Periareolar Region Research Articles

Exploring methylene blue as an effective alternative to radiotracer for sentinel lymph node biopsy in early breast cancer in resource-limited settings

Background: Sentinel lymph node biopsy is the recommended approach in the evaluation of axilla during breast cancer surgery. This study evaluated the results of patients who underwent methylene blue sentinel lymph node biopsy. Methods: The study included 35 female patients with T1, T2 and T3 tumours. 5 ml of 1% methylene blue was injected into the periareolar region. The axillary sentinel lymph node was found and removed, and axillary dissection was performed. The sentinel lymph node and axillary dissection specimen were histopathologically examined, and the results were compared. Results: The sentinel lymph node was found in 33 (90%) patients. There were no complications associated with the use of methylene blue dye. Methylene blue-stained sentinel nodes were histologically negative for malignancy in 42% and positive in 58% of patients. Corresponding to sentinel nodes, the final axillary staging was negative in 60% and positive in 40% of patients. On diagnostic accuracy parameters, the sensitivity of the methylene blue method in early breast cancer (cT1-3N0M0) patients was 90.47%, and the specificity was 100%. The PPV of the technique under study was found to be 100% and NPV was 85.71%. The accuracy rate was 93%, and the false negative rate was identified as 9.5%. Conclusions: Sentinel lymph node biopsy by methylene blue is a method that can be applied with high accuracy. Methylene blue can be considered as an alternative to radio colloid dye in sentinel lymph node biopsy in a limited resource setting.

Infarcted Fibroadenoma of the Breast: Difficulties in Diagnosis

Introduction: Infarction is a very rare complication of fibroadenoma. Diagnosis of such a situation is not easy. Case Presentation: 23-year-old woman with a painful tumor of the right breast with mild erythema at the periareolar region. Breast ultrasound shows a heterogeneous lesion of 31×30 mm, in the retroareolar right breast with well-defined borders, and does not present vascular flow inside. Antibiotic treatment was administered without improvement. The breast ultrasound was repeated with no significant changes. Surgical removal of a well-encapsulated cystic lesion was performed. The patient was discharged the same day of surgery, and her postoperative evolution was correct. Histopathologic evaluation revealed an infarcted fibroadenoma. Conclusion: Breast ultrasound could be very useful in the diagnosis of infarcted fibroadenoma; treatment consists of local excision of the lesion.

Uncommon Location of Idiopathic Granulomatous Mastitis: A Case Report

Background Idiopathic granulomatous mastitis (IGM) is a rare benign disease involving breast parenchyma mostly in periareolar region. Women of childbearing with recent history of pregnancy and lactation are more at risk of IGM. The common locations of IGM are retro areolar and periareolar of the breast, however involvement of axillary region has never been reported elsewhere.
 Case presentation A 36-year-old female with history of two times pregnancy and lactation 8 months prior to presentation, referred with pain and swelling in the right axillary area. The past medical history and habitual history were negative and she did not use oral contraceptives or other medications. Local physical examination showed normal breasts with bilateral accessory breasts. A tender mass with the size of 4x6cm was palpable in the right axillary region accompanied by erythema and a few secretory fistulas without lymphadenopathy. Routine blood test came back negative and serum prolactin was normal. Ultra-sonography (US) demonstrated a soft tissue swelling, edema, and decreased echogenicity area in the right axillary region compatible with IGM. The patient started on prednisolone 50 mg per day, and the condition has not been improved for two months. To exclude other possible etiologies due to atypical location, the patient underwent a second US and core-needle biopsy which confirmed the diagnosis of axillary IGM. Prednisolone tapered off and a non-steroidal anti-inflammatory drug (NSAID) started. All the symptoms improved in a month and fully resolved in 3 months.
 Conclusion Since IGM is not fully known yet, the presentation and the location can be variable. Considering IGM as a probable diagnosis in inflammatory presentation in the axillary region in patients with accessory breasts is suggested.

