Breast Lymphoscintigraphy Research Articles

Incidental Detection of a Toxic Autonomous Thyroid Nodule During Breast Lymphoscintigraphy

A 54-year-old woman with newly diagnosed infiltrating ductal carcinoma of the right breast underwent lymphoscintigraphy for preoperative sentinel lymph node detection. After intraparenchymal injection of technetium-99m sulfur colloid into the right breast, images revealed focal uptake in the lower pole of the left thyroid lobe. An iodine-123 thyroid scan demonstrated a large hyperfunctioning nodule at the lower pole of the left thyroid lobe with suppression of the remaining gland, consistent with a toxic autonomous thyroid nodule.

Lymphatic mapping and sentinel node biopsy in women with an ipsilateral second breast carcinoma and a history of breast and axillary surgery

Background Women with a history of breast and axillary surgery may demonstrate aberrant lymphatic drainage caused by disrupted lymphatic channels. Lymphoscintigraphy may be valuable in evaluation and staging of an ipsilateral second breast carcinoma. Methods We conducted a retrospective review of 16 women treated for a second ipsilateral breast carcinoma who underwent breast lymphoscintigraphy and intraoperative lymphatic mapping. Drainage patterns were compared with pathologic and operative findings. Results Lymphoscintigraphy succeeded in 69% of patients and demonstrated widely varied drainage patterns including ipsilateral axillary and supraclavicular as well as contralateral axillary and supraclavicular basins. No trend between successful lymphatic mapping and multiple clinical and pathologic measures was seen. Conclusions In women with a second ipsilateral breast carcinoma and history of previous breast and axillary surgery, lymphoscintigraphy is feasible. Drainage patterns vary widely including across the midline of the thorax. Preoperative lymphoscintigraphy may be useful to ensure inclusion of potential sentinel nodes within the operative field.

Extremely Indirect Dermal Lymphatic Channels: Value of Areolar-Cutaneous Junction Injection Technique for Breast Lymphoscintigraphy

This case describes a patient who initially had peri-excisional injections of radiocolloid around a lumpectomy site that failed to visualize sentinel nodes during lymphoscintigraphy. After additional areolar-cutaneous junction injections, extremely indirect dermal lymphatic pathways were evident with resultant drainage to two sentinel nodes, both of which contained disease. Hybrid combination injections of radiotracer during sentinel lymph node biopsy is gaining in popularity. This case illustrates the validity of the hybrid injection techniques and the demonstrated accuracy despite seemingly disconnected and extremely tortuous pathways as demonstrated in the figure.

Lymphatic Drainage Patterns on Early Versus Delayed Breast Lymphoscintigraphy Performed after Injection of Filtered Tc-99m Sulfur Colloid in Breast Cancer Patients Undergoing Sentinel Lymph Node Biopsy

The axillary lymph node status is the most important predictor of prognosis and aids in breast cancer treatment planning. Patients with breast cancer now frequently undergo sentinel lymph node (SLN) biopsy rather than axillary lymph node dissection to determine the status of the regional lymph nodes. However, the optimal timing of radionuclide injection relative to the timing of SLN biopsy remains controversial. The objective of this study was to compare the lymphatic drainage patterns on lymphoscintigraphy performed at 15 minutes to 4 hours and at 18 to 24 hours after injection of filtered Tc-99m sulfur colloid, and to determine whether, over time, radiocolloid migrates to second-echelon nodes that are not the SLNs. Fifteen women with breast cancer (mean age, 55 years; range, 38-78 years) were scheduled to undergo SLN biopsy after each received an injection of 18.5 MBq (0.5 mCi) filtered Tc-99m sulfur colloid into the breast parenchyma surrounding the tumor or biopsy cavity. Both early (15 minutes to 4 hours after radionuclide injection) and delayed (18-24 hours after radionuclide injection) lymphoscintigraphy was performed in each patient. SLN biopsy was performed, followed by completion axillary lymph node dissection and planned breast surgery. In each patient the patterns of distribution of the radionuclide in the lymph nodes were the same on early and delayed lymphoscintigrams. These findings, that the distributions of radionuclide in lymph nodes are identical on early and delayed images obtained after injection of filtered Tc-99m sulfur colloid, suggest that performing SLN biopsy on the day after injection does not diminish the accuracy of the technique in predicting the potential site of metastasis in the regional lymph nodes in patients undergoing this procedure for breast cancer.

