Preoperative Lymphoscintigraphy Research Articles

SPECT-CT and intraoperative portable gamma-camera detection protocol for sentinel lymph node biopsy in oral cavity squamous cell carcinoma.

The aim of this study was to evaluate a multimodality approach to sentinel lymph node biopsy (SLNB) detection with lymphoscintigraphy and single-photon emission computed tomography (SPECT)/computed tomography (CT). When combined with intraoperative imaging by a portable gamma camera (PGC), improved SLNB accuracy and detection rate may result. A total of 42 patients selected for SLNB in node-negative T1 and T2 oral squamous cell carcinoma were retrospectively analyzed. The detection protocol consisted of preoperative lymphoscintigraphy and SPECT/CT performed the day before surgery. Intraoperative sentinel lymph node (SLN) detection was done with the aid of a PGC in association with hand-held gamma probe. All SLN detected in the preoperative study could be harvested except for one case. A total of 131 SLN were resected. This number was higher than the SLN depicted on lymphoscintigraphy (119 SLNs) and SPECT/CT (123 SLNs). Sublingual SLNs were observed in two cases (4.76%). These SLNs were detected by SPECT/CT but not by lymphoscintigraphy. Five (3.8%) additional SLNs not previously visualized on lymphoscintigraphy or on SPECT/CT were detected intraoperatively with the aid of the PGC. Positive SLNs were detected in eight cases (19%). Micrometastases were detected in five cases (62%) and macrometastases in three cases (38%). The SLNB detection protocol described contributes to more accurate study and detection.

Pre-operative sentinel lymph node localization in breast cancer with superparamagnetic iron oxide MRI: the SentiMAG Multicentre Trial imaging subprotocol.

Sentinel lymph node biopsy (SLNB) with a superparamagnetic iron oxide (SPIO) tracer was shown to be non-inferior to the standard combined technique in the SentiMAG Multicentre Trial. The MRI subprotocol of this trial aimed to develop a magnetic alternative for pre-operative lymphoscintigraphy (LS). We evaluated the feasibility of using MRI following the administration of magnetic tracer for pre-operative localization of sentinel lymph nodes (SLNs) and its potential for non-invasive identification of lymph node (LN) metastases. Patients with breast cancer scheduled to undergo SLNB were recruited for pre-operative LS, single photon emission CT (SPECT)-CT and SPIO MRI. T1 weighted turbo spin echo and T2 weighted gradient echo sequences were used before and after interstitial injection of magnetic tracer into the breast. SLNs on MRI were defined as LNs with signal drop and direct lymphatic drainage from the injection site. LNs showing inhomogeneous SPIO uptake were classified as metastatic. During surgery, a handheld magnetometer was used for SLNB. Blue or radioactive nodes were also excised. The number of SLNs and MR assessment of metastatic involvement were compared with surgical and histological outcomes. 11 patients were recruited. SPIO MRI successfully identified SLNs in 10 of 11 patients vs 11 of 11 patients with LS/SPECT-CT. One patient had metastatic involvement of four LNs, and this was identified in one node on pre-operative MRI. SPIO MRI is a feasible technique for pre-operative localization of SLNs and, in combination with intraoperative use of a handheld magnetometer, provides an entirely radioisotope-free technique for SLNB. Further research is needed for the evaluation of MRI characterization of LN involvement using subcutaneous injection of magnetic tracer. This study is the first to demonstrate that an interstitially administered magnetic tracer can be used both for pre-operative imaging and intraoperative SLNB, with equal performance to imaging and localization with radioisotopes.

The Added Value of SPECT/CT in Sentinel Lymph Nodes Mapping for Endometrial Carcinoma.

This study was designed to evaluate the detection rate (DR) and sensitivity of sentinel lymph node (SLN) mapping in patients with endometrial cancer using TC99m colloid and blue dye and to evaluate the contribution of preoperative planar lymphoscintigraphy (PLSG) and SPECT/CT. A retrospective analysis of patients who underwent SLN mapping as part of their primary surgery for endometrial cancer. Patients underwent preoperative PLSG and later with additional SPECT/CT. Intraoperative detection was performed using TC99m colloid and blue dye by cervical injections. SLNs were sent separately for pathologic evaluation with ultrastaging. Fifty-three patients were included in this study. Successful preoperative mapping was achieved in 31 of 37 patients (84 %) who underwent SPECT/CT compared with only 30 of 45 patients (67 %) who underwent PLSG. SPECT/CT localizations of SLNs were anatomically accurate in 91 % of cases. Intraoperative DR of at least one SLN was 77 %, whilst the bilateral DR was 49 %. DR was significantly better using combined blue dye and TC99m colloid injections compared with blue dye alone: 81 versus 57 % for unilateral and 54 versus 28 % for bilateral mapping (P = 0.01, 0.009, respectively). Six cases of nodal metastasis were diagnosed: four by positive SLNs, and two cases were diagnosed using side-specific full dissection according to the SLN algorithm when SLN detection failed. There were no cases of false-negative results. SLN detection using cervical injections of TC99m colloid and blue dye is feasible and sensitive for patients with endometrial cancer. SPECT/CT aids to accurate locating of the SLN.

