Number Of Sentinel Lymph Node Research Articles

Sentinel lymph node mapping for T1 esophageal cancer.

7 Background: Extended radical esophagectomy with three-field lymph node dissection has been recognized as the standard procedure for thoracic esophageal cancer in Japan, even for clinically T1N0 cases. However, to eliminate the uniform application of the highly invasive surgery, we hypothesized that sentinel lymph node (SLN) mapping would play a key role to obtain individual information and allows modification of the surgical procedure for early esophageal cancer. Methods: We have established radio-guided method to detect SLNs in patient with early esophageal cancer using endoscopic injection of technetium-99m tin colloid. Preoperative lymphoscintigraphy and intra-operative use of hand held gamma probe were reliable to locate the radioactive SLNs. Intra-operative gamma probing was also feasible in thoracoscopic or laparoscopic surgery using a special gamma detector which is introducible from trocar ports. Results: SLN mapping has been performed for 70 patients with clinically N0 and early (pT1) esophageal cancer in our institute since 1999. Detection rate of hot node using our procedure was 94% (66/70). The mean number of sentinel nodes per case was 4.6. Twenty-one of 23 cases (91%) with lymph node metastasis showed positive SLNs. Accuracy of metastatic status based on SLN was 97% (64/66). SLNs widely spread from cervical to abdominal areas. In more than 80% of the cases, at least one SLN was located in the 2nd or 3rd compartment of regional lymph nodes. However, 56 (85%) of 66 patients had no lymph node metastasis or metastasis (+) only in SLNs. Conclusions: Our results suggest that SLN concept for clinically N0 and T1 esophageal cancer could be validated. Theoretically more than 80% of patients with pT1b esophageal cancer may be controlled by local treatments such as surgery and chemoradiotherapy targeting primary tumors plus their SLNs. Individualized selective and modified lymphadenectomy targeted on SLN basins for clinically N0 early esophageal cancer should become feasible and clinically useful as less invasive surgical procedures.

P3-07-17: Optimal Number of Sentinel Lymph Nodes That Could Avoid Completion of Axillary Lymph Node Dissection in Operable Breast Cancer.

Abstract Background Axillary lymph node dissection (ALND) has been the standard of care for breast cancer patients with sentinel lymph node (SLN) metastasis. It is now under discussion since the publications of ACOZOG Z0011 and NSABP-32. The 1–3% rate of axillary recurrence is very low in these studies, whereas the rate of additional nodal metastasis after the completion of ALND varies from 15% to 35%. The purpose of this study was to determine the optimal number of nodes to be removed in order to obtain an axilla free of disease after initial surgery. Patients and methods: 4928 consecutive patients treated for breast cancer ≤ 2 cm with primary breast surgery with SNB between 2000 and 2009 were reviewed from the Institut Curie breast cancer prospective database. 1165 patients with a positive SLN (macrometastasis, micrometastasis and isolated tumor cells) underwent ALND. The proportion of patients with positive ALND was analysed according to the total number of sentinel lymph nodes biopsied. Results were compared with Chi-square test for qualitative variables and with Kruskal-Wallis for quantitative variables. Results: Among the 1165 patients, 308 (26.4%) had a positive ALND. Among them, 81.1% of patients had a macrometastasis in the SLN versus 45.6% in the 857 patients with negative ALND (p<0.0001); 10.8% had a micrometastasis versus 31.4% (p<0.001) and 8.1% of patients had isolated tumor cells in the SLN versus 23% (p<0.001). The proportion of patients with positive ALND decreased with the number of sentinel nodes removed (Figure 1), independently of the number of positive SLN. Among the 1165 patients, the rate of patients with 5 nodes removed or more and with residual disease in the axilla was < 1% (n=11). Those patients could have avoided completion ALND, representing 3.6% of the total positive ALND that would have been neglected. Conclusions: We showed that patients with positive SLN have a very low risk (<1%) of residual disease in the axilla when 5 nodes or more have been removed. This number which is a major component of nomograms, could be used as a threshold to avoid completion ALND. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-17.

P3-07-47: Validated Nomogram To Predict Sentinel Lymph Node Positivity in Breast Cancer Patients.