Reverse echelon node and a lymphatic ectasia in the same patient during breast lymphoscintigraphy: the importance of injection and imaging technique

Lymphoscintigraphy, along with triangulated patient body marking, can serve as a guide for surgeons during sentinel lymph node harvesting. Unique drainage patterns have been noted, especially with areolar or intradermal based injections, which are becoming increasingly popular. The images lymphoscintigraphy provide have been invaluable in delineating these patterns. The authors present a case that simultaneously illustrates two separate points in the same patient, a reverse echelon node and a lymphatic ectasia. To our knowledge, this combination has never been described in the same patient. Perilesional and areolar-cutaneous junction injections were performed sequentially and generated these patterns that could potentially have resulted in added morbidity and a false-negative sentinel node if not realised before surgery. Lymphoscintigraphy added valuable information in the management of this patient, which can occasionally present with complex patterns of activity during sentinel node harvesting.

The Safety of Lymphatic Mapping in Pregnant Breast Cancer Patients Using Tc-99m Sulfur Colloid

This investigation was undertaken to assess the risk to the embryo/fetus associated with sentinel lymph node biopsy and lymphoscintigraphy of the breast performed in pregnant patients. Approximately 92.5 MBq (2.5 mCi) of filtered Tc-99m sulfur colloid was injected peritumorally the day before surgery in two nonpregnant women with breast cancer. The whole-body distribution of the radiopharmaceutical was evaluated using a gamma camera 1 hour after injection. We then calculated the absorbed dose to the embryo/fetus for three theoretical extreme scenarios of biodistribution and pharmacokinetics: 1) all of the injected radiopharmaceutical remains in the breast and is eliminated only by physical decay; 2) all of the injected radiopharmaceutical is instantaneously transported to the urinary bladder, where it remains and is eliminated only by physical decay; and 3) the injected radiopharmaceutical behaves as though it were administered intravenously, that is, it has the biodistribution and pharmacokinetics of Tc-99m sulfur colloid injected for a liver/spleen or bone marrow scan. The fetal radiation absorbed dose was then estimated for two Tc-99m dosages: 18.5 MBq (0.5 mCi) and 92.5 MBq (2.5 mCi). The Medical Internal Radiation Dosimetry (MIRD) program was used to estimate the absorbed doses to the embryo/fetus for the first two scenarios. Published data were used to calculate the doses for the third scenario. A single breast is not among the source organs in the MIRD program, so the heart was used as a surrogate in the first scenario. In the two breast cancer patients, whole-body gamma-camera images obtained 1 hour after radiopharmaceutical injection revealed no radioactivity except in the vicinity of the injection site. In the theoretical scenarios, with 92.5 MBq, the highest absorbed doses to the embryo/fetus were as follows: scenario 1, 7.74 x 10(-2) mGy at 9 months of pregnancy; scenario 2, 4.26 mGy during early pregnancy; and scenario 3, 0.342 mGy at 9 months of pregnancy. The maximum absorbed dose to the fetus of 4.3 mGy calculated for the worst-case scenario is well below the 50 mGy that is believed to be the threshold absorbed dose for adverse effects. Thus breast lymphoscintigraphy during pregnancy appears to present a very low risk to the embryo/fetus.

Clinical breast lymphoscintigraphy: optimal techniques for performing studies, image atlas, and analysis of images.

Breast lymphoscintigraphy is increasingly performed before surgery to delineate the drainage to the sentinel node (SN) in the axilla. On the basis of the histologic status of harvested SNs, the disease status of the entire axilla can be predicted. This prediction allows a more limited dissection to be performed while maintaining staging accuracy comparable with that of classic axillary lymph node dissection. Lymphoscintigraphy assists surgeons in harvesting the SN during gamma probe-assisted axillary biopsy or dissection and provides a wide field of view survey, among other benefits. When certain injection protocols are used, lymphoscintigraphy can be performed in the afternoon before surgery the next morning, thus minimizing disruptions of tight surgical schedules. Image acquisition can be optimized and SN activity can be maximized by means of such factors as parameters for preparation of the radiotracer, injection techniques, energy settings for the gamma camera, breast displacement maneuvers, and techniques for marking and outlining the patient's body. The ultimate goals are to delineate the true SN, maximize activity in the node for facilitated removal (even at next-day surgery), and deliver the information to the surgeon without delaying the surgical schedule.