Study of internal mammary sentinel lymph node biopsy in breast cancer patients after neoadjuvant chemotherapy.

Dear editor Internal mammary lymph node (IMLN) metastasis has a similar prognostic importance as axillary lymph nodal involvement in breast cancer patients.1 Patients with both axillary- and internal mammary-positive nodes have a very poor prognosis.2 Reliable data for internal mammary nodal metastases are reported to be present in 18%–33% (mean 23.4%) of patients who have not been treated with neoadjuvant chemotherapy (NAC) mostly concomitant with axillary metastases, and metastases exclusively situated in the internal mammary chain occur in 2%–11% of patients,3 but limited data are available in the context of NAC. Current imaging techniques, such as positron emission tomography/computed tomography, ultrasound, and magnetic resonance imaging, could usually detect metastases lesions larger than 5 mm.1 Zhang et al reported that of a total of 112 (n=809; 13.8%) patients considered to have IMLN-positive diseases (the median size of the enlarged IMLN was 1.3 cm [range: 0.5–3.0 cm]) on the basis of imaging reports, only ten patients underwent ultrasound-guided fine-needle aspiration to obtain pathologic confirmation and all of the sampled lymph nodes were confirmed to contain malignant cells before receiving chemotherapy. Patients with positive IMLN before NAC received adjuvant radiation to the breast or the chest wall and the regional lymphatics including the IMLN chain with a median dose of 60 Gy if the IMLNs normalized after chemotherapy and 66 Gy if they did not.4 However, some patients with positive IMLN could not be detected by imaging techniques and fine-needle aspiration could not be performed for all suspicious positive IMLNs under ultrasonographic guidance. High-risk did not mean IMLN metastases, and low-risk did not mean IMLN negative.1 Hence, we recommend internal mammary sentinel lymph node biopsy (IM-SLNB) as a minimally invasive technique for the efficient evaluation of the status of internal mammary sentinel lymph node (IM-SLN) to obtain complete nodal staging and guide adjuvant radiotherapy. Sixty female patients who had histologically proven clinical stage T1 through T4, N0 through N3, M0 primary invasive breast cancer treated at the Breast Cancer Center in Shandong Cancer Hospital and Institute between 2012 and 2014 were enrolled in the study. Anthracycline- and taxane-based regimens were done. An amount of 18.5–37 MBq of 99mTc-labeled sulfur colloid in 1.0–1.2 mL volume was injected intraparenchymally at the 6 and 12 o’clock positions 2–3 cm away from the nipple under ultrasonographic guidance 3–18 hours before surgery in all patients. Subsequently, lymphoscintigraphy was performed 0.5–1.0 hours before surgery. IM-SLNB was performed on all patients with IM-SLN detected by preoperative lymphoscintigraphy or intraoperative gamma-probe. The IM-SLNB was performed from the sternal border in a lateral direction for 3–4 cm, and the pectoral major and minor muscle fibers were separated to expose the posterior intercostal space. The external and internal intercostal muscles were divided transversally from the sternal border. In this procedure, particular care must be taken to avoid injury to the inferior parietal pleura and internal mammary vessels. The visualization rate of IM-SLNB was 63.3% (38/60). The median age of the 38 patients was 50 years (range: 32–68 years). The success rate of IM-SLNB was 97.4% (37/38). The median number of IM-SLNs was 2 (total 60, range: 1–4). The site of IM-SLNs concentrated in the second (44.7%, 17/38) and third (55.3%, 21/38) inter-costal space. The median time consuming was 10 minutes (range: 5–30 minutes). The IM-SLN-positive rate was 8.1% (3/37), and all of them combined with positive axillary lymph nodes. Only two patients had intraoperative surgical complications. One had an injury to pleura and another had an injury to the internal mammary artery. They were repaired intraoperatively with no pneumothorax on postoperative chest radiography and postoperative bleeding. It is necessary to perform IM-SLNB after NAC to ascertain the nodal staging and pathological status as there were still 8.1% of patients with IM-SLNs metastases after NAC. The visualization and success rates of IM-SLNB are acceptable. The 2015 National Comprehensive Cancer Network Breast Cancer Clinical Practice Guidelines5 recommended that internal mammary radiotherapy should be performed on those patients with clinically and pathologically involved IMLN. IM-SLNB could help to make clear the pathological status and provide an accurate indication of radiation to the internal mammary area in case of under-stage and under-/over-treatment.