Abstract Background: Sentinel lymph node(SLN) biopsy is commonly used to assess axillary lymph node status in breast cancer patients. Intraoperative (frozen section) evaluation of SLN may lead to immediate axillary dissection if the lymph node is found to be positive. In light of the recent outcomes of the Z00011 trial, the use of intraoperative evaluation for SLN should diminish since only select patients appear to benefit from axillary dissection. We have previously reported that tumor size and lymphovascular invasion (LVI) strongly predict SLN positivity in a cohort of 350 breast cancer patients [Modern Pathology (2011) 24, 30A]. From this test cohort, we developed a nomogram which could help identify patients more likely to have sentinel lymph node positivity. The aim of this study was to validate the efficacy of this nomogram by applying a new, non-overlapping cohort of breast cancer patients who had undergone sentinel lymph node sampling. Materials and Methods: 93 breast cancer patients aged 29–82 (mean:59) who underwent excision (54, 58%) or mastectomy (39, 42%) with a SLN biopsy were studied. Patients who had undergone neoadjuvant chemotherapy were excluded. Clinicopathologic parameters such as number of sentinel lymph nodes removed and/or positive, number of non-sentinel lymph nodes removed and/or positive, tumor size, histologic type/grade, presence of lymphovascular invasion, biomarker expression (ER,PR, HER-2/neu) and multifocality were recorded. Statistical analysis was performed to identify which variables correlated with SLN positivity in this validation cohort. In addition, the probability of SLN positivity for each case was determined by using the nomogram and this value was then compared to the patient's true SLN status. Results: When analyzed separately, tumor size (p=0.03) and LVI (p=0.01) were variables that were significantly associated with SLN positivity in both the test and validation cohorts. Employment of the nomogram demonstrated that 60% of patients who were predicted to have a positive SLN with at least 0.8 probability were truly positive by histologic and immunohistochemical examination. Moreover, 89% of patients who were predicted to have a negative SLN with at least 0.8 probability were truly negative by histologic and immunohistochemical examination. Conclusions: We conclude that the utility of this nomogram prior to surgery can help predict SLN positivity. This can serve as a complimentary adjunctive tool to better select patients who will likely need intraoperative evaluation of their sentinel lymph node due to their higher risk of sentinel node positivity and thus, benefit from the option of immediate axillary dissection at that time. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-47.

P3-07-41: Sentinel Lymph Node Biopsy Is a Reliable Method for Lymph Node Evaluation in Neoadjuvant Chemotherapy Treated Breast Cancer Patients.

Abstract Background: Successful sentinel lymph node mapping in breast cancer patients treated with neoadjuvant chemotherapy has been debated by practicing surgeons due to the potential compromise of the lymphatic drainage system after treatment. Furthermore, whether clinicopathologic variables associated with sentinel lymph node positivity in breast cancer patients differ from similar patients who have been treated with neoadjuvant chemotherapy has not been well-studied. Materials and Methods: Breast cancer patients who received neoadjuvant chemotherapy were identified in our files. A similar number of breast cancer patients who did not receive such therapy was also selected as a comparison group. Clinicopathologic parameters such as age, type of surgical procedure, number of sentinel lymph nodes removed and/or positive, number of non-sentinel lymph nodes removed and/or positive, tumor size, histologic type/grade, presence of lymphovascular invasion, biomarker expression (ER,PR, HER-2/neu) and multifocality were recorded for each patient in both cohorts. Statistical analysis was performed for each cohort to identify variable(s) that correlated with sentinel lymph node positivity. Additional analysis was performed by computing the odds ratio of sentinel lymph node positivity after adjusting for selected variables. Results: Ninety-seven and ninety-three patients who were and were not treated with neoadjuvant chemotherapy, respectively, were identified. In all patients, successful sentinel lymph node mapping was achieved. When these cohorts were separately analyzed, tumor size, lymphovascular invasion, and non-sentinel lymph node positivity were associated with sentinel lymph node positivity in the cohort that did not receive neoadjuvant chemotherapy. In the cohort that received therapy, lymphovascular invasion and non-sentinel lymph node positivity were associated with sentinel lymph node positivity. In addition, after adjusting for tumor size, lymphovascular invasion and histologic grade, patients treated with neoadjuvant chemotherapy were more likely to have sentinel lymph node positivity than those who did not have this treatment (odds ratio: 5.4, 95% CI 2.4, 12.1). Conclusions: Successful sentinel lymph node mapping was achieved in all ninety-seven breast cancer patients studied. Regardless of whether neoadjuvant chemotherapy was administered, the presence of lymphovascular invasion and non-sentinel lymph node positivity were found to predict sentinel lymph node positivity. By comparing two cohorts of breast cancer patients differing only in the use of neoadjuvant chemotherapy and adjusting for select variables, those in the treated cohort still remained more likely to have a positive sentinel lymph node. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-41.

P3-07-46: Accuracy of SPIO-Enhanced MR Imaging Alone for the Diagnosis of Sentinel Node Metastases in Patients with Breast Cancer.

