Patients Underwent Sentinel Lymph Node Mapping Research Articles

The fluorescence imaging for laparoscopic and laparotomic endometrial sentinel lymph node biopsy (FILLES) trial: Siriraj gynecologic sentinel node of endometrial cancer (SiGN-En) study.

The objective of this study is to establish the detection rate of sentinel lymph node (SLN) biopsies and to determine the sensitivity and false-negative rate of SLN biopsies compared with those of systematic pelvic and para-aortic lymphadenectomies in endometrial cancer. This prospective cohort study enrolled patients with endometrial cancer who were scheduled for surgical staging. Patients with a history of chemotherapy or radiotherapy, an abnormal liver function test, or an allergy to indocyanine green (ICG) were excluded. All patients underwent surgical staging with an ICG injection at the cervix. SLNs were identified by a near-infrared fluorescent camera. All SLNs were sent to a pathologist for ultrastaging. From November 2019 to June 2023, 142 patients underwent SLN mapping and surgical staging. SLNs were not detected bilaterally in 8 patients. The detection rate of the SLN biopsies in this study was 91.2%. Thus, the accuracy of the SLN biopsies was 97.6%. The sensitivity for finding metastatic SLNs was 84.2%, with a negative predictive value of 97.22%. A SLN biopsy in endometrial cancer has a high detection rate and high accuracy. However, surgical expertise and a learning curve are required.

Sentinel Lymph Node Mapping in Presumed Low- and Intermediate-Risk Endometrial Cancer Management (SLIM): A Multicenter, Prospective Cohort Study in The Netherlands.

The aim was to investigate the incidence of sentinel lymph node (SLN) metastases and the contribution of SLN mapping in presumed low- and intermediate-risk endometrial cancer (EC). A multicenter, prospective cohort study in presumed low- and intermediate-risk EC patients was performed. Patients underwent SLN mapping using cervical injections of indocyanine green and a minimally invasive hysterectomy with bilateral salpingo-oophorectomy. The primary outcome was the incidence of SLN metastases, leading to adjusted adjuvant treatment. Secondary outcomes were the SLN detection rate and the occurrence of complications. Descriptive statistics and univariate general linear model analyses were used. A total of 152 patients were enrolled, with overall and bilateral SLN detection rates of 91% and 61%, respectively. At final histology, 78.9% of patients (n = 120) had truly low- and intermediate-risk EC. Macro- and micro-metastases were present in 11.2% (n = 17/152), and three patients had isolated tumor cells (2.0%). Nine patients (5.9%) had addition of adjuvant radiotherapy based on SLN metastases only. In 2.0% of patients with high-risk disease, adjuvant therapy was more limited due to negative SLNs. This study emphasizes the importance of SLN mapping in presumed early-stage, grade 1 and 2 EC, leading to individualized adjuvant management, resulting in less undertreatment and overtreatment.

Sentinel Lymph Node Mapping in High-Grade Endometrial Cancer.

Sentinel lymph node (SLN) mapping is becoming an acceptable alternative to full lymphadenectomy for evaluating lymphatic spread in clinical stage I endometrial cancer (EC). While the assessment of pelvic and para-aortic lymph nodes is part of the surgical staging of EC, there is a long-standing debate over the therapeutic value of full lymphadenectomy in this setting. Although lymphadenectomy offers critical information on lymphatic spread and prognosis, most patients will not derive oncologic benefit from this procedure as the majority of patients do not have lymph node involvement. SLN mapping offers prognostic information while simultaneously avoiding the morbidity associated with an extensive and often unnecessary lymphadenectomy. A key factor in the decision making when planning for EC surgery is the histologic subtype. Since the risk of lymphatic spread is less than 5% in low-grade EC, these patients might not benefit from lymph node assessment. Nonetheless, in high-grade EC, the risk for lymph node metastases is much higher (20–30%); therefore, it is crucial to determine the spread of disease both for determining prognosis and for tailoring the appropriate adjuvant treatment. Studies on the accuracy of SLN mapping in high-grade EC have shown a detection rate of over 90%. The available evidence supports adopting the SLN approach as an accurate method for surgical staging. However, there is a paucity of prospective data on the long-term oncologic outcome for patients undergoing SLN mapping in high-grade EC, and more trials are warranted to answer this question.

