Identify Sentinel Lymph Nodes Research Articles

Difficulty to Identify Sentinel Lymph Nodes with Computed Tomography-lymphography in Patients with Cutaneous Melanoma

Difficulty to Identify Sentinel Lymph Nodes with Computed Tomography-lymphography in Patients with Cutaneous Melanoma

Abstract P1-01-33: Sentinel Lymph Node Biopsy in Breast Cancer Patients Treated with Neoadjuvant Chemotherapy

Abstract Background: sentinel lymph node biopsy (SLNB) as a reliable surrogate for the standard axillary dissection has became a widely used staging method for patients with primary operable breast cancer. Neoadjuvant chemotherapy modifies the anatomical conditions in the breast and axilla and thus SLNB in patients treated with preoperative cytotoxic therapy still remains controversial technique generally not accepted as equivalent to standard axillary dissection. The primary aim of our study was to evaluate success rate for identification and isolation of sentinel node(s) as well as false negative rate of this procedure to declare whether or not SLNB technique is feasible also in patients with preoperative chemotherapy. The secondary aim was to identify factors that can influence the accuracy of this technique. Methods: during the years 2005-2009 were in our institution diagnosed 1719 new patients with primary breast cancer. 465 of them started neoadjuvant chemotherapy in a curative manner with the intend to be followed by surgery. After completion of neoadjuvant chemotherapy was in 343 patients performed lymphatic mapping to be able to identify sentinel lymph node. In all of these subjects the attempt to identify sentinel node(s) was performed followed by standard axillary dissection without regard to the extent of surgery of the breast — this group of patients is analysed in this study. Results: one or more sentinel lymph nodes were successfully dissected in 277 patients — thus reaching success rate of 80,8%. From the remaining 66 patients there were 54 (15,7%) in whom no radioactivity uptake could be detected in axilla. This success rate was strongly influenced by clinical lymph node status (higher success rate in node negative patients); it was also dependent on features of the tumor (more frequent identification rate associated with estrogen receptor positivity, lower proliferation index and absent lympho-vascular space invasion).and on the age of patients (sentinel mode(s) were more often found in patients under the age of 50). One or more sentinel lymph node was positive in 95 cases out of 271 subjects with identified sentinel nodes and at least one non-sentinel node (35,1%). In 53 patients (19,6%) sentinel node(s) were the only positive nodes in axillary basin. In 23 patients sentinel lymph node was negative even in the case of at least one non-sentinel node with detected malignant cells. This results in false negative rate of 19,5%. This false negativity was only marginally significantly different according to lympho-vascular space invasion (higher false negativity occurred in the absence of lymphovascular invasion, p = 0,048). The overall accuracy of SLNB to correctly predict axillary lymph node status is 91,5%, sensitivity is 80,5% and negative predictive value 86,9%. Conclusion: detection rate as well as false negativity rate were in our study higher than corresponding values in patients without neoadjuvant chemotherapy and as such SLNB should not be recommended as surrogate to standard axillary dissection. On contrary we still believe that after necessary modifications of the technique SLNB can become a reliable predictor of axillary lymph node status in properly selected group of patients after preoperative cytotoxic therapy. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-33.

Accuracy of Sentinel Node Biopsy for Breast Cancer Using Blue Dye Alone

Blue dye alone (BDA), lymphoscintigraphy alone, or, a combination of the two techniques are used for sentinel node biopsy (SNB) in breast cancer. This study reviews the effectiveness of the SNB technique using BDA by measuring the node identification rate and comparing the cohort node positivity with expected rates from established nomograms. A consecutive case series was examined from the database. This included the learning experience of six surgeons. Patients with unifocal tumors estimated at less than 31 mm were eligible. The tumor and axillary nodal histology was recorded. Published data were then used to calculate and predict node positivity rates in the study according to the size and grade of the tumors. There were 332 SNB procedures from 2001 to 2008. BDA successfully identified nodes in 94.6% (314/332) of the cases. The identification rate improved with experience. In patients with invasive cancer, 28.4% (85/299) of SNB were found to be positive for metastases or micrometastases. The node identification rate and the node positivity rate were found to be within published predicted ranges for the size and grade of the study tumors. The SNB with BDA was found to be effective in identifying sentinel nodes (SLN) in breast cancer. Surgeon experience was a factor in the success of the technique. Rates of detecting metastases were consistent with internationally published data, suggesting that BDA may perform as well as other techniques in experienced hands.

