracy of Sentinel Lymph Node Mapping in Early Stage Breast Cancer: Comparison with Core Needle Biopsy

Despite the successful application of sentinel node mapping in breast cancer patients, its use in patients with a history of previous excisional biopsy of the breast tumors is a matter of controversy. In the present study we evaluated the accuracy of sentinel node biopsy in this group of patients and compared the results with those in whom the diagnosis of breast cancer was established by core needle biopsy. Eighty patients with early stage breast carcinoma were included into our study. Forty patients had a history of previous excisional biopsy and the remainder 40 had undergone core needle biopsy. Intradermal injections of 99mTc-antimony sulfide colloid as well as patent blue were both used for sentinel node mapping. Sentinel nodes were harvested during surgery with the aid of surgical gamma probe. All patients underwent standard axillary lymph node dissection subsequently. Detection rate was 97.5 per cent for both groups of the study. Number of detected sentinel node during surgery was not significantly different between groups. False negative rate was 0 per cent for both groups of the study. In conclusion sentinel node biopsy is reliable in patients with previous history of excisional biopsy of the breast tumors and has a low false negative rate.