Efficacy of sentinel lymph node mapping in endometrial cancer with low‐ or high‐intermediate risk

This study was aimed to evaluate the efficacy of sentinel lymph node (SLN) mapping using indocyanine green (ICG) in Chinese women with endometrial cancer (EC). Consecutive EC patients undergoing SLN mapping at Obstetrics and Gynecology Hospital of Fudan University were retrospectively reviewed. Overall and bilateral SLN detection rates and SLN locations were presented. Sensitivity, negative predictive value (NPV), and agreement rate were calculated and were compared between patients with low-intermediate (LIR) or high-intermediate risk (HIR). There were 454 patients screened, with SLN mapping with ICG performed in 428 patients and systematic lymphadenectomy performed in 159 patients. Overall and bilateral SLN detection rates were 96.50% and 82.71%, respectively. The sensitivity of SLN mapping was 80.00%, and the NPV was 97.76%. SLNs were most commonly located in obturator and external iliac regions. Efficacy of SLN mapping was higher in LIR patients than in HIR patients, with sensitivities of 100.00% and 75.00% (p > 0.05), NPVs of 100.00% and 90.00% (p = 0.002), and agreement rates of 100.00% and 92.31% (p = 0.007), respectively. SLN mapping with ICG had acceptable diagnostic efficacy in Chinese women with EC, but may cause more missed diagnoses in patients with HIR due to relatively low NPV and agreement rate.

Ultrasound guided tattooing of axillary lymph nodes in breast cancer patients prior to neoadjuvant therapy, and identification of tattooed nodes at the time of surgery

BackgroundBreast cancer patients with lymph node (LN) metastases at diagnosis often undergo neoadjuvant therapy (NAT). Identification of a LN which regressed after NAT remains a challenge. ObjectiveTo evaluate marking of involved nodes by tattooing with carbon suspension, and identifying these nodes during surgery. MethodsA small amount (0.2–0.5 ml) of carbon suspension was injected into one or two axillary LNs under ultrasound guidance at the time of LN biopsy or before or shortly after starting NAT for LN positive breast cancer. During surgery an attempt was made to identify and remove the tattooed LN as a separate specimen. All patients underwent sentinel LN mapping and biopsy and/or axillary LN dissection as mandated by their clinical status. ResultsSixty three patients underwent tattooing of axillary LNs with no complications or adverse events. At surgery a tattooed node was identified in 60 patients (95%; 95% CI 87, 98). Of 56 patients who underwent sentinel mapping with Tc99, in 51 (91%; 95% CI 81, 96) at least one radioactive LN was identified. Of 50 patients in whom both radioactivity and tattoo were identified in axillary LNs, in 40 (80%; 95% CI 67, 89) LNs were radioactive and tattooed, however in 10 patients (20%; 95% CI 11, 33), the tattooed LN was not radioactive. ConclusionsTattooing of axillary LNs is safe and easily performed. Tattooing was helpful in identifying the marked LN in the majority of cases. This technique helps to ensure that metastatic LNs are identified and removed at surgery after NAT.

Risk factors for failure of sentinel lymph node mapping using indocyanine green/near-infrared fluorescent imaging in endometrial cancer.

Side-specific systematic lymphadenectomy is suggested if sentinel lymph node (SLN) mapping failed in early stages endometrial cancer. This study aimed to evaluate the risk factors associated with failed mapping which may lead to modify SLN mapping technique, increase the success of SLN mapping and reduce the necessity of systematic lymphadenectomy. Patients with early stage endometrial cancer were included in this study. All patients underwent SLN mapping with indocyanine green/near-infrared compatible surgical platforms. Indocyanine green was injected intracervical. "Bilateral mapping" and "failed bilateral SLN mapping (unilateral or bilateral failed mapping)" groups were compared for demographic, clinical, surgical, and pathological features. 101 cases were analyzed. The overall, unilateral, and bilateral SLN detection rates were 94.1%, 19.8%, and 74.3%, respectively. The failed (unilateral or no mapping) bilateral detection rate was 25.7%. Failed bilateral mapping rates were higher in patients with longer cervical and uterine longitudinal lengths, deep myometrial invasion and larger tumor size without statistical significance. Body mass index and operation type were not related with failed mapping. Increasing number of operations or injection of larger volume of indocyanine green (4mL vs. 2mL) did not improve mapping rate significantly. Cervical indocyanine green injection may overcome the negative effect of obesity on bilateral mapping. Although there was a negative correlation trend between the longitudinal cervical and uterine lengths and bilateral mapping, this possible relation needs to be confirmed in further studies.