Image Synthesis Using a Mini Gamma Camera and Stereo Optical Cameras

We have previously developed a method that combines a mini gamma camera with an optical camera to synthesize the two kinds of images and help surgeons to easily identify sentinel lymph nodes on the gastric surface in cancer resection surgery. Since we assumed in this method that the object surface is flat, its application was limited. In this article, we extend this method so as to estimate the three-dimensional shape of the object from stereo optical cameras. A prototype system with a mini gamma camera and two optical cameras was constructed and a preliminary experiment with a rigid machine-made phantom was performed. From comparison with results obtained by the previous method, we confirmed the effectiveness of using the three-dimensional shape.

Nanotechnology in Thoracic Surgery

Nanotechnology is an exciting and rapidly progressing field offering potential solutions to multiple challenges in the diagnosis and treatment of lung cancer, with the potential for improving imaging and mapping techniques, drug delivery, and ablative therapy. With promising preclinical results in many applications directly applicable to thoracic oncology, it is possible that the frontiers of minimally invasive thoracic surgery will eventually be explored at the nanoscale.

Intérêt de l’imagerie hybride TEMP-TDM pour la détection du ganglion sentinelle dans les cancers du sein

Introduction Single-Photon Emission Computed Tomography-Computed Tomography (SPECT-CT) is an hybrid technique which associates functional and morphological images. The aim of this study was to assess the role of SPECT-CT lymphoscintigraphy in sentinel node identification in patients with breast cancer. Methods Twelve months prospective study was undertaken. Lymphoscintigraphy comprising planar and SPECT-CT acquisition was performed in 51 consecutive patients with breast cancer (mean age: 62 ± 11.3, range: 33–83 years). Planar and SPECT-CT images were interpreted separately and the two imaging techniques were compared with respect to their ability to identify sentinel node. Results An add-value of SPECT-CT images was evidenced in 31% of cases: a more accurate anatomic localization in 21% of cases and identification of undeterminate sites of uptake in 10% of cases. Furthermore, SPECT-CT detected intramammary (4% of cases) and retromammary (2% of cases) sentinel nodes missed by planar imaging. SPECT-CT was more sensitive for internal mammary drainage detection (6% of cases). The added value proved higher in obese patients. Finally, functional and anatomical images fusion and three-dimensional overview provided clear and readily usable informations to the surgeon. Conclusion Hybrid SPECT-CT imaging improves the preoperative localisation of sentinel nodes in patients with breast cancer, in particular in obese patients. SPECT-CT provides readily usable informations to the surgeon.

A Portable γ-Camera for Intraoperative Detection of Sentinel Nodes in the Head and Neck Region

We introduced and evaluated a portable gamma-camera for intraoperative visualization of sentinel nodes in the head and neck region. Planar lymphoscintigraphy and SPECT/CT were performed after peritumoral injection of (99m)Tc-nanocolloid in 25 patients (head and neck melanoma or oral cavity carcinoma). Sentinel nodes were localized intraoperatively with a portable gamma-camera and a hand-held gamma-probe. The portable gamma-camera was used to determine the distribution of remaining radioactivity after excision of the sentinel nodes. The portable gamma-camera visualized all 70 preoperatively identified sentinel nodes. Sentinel nodes at difficult sites could be localized more efficiently, and in 6 patients, 9 additional nodes (1 tumor-positive) were identified with the portable gamma-camera after excision. Intraoperative identification of sentinel nodes in the head and neck region with a portable gamma-camera is feasible and might lead to detection of more sentinel nodes.

340 Disconcordance between number of scintigraphic and perioperatively identified sentinel lymph nodes and axillary tumour recurrence