Abstract Background Superparamagnetic iron oxide (SPIO)-enhanced MR imaging has been reported to be promising for the detection of metastases in sentinel nodes localized by CT lymphography in patients with breast cancer (Motomura, Ann Surg Oncol 2011). The current SPIO technique involves imaging before and after contrast administration. This study evaluated the accuracy of SPIO-enhanced MR imaging alone without unenhanced imaging. Methods: This study included 120 patients with breast cancer demonstrating clinically negative nodes. Sentinel nodes were identified by CT lymphography, and MR imaging of the axilla before and 18–24 hr after interstitial administration of SPIO was performed. A node was considered non-metastatic if it showed a homogenous low signal intensity and metastatic if there was an absence of low signal intensity either in the entire node or in a focal area on SPIO-enhanced MR imaging. The diagnostic accuracy of the SPIO-enhanced imaging alone was compared with that of combined unenhanced and SPIO-enhanced imaging. Results: The mean number of sentinel nodes identified by CT lymphography was 1.2 (range 1–3). Pathologic evaluation demonstrated that 28 (23.3%) of 120 patients showed metastasis to at least one node. One false negative result was added when the evaluation was based solely on SPIO-enhanced MR imaging. Consequently, the sensitivity decreased from 84.0% to 80.0% and the accuracy decreased from 89.2% to 88.3%, respectively, in the SPIO-enhanced MR imaging alone. However, the differences in sensitivity and accuracy between SPIO-enhanced MR imaging alone and the combined unenhanced and SPIO-enhanced imaging were not significant (McNemar's test; p=1.0). The specificity of enhanced imaging alone and that of combined unenhanced and SPIO-enhanced imaging were both 90.5%. Conclusions: A single MR imaging examination performed after SPIO administration can be used for accurate diagnosis of sentinel node metastases, and thus reduce the time and cost of imaging. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-46.

Sentinel lymph node biopsy for breast cancer patients using fluorescence navigation with indocyanine green.

BackgroundThere are various methods for detecting sentinel lymph nodes in breast cancer. Sentinel lymph node biopsy (SLNB) using a vital dye is a convenient and safe, intraoperatively preparative method to assess lymph node status. However, the disadvantage of the dye method is that the success rate of sentinel lymph node detection depend on the surgeon's skills and preoperative mapping of the sentinel lymph node is not feasible. Currently, a vital dye, radioisotope, or a combination of both is used to detect sentinel nodes. Many surgeons have reported successful results using either method. In this study we have analyzed breast lymphatic drainage pathways using indocyanine green (ICG) fluorescence imaging.MethodsWe examined the lymphatic courses, or lymphatic vessels, in the breast using ICG fluorescence imaging, and applied this method to SLNB in patients who underwent their first operative treatment for breast cancer between May 2006 and April 2008. Fluorescence images were obtained using a charge coupled device camera with a cut filter used as a detector, and light emitting diodes at 760 nm as a light source. When ICG was injected into the subareola and periareola, subcutaneous lymphatic vessels from the areola to the axilla became visible by fluorescence within a few minutes. The sentinel lymph node was then dissected with the help of fluorescence imaging navigation.ResultsThe detection rate of sentinel nodes was 100%. 0 to 4 states of lymphatic drainage pathways from the areola were observed. The number of sentinel nodes was 3.41 on average.ConclusionsThis method using indocyanine green (ICG) fluorescence imaging may possibly improve the detection rate of sentinel lymph nodes with high sensitivity and compensates for the deficiencies of other methods. The ICG fluorescence imaging technique enables observation of breast lymph vessels running in multiple directions and easily and accurately identification of sentinel lymph nodes. Thus, this technique can be considered useful.

Application of ⁹⁹mTc-SPECT-CT and carbon nanoparticles suspension injection in sentinel lymph node mapping for rectal cancer

To evaluate the accuracy of sentinel lymph node mapping(SLM) in patients with rectal cancer by single-photon emission computed tomography (SPECT-CT) lymphoscintigraphy and carbon nanoparticles suspension injection. Twelve patients with clinical T(1-2)N(0)M(0) rectal cancer were selected and locally injected with technetium-(99m)sulfur-colloid and carbon nanoparticles suspension by endoscope one day before surgery, followed by SPECT-CT scanning 1, 3 and 5 hours later. Radioactive isotope(RI) uptake of each sentinel node(SN) basin with location preoperatively determined by SPECT-CT was postoperatively calculated using gamma probe. Nodes with the highest RI uptake, the number of which was also pre-determined by SPECT-CT, was defined as SNs. Immunohistochemical cytokeratin staining was performed for all the SNs and non-SNs. The rate of sentinel node detection was 91.7%(11/12) with at least one SN(1-3) per patient. Ten cases showed metastasis-negative in SNs as well as all the resected regional nodes by immunohistochemical cytokeratin staining. Only one patient had positive nodes in both SN and non-SNs. The accuracy of SLM was 100%. SPECT-CT lymphoscintigraphy and carbon nanoparticles suspension injection can effectively detect the anatomic location and number of sentinel nodes, and improve the accuracy of SLM for rectal cancer.