Green versus blue: Randomized controlled trial comparing indocyanine green with methylene blue for sentinel lymph node detection in endometrial cancer

ObjectiveTo ascertain the increase in detection rate of sentinel lymph node (SLN) associated with the use of indocyanine green (ICG) in comparison with methylene blue dye in women with endometrial cancer. MethodsFor this randomized controlled trial, all patients underwent SLN mapping after injection of blue dye on one side of the cervix and ICG on the other side. Randomization was for the side (right vs. left) on which ICG was used so that each patient's contralateral hemipelvis (HP) served as a control to her ipsilateral HP. We performed a two-tailed, normal-approximate McNemar test for paired-matched data. The primary endpoint was the difference in SLN detection rate for each HP according to the dye used. ResultsThis trial included 132 patients, and 46 patients underwent robotic-assisted surgery while 86 had standard laparoscopic surgery. Successful detection of SLN was 90.9% using ICG and 64.4% using blue dye (p < 0.0001). There were no differences in the duration of the SLN procedure (median 10 min per HP) and number of SLN per HP (mean 1.2) according to the dye used. The SLN detection rates for either dye were very similar whether the surgical approach was robotic (mean BMI 45) or laparoscopic (mean BMI 29). Crossover of dye to the contralateral HP was present in 3% of cases. ConclusionThe use of ICG instead of blue dye results in a 26.5% (95% CI 17.4%–35.6%) increase of SLN detection rates per HP in women with endometrial cancer.

Risk of empty lymph node packets in sentinel lymph node mapping for endometrial cancer using indocyanine green.

To determine whether the rate of sentinel lymph node (SLN) dissections that do not yield a lymph node on pathological analysis ('empty packet dissection') changes with increasing surgeon experience in the setting of patients undergoing minimally invasive hysterectomy and SLN mapping using indocyanine green dye for endometrial cancer. All patients undergoing SLN mapping using indocyanine green dye at the time of minimally invasive hysterectomy for endometrial cancer or complex atypical hyperplasia were identified between January 2013 and September 2017 at our institution. All surgeons had prior experience performing SLN mapping for endometrial cancer using other methods. The rate of empty packet dissections and SLN counts were evaluated using a logistic regression model analysis. In total, 236 patients undergoing SLN mapping for either endometrial cancer (85%) or complex atypical hyperplasia (15%) were identified from a prospectively maintained database. When examining all six surgeons together, the percentage of empty packet dissections decreased with increasing number of procedures performed. Each additional procedure was associated with a 3.6% reduction in the odds of an empty packet SLN dissection. After adjusting for individual surgeons, each additional procedure was associated with a 4.9% reduction in the odds of an empty packet. The expected odds of an empty packet after 10 additional procedures decreased by 40.1% (95% CI 12.4% to 58.6%). The addition of two covariates (age and body mass index) did not contribute significantly to the model (likelihood ratio test: X2=2.75, p=0.25). The rate of empty packets appeared to stabilize after approximately 30 procedures. The number of SLNs removed did not change with increasing surgeon experience. The rate of empty packet SLN dissections using indocyanine green dye decreases with increasing number of procedures. This stabilizes after 30 procedures, suggesting completion of a learning curve.