Intraoperative assessment of sentinel lymph nodes (SLNs) has the advantage of allowing breast cancer patients with tumor-positive SLNs to avoid a second surgery by immediately proceeding to axillary lymph node dissection (ALND). However, there are several reasons why the use of intraoperative assessment should be questioned. Whereas ALND was traditionally advised for all breast cancer patients with tumor-positive lymph nodes for axillary staging and locoregional control, more recent studies have demonstrated safety of omitting ALND in a substantial number of patients.In addition, there are concerns about the accuracy of intraoperative assessment methods including frozen section analysis, touch preparation cytology and one-step nucleic acid amplification. Moreover, intraoperative assessment of SLNs denies patients the opportunity to contribute to their treatment planning. In our opinion, intraoperative assessment of axillary lymph nodes should be reserved for patients who still have a strict indication for ALND. Patients with clinical node negative disease (cN0) and one or two positive SLNs can be safely treated with breast conserving surgery and radiotherapy. There has been more controversy for cN0 patients who are treated with mastectomy since radiotherapy is not routinely administered in these patients. However, there is increasing evidence that ALND may be omitted in patients undergoing mastectomy who have a low tumor-burden in their SLNs. Therefore, we defend the position that in cN0 patients undergoing mastectomy, SLNB should be performed and full pathologic evaluation of the SLN should be awaited. In cN0 patients undergoing neoadjuvant systemic therapy (NST) intraoperative assessment of SLNs can be omitted since ALND will not provide therapeutic benefit. It is being hypothesized that patients with limited axillary disease prior to NST who remain node-positive after NST could be treated safely with axillary radiotherapy instead of ALND. In these patients, omitting intraoperative assessment might be a reasonable option. In patients with extensive nodal disease prior to NST intraoperative assessment of axillary lymph nodes should be performed.

300 Intercostobrachial nerve(s) must be preserved during axillary lymph node dissection for breast cancer

The objective of the present study was to determine the effectiveness and reliability of sentinel lymph node biopsy (SLNB) performed under local anesthesia (LA) for patients with breast cancer, by comparing the results with those obtained under general anesthesia (GA). Between January 2006 and February 2007, SLNB was performed under LA or GA in 37 and 94 patients with clinical Tis, T1, T2 or T3 N0 breast cancer, respectively. All underwent radiocolloid and blue dye injections to identify sentinel nodes. The sentinel node detection rate, the number of nodes harvested and the number of positive nodes were compared between the two groups. The sentinel node identification rates were similar for both groups. The number of sentinel and axillary nodes removed and number of positive nodes did not differ significantly between the two groups. SLNB performed under LA is an effective and reliable alternative to SLNB done under GA.

Evaluation of sentinel node biopsy by combined fluorescent and dye method and lymph flow for breast cancer

Background Conservative breast resection with subsequent sentinel lymph node biopsy (SNB) is an increasingly popular initial approach for the treatment of breast cancer due to decreased invasiveness. SNB is a shorter procedure with fewer side effects than more substantial surgical procedures, but it sometimes fails to identify metastatic disease. Therefore, a highly sensitive and convenient method is needed to identify sentinel lymph nodes (SLN) with a high probability of containing disease in SNB. We compared the combination of radioisotope or dye with a fluorescence compound to analyze lymph flow to identify targets for SNB. Materials and methods We examined patients with breast cancer lacking metastases in the axillary lymph node (ALN). Two methods for targeted SNB were developed: (1) Indocyanine Green (ICG) and Patent blue were injected into the skin overlying the tumor and sub-areolar region just before the surgical procedure. (2) ICG and radiocolloid were injected into the skin overlying the tumor and sub-areolar region. The draining fluorescent lymphatic duct was visualized using a Photodynamic Eye (PDE). We removed the SLNs that were identified by the dye and fluorescence imaging methods. Method 1 was applied to 113 patients undergoing SNB, and 29 patients were treated with Method 2. In our study, patients were grouped by lymph flow into two types: Type C demonstrated convergence to one lymph duct. Type S demonstrated separate lymph ducts. Results Using the fluorescence imaging method, 99.3% of SLNs were identified, and 3.8 SLNs per patient were seen. The SLN identification rates for Patent blue dye and radiocolloid were 92.9% and 100%, respectively, while 1.9 and 2.0 SLNs per patient, respectively, were seen with these methods. We classified two types of lymph flow based on the pattern of lymphatic drainage. Type C converged to a single lymph duct, while Type S drained to separate ducts. Type S lymph drainage was seen in 29/142 patients (20.4%), and Type C drainage was found in 113/141 patients (79.6%). Of the patients with Type S drainage, there were 4.1 SLNs per patient, but only 3.4 SLNs per patient were seen in individuals with Type C drainage. Forty cases had metastases found in the ALNs, and five of these cases were dye-negative and fluorescence-positive. Among these cases, the average number of SLNs identified was one. Conclusion The combination of fluorescence with a visible dye is a highly sensitive method for SLN identification. When SNB is guided by only the dye method, there is a risk of missing appropriate SLNs in patients with Type S lymph drainage or weak dye staining. The use of a fluorescence method together with dye could increase sensitivity of detection in these cases. Furthermore, fluorescent methods are ideal for hospitals that cannot use conventional radioactive measures.