Factors predicting non-sentinel lymph node involvement in sentinel node positive breast carcinoma

In routine practice, axillary lymph node dissection is performed in early invasive breast cancer patients with positive sentinel node biopsy. However, sentinel node is the only involved axillary node in 40-70% of patients, and determining factors that predict axillary non-sentinel node involvement will therefore prevent unnecessary axillary lymph node dissection and decrease morbidity. In this study, 119 invasive breast cancer patients with sentinel node metastasis who underwent axillary lymph node dissection between 1998-2009 at our institution were studied. Primary tumor characteristics and features of the metastatic tumors in sentinel nodes, such as microanatomic location, size of metastasis, and the ratio of metastatic tumor area to the total sentinel node area were evaluated. Student's t-test and multivariate logistic regression were used for statistical analysis. The mean age of the patients was 50.7 years (28-80). Forty-three patients (36%) had invasive ductal and 25 patients (21%) had invasive lobular carcinoma. Most of the patients had either pT1 (44%) or pT2 (54%) tumors. Fifty-four patients (45%) had no further positive nodes in the axilla. The metastatic deposits in the sentinel node were subcapsular in 16 patients (13%). The percent area of sentinel node occupied by tumor (p < 0.001), number of sentinel nodes (p=0.041), and microanatomic location of metastatic tumor (p=0.002) were significantly associated with non-sentinel node metastasis in univariate analysis. The percent area of sentinel node occupied by tumor (p < 0.001) and number of sentinel nodes (p=0.033) remained significantly associated with non-sentinel node involvement in multivariate analysis. In patients with invasive breast cancer and positive sentinel node, area percent of sentinel node occupied by tumor, and the number of sentinel nodes removed are independently predictive of non-sentinel node involvement.

Optimal Sampling Number of Sentinel Lymph Nodes in Invasive Breast Cancer: Results of 1,026 Sentinel Lymph Node Biopsies Done by Radioisotope

부분의 유방암 환자에게 감시림프절 생검술이 시행되고 있으며 Purpose: For isotope mapping, many authors have defined the sentinel lymph node (SLN) as the one containing isotope counts higher than the axillary background. However, no study has sought to define an optimal guideline, and the number of SLNs needed for precise detection of metastatic SLNs is still a subject of debate. Accordingly, we set out to determine the optimal sampling number of SLNs. Methods: Between January 2005 and December 2008, we enrolled 1,026 patients with primary invasive breast cancer. These patients had received sentinel lymph node biopsy (SLNB) using radioisotopes at Yeungnam University Hospital. During SLNB, ex vivo isotope counts were measured for each SLN. And, the number and metastatic status of harvested SLNs were investigated. We defined SLNs as lymph nodes that show an isotope count ≥10 times that of the axillary background. Each SLN was labeled as S1 (highest isotope count), S2 (second highest), or S3 and so on, in descending isotopecount-order. If an SLN was positive for metastasis, completion axillary lymph node dissection was performed. Results: The mean age of patients was 48.9 years (ranges, 22-83 years). The mean number of removed SLNs was 2.8 (ranges, 1-11). Of the 1,026 patients enrolled, 311 (30.3%) had SLN metastasis: S1 was positive (S1+) in 258 patients (82.9%), S2 was positive (S1-, S2+) in 40 patients (12.3%), and S3 was positive (S1-, S2-, S3+) in 13 patients (3.9%). There was no metastasis in SLNs defined as S4, S5 and so on. The average number of sampling SLNs until detecting metastasis in S1, S2, and S3 was 1.24 (1-4), 2.45 (2-4), and 3.46 (3-5). Conclusion: During SLNB done using radioisotopes, for accurate axillary lymph node staging, up to the 3rd isotope-count-order of SLNs should be removed. The average number of SLNs needed for detecting metastasis in S3 is four.

How Many Sentinel Lymph Nodes Are Enough for Accurate Axillary Staging in T1-2 Breast Cancer?