Indocyanine Green versus Radiotracer with or without Blue Dye for Sentinel Lymph Node Mapping in Stage >IB1 Cervical Cancer (>2 cm)

Study ObjectiveTo compare sentinel lymph node (SLN) mapping in women with cervical cancer stage >IB1 (tumor size >2 cm) using indocyanine green (ICG) versus the standard technique using radioisotope technetium 99m radiocolloid (Tc99m) radiotracer with or without blue dye. DesignEuropean multicenter, retrospective observational study (Canadian Task Force classification II-2). SettingFour academic medical centers. PatientsNinety-five women with stage IB1 cervical cancer (>2 cm) who underwent SLN mapping with Tc99m with or without blue dye or ICG and radical hysterectomy. InterventionThe detection rate and bilateral mapping rate were compared between ICG and standard Tc99m radiotracer with or without blue dye. Lymphadenectomy was performed, and the false-negative rate was assessed. Measurements and Main ResultsForty-seven patients underwent SLN mapping with Tc99m with or without blue dye, and 48 did so with ICG. All patients underwent radical hysterectomy with or without bilateral salpingo-oophorectomy between 2008 and 2016. The overall detection rate of SLN mapping was 91.5% for Tc99m with or without blue dye and 100% for ICG. A 91.7% rate of bilateral migration was achieved for ICG, significantly higher than the 66% obtained with Tc99m with or without blue dye (p = .025). Nine of the 23 SLN-positive patients (39.1%) were diagnosed exclusively as a result of the ultrastaging used to identify micrometastases or isolated tumor cells only. ConclusionsIn advanced cervical cancer (stage IB1 >2 cm), the detection rate and bilateral migration rate on real-time fluorescent SLN mapping were higher with ICG than with Tc99m radiotracer with or without blue dye. SLN mapping and ultrastaging can provide additional information for nodal staging in advanced cervical cancer. In this setting, ICG is a promising tool for mapping, appearing less affected by higher disease stage compared with traditional methods.

Sentinel lymph node mapping for early-stage cervical cancer: A single institution's experience

Objectives: Lymph node assessment remains a key part of surgical evaluation for patients with early-stage cervical cancer, and provides important prognostic information to determine appropriate adjuvant therapy. We aim to compare our experience with sentinel lymph node (SLN) mapping in patients with early-stage cervical cancer with a historical cohort of patients at our institution. Methods: We searched an institutional database for patients with cervical cancer between 1982 and 2014. Pertinent clinical and pathologic data were abstracted from the medical records. A historical cohort included patients from 1982 to 2009 who underwent selective lymph node (LN) sampling. An SLN mapping algorithm was performed according to institutional protocol in a cohort of patients from 2005 to 2014 (SLN cohort). Isolated tumor cells, micrometastases, and macrometastases were considered positive. Only patients with stage IB1 or IB2 squamous cell carcinoma or adenocarcinoma of the cervix were included. Appropriate statistical tests were performed. Results: We identified 531 patients with cervical cancer who underwent surgical evaluation at our institution: 123 (23.2%) patients in the SLN cohort and 408 (76.8%) in the historical cohort. Median of the 2 groups was similar (SLN: median 36.5 years, range 20–77 years; historical cohort: median 40 years, range 20–92 years; P = .052). Most patients had stage IB1 disease (91.1% in the SLN and 90.4% in the historical cohort). More patients in the historical cohort had squamous cell carcinoma (43 [35%] in the SLN vs 208 (51%) in the historical cohort, P = .002). Patients received adjuvant radiation at a similar rate in both groups (28.5% in the SLN vs 27.2% in the historical cohort, P = .05). Fewer LNs were removed (19 [range, 2–70] vs 27 [range, 1–80], P < .0001) and more positive LNs were detected in the SLN cohort (23 [18.7%] vs 51 [12.5%], P = .03]. Median follow-up was similar between the 2 groups (51.6 months [range, 0.5–109] in the SLN vs 56.5 months [range, 1.0–338.8], P = .22 in the historical cohort). Median recurrence-free (RFS), disease-specific (DSS), and overall survival (OS) was not reached in either group. Five-year RFS (100% vs 93.1% ± 1.4%, P = .006), DSS (97.7% ± 1.6% vs 91.3% ± 1.6%, P = .047), and OS (95.1% ± 2.2% vs 87.2% ± 1.8%, P = .027) were greater in the SLN cohort. Conclusions: Patients undergoing SLN mapping have fewer total LNs removed but a higher detection rate of positive LNs compared with a historical cohort. In this single institution comparison, SLN mapping did not compromise the detection of positive LNs or outcome of patients with squamous cell or adenocarcinoma of the cervix.