Sentinel lymph node biopsy using methylene blue dye and intraoperative palpation method in node-negative early breast cancer

Background: Early breast cancer with clinical or radiological node-negative axilla is treated with breast conservation surgery where lumpectomy with axillary dissection is done. Sentinel lymph node biopsy (SLNB) is an acceptable alternative to axillary clearance and has relatively lesser morbidity. SLNB methods include radioisotope (RI)-guided, blue dye-guided, or a combination of both. However, access to RI can be limited in certain geographic locations. Objective: This study aimed to determine the effectivity of methylene blue (MB) dye-guided SLNB as an alternative to RI. Methods: In this investigation, 43 clinically nodenegative early breast cancer patients were prospectively enrolled. SLNB was performed using MB dye (1%) administered to the peritumoral or periareolar region. The histopathology reports of the harvested nodes were studied, and the results were computed using SPSS and 2×2 contingency table. Results: The sensitivity, specificity, false-negative rate (FNR), and accuracy of MB-guided SLNB in our study were 92.8%, 100%, 7.14%, and 97.7%, respectively. Conclusion: The use of MB dye along with intraoperative palpation after meticulous lymph node dissection in each level is more effective and has lower FNR than RI.

Determination of scatter radiation to the breast during lumbosacral x-ray examination using thermoluminescence dosimeter

Objective: Exposure to ionizing radiation during radiographic examination is associated with some biological effects. The study was aimed to determine the amount of scatter radiation to the breast during lumbosacral x-ray examination.
 Materials and Methods: The study was a prospective, cross-sectional study carried out among 60 women referred for Lumbosacral spine radiography from September 2019 to December 2019. Ethical approval was granted by the hospital ethical committee. A single-phase mobile X-ray unit was used to dispense the radiation while a thermoluminescent dosimeter (TLD) chip was used to measure the radiation dose. The TLD chip was attached to the peri-areolar region of the left breast and held in place by a transparent adhesive tape. The TLD was carefully enclosed in a black polythene sachet before and after the investigation to shield it from background radiation. After the investigation the TLD,s were sent to the Centre for Energy Research and Training (CERT) for reading and annealing. 
 Results: The mean age and BMI of participants were 55.32±12.35years and 29.70±7.09kg/m2 respectively. The cumulative mean (±SD) ESD to the breast was 3.87±0.87mGy. The highest scatter radiation dose was observed in the age group 60-69 years. Pearson’s correlation showed a week correlation between age and ESD.
 Conclusion: The study showed that there were scatter radiations to the breast during lumbosacral X-Ray investigations which was was lowest among the age group 50-59years. No significant difference was seen between AP and lateral positions. The cancer risk was 1 in 6,000 indicating that there might be needed to shield the breast while performing lumbosacral X-ray.

Near-infrared laparoscopy with indocyanine green for axillary sentinel lymph node biopsy in early breast cancer: preliminary experience of a single unit.

A sentinel lymph node biopsy (SLNB) is a routine procedure for axillary staging in cN0 breast cancer (BC) patients. Indocyanine green (ICG) fluorescence can detect sentinel lymph nodes with higher sensitivity than carbon nanoparticle suspension (CNS). The present study investigated the availability and benefits of a near-infrared (NIR) laparoscopy-assisted SLNB using ICG and carbon nanoparticle suspension as tracers. Forty patients with invasive BC, who had clinically negative axillary lymph nodes, participated in this observational study. ICG and CNS tracers were injected into the periareolar region simultaneously or sequentially. In the endoscopy-assisted group (n=20), the patients were given NIR laparoscopic SLNB based on ICG fluorescence and CNS staining. In the open-surgery group, the patients were given traditional SLNB using an open incision, and CNS tracers were injected into the same region as that in the endoscopy-assisted group. In the endoscopy-assisted group, lymphatic vessels and sentinel lymph nodes (SLNs) were successfully identified using ICG fluorescence imaging in most patients (19/20). The average number of SLNs removed was 2.85 (range, 1-4) in the endoscopy-assisted group, and 3.40 (range, 1-7) in the open-surgery group. There was no significant difference between the number of detected nodes (P=0.30). The patients who underwent endoscopy-assisted SLNBs had similar operating times, blood loss and hospital-stay lengths, but lower postoperative drainage volumes and higher satisfaction scores, as they did not have axillary incisions. The NIR laparoscopy-assisted ICG-guided technique is a feasible and surgeon-friendly method for SLNB with good efficacy and acceptable safety. When combined with CNS, more SLNs can be detected and dissected.