Single-Stage, Dual Gastroepiploic Lymph Node Flaps for the Surgical Treatment of Lymphedema

BACKGROUND: Several donor sites have been described for lymph node flap (LNF) harvest from around the body. The gastroepiploic donor site has several advantages, including constant anatomy, large-caliber vasculature, and no reported associated iatrogenic lymphedema. The purpose of this case report was to review the technique of expanding the gastroepiploic donor site to two flaps (Figure 1), based on the right and left gastroepiploic artery and vein (RGEA/V and LGEA/V), for distal and proximal vascularized lymph node transfer for extremity lymphedema (Figure 2).Figure 1: Schematic drawing of the dual gastroepiploic lymph node flap, based on the right and left gastroepiploic artery and vein (RGEA/V and LGEA/V). Adjacent omental vessels are shown.Figure 2: Distal and proximal inset of the dual gastroepiploic lymph node flap in the lymphedematous extremity.METHODS: Prospective data was collected on our first case of dual gastroepiploic lymph node flaps. Demographic data, indication, and perioperative details were recorded. RESULTS: Our patient was a 65-year-old female with cervical cancer-related right lower limb ISL stage II lymphedema, with progressive limb enlargement and decreased mobility for three years. Comorbidities included obesity (BMI = 35.4kg/m2) and poorly controlled hypertension. Preoperative circumferential measurements were 66.6cm thigh/ 44.3cm calf / 25.3cm ankle / 24.5cm foot, versus 56.5/39/1.6/22.4 contralaterally. Circumferential differentiation calculations were 17.9%/13.6%/17.1%/9.4%, with an average circumferential differentiation of 14%. Tonicity was not measureable at the thigh and leg, versus 87 / 86 contralaterally. Preoperative lymphoscintigraphy showed obstructive right lower limb lymphedema with dermal backflow distal to the thigh. Both gastroepiploic lymph node flaps survived, and no reexploration was required. Operative time was 575 minutes, harvest time was 140 minutes with open approach, and ischemia time was 120 minutes. All microanastomoses were performed in end-to-end fashion with 10-0 nylon. The anastomoses were the RGEA to the medial plantar artery, with corresponding veins, and the LGEA to the medial sural artery, with corresponding veins. Local flaps and small skin grafts were used for closure, to allow monitoring. Primary wound healing was achieved and there were no perioperative complications. CONCLUSIONS: The single-stage, dual gastroepiploic lymph node flap is a safe and novel option for the surgical treatment of extremity lymphedema. Long-term follow-up and further studies are warranted to further evaluate the potential of this flap.

Sentinel lymph node biopsy in melanoma: Our experience over 8 years in a universitary hospital

Abstract Background Since the introduction of sentinel lymph node biopsy, its use as a standard of care for patients with clinically node-negative cutaneous melanoma remains controversial. Our experience of sentinel lymph node biopsy for melanoma is presented and evaluated. Material and methods A cohort study was conducted on 69 patients with a primary cutaneous melanoma and with no clinical evidence of metastasis, who had sentinel lymph node biopsy from October-2005 to December-2013. Sentinel lymph node biopsy was identified using preoperative lymphoscintigraphy and subsequent intraoperative detection with gamma probe. Results The sentinel lymph node biopsy identification rate was 98.5%. The sentinel lymph node biopsy was positive for metastases in 23 patients (33.8%). Postoperative complications after sentinel lymph node biopsy were observed in 4.4% compared to 38% of complications in patients who had complete lymphadenectomy. Conclusion The sentinel lymph node biopsy in melanoma offers useful information about the lymphatic dissemination of melanoma and allows an approximation to the regional staging, sparing the secondary effects of lymphadenectomy. More studies with larger number of patients and long term follow-up will be necessary to confirm the validity of sentinel lymph node biopsy in melanoma patients, and especially of lymphadenectomy in patients with positive sentinel lymph node biopsy.