Laparoscopic Indocyanine Green Sentinel Lymph Node Mapping in Endometrial Cancer.

BackgroundIn endometrial cancer (EMCA), indocyanine green (ICG) sentinel lymph node (SLN) mapping has been reported, mainly in conjunction with robotic surgery.ObjectiveWe aimed to evaluate detection rates, sensitivity, and false negative (FN) rate of laparoscopic ICG SLN mapping in EMCA, and to evaluate differences in surgical outcomes between patients subjected to SLN biopsy only versus lymphadenectomy.MethodsA retrospective analysis of EMCA patients undergoing ICG SLN mapping ± pelvic (PLND) and/or para-aortic lymphadenectomy (PALND) was performed. Detection rates were calculated for the entire cohort. Sensitivity and FN rates were calculated for patients undergoing lymphadenectomy after SLN mapping, and surgical outcome was compared among patients undergoing SLN mapping only versus lymphadenectomy.ResultsOf 75 patients, 33 underwent SLN mapping and 42 underwent SLN mapping followed by PLND/PALND. Overall and bilateral detection rates were 96 % (72/75) and 88 % (66/75), respectively, and the median number of removed SLNs, pelvic non-SLNs (NSLN) and para-aortic NSLNs was 3, 27, and 19, respectively. With a FN rate of 8.3 %, only one patient had bilateral FN SLNs and a metastatic para-aortal NSLN. Estimated blood loss (EBL) and operative (OR) time were significantly lower in patients undergoing SLN mapping only. No differences in complication rates between patients undergoing SLN mapping only and patients undergoing lymphadenectomy were recorded.ConclusionsLaparoscopic ICG SLN mapping has excellent overall and bilateral detection rates and a low FN rate. Compared with lymphadenectomy, SLN biopsy is associated with significantly lower EBL and shorter OR time.

子宮頸癌手術におけるインドシアニングリーンを用いた蛍光色素による腹腔鏡下センチネルリンパ節同定法

Objective: Radical hysterectomy with pelvic lymphadenectomy is standard therapy for cervical cancer. The standard surgical lymph node assessment is a systematic lymphadenectomy, but the procedure is associated with lymphedema and lymphocysts. A sentinel lymph node (SLN) is the first node draining the lymphatic flow from a primary tumor. If the SLN is negative for metastasis, nodes after the SLN are also considered to be negative. We report our experience using a new laparoscopic fluorescence imaging system with indocyanine green (ICG) for SLN detection with cervical cancer.Methods: Participants included 12 patients treated from April 2014 to April 2015. Median age was 41.8 years (range, 27-56years) and median body mass index was 20.2 kg/m2 (range, 15-31 years). Patients underwent SLN mapping by intracervical injection of ICG at 3 and 9 o'clock positions. Following SLN mapping, radical hysterectomy and pelvic lymphadenectomy was performed. Result: Median SLN count was 2.8 (range, 1-7). The overall and bilateral detection rate was 100% (12/12) and 83% (10/12), respectively. Positive SLNs were identified in 2 of 12 patients (16%). SLNs were identifided in the external iliac, internal iliac, obturator and common iliac regions and sensitivity, specificity and NPV were all 100%. Conclusions: Fluorescence imaging using ICG is a feasible and safe method for SLN detection. In the future, this technique may represent a useful treatment for patients with early cervical cancer.

Clinical application of sentinel lymph node mapping in colon cancer: in vivo vs. ex vivo techniques.

PurposeClinical usefulness of sentinel lymph node (SLN) mapping in colorectal cancer remains controversial. The aim of this study is to evaluate the accuracy of the SLN mapping technique using serial sectioning, and to compare the results between ex vivo and in vivo techniques.MethodsFrom February 2011 to October 2012, 34 colon cancer patients underwent SLN mapping during surgical resection. Eleven patients were analyzed with the in vivo method, and 23 patients with the ex vivo method. Patient characteristics and results of SLN mapping were evaluated.Results The SLN mapping was performed in 34 patients. Mean age was 67.3 years (range, 44-81 years). Primary tumors were located in the following sites: 13 in the right colon (38.2%) and 21 in the left colon (61.8%). SLN mapping was performed successfully in 88.2% of the patients. There was no significant difference in the identification rate between the two methods (90.9% vs. 87.0%, P = 1.000). Both the mapping methods showed a low sensitivity and high rate of skip metastasis.ConclusionThis study showed that SLN evaluation using serial sectioning could not predict the nodal status with clinically acceptable accuracy despite the high detection rate.