Ki67/MART1 and p63/SOX10 Dual Immunohistochemistry Allows a Correct Interpretation of the Melanocytic Component in the Diagnosis of Pigmented Pilomatricoma.

Pilomatricoma is a relatively common benign cutaneous adnexal tumor and a well-recognized entity, while its pigmented variant is far less common and less reported. Its estimated frequency ranges from 11 to 24%, according to a limited number of published case series. This article describes the case of a 42-year-old man presenting a firm subcutaneous nodule of the periareolar region. Histopathologic examination revealed a cystic lesion composed of matrical and supramatrical cells accompanied by a foreign body granulomatous cell reaction. Interestingly, a hyperpigmented area with numerous hyperplastic melanocytes and few mitoses was detectable. In order to assess the cell lineage of the mitotically active component in the hyperpigmented area, double immunohistochemistry with Ki67/Mart1 and p63/SOX10 was performed. Pigmented pilomatricoma is an underrecognized, underreported variant, and double immunohistochemistry stain is an effective tool in providing the correct interpretation of the proliferative activity in the different cellular populations.

Incidence of epidermoid cyst of the breast: An analysis on clinico-pathological and radiological correlation

Introduction: Breast diseases are the major pathological lesion occurring among Tropical females with high co-morbidities. Cystic disease of breast is a broad entity often having many differentials clinically reaching out to the Pathologists. Epidermoid cysts of breast are condition occurring in cutaneous adnexae of extremities and its occurrence in breast is a rare entity. While trauma/therapeutic surgery including trucut biopsy is the major underlying cause, it is characterized by cystic lesion in dermis especially in peri-areolar region. Though radio-imaging serves to pick up cystic lesions, it downplays in categorizing the nature of the cyst. Cytology plays a major role in diagnosing the disease, appropriate clinico-pathological correlation with radio-imaging may improvise early pick up of this condition, thereby aiding in prompt treatment. Materials and Methods: The present study was conducted for a period of 4 years with specific inclusion and exclusion criteria. All the clinical details including history of surgery, trauma, site, socio-demography, size, radio diagnosis etc, were documented in a proforma. Patients are subjected to routine cytology procedure at clinician’s request. Biopsy was done in specific indicated cases as therapeutic procedure and also for histological correlation the data are entered in tables and analysis was done aiming to frame clinico-pathological correlation with radio-imaging interpretation. Results and Observations: A total number of 10 cases were analysed in the study period. Left breast was predominantly affected and age incidence ranged between 3rd to 5th decade. While retro-areolar region was commonly involved, clinical diagnosis had many differentials. Cytology aspirates showed pultaceous to blood mixed material and corresponding Cytology showed keratinous cells with inflammation which were confirmed on histology on 7 available cases. Conclusion: Epidermoid cyst of breast is a rare condition and should be kept as one of the differential diagnosis by clinician and Pathologist while dealing with cystic breast diseases. Cytology procedure holds good in effective diagnosis of the condition and Clinico-Pathological correlation aids in improvising early diagnosis thereby alleviating patient’s stress. Keywords: Epidermoid cyst of Breast, FNAC, Histopathology, Radio-imaging.

Primary Leiomyosarcoma of the Breast Papilla: A Case Report

Background: Breast leiomyosarcoma is a rare subtype of breast sarcoma, constituting 5–10% of the cases. Less than one-third of reported cases are located in the nipple papillary region, making it an extraordinarily rare malignancy, responsible for less than 0.1% of all malignant breast tumors. As no radiological criteria allow definitive diagnosis of papillary leiomyosarcoma, histopathological and immunohistochemical examination of suspicious lesions is required. The prognosis is generally optimistic compared with those for other breast sarcomas.Case presentation: A 54-year-old previously healthy woman reported the appearance of a nodule in her right nipple in the preceding 9 months, associated with pruritus. Physical examination revealed that the lesion had a cystic consistency and measured approximately 3.0 cm. Imaging examinations showed no involvement of the adjacent breast parenchyma or axillary region and the lesion was classified as Breast Imaging-Reporting and Data System (BI-RADS) category IV. The lesion was excised, and the histopathological diagnosis was well-differentiated leiomyosarcoma of the mammary papilla, with immunohistochemical examination showing positivity for smooth-muscle tissue antigens. A staging CT examination was performed, showing no evidence of distant metastasis. After 2 years of follow-up, the patient shows no sign of tumor recurrence.Conclusion: Although rare, leiomyosarcoma must be included in differential diagnosis of breast masses, especially those involving the periareolar region. Due to its good prognosis, reporting on this type of tumor is important to guide therapeutic planning, and to identify and track possible complications of its underdiagnosis.