Clinical Significance of Sentinel Node Positivity in Patients with Superficial Esophageal Cancer.

Sentinel node (SN) mapping in esophageal cancer has been reported to be technically feasible with an acceptable detection rate and accuracy. However, the clinical significance and survival analysis findings associated with the metastatic status of SNs in patients with early-stage esophageal cancer have not been clarified. In this study, we investigated the clinical significance and survival impact of SN mapping in early-stage esophageal cancer. Among patients who were diagnosed preoperatively with clinical T1N0M0 or T2N0M0 esophageal cancer and who underwent SN mapping, 70 consecutive patients who were diagnosed with pathological T1 primary thoracic esophageal cancer were enrolled in this study. Sixty-four (91 %) patients were diagnosed with squamous cell carcinoma while 5 (7 %) patients were with adenocarcinoma. Endoscopic injection of technetium-99m tin colloid was performed before surgery, and radioactive SNs were identified by preoperative lymphoscintigraphy and intraoperative gamma probing. Standard esophagectomy with lymphadenectomy was performed in all patients, and all resected nodes were evaluated by routine pathological examination. SNs were successfully detected in 65 (92.9 %) of 70 patients with pT1 esophageal cancer. The sensitivity to predict lymph node metastasis was 91.7 %, and the diagnostic accuracy based on SN status was 96.9 %. Although there was a wide distribution of SNs from cervical to abdominal areas, 84.5 % of the patients had no lymph node metastasis or had lymph node metastasis only in SN. The disease-specific survival of the patients with metastatic non-SNs was significantly worse relative to that of the patients with no lymph node metastasis or lymph node metastasis only in SN. This study demonstrated that radio-guided SN mapping is useful not only as an accurate diagnostic tool for detecting lymph node metastasis but also as a tool for prognostic stratification in patients with cN0 early esophageal cancer.

Lymphoscintigraphy and sentinel lymph node biopsy, in cutaneous melanoma staging and treatment decisions.

Sentinel lymph node biopsy (SLNB) is a widely accepted method in the management of clinically localized cutaneous melanomas. The aim of this study was to report the results on patients scheduled for preoperative lymphoscintigraphy and SLNB for staging and further treatment planning. Two hundred and one patients (115 male and 86 female, median age 57 years, range 9-81) with cutaneous melanoma having undergone SLB at Military Medical Academy between November 2010 and October 2014, were recruited for retrospective study. Dual labeling method (Tc-99m Nanocolloid (blue dye) was used. In order to delineate the relation between patients' tumors and scintigraphic characteristics with positive SLN findings, we examined all variables by univariate logistic regression with odd ratios representing the size effect. The overall identification rate of SLN was 98.5%. One or more positive SLN were seen in 47 (23.4%) of the patients. Drainage to one regional basin was noticed in 176 (88%) and multiple drainage regions, up to three, was noticed in 24 patients (12%). Transit lymph nodes were detected in 20 patients (10%). The characteristics that were assotiated significatly with sentinel lymph node metastases were Breslow thickness, nodular melanoma histological subtype and acral localization. Besides the well established primary tumor thickness being a predictor of SLN malignancy, we observed: acral body site location and nodular melanoma histological subtype to be significant independent factors in increasing the risk for regional metastases. Our results suport the clinical usefulness of SLNB within a multidisciplinary approach (dermatooncology, plastic/head and neck surgery, pathology, nuclear medicine), as a reliable method in staging and for treatment planning in melanoma patients.

Biopsia selectiva del ganglio centinela en melanoma: experiencia durante 8 años en un hospital universitario

BackgroundSince the introduction of sentinel lymph node biopsy, its use as a standard of care for patients with clinically node-negative cutaneous melanoma remains controversial. Our experience of sentinel lymph node biopsy for melanoma is presented and evaluated. Material and methodsA cohort study was conducted on 69 patients with a primary cutaneous melanoma and with no clinical evidence of metastasis, who had sentinel lymph node biopsy from October-2005 to December-2013. Sentinel lymph node biopsy was identified using preoperative lymphoscintigraphy and subsequent intraoperative detection with gamma probe. ResultsThe sentinel lymph node biopsy identification rate was 98.5%. The sentinel lymph node biopsy was positive for metastases in 23 patients (33.8%). Postoperative complications after sentinel lymph node biopsy were observed in 4.4% compared to 38% of complications in patients who had complete lymphadenectomy. ConclusionThe sentinel lymph node biopsy in melanoma offers useful information about the lymphatic dissemination of melanoma and allows an approximation to the regional staging, sparing the secondary effects of lymphadenectomy. More studies with larger number of patients and long term follow-up will be necessary to confirm the validity of sentinel lymph node biopsy in melanoma patients, and especially of lymphadenectomy in patients with positive sentinel lymph node biopsy.