PurposeDuring a sentinel lymph node biopsy (SLNB) for breast cancer, the appropriate number of sentinel lymph nodes (SLNs) to be removed for accurate axillary staging is still controversial. We hypothesized that there might be an optimal threshold number of SLNs. We investigated how many SLNs should be removed to achieve an acceptable accuracy and ensure minimal morbidity.MethodsWe reviewed data of 328 patients with invasive breast cancer who underwent SLNB followed by complete level I and II axillary dissection between January 2004 and December 2005. The false negative rate (FNR) and accuracy of SLNB according to the number of removed SLNs were evaluated.ResultsThe mean number of SLNs removed was 3.0 (range, 1-14), and that of total retrieved axillary lymph nodes was 17.5 (range, 10-40). In total, 111 (33.8%) patients had positive nodes on the permanent pathological report. Among them, 12 patients had negative SLNs; thus, the overall FNR of SLNB was 10.8% (12/111) and the accuracy was 96.3% (316/328). The FNR was 26.6% for a single SLN, 8.0% for two, and 11.1% for three. In cases where four or more SLNs were removed, the FNR decreased to 0% and accuracy reached 100%.ConclusionOur data suggest that a SLNB should not only remove one or two of the hottest node(s) when other hot nodes exist. We also suggest that four might be an optimal threshold number of SLNs to be removed and that removal of more than four SLNs does not improve axillary staging accuracy.

Abstract P1-01-05: Clinical Significance of Tumor Burden in the Sentinel Nodes after Neoadjuvant Therapy Differs from Sentinel Nodes in the Adjuvant Setting and This May Influence the Management of the Axilla

Abstract Background. Lymph node metastases are the most significant prognostic factor for breast cancer patients. The use of sentinel node biopsy (SLN) has generated an increased detection of positive nodes through the identification of isolated tumor cells (ITC) and micrometastasis. The objective of this study is to evaluate the significance of SLN micrometastasis and ITC for patients undergoing neoadjuvant chemotherapy versus patients undergoing surgery first. Material and Methods. A total of 571 patients with clinically node negative T1-T3 breast cancer underwent SLN surgery from 2004 to 2008. Clinicopathological data were reviewed and comparison was made between results in the adjuvant and neoadjuvant setting. Results. Of the 571 patients, 71 patients (12.5%) underwent SLN biopsy after neoadjuvant chemotherapy and 500 (87.5%) underwent surgery first. The SLN identification rate in the adjuvant and neoadjuvant therapy groups were similar (96.2% vs 95.8%). Mean number of sentinel nodes removed were 2,2 (range 1-15) in the adjuvant group and 2.2 (range 1-7) in the neoadjuvant group. The SLN was positive in the adjuvant group in 151 patients (30%) while in 27 patients (37.5%) in the neoadjuvant group. The SLN was the only positive node in 106 patients (70.1%) in the adjuvant group and in 6(26%) in the neoadjuvant group. Micrometastasis in the SLN was found in 39 patients (7.8%) in the adjuvant group and in 7 (9.8%) patients in the neoadjuvant group. In the adjuvant group, 7 patients (17.9%) had additional non SLN positive in the axillary dissection (ALND), while 3 (49%) in the neoadjuvant group. ALND was performed in all patients with ITC in the SLN in the neoadjuvant setting and 50% of them had additional nonSLN. Discussion. The significance of micrometastasis or ITC in the sentinel node seems to differ in patients with neoadjuvant therapy or surgery first. Micrometastsis or ITC in patients with prior neoadjuvant therapy may reflect residual disease in the axilla, as 50% of patients will have additional positive nodes. Completion axillary node dissection should be considered in this group of patients. Even more, the majority of patients with a positive SLN in the neoadjuvant group harbored additional positive axillary nodes. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-05.

Sentinel Lymph Node Biopsy in Breast Cancer: An Analysis of the Maximum Number of Nodes Requiring Excision