Accuracy of sentinel lymph node detection following intra-operative cervical injection for endometrial cancer: A prospective study

ObjectiveThe objective of this study is to evaluate the detection rate and diagnostic accuracy of sentinel lymph node (SLN) mapping using intra-operative cervical injection of filtered 99mTc-sulfur colloid (99mTc-SC) and patent blue in patients with endometrial cancer. MethodsProspective evaluation of the first 100 endometrial cancer patients undergoing SLN mapping using cervical injection of patent blue combined with filtered 99mTc-SC in the operating room was done. Patients underwent robotic-assisted lymphatic mapping with frozen section, hysterectomy, BSO, and completion bilateral lymphadenectomy (including para-aortic nodes in grade 2 and 3 tumors). ResultsAt least one SLN was detected in 92% of patients; in 66 of these (72%) bilateral SLN were detected, and in 15 cases the SLN was in the para-aortic area. Eleven percent of all patients had lymph node metastases, and 4 of which had pre-operative grade 1 tumor. The SLN was the only positive node in 44% of the cases with positive nodes. Sensitivity was 89% with 1 false negative result, yielding a negative predictive value of 99% (95% CI 93–100). Specificity was 100% (95% CI 94–100), and positive predictive value was 100% (95% CI 60–100). No complications or anaphylactic reactions were noted. ConclusionsIntra-operative SLN biopsy, using cervical injection of patent blue and filtered 99mTc-SC in endometrial cancer patients is feasible and yields adequate detection rates.

Does Blue Dye Contribute to Success of Sentinel Node Mapping for Breast Cancer?

We sought to evaluate the utilization of blue dye in addition to radioisotope and its relative contribution to sentinel lymph node (SLN) mapping at a high-volume institution. Using a prospectively maintained database, 3,402 breast cancer patients undergoing SLN mapping between 2002 and 2006 were identified. Trends in utilization of blue dye and results of SLN mapping were assessed through retrospective review. Statistical analysis was performed with Student t test and chi-square analysis. 2,049 (60.2%) patients underwent mapping with dual technique, and 1,353 (39.8%) with radioisotope only. Blue dye use decreased gradually over time (69.8% in 2002 to 48.3% in 2006, p<0.0001). Blue dye was used significantly more frequently in patients with lower axillary counts, higher body mass index (BMI), African-American race, and higher T stage, and in patients not undergoing skin-sparing mastectomy. There was no difference in SLN identification rates between patients who had dual technique versus radiocolloid alone (both 98.4%). Four (0.8%) of 496 patients who had dual mapping and a positive SLN had a blue but not hot node as the only involved SLN. None of these four had significant counts detected in the axilla intraoperatively. Nine (0.4%) of 2,049 patients who had dual mapping had allergic reactions attributed to blue dye. Blue dye use has decreased with increasing institutional experience with SLN mapping. In patients with adequate radioactive counts in the axilla, blue dye is unlikely to improve the success of sentinel node mapping.

Standard versus pH-adjusted and lidocaine supplemented radiocolloid for patients undergoing sentinel-lymph-node mapping and biopsy for early breast cancer (PASSION-P trial): a double-blind, randomised controlled trial