SPECT/CT for SLN dissection in vulvar cancer: Improved SLN detection and dissection by preoperative three-dimensional anatomical localisation

ObjectiveIn this study, we assessed the feasibility and clinical advantages of single photon emission computed tomography with CT (SPECT/CT) for sentinel lymph node (SLN) detection in vulvar cancer. MethodsThis is a unicentric prospective trial. Vulvar cancer patients underwent preoperative SLN marking (10MBq Technetium (TC)-99m-nanocolloid) and subsequent planar lymphoscintigraphy (LSG) and SPECT/CT for SLN visualization. Directly before surgery, a patent blue dye was injected. We assessed detection rates of SPECT/CT and those of planar LSG and intraoperative detection. We analyzed the sensitivity, negative predictive value and false negative rate. ResultsAt Hannover Medical School, 40 vulvar cancer patients underwent SLN dissection after preoperative LSG and SPECT/CT. The mean diameter of all tumors in final histology was 2.23 (0.1–10.5) cm with a mean tissue infiltration of 3.93 (0.25–11) mm.In preoperative imaging, SPECT/CT identified significantly more SLNs (mean 8.7 (1–35) LNs per patient) compared to LSG (mean 5.9 (0–22) LNs, p<0.01). In addition, SPECT/CT led to a high spatial resolution and anatomical localization of SLNs. Thus, SPECT/CT identified aberrant lymphatic drainage in 7/40 (17.5%) patients. There were no significant differences, but significant correlation was found between SPECT/CT and intraoperative SLN identification. Regarding inguino-femoral LNs, for all patients who underwent complete groin dissection, sensitivity was 100%, NPV was 100% and false negative rate was 0%. ConclusionSPECT/CT leads to higher SLN identification compared to LSG in vulvar cancer. Due to its higher spatial resolution and three-dimensional anatomical localisation of SLNs, SPECT/CT provides the surgeon with important additional information, facilitates intraoperative SLN detection and predicts aberrant lymphatic drainage.

Sentinel Lymph Node Detection in Contralateral Axilla at Initial Presentation of a Breast Cancer Patient: Case Report.

The main basin for breast lymphatic drainage is ipsilateral axilla. However, extra-axillary drainage may be seen in some patients. The most common extra-axillary site is internal mammary chain, while contralateral axillary drainage is an extremely rare situation in previously untreated patients. We describe a case of untreated right breast retroareolar carcinoma with contralateral axillary drainage detected on preoperative lymphoscintigraphy. Contralateral axillary dissection was performed based on the result of frozen section examination of the sentinel lymph node (SLN) which turned out to burden micrometastasis. Postoperative histopathological examination revealed invasive ductal carcinoma metastasis in 17 out of 22 lymph nodes from the ipsilateral axillary dissection, whereas 14 lymph nodes from contralateral axillary dissection other than the SLN were nonmetastatic. In our opinion, determination of contralateral axillary metastasis in primary staging process had a major contribution to the management of the patient.

Impact of delayed lymphoscintigraphy for sentinel lymphnode biopsy for breast cancer

Despite universal adoption of sentinel lymph node biopsy (SLNB) for breast cancer, there remains no standardized protocol for preoperative lymphoscintographic assessment of sentinel nodes. Both immediate and delayed lymphoscintigraphy are currently utilized, although it is unclear how delayed imaging impacts SLN identification. Among patients diagnosed with breast cancer who underwent SLNB at Duke from 2011 to 2012, two protocols for preoperative lymphoscintigraphy were used: protocol A included both immediate and delayed lymphoscintigraphy (n = 152), while protocol B involved immediate lymphoscintigraphy only (n = 103). The overall intraoperative SLN identification rate was 98.4% and did not differ between groups. A lower number of SLN were visualized on the immediate scan using protocol A compared to protocol B (P < 0.001). Although a greater total number of nodes was excised using protocol A, this result was not statistically significant (P = 0.08). Moreover, there was no significant difference in the number of negative SLN between groups (P = 0.51). We found no significant impact on identification rate or number of SLN excised with the use of delayed versus immediate imaging. These findings support abandoning delayed lymphoscintographic imaging, except in those cases where aberrant drainage is suspected.