Sentinel lymph node biopsy (SNB) is now the standard of care in assessment of patients with clinically staged T1-2, N0 breast cancers. This study investigates whether there is a maximum number of sentinel lymph nodes (SLN) that need to be excised without compromising the false-negative (FN) rate of this procedure. Data were prospectively collected for 319 patients undergoing SNB between February 2001 and December 2006 at our institution. This data were analysed, both in terms of the order of SLN retrieval and relative isotope counts of the SLNs, in order to determine the maximum number of SLNs that need to be retrieved without increasing the FN rate. Furthermore, we investigated the relationship between SLN blue dye concentration and the presence of SLN metastases. The SLN identification rate was 97% with no false-negative cases amongst patients undergoing simultaneous axillary clearance historically during technique validation. In patients with SLN metastases, excision of the first 4 SLNs encountered results in the identification of a metastatic SLN in all cases. Although the majority (86%) of SNB metastases are in the hottest node, the SLN containing the metastasis is in the first 4 hottest nodes in 99% of patients with nodal metastases. The remaining 1% of SLN metastases were identified by blue dye. There was no statistically significant association between the SLN blue dye concentration and the presence of SLN metastases. A policy to remove a maximum of four blue and/or hot SLNs along with any palpably abnormal lymph nodes does not result in an increased false-negative rate of detection of SLN metastases.

Modified Alcian Blue Enhances the Intraoperative Diagnosis of Sentinel Lymph Node Metastasis in Invasive Lobular Carcinoma: A Prospective Study

The sensitivity of an intraoperative diagnosis of sentinel lymph node metastasis of invasive lobular carcinoma using conventional staining is low. To develop a fast, modified, Alcian blue stain to decrease the intraoperative false-negative results in testing for metastatic invasive lobular carcinoma. Modified Alcian blue was optimized. Patients who had invasive lobular carcinoma on needle biopsy were candidates for this study. Touch preparations from every sentinel lymph node were prospectively prepared in the same manner, one stained with modified Alcian blue and one with conventional staining. These slides were independently interpreted. A total of 121 sentinel lymph nodes from 31 patients with invasive lobular carcinoma were studied. There were 11 patients (35.5%) who had at least one positive lymph node test result. There were a total of 18 positive lymph node results (14.9%). Although 10 sentinel lymph nodes with abnormalities were detected in 7 patients with conventional staining, modified Alcian blue detected 15 sentinel lymph node abnormalities in 10 patients. Modified Alcian blue increased the sensitivity compared with conventional staining from 63.6% to 90.9% (calculated based on the number of patients) and from 55.6% to 83.3% (calculated based on number of sentinel lymph nodes). The staining process takes approximately 11 minutes. Modified Alcian blue stain is a relatively rapid, cheap, highly sensitive, and specific method of detecting metastatic invasive lobular carcinoma. This method can be used in conjunction with conventional staining methods used intraoperatively.

Comparison of different tracer methods in detecting sentinel lymph nodes in gastric cancer

Objective To explore the optimum sentinel lymph node (SLN) mapping method in gastric cancer. Methods The clinical data of 59 patients who were confirmed with gastric cancer at Guangzhou General Hospital of Guangzhou Military Command from January 2004 to August 2008 were retrospectively analysed. Patent blue V dye was used in 20 patients (group A), technetium-99m sulfur colloid was used in 20 patients (group B),and a combination of patent blue V dye and technetium-99m sulfur colloid were used in 19 patients (group C).The number of SLNs detected, and accuracy and false-negative rate of SLNs in diagnosing regional lymph node metastasis were analysed by t test and chi-square test. Results The numbers of SLNs detected in groups A, B and C were 38 (1.9 per case), 31 (1.6 per case) and 56 (2.9 per case), respectively. In group C, 46 SLNs were screened out by patent blue V dye and technetium-99m sulfur colloid simultaneously, six SLNs were only detected by patent blue V dye and four only by technetium-99m sulfur colloid. There was a significant difference in the number of SLNs detected among the three groups (t = 4.35, P ＜ 0. 05 ). The number of SLNs detected in group C was significantly greater than that in groups A and B (t = 4. 21, 3. 54, P ＜ 0.05 ). The accuracy and false-negative rate of SLNs in diagnosing regional lymph node metastasis were 95% (19/20) and 5% (1/20) in group A, 90% (18/20) and 10% (2/20) in group B, and 100% (19/19) and 0 in group C. The accuracy was significantly higher (x2 = 163.01, P ＜ 0.05) and the false-negative rate was significantly lower in group C compared with those in groups A and B (x2 = 170. 14, P ＜ 0. 05). Conclusion A combination of dye and radioactive tracer is a favorable method for detecting SLNs in gastric cancer. Key words: Gastric neoplasms; Sentinel lymph nodes; Tracer methods; Dye; Nuclide

Intra-operative sentinel lymph node identification using a novel receptor-binding agent (technetium-99m neomannosyl human serum albumin, 99mTc-MSA) in stage I non-small cell lung cancer