Primary cutaneous follicle center lymphoma of the breast: Management of an exceedingly rare malignancy.

Primary cutaneous follicle center lymphoma (PCFCL) is defined as a low-grade B-cell non- Hodgkins lymphoma, which primarily occurs and remains confined to the skin, without evidence of extracutaneous or systemic involvement at the time of diagnosis. PCFCL affecting the breast skin is an exceedingly rare entity with only two cases reported in the English literature. We present a case of PCFCL affecting the periareolar breast skin and review the relevant literature. Our patient was a 64-year-old female who presented with an erythematous plaque in the periareolar region of the left breast. The diagnosis of PCFCL was confirmed by a biopsy performed with a seven-month delay, as the tumor had been initially misdiagnosed as a benign lesion. The patient was successfully treated with local radiation therapy. PCFCL is an indolent lymphoma associated with an excellent prognosis. For localized lesions, skin-directed therapies mainly consisting of radiation therapy or complete surgical excision are curative therapeutic approaches, while systemic chemotherapy should be reserved for patients with extensive disease. This case highlights the need to consider PCFCL as an important differential diagnosis in patients presenting with non-resolving erythematous breast skin lesions. A timely biopsy should be obtained to avoid delays in the initiation of appropriate treatment.

Sentinel-Lymphnode Biopsy in primary breast cancer: 99mTc versus ICG—A prospective, randomized trial.

575 Background: Sentinel-Lymphnode Biopsy (SLNB) is the standard procedure in primary breast cancer, routinely performed with 99mTechnetium radioactive tracers. Awareness of nuclear waste, costs and time consumption lead to the desire of breast surgeons to find safe and effective alternative options for detection of sentinel lymph nodes (SLN) in breast cancer and melanoma. Indocyaningreen is a tracer which emits fluorescence with near-infrared light of 780-810 nm when injected in the peritumoral or periareolar region, enabling surgeons to detect SLN and lymphatic pathways at the breast. Methods: We performed a prospective, randomized trial with patients with primary breast cancer. Both detection methods have been applied to patients of the study cohort comparing the preparation time, time to identify, concordance of the two methods and costs. Reference method was preoperative lymphszintigraphy. Results: 55 patients have been analyzed in this first report. Preparation time was 75,8 min (range 60-120 min) for 99mTc-tracer and a standard of 20 min for ICG. Time to identify SLN at a mean of 3,8 min(range 1-15 min) for 99mTc and 3 min (range 1-8 min) for ICG. Concordance rates were 98,2 % for the 1st SLN, 93,8 % both for 2nd and 3rd SLN. After neoadjuvant chemotherapy, all SLN have been been detected by both techniques, in 3 patients additional SLN have been found by ICG. Costs have been cut down to 1/10 with the use of ICG, coming up to saving of 27 000 US-$ per each 100 SLNB procedures performed. Conclusions: We report a high concordance rate between the 2 techniques - 99mTechnetium and ICG with near-infrared - for detection of SLN in breast cancer. Preparation time is cut down to less than 30 %, and costs to less the 10 % of radioactive labelling. Clinical trial information: 18-8054-BO .