Sentinel-lymph-node (SLN) mapping and biopsy maintains staging accuracy in early breast cancer and identifies patients for selective lymphadenectomy. SLN mapping requires injection of technetium-99m-sulfur colloid-an effective but sometimes painful method, for which better pain-management strategies are needed. In this randomised, double-blind trial, we compared degree of pain between standard radiocolloid injection and pH-adjusted and lidocaine-supplemented formulations for patients undergoing SLN mapping for breast cancer. Between Jan 13, 2006, and April 30, 2009, 140 patients with early breast cancer were randomly assigned in a 1:1:1:1 fashion to receive the standard topical 4% lidocaine cream and injection of [(99m)Tc]Tc-sulfur colloid (n=35), or to one of three other study groups: topical placebo cream and injection of Tc-sulfur colloid containing either sodium bicarbonate (n=35), 1% lidocaine (n=35), or sodium bicarbonate and 1% lidocaine (n=35). The randomisation sequence was computer generated, and all patients and investigators were masked to treatment allocation. The primary endpoint was patient-reported breast pain immediately after radioisotope injection, using the Wong-Baker FACES pain rating scale and McGill pain questionnaire, analysed in the per-protocol population. This study is registered with ClinicalTrials.gov, number NCT00940199. 19 of the 140 patients enrolled were excluded from analysis: nine declined study participation or sought care elsewhere, nine did not undergo SLN mapping because of disease extent or a technical problem, and one had unreliable data. There were no adverse events. Mean pain scores on the Wong-Baker scale (0-10) were: 6.0 (SD 2.6) for those who received standard of practice, 4.7 (3.0) for those who received radiocolloid plus bicarbonate, 1.6 (1.4) for those who received radiocolloid plus 1% lidocaine, and 1.6 (1.3) for those who received radiocolloid plus bicarbonate and 1% lidocaine (p<0.0001). Mean pain rating, according to the McGill questionnaire (0-78), was 17.5 (SD 11.8) for the standard-of-care group, 15.4 (14.4) for the sodium bicarbonate group, 4.6 (4.5) for the 1% lidocaine group, and 3.4 (5.1) for the sodium bicarbonate plus 1% lidocaine group (p<0.0001). SLN identification rates for each group were: 96% for the standard of care, 97% for sodium bicarbonate, 90% for 1% lidocaine, and 90% for sodium bicarbonate plus 1% lidocaine group (p=0.56). For centres that use radiocolloid injections for SLN mapping in patients with early breast cancer, the addition of 1% lidocaine to the radioisotope solution can improve patient comfort, without compromising SLN identification. US Military Cancer Institute, the Clinical Breast Care Project, and the Army Regional Anesthesia and Pain Management Initiative.

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

The pathologic status of the sentinel lymph node (SLN) is a powerful prognostic factor for patients with intermediate thickness melanoma. We hypothesize that a high number of SLNs identified may be associated with poor outcome. We evaluated the impact of number of SLNs removed in patients undergoing SLN mapping for cutaneous melanoma at our institution between 1996 and 2006. We excluded patients with multiple primary or synchronous primary lesions (n = 144) to eliminate any chance of erroneous association between a SLN and the wrong primary melanoma. We also excluded patients with in-transit disease (n = 37) and one patient in whom no SLN was identified, leaving 970 patients. We evaluated factors associated with the number of SLNs removed by multivariate Poisson regression and determined whether an increased number of SLNs was associated with poorer overall (OS) or recurrence-free survival (RFS). Clinical factors independently associated with increased number of SLNs were younger age and head and neck primary site. Pathologic factors associated with an increased number of SLNs were lymphovascular invasion and increased Breslow thickness. There was no association between number of SLNs removed and OS or RFS in all patients or in patients with negative SLNs (n = 803). The number of SLNs identified during staging of the regional nodal basin for primary melanoma is not an independent prognostic factor. Drainage to multiple SLNs is more common in the setting of an increased Breslow depth and lymphovascular invasion suggesting that tumors with these adverse features may enhance peritumoral lymphangiogenesis.

Sentinel Node Mapping for Breast Cancer: The Operative Experience of a Breast Surgeon in a Rural Community

Sentinel lymph node biopsy has become an accepted procedure for staging the axilla in early stage breast cancer. Our objectives were to review our practice of sentinel lymph node (SLN) mapping in breast cancer, to determine the impact of frozen section (FS) analysis of the SLN on patient management, and to compare our results to national data. We retrospectively reviewed the medical records of our patients with breast cancer who underwent SLN mapping with or without axillary lymph node dissection (ALND) between 1999 and 2006. During this period, 478 patients were treated for breast cancer, with 227 patients undergoing SLN mapping. The SLN was identified in 201 patients, with a positive SLN found in 52 patients (25.9%). There was a discrepancy between the intraoperative analysis (FS/touch prep) and final pathology in 20 patients (11.3%). Nineteen of those patients had a negative FS with positive final pathology. Six of these patients underwent completion ALND. One patient had a false-positive FS with a negative ALND. No axillary recurrences were observed. Eight patients (3.5%) developed postoperative complications. Our practice has been to use intraoperative evaluation of the SLN to reduce the number of patients requiring a secondary ALND. In our study, six patients returned to the operating room for a completion ALND. Our complication rate and axillary recurrence rates were similar to national data.