In the previous report, to simplify the synthesis and labelling procedures and to improve the biological properties, we developed a novel mannose receptor-binding agent, technetium-99m human serum albumin (99mTc-MSA), for sentinel lymph node detection. This study is the first clinical trial designed to test the reliability and feasibility of sentinel node detection using this new radioactive agent in patients with stage I non-small cell lung cancer. Forty-two patients (30 men, 12 women; mean age 63.3 + or - 8.9 years) that were candidates for lobectomy with mediastinal lymph node dissection for stage I non-small cell lung cancer were enrolled. A total dose of 1mCi of 99mTc-MSA in 0.2 ml was administered in one shot at the peritumoural region approximately 3h before surgery. The radioactivity in the lymph nodes was counted before (in vivo) and after (ex vivo) dissection with a hand-held gamma probe. A sentinel lymph node was defined as any node for which the radioactivity count was 5 times that of the resected lung tissue with the lowest count for the ex vivo counts. All harvested lymph nodes were cut into 2-mm slices and ultimately diagnosed by using formalin-fixed and paraffin-embedded sections with haematoxylin and eosin staining. 99mTc-MSA was taken up by the lymph nodes and its detection did not change until 21 h after the injection. The number of dissected lymph nodes per patient was 22.1 + or - 11.6 (range 4-57). Among 42 patients, the sentinel lymph nodes could be identified in 40 patients (95.2%). The number of sentinel lymph nodes identified was 2.3 + or - 1.1 stations (range 1-5) per patient. Ten out of 40 patients (25.0%) had metastases in 11 sentinel lymph nodes. Three of these 11 sentinel lymph nodes (27.3%) had skip metastases. No false-negative sentinel lymph nodes were detected in any of the 10 patients with N1 or N2 disease (0%). The relationship between in vivo and ex vivo results for mediastinal sentinel lymph nodes showed concurrence in 29 out of 40 patients (72.5%). Intra-operative sentinel lymph node identification using 99mTc-MSA appears to be feasible and reliable in stage I non-small cell lung cancer.

323 Does intra-operative assessment of sentinel lymph nodes cause over-running of theatre lists or cancellation of operations?

The optimal number of sentinel lymph nodes (SLN) that need to be harvested to achieve favorable survival outcome during a SLN biopsy (SLNB) has not yet been established.Six hundred and thirteen patients with clinically node-negative breast cancer who underwent SLNB were reviewed. Survival outcomes according to the number of total harvested lymph nodes (THLNs), defined as the sum of enumerated SLNs and non-SLNs were analyzed.Patients with only 1 THLN showed lower recurrence-free survival (RFS) as compared to those with ≥2 THLNs (p = 0.049). In multivariate analysis, only 1 THLN was associated with poor RFS (HR = 2.711; p = 0.029).Removing at least 2 lymph nodes during SLNB may be acceptable. Harvesting only 1 lymph node should be undertaken cautiously because of false negative results and increasing the subsequent recurrence rate.

599 Does radiopharmaceutical molecule size change number of sentinel lymph node in breast cancer patients?

To investigate the impact of breast density on the performance of radiologists when mammograms are digitally acquired and displayed.A total of 150 craniocaudal digital mammograms including 75 cases with cancer were examined by 14 radiologists divided into two groups: those who read more (six) and less (eight) than 2000 mammograms per year. Cases were classified as low or high mammographic density. For both types of cases, detection of cancers within and outside the dense fibroglandular tissue was investigated. The performance of radiologist was measured using jack-knife free-response receiver operating characteristic (JAFROC) figure of merit (FOM).Radiologists with over 2000 annual reads had significantly higher JAFROC FOM (P = .03) for high (0.76) mammographic density compared to low (0.70) mammographic density cases. When lesions overlaid the fibroglandular tissue, cases with high mammographic density compared to low mammographic density displayed increased location sensitivity for all radiologists (P = .03) and for those radiologists reading more than 2000 mammograms annually (P = .04), whereas JAFROC FOMs increased for all radiologists (P = .05). No significant changes were observed when the lesion was outside the fibroglandular region.Increased mammographic density improves the performance of experienced radiologists when using digital mammograms. This finding, which does not align with those previously reported for film screen systems, may be because of windowing/leveling opportunities available with digital images.

An Increased Number of Sentinel Lymph Nodes Is Associated with Advanced Breslow Depth and Lymphovascular Invasion in Patients with Primary Melanoma

An Increased Number of Sentinel Lymph Nodes Is Associated with Advanced Breslow Depth and Lymphovascular Invasion in Patients with Primary Melanoma

Prolonged Injection Site Mass Can Occur with Methylene Blue but Not Lymphazurin Blue after the Sentinel Node Procedure.