Round Block Mammaplasty One Technique for All Breast Quadrants

Scar placement has always been a bit of a concern for patients as well as surgeons; therefore, various periareolar oncoplastic techniques were introduced in an attempt to eliminate scars visibility, by limiting them to the periareolar region. Among these oncoplastic techniques, round block mammaplasty has recently been gaining more popularity. Round block mammaplasty is a level II volume displacement oncoplastic breast surgery technique involving adequate resection of the tumour while maintaining a good cosmetic outcome. Eighty-six patients who had round block mammaplasty over a period of 3 years were included in this retrospective study. The participants’ demography, breast cancer characteristics, postoperative complications and patients’ satisfaction were collected from their clinical records and their standard patient’s questionnaires. The standard patient’s questionnaire was completed by most patients as a mean of assessing patients’ outcome and satisfaction after a round block mammaplasty. Out of all 86 patients who underwent a round block mammaplasty, the average tumour size was 26 mm, and the average weight of the specimen was 52 g. Four patients (4.6%) had involved/close margins, two of which (2.3%) had re-excision in order to achieve clear margins and the other two patients (2.3%) required mastectomy. Twenty-six patients (41%) thought they had excellent results, 21 patients (33%) good results and 16 patients (26%) fair results. The round block mammaplasty technique can be used safely for management of all quadrants breast lesions with favourable cosmetic results and high degree of patient satisfaction.

Vitiligo as a Köebner phenomenon after oncoplastic breast surgery

The Köebner phenomenon is characterized by the appearance of several types of dermatological lesions after traumatic stimulation. The triggering of this phenomenon after breast surgery is uncommon and usually associated with psoriatic lesions. The aim of this study was to describe two cases of vitiligo as the initial manifestation of Köebner phenomenon after breast oncoplastic surgery. Case 1: female, 41 years old, no history of dermatological pathologies, presenting with tubular carcinoma in the right breast. Quadrantectomy and sentinel lymph node biopsy were performed, followed by reconstruction with mammoplasty. Later, the patient started on tamoxifen and underwent radiotherapy, without complications. Thirty days after treatment, the patient presented progressive depigmentation of the areola-papillary complex. Topical treatment was started with dermatological ointment tacrolimus monohydrate and, after one year, the condition was completely resolved. Case 2: 52-yearold woman with previous history of vitiligo on the face, with complete clinical response after dermatological treatment. She was diagnosed with ductal carcinoma in situ on the left breast and underwent quadrantectomy, by means of mammoplasty using the round block technique. Afterwards, she underwent radiotherapy and started tamoxifen. Four years after the surgery, she developed dyschromia in the ipsilateral periareolar region and was diagnosed with vitiligo. Local dermopigmentation was offered, but the patient opted for an expectant conduct and clinical follow-up. To our knowledge, this is the first description of Köebner phenomenon after breast oncoplastic surgery. In these cases, the therapeutic approach must be multidisciplinary and count on the assessment of multiple clinical and individual parameters.

Donut Mastopexy Lumpectomy.

Advancements in oncoplastic techniques have enhanced commitment to restore shape and, hence, has improved cosmetic outcomes. Donut mastopexy lumpectomy is one such technique and is best utilized in a setting of a malignancy not extending to the skin or the nipple-areolar complex. As a potential alternative to standard lumpectomy, it has many advantages including restriction of scar to the periareolar region, ease and rapidity of surgery, retention of nipple-areolar sensation, and the possibility of performing augmentation mammoplasty. A mini breast lift is also provided without ugly and visible scars. This report provides an insight into the technical details and utility of donut mastopexy lumpectomy (DML) in breast oncoplasty.

Autoimmune granulomatous mastitis – Case report

Introduction: Idiopathic lobular granulomatous mastitis (ILGM) is a chronic, benign, inflammatory disease which affects women with mean age of 33 years, usually with recent lactation. Defined by granulomas and microabscesses in mammary lobes, it can be suggestive of carcinoma, both clinically and radiologically. There are three hypotheses for the disease: infection, hormonal and autoimmune disorder, being the latter the most accepted one. Objective: To report the case of SFI, female, 34 years of age, Caucasian, non-lactating, without family history of breast cancer, diagnosed with autoimmune granulomatous mastitis. Method: Case report based on medical records and in agreement with the signed informed consent form. In 2017, the patient presented with trauma in the right breast, and after eight months, local lesion and mastalgia. In the physical exam, we observed one-sided mammillary retraction, periareolar hyperemia, signs of fluctuation, pain at superficial palpation and palpable lymph nodes. The ultrasound showed fluid collection of 25x6 mm, with thick content, irregular walls in the upper medial quadrant, with an area close to the skin in the periareolar region; two smaller collections measuring 4 to 6 mm in the retroareolar region; without solid nodules. After surgical drainage, the sample indicated chronic granulomatous inflammation; analysis of fungi and acid-alcohol-resistant bacilli were negative, and malignancy was not present. Then, she was started on Prednisone, 80mg/day. However, after the onset of a new inflammatory condition, a weekly 15mg dose of Methotrexate was associated. In the following month, being clinically stable, Methotrexate was suspended, and the dose of Prednisone was gradually reduced, until its suspension. She did not present with acute mastitis or abscess. The patient persisted with palpable granulomas in all quadrants, and major complications with mastalgia, which became incapacitating. A new attempt of immunosuppressive therapy was made, but had no success against mastalgia, as well as the use of Tamoxifen and Cabergoline. Results and Conclusion: Due to clinical untreatability and the patient’s wish, the choice was to perform skin-sparing mastectomy and immediate prosthetic reconstruction. Even though the ideal treatment is still uncertain, due to its unknown etiology, clinical follow-up is important, even after the surgical excision of the nodule, because of the chance of recurrence and slow resolution.