Superiority of Radioisotope over Blue Dye for Sentinel Lymph Node Detection in Breast Cancer

Background: 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). Patients and Methods: 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. Results: 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. Conclusion: These data suggest that radioisotopes are superior to blue dye in detecting SLN in breast cancer.

Endoscopic Sentinel Lymph Node Biopsy in Breast Cancer Surgery: Feasibility and Accuracy of the Combined Radioisotope and Blue Dye

액와부림프절전이가없는조기유방암이증가하여우리나라에서 Purpose: Since its introduction in the mid-1990s, sentinel lymph node biopsy has been rapidly and widely adopted for the axillary staging of clinically node-negative breast cancer patients. However, there is some controversy in the clinical application because of its various identification rates and its false negative rates. The objective of this study was to assess the usefulness of endoscopic sentinel lymph node biopsy (ESNB) and to compare the value of two methods for identification of ESNB using blue dye only or a combination of blue dye and radioisotope. Methods: This study was carried out in 137 breast cancer patients (bilateral breast cancer, 3 cases) who underwent ESBN, at the Department of Surgery in Soonchunhyang University from May of 2007 to August of 2008. The technique involved the injection of 5 mL of 0.5% indigocarmine or Tc-99m tin colloid into subareolar plexus. The Visiport docked with a telescope was inserted through a low transverse axillary incison (1.0 cm in size) lateral to the pectoralis major. During the dissection, we identified sentinel nodes by following blue-stained lymphatic duct directly into blue-stained lymph nodes. We compared the value of two methods for identification of ESNB using blue dye only or a combination of blue dye and radioactive tracer. Results: The mean number of sentinel nodes was 1.27 (range, 1-4). The identification rate and false negative rate of the sentinel node were 94.3% (132/140) and 6.9% (3/43), respectively. We compared ESNB with using blue dye only (n=77) vs. a combination of blue dye and radioactive tracer (n=63). Sentinel lymph node identification rate were 90.9% (70/77) vs. 98.4% (62/63) (p=0.043). Conclusion: The endoscopic technique of sentinel node biopsy can keep better operative visual fields and is less invasive. The combination of blue dye and radioactive tracer was superior to blue dye only for identification rates.

3D－CTを併用したセンチネルリンパ節同定を行った外陰部Paget病の3例

今回，我々は外陰部Paget病におけるセンチネルリンパ節（以下，SLN）の同定に際し，Radio isotope法（以下，RI法），色素法に加え，CT用造影剤をトレーサーとして用いた3D－CTによるSLNの同定を行った。3D－CTを用いることでリンパ管とSLNとの関係，SLNの解剖学的位置を把握しやすくなり，術中にセンチネルリンパ節の位置をイメージしやすく，術者の助けになると思われた。

CT Based Lymphatic Mapping and Localization – A New Method To Detect Sentinel Lymph Node in Breast Cancer Patients.