Abstract Objectives: The purpose of this study is to evaluate the differences in outcomes and complications of the sentinel node dissection for breast cancer using Methylene blue and Lymphazurin blue.Methods: From 2004-2008, 160 patients underwent the sentinel node procedure at a county hospital, teaching institution. The sentinel node procedure was performed using the combined technique of blue dye and radioactive isotope. From 2004 to June 2006, Lymphazurin blue (LB) was used. From July 2006 to 2008, Methylene blue (MB) was used. Axillary dissection was performed if the sentinel node procedure revealed positive lymph nodes or failed.Results: Fifty patients underwent the sentinel node procedure with LB and 110 underwent the procedure with MB. The patients were of similar age and stage of presentation. More patients in the MB group were Hispanic and underwent preoperative chemotherapy. The sentinel node identification rate was 100% in the LB group and 99% in the MB group (P = 1.0). The mean numbers of sentinel lymph nodes were similar (LB 2.2 vs. MB 2.7). In the LB group 34% of patients were lymph node positive compared to 40% in the MB group.There were no allergic reactions in either group. The infection rate in the breast was similar in both groups LB (2%) and MB (1.8%). Previous studies have reported skin manifestations of necrosis, ulceration, tattooing, erythema, rash, or telangiectasia/vascular change at the site of injection with methylene blue. These findings were not seen in any of the patients in this study. In ten of the 110 patients (9%) who underwent the procedure with MB, however, a local inflammatory reaction occurred which resulted in a palpable mass at the site of injection. No injection site reactions were noted in LB group. In the MB group, the masses were clearly more prominent than the surrounding breast tissue and identified either at the one week postoperative check (6) or at the first 6-month followup (4). Ultrasound of the injection sites did reveal a hypoechoic mass in one patient. Biopsies were performed on the first four patients, but revealed only inflammation and non-atypical hyperplasia. Nearly all of the masses resolved by one year, however, one resolved after 18 months.Conclusion: Methylene blue is a reasonable alternative to lymphazurin blue in the sentinel node procedure for breast cancer. Awareness of injection site reactions to MB are important, as a new dominant mass is always reason for concern in breast cancer patients. Palpable mass at the site of MB injection can occur but typically resolve over a one year period. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3115.

SPIO Enhanced MR Imaging for the Detection of Metastases in Sentinel Nodes Localized by CT Lymphography in Patients with Breast Cancer.

Abstract Background: Ultrasonography, magnetic resonance (MR) imaging, and computed tomography (CT) may detect nodal metastases in patients with breast cancer, but there is not sufficient accuracy with the conventional methods. Recently, superparamagnetic nanoparticles-enhanced MR imaging has been reported to be a promising improvement for diagnostic imaging of lymph node metastases from various tumors. Moreover, sentinel nodes have been reported to be well-identified using CT lymphography in patients with breast cancer. This study evaluated MR imaging with superparamagnetic iron oxide (SPIO) enhancement for the detection of metastases in sentinel nodes localized by CT lymphography in patients with breast cancer, with histopathologic findings as the reference standard.Methods: This study included 102 patients with breast cancer with clinically negative nodes. Each contrast agent was injected intradermally into the skin overlying the breast tumor and in the subareolar region. Sentinel nodes were identified by CT lymphography, and SPIO-enhanced MR imaging of the axilla was performed to detect metastases in the sentinel nodes. A node was considered non-metastatic if it showed a homogenous low signal intensity and metastatic if the entire node or a focal area did not show a low signal intensity on MR imaging. Sentinel node biopsy was performed using a combination of dye and radiocolloid. Imaging results were correlated with histopathologic findings.Results: The mean number of sentinel nodes identified by CT lymphography was 1.1 (range 1–3). Twenty-one of 25 patients with positive sentinel nodes definitively diagnosed by pathology demonstrated metastases on SPIO-enhanced MR imaging. Seventy of 77 patients with negative sentinel nodes definitively diagnosed by pathology were non-metastatic on imaging studies. The sensitivity, specificity, and overall accuracy of MR imaging for the diagnosis of sentinel node metastases were 84%, 91%, and 89%, respectively. In four of 10 patients with micrometastases, the metastases were not detected, but all 15 patients with macrometastases were successfully demonstrated. There were no adverse events associated with either CT or MR imaging.Conclusions: SPIO-enhanced MR imaging is a useful method of detecting metastases in sentinel nodes localized by CT lymphography in patients with breast cancer. Patients with clinically negative nodes may be spared sentinel node biopsy when the sentinel node is diagnosed as disease-free using SPIO-enhanced MR imaging. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1010.