Quadruped and Dermal Bridge Flap for Nipple Reconstruction.

Background:This report describes the authors' novel preferred method of nipple reconstruction over 10 years.Methods:The procedure was used in 39 patients (unilateral 38, bilateral 1). The circle is designed as the new nipple cap. Then, 4 fan-shapes (one-quarter of the circle) are drawn so that the base portion is in contact with the circumference. These fanshapes are deepithelialized, and their linear portions are cut with full thickness of skin and elevated as dermal flaps. Then, the cross-type flap is elevated with sufficient subcutaneous fat. The two pairs of dermal flaps are sutured to each other on a diagonal line. Double-layer dermal bridge flaps sustain the base of the pocket. As a result, the cross flap becomes a birdcage-like tower. The rolled auricular cartilage is placed into the pocket.Results:In one early case, the cartilage was exposed. Early postoperatively, the other three cases underwent reoperation during other procedures because the reconstructed nipple was too large or too small. The projection of the flap was designed to be 7–15 mm (average, 9.3 mm). The average follow-up period was 25.7 ± 22.0 months. The reconstructed nipple projection was maintained at 4.4 ± 2.4 mm (maintenance rate, 48.4% ± 27.0%).Conclusions:All scars were contained within the periareolar region and thus could be completely camouflaged by tattooing. The perfusion of the skin flap is stable because of sufficient circulation from quadruped pedicle. The cartilage supported by the double-layered dermal bridge flaps contributes to nipple projection. We recommend it for patients seeking nipple reconstruction.

Near Infrared Fluorescence Imaging to Assess Breast Flap Perfusion and Prevention of Ischemia: Case Report

Introduction: Breast skin flap ischemia and necrosis is a serious consequence of breast reconstruction with reported incidence of 10% to 15%. Current clinical method of assessing breast skin flap perfusion includes combination of skin color, temperature, dermal edge bleeding, and capillary refill. Given the high incidence of ischemia and the presence of certain cohort of patient with greater risk, there is a need for an objective method of assessing the skin flap perfusion. Near infrared fluorescence imaging using indocyanine green is a new technique of assessing skin flap perfusion. We present a first reported case where breast skin flap ischemia was objectively identified intraoperatively by NIRF imaging, and this ischemia was reversed through active intra- and postoperative measures, which was objectively again identified by NIRF imaging. Case presentation: A 36-year-old female patient underwent bilateral nipple sparing mastectomies with immediate reconstruction using tissue expanders. Clinical assessment of the breast skin flap was equivocal. NIRF imaging using SPY imaging system (Novadaq Technologies Inc, Toronto, ON, Canada) showed poor perfusion in the periareolar region. As a result, it was decided to completely deflate the expander, actively warm the skin flap and encourage cutaneous perfusion through use of topical glycerin trinitrate patch. A repeat NIRF imaging 48 hours showed 10-fold increase in perfusion in the skin flap. Conclusion: NIRF imaging is a useful tool in assessing breast skin perfusion and to predict potential ischemia, which can aid in surgeon's management of patient.

