Abstract
BackgroundThis study aimed to explore the sentinel lymph node (SLN) identification rate in breast cancer by subcutaneous and intradermal injection of ultrasound contrast agent in the mammary areola region, compared to the results achieved with methylene blue (MB).MethodsA total of 390 breast cancer patients with planned sentinel lymph node biopsy from our breast surgery department from July 2017 to February 2019 were enrolled. All patients were subjected to preoperative contrast-enhanced ultrasound (CEUS), that involved an intracutaneous injection of 1 mL ultrasonic contrast agent (UCA) at 3 and 6 o ‘clock, as well as a subcutaneous injection of 1 mL UCA at 9 and 12 o’clock. The enhanced lymph nodes along the enhanced lymphatic vessels from the mammary areola were traced. The number of enhanced lymph nodes were recorded, and an ultrasound-guided injection of 1:10 diluted carbon nanoparticles were used to mark all first site enhanced lymph nodes (i.e., SLNs). An intraoperative dye method (MB) was used to track the SLNs and the results were compared with the CEUS findings.ResultsAmong the 390 cases of breast cancer, enhanced SLNs were observed in 373 patients after an injection of UCA with an identification rate of 95.64 % (373/390), compared to the identification rate of 92.05 % (359/390) using the intraoperative MB. The difference between the two methods was statistically significant (P = 0.016). And among the 390 patients, a total of 808 enhanced lymph nodes were traced by preoperative CEUS, with a median of 2 (1,3). A total of 971 blue-stained lymph nodes were traced using the intraoperative MB, with a median of 2 (2,3), indicating a statistically significant difference (p < 0.001).ConclusionsIntradermal and subcutaneous injections of UCA in the mammary areola region may have clinical application value for the identification and localization of SLNs in breast cancer patients. The identification rate is higher than that of blue dye method, which can be used as a new tracer of sentinel lymph node biopsy and complement other staining methods to improve the success rate.
Highlights
This study aimed to explore the sentinel lymph node (SLN) identification rate in breast cancer by subcutaneous and intradermal injection of ultrasound contrast agent in the mammary areola region, compared to the results achieved with methylene blue (MB)
Since the lymph nodes of the ipsilateral axilla drain the majority of the breast lymphatic drainage systems (> 75 %), the axillary lymph node (ALN) status is an important factor that affects the prognosis of breast cancer patients
A Philips iU Elite was set to contrast-mode, and 360° scanning of the areola area was performed to detect enhanced lymphatic vessels and trace the enhanced lymph nodes along the enhanced lymphatic vessels with a L9-3 high frequency linear array probe. 0.1ml prepared 1:10 diluted carbon nanoparticles was injected into the first SLN site in contrastenhanced ultrasound (CEUS), and the number of lymph nodes traced by CEUS were recorded and the lymphatic vessel routes as well as the lymph node location were marked using a marking pen (Fig. 1)
Summary
This study aimed to explore the sentinel lymph node (SLN) identification rate in breast cancer by subcutaneous and intradermal injection of ultrasound contrast agent in the mammary areola region, compared to the results achieved with methylene blue (MB). Breast cancer is the most common malignant tumor with the highest morbidity in women; breast cancer has a relatively good prognosis and prolonged survival time due to the development of recent treatment methods, such as radiotherapy, chemotherapy, endocrine therapy, and molecular targeted therapy [1]. Despite these methods, surgery remains the primary method of breast cancer treatment. While a large number of studies have shown that patients with ALND have some sequelae, since ACOSOG Z0011 study less axillary surgery is being performed, and it is very important to identify the sentinel lymph node (SLN), so not to over treatment with the potential sequelae or undertreatment with potential recurrence [4, 5]
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