Abstract P2-01-07: Reoperative sentinel lymph node biopsy for ipsilateral breast tumor recurrence: Impact of axillary surgery and radiation therapy on lymphatic drainage patterns

Abstract Background: While sentinel lymph node biopsy (SLNB) is a well-established method for patients with clinically node-negative primary breast cancer, reoperative sentinel lymph node biopsy (re-SLNB) for ipsilateral breast tumor recurrence (IBTR) still remains controversial. The aim of this study was to evaluate the location of reoperative sentinel lymph nodes (re-SLNs) and the factors related to aberrant drainage patterns after breast conserving surgery (BCS). Methods: Between April 2005 and August 2013, we performed re-SLNB on 132 patients who developed IBTR with no metastatic lymph nodes in preoperative examination. Both injection of radioisotope (Tc-99m phytate) and preoperative lymphoscintigraphy were performed on 97 patients of them, who were eligible for this retrospective study. We divided these patients into two groups according to their previous axillary surgery: 55 patients with just SLNB or no axillary surgery to the group S, and 42 patients with previous axillary lymph node dissection (ALND) to the group D. The patients in the group S were divided into two subgroups: 19 with adjuvant radiation therapy (RT) and 36 without RT. We compared visualization rates of lymph drainage patterns in these groups statistically by using Chi-square test. We evaluated the relationship between previous local treatments and lymphatic drainage patterns. Results: Number of cases in which lymphatic drainage was visualized were 52 (94.5%) in the group S and 33 (78.6%) in the group D (P &amp;lt; 0.001). Re-SLNs were observed at ipsilateral axilla in 47 patients (90%) in the group S and 19 patients (58%) in the group D (P &amp;lt; 0.001), at internal mammary (IM) in 9 (17%) and 16(49%) (P &amp;lt; 0.01), and at contralateral axilla in 8 (15%) and 5(15%), respectively. Within the group S, lymphatic drainage was visualized in 34 (94.4%) of 36 patients without RT and 18 (94.7%) of 19 patients who had received RT after BCS. Re-SLNs were visualized at ipsilateral axilla in 34 (100%) and 13 (72%) (P &amp;lt; 0.01), at IM in 5 (15%) and 4 (22%), and at contralateral axilla in 1 (3%) and 7 (39%) (P &amp;lt; 0.001). Re-SLNB was successfully performed in 62 (94%) of 66 patients whose lymphatic drainage was observed at ipsilateral axilla. Metastases for carcinoma in re-SLNs were found in 8 (13%) of them. At IM, re-SLNB was successful in 15 (60%) of 25, and 2 (13%) of them were positive for cancer. At contralateral axilla, re-SLNB was successful in 8 (62%) of 13 while no metastases were found among them. Conclusion: Previous ALND affected the visualization rates of re-SLNs. In patients after previous ALND, SLN was more likely to be in IM. Adjuvant RT effected a change in lymphatic drainage patterns, but did not affect the visualization rate of re-SLN. At ipsilateral axilla, the rates of successful re-SLNB and metastases at re-SLNs were similar to SLNB for primary breast cancer. Metastasis to SLN of recurrent cancer is one of the most important information for management of IBTR. However, it was very difficult to predict localization of re-SLN because lymphatic drainage patterns could have been affected by previous treatments. Therefore, we recommend re-SLNB using radioisotope with lymphoscintigraphy in surgery for IBTR. Citation Format: Ayaka Sato, Takehiko Sakai, Fumiko Moroo, Kiyomi Kimura, Masahiko Tanabe, Rie Horii, Futoshi Akiyama, Takuji Iwase. Reoperative sentinel lymph node biopsy for ipsilateral breast tumor recurrence: Impact of axillary surgery and radiation therapy on lymphatic drainage patterns [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-01-07.

Lymphoscintigraphy and sentinel nodes.