Abstract PD2-03: Sentinel lymph node mapping with dual tracer combination: Fluorescent fluorescein with methylene blue compared to radio active sulphur colloid with methylene blue: A randomised comparison

Abstract Objective-Fluorescein and methylene blue (FWMB) combined tracer is non-inferior to Tc99- Sulphur colloid and methylene blue (TWMB) in identification of sentinel lymph nodes in women with operable breast cancer. Rationale-Sentinel node biopsy (SNB) is the standard procedure for axillary nodal evaluation. Most authors recommend dual tracers, a radioactive dye tagged with large particulate matter like albumin or sulphur colloid and blue dye like lymphazurin, methylene blue or patent blue for identification of sentinel lymph nodes. In Asian countries like India, the availability of radioactive pharamaceutical and gamma probe facility are sparse. Hence, we have compared a combination of fluorescein and methylene blue with technetium and methylene blue in a two arm randomized controlled trial with non-inferiority hypothesis and 1:1 allocation ratio on 81 patients with operable breast cancer. The non inferiority margin was set at 5 %.The study was conducted in All India Institute of Medical Sciences, New Delhi from June 2015 to November 2016. The study included ladies with operable breast cancer of all histological types after getting informed written consent. Novelty- This is the first randomized trial comparing fluorescein with technetium sulphur colloid in sentinel lymph node biopsy in breast cancer . In the fluorescein and methylene blue arm, one ml of 20% fluorescein diluted with 4 ml of normal saline was injected in the periareolar region, half the dye injected intradermally and half in the sub areolar plane. One ml of 1% Methylene blue dye diluted in 4 ml normal saline was also injected in similar manner. It was followed by gentle massage for 5 minutes. An incision was made on lateral axillary skin crease and fluorescent or blue lymphatics dissected to the level of sentinel lymph nodes. Fluorescent lymphatics were identified with a blue light lamp (480 nm). Sentinel lymph node(s) were excised and sent for histopathological examination. Radioactive node was picked up by gamma probe. Results- The base line patient and tumour characteristics of the two groups showed no significant difference. Since it was a non inferiority trial, we performed per protocol analysis revealing the identification of sentinel nodes = 84.6% in both arms (effect size-zero and 90% confidence interval -13.4 to +13.4.). Results of subgroup analysis before and after chemotherapy and SNB done under local and general anaesthesia has been given in tables 1 and 2. Table 1. Identification of sentinel nodes (Per protocol analysis) TWMBFWMBEffect size (ninety percent confidence interval)Total33/39(84.6)33/39(84.6)0.0(-13.4,13.4)Prechemo patients26/29(89.7)26/30(86.7) Postchemo patients7/10(70)7/9(77.8)7.8(-25.2,+40.8)Local Anaesthesia23/25(92.0)22/23(95.7)3.7(-7.7,+14.9)General Anaesthesia10/14(71.4)11/16(68.8) Table 2. Identification of sentinel nodes (Intention to treat analysis) TWMBFWMBTotal33/39(84.6)33/40(82.5)Prechemo patients26/29(89.7)26/31(83.9)Postchemo patients7/10(70)7/9(77.8)Local Anaesthesia23/25(92.0)22/24(91.7)General Anaesthesia10/14(71.4)11/16(68.8) Conclusion- Fluorescein + methylene blue offer an attractive cheap method of SNB. Citation Format: Srivasatava A, Suresh J, Ranjan P, Kumar A, Kataria K, Dhar A, Vathulru S. Sentinel lymph node mapping with dual tracer combination: Fluorescent fluorescein with methylene blue compared to radio active sulphur colloid with methylene blue: A randomised comparison [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD2-03.

Abstract P2-01-02: The predictive value of sentinel node biopsy (SNB) in early breast cancer after neo-adjuvant chemotherapy (NACT): A prospective study