Prospective Study of 162 Sentinel Lymph Node Biopsies in Breast Cancer: Usefulness of Ultrasonography in Patients Selection

Purpose: Sentinel lymph node (SLN) biopsy has been widely used in the management of melanoma and breast cancer. The aims of this study were (1) to compare the results obtained with the different injection, intraoperative sentinel node evaluation, and postoperative evaluation; and (2) to determine the reliability of SLN to predict the regional lymph node status. Methods: We prospectively studied selected 162 female primary breast cancer patients from Jun. 1999 to Apr. 2003. For identification of sentinel lymph node, Tc99m-antimony trisulfate was used as a tracer with two injection methods and SLN biopsy using a gamma-detection probe was done after breast lymphoscintigraphy. Frozen section biopsy or touch-print cytology was done for intraoperative evaluation. If a SLN biopsy was free of metastasis by permanent hematoxylin and eosin (HE6:103-108)

Internal Mammary Lymph Node Drainage Patterns in Patients With Breast Cancer Documented by Breast Lymphoscintigraphy

Metastases to internal mammary lymph nodes (IMN) may occur in patients with breast cancer and may alter treatment recommendations. The purpose of this study was to identify the frequency of IMN drainage in patients undergoing breast lymphoscintigraphy and sentinel lymph node dissection (SLND). The combined technique of peritumoral injection of radiocolloid and Lymphazurin blue for SLND was performed on 220 patients. All patients underwent preoperative lymphoscintigraphy before SLND. Lesion location by quadrant included: 110 upper outer (UOQ), 49 lower outer (LOQ), 30 upper inner (UIQ), 24 lower inner (LIQ), and 7 central. Drainage to any nodal basin was observed in 184 of 220 patients (84%). IMN drainage was documented in 37 of 220 (17%) of patients. IMN drainage without evidence of axillary drainage occurred in 2 of 220 patients(1%). Drainage to the IMN based on quadrant location of the lesion was as follows: UOQ, 10%; LOQ, 27%; UIQ, 17%; LIQ, 25%; and central, 29%. Internal mammary lymph node drainage shown by breast lymphoscintigraphy is common. Tumors in all quadrants may drain to IMNs, although drainage is significantly more common from quadrants other than the UOQ. Further studies are needed to determine whether lymphoscintigraphy drainage patterns identify patients at the highest risk for IMN metastases who may benefit from radiotherapy.

Internal Mammary Lymph Node Drainage Patterns in Patients With Breast Cancer Documented by Breast Lymphoscintigraphy

Internal Mammary Lymph Node Drainage Patterns in Patients With Breast Cancer Documented by Breast Lymphoscintigraphy

PRINCIPLES AND CONTROVERSIES IN LYMPHOSCINTIGRAPHY WITH EMPHASIS ON BREAST CANCER

The concept of the sentinel node lay fallow until lymph node mapping was developed. This article provides a brief history of the sentinel lymph node concept, discusses reproducibility, radiopharmaceuticals, equipment, techniques, and radiation safety, and addresses metastasis in breast cancer and controversies in breast lymphoscintigraphy.