Abstract Background: Sentinel lymph node biopsy in breast cancer patients has not been extensively accepted in mainland China. The main reason is that radioisotope tracer is not available in many hospitals. The objective of this study is to explore CT based lymphatic mapping and localization. The accuracy will be evaluated comparing SLN found by CT with those found by isotope and blue dye.Methods: 18 breast cancer patients who diagnosed by core needle biopsy or excisional biopsy underwent CT scan to locate the SLN before SLNB at the same day of surgery. When CT examination performed, those patients were in supine position, with the arms stretched upward but bent at the elbow with the hands at the side of the cranium which similar to the surgical position. After local anesthesia, 2mL of iopamidol was injected subcutaneously to the peritumoral and peri-areolar areas followed by gentle massage for about 1 minute. Contiguous 2-mm-thick CT images that included the breast and axilla were obtained prior to administration of the contrast agent. After 3D CT reconstruction, the SLN was identified as the most inferiorly visible nodule in the axilla connected to the lymphatic vessel on the CT imaging monitor. A professional intervention doctor punctured the defined lymph node guided by the CT monitor using the Breast Lesion Localization Needles (interv). The needle would stay in the patient's axilla until the surgery. All the lymph nodes including the CT defined one and which marked by methylene blue dye or 99mTc-sulfur colloid tracers were removed, which then would be tested by touch imprint cytology for the intraoperative diagnosis. Patients who had positive SLN would receive axillary dissection. We evaluated the new method by comparing lymph nodes defined by CT and traditional ways.Results: In this study, the success rate of SLNB was 100% (18/18). 15 of 18 patients (83.3%) showed the direct connection of SLN and lymphatic vessels draining from the injection sites on CT monitor successfully. 13 of 15 patients' SLN localization corresponded well with SLN identified by the traditional SLN mapping. Of the 40 SLNs in 15 patients, 7 SLNs in 3 patients were positive and received the ALND. These 7 SLNs were all clearly visualized on CT monitor. Among 15 SLNs (in 15 patients) punctured by needles, 13 SLNs had the highest radioactivity by DGP-guided probe and 12 are blue dye–stained. All of the 15 SLNs had radioactivity or blue stained. None of these 18 patients showed any adverse events during or after CT examination and surgery. With the assistant of CT location, the mean time of SLNB had been shortened from 20 mins to 16 mins.Conclusion: Comparing with usual tracing method, CT guided axillary SLN mapping and localization showed good specificity and gave concordant results in locating sentinel lymph nodes. These results suggest that CT guided localization would be a valuable tool for identify sentinel lymph nodes in breast cancer patients. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1035.

Evaluation of Nodal Coverage for Cervical Cancer by In Vivo Localization of Sentinel Lymph Nodes

To assess coverage of sentinel nodes, as determined by hybrid SPECT/CT scan followed by sentinel lymph node (SLN) dissection, in carcinoma of the cervix by 2D conventional, CT-based 3D conformal (3D-CRT) and intensity modulated radiation therapy (IMRT) pelvic treatment fields. Twenty patients previously enrolled on a prospective trial assessing the role of SPECT/CT scan and SLN dissection in cervical cancer were evaluated. Operative notes, pathology reports, and SPECT/CT scans were used to locate the SLNs. Identified SLNs were then contoured on a representative patient. The initial nodal area was contoured as a 1 cm circle on an axial slice and then volumetrically expanded 0.5 cm axially and 0.75 cm cranio-caudally to create a sentinel node PTV (snPTV). These contours were hidden and 2D conventional (based on bony landmarks: sup. border, L5-S1 interspace; inf. border, obturator foramina; lat. border, 2 cm lateral to pelvic brim; ant. border, symphysis pubis; post. border, behind sacrum), 3D-CRT (based on vessels contours), and IMRT (per RTOG 0418) treatment fields were designed. Adequacy of the treatment fields was determined by whether the treatment field encompassed the snPTV. Of the 20 patients originally enrolled, 18 had evaluable SPECT/CT images. Forty-four SLN (19 right and 25 left) were identified and evaluated. There were 15 external iliac, 11 obturator, 8 internal iliac, 6 common iliac, 3 presacral, and 1 para-aortic SNL identified. Conventional 2D fields inadequately covered the snPTV in 6 patients (33%), representing 6 of 44 (13.6%) of the SLNs. Specifically, 3 common iliac, 2 internal iliac and 1 para-aortic snPTV regions extended outside the treatment portal. In 3 patients (16.6 %), the snPTV extended beyond the superior border of the AP/PA and LAT fields. In 3 patients (16.6%), the snPTV extended laterally outside the AP/PA treatment portal. With 3D-CRT and IMRT, 2 patients (11.1%) had inadequate coverage, representing 4.5% (2 of 44) of the identified sentinel nodes. Of the two inadequately covered snPTV, one was a high common iliac node that extended 2 mm beyond the treatment field superiorly and the second was a para-aortic node located at the L4 vertebral body level and was entirely outside the treatment field. Overall, the majority of SLNs identified were covered by radiation pelvic fields. However, conventional treatment fields were more likely to leave SLNs uncovered compared to 3D-CRT or IMRT treatment plans, with greater than 95% of snPTV regions adequately covered using 3D-CRT and IMRT volumes. In 2 cases involving high common iliac and para-aortic nodes, the expanded superior border in the IMRT and 3D-CRT plans still placed the snPTV outside of the treated volume.