It has been validated that sentinel lymph node biopsy (SLNB) shows whether a patient's breast cancer or melanoma has spread to regional lymph nodes. As a result, management of patients with these cancers has been revolutionized. SLNB has replaced axillary lymph node dissection (ALND) as the staging modality of choice for early breast cancer and has replaced complete lymph node dissection as the staging modality of choice for melanoma in patients whose SLNBs indicate no metastases. Recently concluded multicenter, randomized trials for breast cancer with 5- to 10-y outcome data have shown no significant differences in disease-free survival rates or overall survival rates between SLNB and ALND groups but have shown significantly lower morbidity with SLNB than with ALND. The lowest false-negative rates (5.5%-6.7%) were seen in studies that used preoperative lymphoscintigraphy and dual mapping during surgery. To assess the survival impact of SLNB in melanoma, the Multicenter Selective Lymphadenectomy Trial I was performed. Melanoma-specific survival rates were not different between subjects randomized to SLNB with lymphadenectomy for nodal metastasis on biopsy and subjects randomized to observation with lymphadenectomy for nodal relapse. However, the 10-y disease-free survival rates were better for the SLNB group than for the observation group, specifically among patients with intermediate-thickness melanomas or thick melanomas.

Abstract P2-01-22: Internal mammary sentinel lymph node biopsy with modified injection technique: High visualization rate and accurate staging

Abstract Background: Although the 2009 AJCC incorporated the internal mammary sentinel lymph node biopsy (IM-SLNB) concept, there has been little change in surgical practice patterns due to the low internal mammary sentinel lymph nodes (IM-SLNs) visualization rate (VR) with the traditional radiotracer injection technique (average 13%, 0-37%). In this study, various injection techniques were evaluated in term of the IM-SLNs VR in clinically axilla lymph nodes (ALNs) negative patients, and the impact of IM-SLNB on the diagnostic and prognostic value were analyzed both in clinically ALNs negative (NCT01642511) and positive patients (NCT01668914). Methods: 340 patients with T1-2 invasive breast cancer were enrolled. Clinically ALNs negative patients (n=293) were divided into 3 groups according to the study period and radiotracer injection technique. Group A: traditional technique (peritumoral intraparenchymal injection) for the initial 58 cases; Group B: periareolar intraparenchymal injection under the ultrasonography guidance in the latter 235 cases, the injection sites were chosen at the 6 and 12 o’clock positions 0.5-1.0 cm from areola (about 2.0-4.0 cm from the nipple). Group B was then separated into 2 groups according to the radiotracer injection volume: Group B1, low volume (&amp;lt;0.5ml/point, n=41); Group B2, high volume (≥0.5ml/point, n=194). Clinically ALNs positive patients (n=47) were managed as group B2. IM-SLNB was performed for patients with IM-SLNs visualized on preoperative lymphoscintigraphy and/or detected by intraoperative gamma probe. Results: Clinically ALNs-negative: The IM-SLNs VR was significantly higher by lymphoscintigraphy in Group B than that in Group A (63.0% vs. 13.8%, P&amp;lt;0.001), while the axillary VR was similar in these two groups (84.3% vs. 77.6%, P=0.227). The VR of sentinel lymph nodes was improved by the intraoperative gamma probe compared to lymphoscintigraphy: Group A (axilla: 77.6%→98.3%, P=0.001; internal mammary: 13.8%→15.5%, P=0.794) and Group B (axilla: 84.3%→98.7%, P&amp;lt;0.001; internal mammary: 63.0%→70.6%, P=0.078). Group B2 was found to have the highest IM-SLNs VR (74.2% vs. 53.7% Group B1, P=0.009). The successful rate of IM-SLNB was 95.8%, and arrived 100% after 20 cases learning curve. In the patients who underwent IM-SLNB, the IM-SLNs metastases rate was 8.7%, systemic treatment was changed only in 4.3%; however, radiotherapy treatment was changed in 8.7%. For the patients with upper inner quadrant tumor, systemic and radiotherapy treatment was changed in 8.8% and 20.6%. Clinically ALNs-positive: IM-SLNB was performed in all patients with drainage to IM-SLNs (VR: 70.2%, 33/47); the successful rate was 100 % (33/33). The IM-SLNs was positive in 21.2% patients, and the internal mammary radiotherapy could be guided with this IM-SLNB results. Conclusions: The modified injection technique (periareolar intraparenchymal, high volume and ultrasonography guidance) significantly improved the IM-SLNs VR, making the routine IM-SLNB possible in daily practice. IM-SLNB could provide individual staging, prognosis, and decision-making of the internal mammary radiotherapy for breast cancer patients, especially in positive ALNs and high-risk negative ALNs patients. Citation Format: Peng-Fei Qiu, Bin-bin Cong, Rong-Rong Zhao, Yan-Bing Liu, Guo-Ren Yang, Peng Chen, Yong-Sheng Wang. Internal mammary sentinel lymph node biopsy with modified injection technique: High visualization rate and accurate staging [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-01-22.