Preoperative lymphoscintigraphy during lymphatic mapping for breast cancer: improved sentinel node imaging using subareolar injection of technetium 99m sulfur colloid

Background: Preoperative lymphoscintigraphy has been recommended to confirm the successful uptake and direction of migration of radiotracer into sentinel nodes during lymphatic mapping for breast cancer. In addition, preoperative lymphatic mapping may provide a visually useful aid to the relative location of sentinel nodes within a nodal basin. One common method of breast lymphoscintigraphy involves injections of unfiltered technetium 99m sulfur colloid (Tc-99m-SC) directly into parenchymal tissues surrounding a tumor or biopsy cavity (IP injection). Because of the many imaging failures and prolonged imaging times of IP lymphoscintigraphy, the procedure has fallen into disfavor by oncologic surgeons. The purpose of this study is to document the increased success rate of preoperative breast lymphoscintigraphy using a new anatomic site of injection, the subareolar lymphatic plexus (SA injection). Study Design: In the 12 months between December 1, 1998, and December 29, 1999, 42 women with stage I and II breast cancer underwent preoperative lymphoscintigraphy by either the IP (n = 12, December 1998 to May 1999) or SA (n = 30, May 1999 to December 1999) route of injection. Both groups were injected with 1 mCi (37 MBq) of unfiltered Tc-99m-SC followed immediately by external gamma-camera imaging. The success rate for preoperative sentinel node imaging and the total imaging time were recorded in both groups. Results: The success rate of identifying a sentinel node by SA lymphoscintigraphy was 90% (n = 27 of 30 patients), compared with 50% (n = 6 of 12 patients) for IP lymphoscintigraphy (p = 0.009). The imaging time in the SA injection group was 34 ± 16 minutes, which was 59% shorter than the imaging time in the IP injection group of 82 ± 48 minutes (p < 0.001). No uptake into internal mammary nodes was seen in either group. Conclusions: Moving the site of injection of unfiltered Tc-99m-SC to the subareolar lymphatic plexus (SA injection) increased the success rate of preoperative lymphoscintigraphy to 90%, compared with 50% using IP injections. Preoperative SA lymphoscintigraphy resulted in the rapid visualization of axillary sentinel nodes within 30 minutes of SA injection, enabling a visual determination of the approximate number of sentinel nodes and their relative locations within the axilla. We conclude SA injection of unfiltered Tc-99m-SC is superior to IP injections when performing preoperative breast lymphoscintigraphy and is a visually useful aid to lymphatic mapping for breast cancer.

Selective lymphoscintigraphy: a necessary adjunct to dye-directed sentinel node biopsy for breast cancer?

Dye-directed sentinel node biopsy (SNB) for breast cancer provides accurate staging with low morbidity, but for tumors distant from the axilla, its use has been questioned. Can preoperative breast lymphoscintigraphy (BL) applied selectively to medial hemisphere tumors predict a subset of patients who may not require surgical staging of the axilla? Prospective cohort study. Tertiary, multidisciplinary breast center. Thirty-two women with breast tumors located in the medial hemisphere (30) or inframammary crease (2). Peritumoral injection of 500 microCi of technetium Tc 99m sulfur colloid and biplanar imaging. Nonpalpable lesions were localized with ultrasound or mammography. At the time of definitive breast surgery, isosulfan blue dye-directed SNB was performed. Axillary dissection was performed when the SN contained a tumor or could not be identified. Regional nodal basins identified by BL; success rate of SNB. Preoperative BL demonstrated axillary drainage in 28 patients (88%); 2 patients (6%) had isolated internal mammary radionuclide uptake, and 2 patients had no nodal uptake. Dye-directed axillary SNB succeeded in 27 (87%) of 31 patients, including both patients with failed BL. Breast lymphoscintigraphy had predicted isolated internal mammary drainage in 2 of 4 patients whose SNs could not be identified. Metastases were found in 5 patients (16%). Axillary radionuclide uptake predicts but does not augment dye-directed SN identification. In those few patients with isolated internal mammary drainage, BL may obviate the need for surgical staging of the axilla.

62. Accuracy and limitation of sentinel node detection by breast lymphoscintigraphy: Preliminary results

62. Accuracy and limitation of sentinel node detection by breast lymphoscintigraphy: Preliminary results

Lymphoscintigraphy in Malignant Melanoma and Breast Cancer

Lymphoscintigraphy is the injection of radioactive particles that are then imaged as they pass through lymphatic vessels to their respective lymph nodal drainage basins. Lymphoscintigraphy is receiving increasing interest as a means to stage regional lymph nodes in early stage malignancy. Injection and imaging techniques for performing breast and melanoma lymphoscintigraphy are discussed in this article.