FOXP3 expression of micrometastasis-positive sentinel nodes in breast cancer patients

A number of methods have been established for identifying sentinel nodes (SNs). In the present study, we attempted to clarify the immunological status of SNs with or without micrometastasis in breast cancer patients. SNs were identified by the dye- and gamma probe-guided method. Total RNA was extracted from the SNs, and the expression of T-BET, GATA-3, and FOXP3 were evaluated using quantitative real-time reverse transcriptase-polymerase chain reaction (RT-PCR). Micrometastasis was identified as microscopically negative but positive by RT-PCR specific for mammaglobin. Of 88 patients, 17 (19.3%) showed positive metastasis in SNs (pN1, 14; pN2, 3). Of the 71 metastasis-negative SNs, 11 showed positive bands on RT-PCR specific for mamma-globin [pN0(mol+)]. There was no significant correlation among clinicopathological features with or without micrometastasis. Immunological parameters were compared among the 60 pN0, 11 pN0(mol+), and 17 pN1-2. Although T-BET expression was higher in pN0(mol+) than pN0, FOXP3 expression was also higher in pN0(mol+) than pN0. In pN1-2, T-BET expression decreased compared with pN0(mol+), but FOXP3 expression did not. On the other hand, GATA-3 expression inversely increased in pN1-2 compared with pN0(mol+). In patients with breast cancer, micrometastasis can stimulate Th1 response in SNs. However, the Treg cell response is also induced at the micrometastasis level and persists during the progression of metastasis in SNs. Then, the shift in the Th1/Th2 balance may preferentially lean toward Th2 responses in pN1-2 SNs and suppress antitumor immune responses. Micrometastasis [pN0(mol+)] is a status immunologically distinguishable from pN0 and pN1-2.

A novel approach to identify sentinel lymph nodes using microbubbles and contrast enhanced ultrasound in preoperative breast cancer patients

e11543 Background: In patients with early invasive breast cancer, surgical excision of sentinel lymph nodes (SLN) has been shown to be a safe and accurate first-line technique to stage the axilla. In animal models, superficial lymphatics can be imaged using ultrasound and intradermal microbubbles. We investigated the ability of contrast enhanced ultrasound to identify SLN preoperatively in breast cancer patients. Methods: We recruited 46 consecutive consenting patients with primary breast cancer. Pre-operatively; patients received periareolar intra-dermal injection of microbubble contrast agent, breast lymphatics were visualised by ultrasound and followed to identify putative axillary SLN. In 41 patients, we aimed to place guide-wires in the SLN. Patients then underwent standard operative tumour excision, SLN biopsy and histopathological analysis. Results: Microbubble enhancement identified putative SLN in 5 successive patients. In 36 patients, putative SLN were visualised and guide-wires deployed. Operative findings confirmed the wired lymph nodes (LN) were SLN. In 2 cases, SLN contrast enhancement failed but guide-wires were placed into prominent grey-scale imaged LN. These wired LN were not SLN. In 3 patients, the procedure failed. Contrast enhanced ultrasound correctly identified SLN in 36 of 41 patients (88%). Five patients were found to have metastasis. In all metastatic cases, SLN were correctly identified and localised with guide-wires pre-operatively. Conclusions: Microbubbles readily enter breast lymphatics and contrast enhanced ultrasound may represent a practical method to identify SLN. Improvements in percutaneous techniques may facilitate ultrasound guided SLN excision in the breast clinic and could reduce the numbers of patients requiring axillary surgery. No significant financial relationships to disclose.

Long-term follow-up of patients with minimal sentinel node tumor burden (< 0.1mm) according to Rotterdam criteria: A study of the EORTC Melanoma Group