Tumor-Infiltrating Lymphocytes Predict Sentinel Lymph Node Positivity in Patients With Cutaneous Melanoma

Tumor-infiltrating lymphocytes (TILs) are considered a manifestation of the host immune response to tumor, but the influence of TILs on outcome remains controversial. Studies evaluating the prognostic significance of TILs were published before routine examination of draining lymph nodes by sentinel lymph node (SLN) biopsy, the most important predictor of survival in patients with melanoma. The prognostic implications of TILs were re-evaluated in a large group of patients undergoing SLN biopsy at our institution. All patients who underwent SLN mapping for primary cutaneous melanoma between January 1996 and July 2005 were evaluated. Univariate and multivariate analyses were performed to assess factors that predict SLN positivity and survival. Factors analyzed included Breslow thickness, ulceration, anatomic site, sex, Clark level, age, mitotic rate, and the presence (brisk or nonbrisk) or absence of TIL. Eight hundred eighty-seven patients underwent SLN mapping, and a SLN was identified in 875 patients (98.8%). The SLN was positive for tumor in 156 patients (17.6%). Multivariate analysis revealed that only Breslow thickness (P < .0001), ulceration (P = .0004), male sex (P = .03), and absent TILs (P = .0003) were independently predictive of the presence of SLN metastases. In melanomas with a brisk TIL infiltrate, the probability of a positive SLN was 3.9% as compared with 26.2% for melanomas in which TILs were absent. TILs were not an independent predictive factor for survival. The absence of TILs, together with increasing Breslow thickness, presence of ulceration and male sex, predicts SLN metastasis in patients undergoing SLN biopsy for primary cutaneous melanoma.

Use of Sentinel Node Mapping for Cancer of the Colon: ‘To Map or Not to Map’

Sentinel lymph node (SLN) mapping has become a cornerstone of oncologic surgery because it is a proven method for identifying nodal disease in melanoma and breast cancer. In addition, it can ameliorate the surgical morbidity secondary to lymphadenectomy. However, experience with SLN mapping for carcinoma of the colon and other visceral malignancies is limited. This study represents an update to our initial pilot experience with SLN mapping for carcinoma of the colon. Consenting patients over the age of 18 diagnosed with adenocarcinoma of the colon were included in this study. At the time of operation, 1 to 2 mL of isosulfan blue was injected with a 25-gauge needle into the subserosa at 4 sites around the edge of the palpable tumor. The SLN was identified visually and excised followed by a standard lymphadenectomy and surgical resection. SLNs were evaluated by standard hematoxylin and eosin (H&E) evaluation as well as immunohistochemical (IHC) techniques for carcinoembryonic antigen and cytokeratin if the H&E was negative. Sixty-nine patients underwent SLN mapping. A SLN was identified in 93 per cent (64 of 69) of patients. Nodal metastases were identified in 38 per cent (26 of 69) of patients overall. In 5 patients, the only positive node identified was the SLN, 2 of which were positive by IHC criteria alone. Therefore, 3 per cent (2 of 69) of patients were upstaged by SLN mapping. This technique was 100 per cent specific while being 46 per cent sensitive. Fourteen patients had false-negative SLNs. Metastasis to regional lymph nodes remains the key prognostic factor for colon cancer. SLN mapping is feasible for colon cancer and can identify a subset of patients who could benefit from adjuvant chemotherapy. Although SLN mapping did not alter the surgical management of colon cancer, it does make possible a more focused and cost-effective pathologic evaluation of nodal disease. We do not suggest routine utilization of SLN mapping for colon cancer, but we believe that the data supports proceeding with a national trial.