Abstract Background SNB has replaced axillary lymph node dissection (ALND) in those patients (pts) with clinically node negative axilla. This has reduced the morbidity, in particular lymphedema considerable. SLN after NACT is feasible but not accurate in clinically node positive (cN1-3) pts (false negative rate around 10%). Therefore, continuous efforts have to been made in randomized prospective studies to improve the detetion rate of SNB in order to avoid the morbidity of ALND. The purpose of this study is to determine the negative predictive value of the sentinel node in breast cancer after NACT. Method A single institution prospective study regarding the negative predictive value of the sentinel node in breast cancer after NACT was conducted in the Multidisciplinary Breast Clinic of the Antwerp University Hospital from 29/03/2010 untill 12-2015 (Study number: B30020108368). Inclusion criteria for study participation were: breast cancer, age above 18 years, female, tumor stages T2-T4 N0-3 or T1N1-N3. All pts were staged by a mammography, ultrasound of the axilla, MRI of the breast, 18F-fluoro-2-deoxy-glucose(18F-FDG) positron emission tomography (PET-CT) scan and bone scintigraphy. They received NACT consisting of 12 cycles of Paclitaxel or 4 cycles of Docetaxel followed by dose dense doxorubicin or epirubicin/cyclofosfamide or vice versa as a standard initial treatment. After 6 weeks a 18F-FDG PET-CT scan was performed for early tumor response evaluation. At the day of operation, all the pts had a preoperative injecting with a 99mTC-labelled nanocolloid in the peri-areolar region. A gamma detector was used to localize the SLN(s). All SLN(s) were removed and a complete ALND was performed. Results A total of 150 pts were enrolled in our study of which 129 were eligible for analysis. 53 pts had a positive SLN of which 32 have a positive axillary lymph nodes (ALN) (PPV 60%); 76 pts has a negative SLN of which 6 had a positive ALN (NPV 92%). The sensitivity is 84% and the specificity 76% with a false omission rate (FOR) of 8%. 45 pts had an initial clinical N0 (cN0 is defined as clinical negative and no suspect lymph nodes on ultrasound, on MRI breast and 18F-FDG-PET CT scan). 45 pts had negative SLN, with no ALN and 2 pts had a positive SNL of which 1 pts had axillary involvement (NPV 100%). The FOR of cN1: 5%, cN2: 37%, cN3 33%. A total of 22 pts out of 84 pts (26%) of which 15/49 cN1 (30%), 6/23 (26%) cN2, 1/12 (8%)have after 6 weeks of chemotherapy, 18F-FDG normalization on 18F-FDG PET-CT scan. A total of 17 pts had a negative SLN and ALN. The FOR was 0% Conclusion SNB after NACT in case of cN0 is very reliable with high NPV and low FOR. In case of 18F-FDG-PET CT normalization after 6 weeks of chemotherapy and a negative SLN, no ALND has to be performed. Citation Format: Huizing M, Najim O, Dockx Y, Huyghe I, Van den Wyngaert T, van Goethem M, Verslegers I, Papadimitriou K, Altintas S, Baldewijns M, Trinh B, van Dam P, Tjalma W. The predictive value of sentinel node biopsy (SNB) in early breast cancer after neo-adjuvant chemotherapy (NACT): A prospective study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-02.

Positive Predictive Value of Mammographic Lymphography in the Evaluation of Patients with Breast Cancer: A Preliminary Study

The study aimed to investigate the positive predictive value (PPV) of mammographic lymphography (MLG) for assessing malignant breast disease and lymphatic metastasis in patients in a typical clinical setting. Patients who underwent mammography with Breast Imaging Reporting and Data System (BI-RADS) category 4 or 5 lesions and had abnormal mammographic findings in the upper-outer quadrant of the breast were enrolled. Next, MLG was performed. A water-soluble agent was subcutaneously injected into the upper-outer periareolar region of the bilateral breast, and mammography was then performed. Morphologic characteristics, including lymphatic vessel development, the presence of lymphatic vessel defects, and dilation, were recorded for evaluation. Fifty-one patients with BI-RADS category 4 lesions and 40 patients with BI-RADS category 5 lesions were included in the study. Sixty-one patients were found to have malignant disease, whereas 30 patients were found to have benign disease. Morphologic characteristics were recorded for evaluation. The interobserver agreement was evaluated and was classified as excellent according to kappa analysis. The PPV of MLG characteristics for malignant breast disease and lymphatic metastasis was analyzed by logistic regression, and the presentation of a lymphatic vessel defect was the most predictive characteristic of a malignancy (PPV: 0.89; P value: 0.02) in patients with BI-RADS category 4 lesions. Meanwhile, in patients with malignant breast disease, the PPVs for predicting lymphatic metastasis with lymphatic vessel defect and dilation were 0.50 (P value: 0.02) and 0.67 (P value: <0.01), respectively. The assessment of morphologic characteristics by MLG has the potential to predict malignant breast disease and lymphatic metastasis.