9005 Background: Many studies have identified Sentinel Node (SN) tumor burden as a prognostic factor for additional non- SN (NSN) positivity and / or disease-free (DFS) and melanoma specific survival (MSS). It remains unclear if pts with minimal SN tumor burden can safely be managed without Completion Lymph Node Dissection (CLND). Pts with minimal SN tumor burden might be at risk for late recurrences (> 5 years). Methods: Slides of 595 SN positive patients were reviewed for this pan-European study collaboration in 5 major centers. Slides were reviewed for the microanatomic location and SN tumor burden according to the Rotterdam Criteria (< 0.1mm, 0.1 - 1.0mm and > 1.0 mm) for the maximum diameter of the largest metastasis. MSS, DFS and distant metastasis-free survival (DMFS) rates were calculated, as was NSN positivity. Results: In 595 SN positive pts, the mean and median Breslow thickness was 4.73 and 3.5 mm. Ulceration was present in 51% of melanomas. 67 pts had metastases < 0.1 mm (11%), 226 pts (38%) had 0.1 - 1.0 mm metastases and 302 pts had metastases > 1.0 mm (51%). Mean and median follow-up was 48 and 40 months for all patients (range 1 - 172). Patients with metastases < 0.1 mm had mean and median follow-up of 61 and 57 months, 46% (31pts) had follow up > 5 years and 25% (17 pts) had follow-up longer than 80 months (range 3 - 132). 5-year MSS rates were 94% for metastases < 0.1 mm, 70% for 0.1 - 1.0 mm and 57% for > 1.0 mm (p<0.001). 5-year DMFS rate was 91% for metastases < 0.1 mm. NSN positivity occurred in 5% of < 0.1mm, 17% of 0.1 - 1.0 and 29% of metastases > 1.0 mm (p<0.001). Conclusions: This large multicenter experience (n=595) has demonstrated that long-term follow-up of melanoma patients with minimal SN tumor burden (< 0.1 mm) indicates very low relapse rates and excellent MSS, seemingly identical to SN negative patients. With prolonged follow-up, an increase in the occurrence of relapses of any kind between 5 and 10 years follow up has not been identified, and excellent 10-year survival rates are expected. No significant financial relationships to disclose.

Fluorescence navigation with indocyanine green for detecting sentinel nodes in extramammary Paget's disease and squamous cell carcinoma

The radioisotope navigation method, which has usually been used for identification of sentinel nodes, is less useful in locating sentinel nodes close to primary lesions in cases of extramammary Paget's disease because of overlapping radioactivity from the primary site. We applied fluorescence navigation with indocyanine green (ICG) in two patients with skin cancer to cover this defect. The use of a charge-coupled device camera enabled real-time visualization of dynamic lymph flow without skin incision. The inguinal skin over the identified sentinel node with a handheld gamma probe was in accordance with the point detected by ICG fluorescence in a patient with squamous cell carcinoma of the foot. Sentinel node biopsy using fluorescence navigation with ICG proved to be easy and reliable.

A Randomized Study Comparing the Effectiveness of Methylene Blue Dye with Lymphazurin Blue Dye in Sentinel Lymph Node Biopsy for the Treatment of Cutaneous Melanoma

Radioactive colloid with a gamma probe is the most effective method of identifying sentinel lymph nodes (SLN). Nevertheless, since vital blue dyes are also helpful for visually identifying SLN during surgical dissection, they are often used together with radioactive colloid. There has occasionally been a shortage of lymphazurin blue (LB) dye for use in sentinel lymph node biopsies (SLNB). There have also been reports of anaphylactic reactions to the use of LB dye. Therefore, we were interested in using methylene (MB) blue dye to aid in the visualization of the SLN for biopsy because of its ready availability and greater safety. The purpose of this study of SLN biopsies was to compare the effectiveness of MB with that of LB dye. We randomly assigned 159 consecutive patients with intermediate and high-risk melanomas, who were treated by a single surgeon at the Yale Melanoma Unit between January 10, 2005, and June 13, 2007 with SLN biopsy, with radioactive colloid and either LB or MB. A total of 443 SLN were identified and removed from these 159 consecutive patients. MB dye was found to be as effective as LB dye in visually identifying SLN: blue dye was visible in 62% of SLN in the MB group compared with 58% in the LB group. When the SLN were separated into three anatomic locations the visualization results were LB 36% and MB 72% (P = 0.010) for head and neck, LB 65% and MB 61% (P = 0.919) for axilla, and LB 59% and MB 67% (P = 0.001) for groin. SLN were identified in all 158 patients. Approximately 60% of these SLN were also visibly blue. In the cervical and groin regions, MB dye was more visible in the SLN than was the LB dye, and in the axilla the SLN were equally stained blue by both dyes. Generally, if surgeons wish to use intradermal injections of vital blue dye to help visualize SLN, we have found in this study that MB is at least as effective as LB for the visualization of these SLN. The cost of MB is less than that of LB.