Prognostic Significance of Tumor-Positive Internal Mammary Sentinel Lymph Nodes in Breast Cancer: A Multicenter Cohort Study.

The introduction of the sentinel lymph node biopsy (SLNB) in breast cancer has renewed interest in lymphatic drainage to the internal mammary (IM) nodes. The clinical impact of tumor positive IM nodes is not completely clear. This study evaluated the incidence and impact on overall survival of metastatic IM SLNs. Between 1997 and 2010, 3685 patients underwent surgery including SLNB for primary breast cancer following an intratumoral or peritumoral radioactive-tracer injection. The presence of lymph node metastases was categorized according to the TNM-classification. Cumulative overall survival was estimated and the influence of metastases in the IM nodes and other factors was assessed by Cox-regression-analysis. In 754 patients (20.5 %) ipsilateral IM lymph nodes were visualized on preoperative lymphoscintigraphy, retrieval rate of IM SLNs was 81.0 %. IM metastases were detected in 130 patients (21.3 % of retrieved SLNs and 3.5 % of all patients respectively). The presence of IM metastases was associated with axillary metastases (p < 0.001). After a median follow-up of 61.2 months, 10.9 % of patients had died. In a multivariate analysis IM metastases did not have a significant effect on overall survival [HR] 1.20; CI: 0.73-1.98. In patients without axillary metastases (n = 2398), the presence of IM metastases (n = 43) was associated with worse survival [HR] 2.68; 95 % CI: 1.30-5.54. Overall, the presence of IM metastases did not effect overall survival independent of other prognostic factors including axillary metastases. However, the small subgroup of patients who had IM metastases alone had worse outcome than patients without any regional lymph node metastases.

Presence of intramammary lymph nodes in the preoperative lymphoscintigraphy to locate the sentinel lymph node. Clinical significance

The routes of lymphatic drainage from a breast cancer are the axilla (the most frequent) and the extra axillary regions. Among the latter, there are the so-called intrammamary lymph nodes (IMLN). This study has aimed to assess the incidence of IMLNs in our patients and study the evolution of these cases with IMLN in the lymphoscintigraphy. Thirty-eight patients (out of 1725) with IMLN in the pre-operative lymphoscintigraphy were assessed. During the surgical procedure, using a gamma probe, IMLNs were located and excised. After their harvesting, a meticulous surgical field scan was performed. When the axillary sentinel node was positive for metastasis, a complete axillary lymphadenectomy was performed. In those where the axillary sentinel node was negative and IMLN was positive (IMLN+), axillary lymphadenectomy was also performed, except for one case. Thirty-four out of the 38 IMLNs were obtained (89.5%), because no lymphatic tissue was found in pathology analysis in three cases (8%) and in one patient (3%) IMLN was not found during surgery. Ten (26%) metastatic IMLNs were located and the remaining 24 IMLNs cases (63%) were metastasis-free. During the clinical follow-up, one patient with IMLN+ developed hepatic metastases. The remaining 33 patients did not present any recurrence. No follow-up data were available for three patients. IMLN and axillary sentinel node biopsy are recommended when both are depicted in preoperative lymphoscintigraphy. The axilla treatment will only depend on the axillary sentinel node status. Based on the data from other authors and our own experience, avoiding the axillary lymphadenectomy when a metastatic IMLN without axillary involvement seems reasonable.

Presence of intramammary lymph nodes in the preoperative lymphoscintigraphy to locate the sentinel lymph node. Clinical significance

ObjectiveThe routes of lymphatic drainage from a breast cancer are the axilla (the most frequent) and the extra axillary regions. Among the latter, there are the so-called intrammamary lymph nodes (IMLN). This study has aimed to assess the incidence of IMLNs in our patients and study the evolution of these cases with IMLN in the lymphoscintigraphy. Material and methodsThirty-eight patients (out of 1725) with IMLN in the pre-operative lymphoscintigraphy were assessed. During the surgical procedure, using a gamma probe, IMLNs were located and excised. After their harvesting, a meticulous surgical field scan was performed. When the axillary sentinel node was positive for metastasis, a complete axillary lymphadenectomy was performed. In those where the axillary sentinel node was negative and IMLN was positive (IMLN+), axillary lymphadenectomy was also performed, except for one case. ResultsThirty-four out of the 38 IMLN were obtained (89.5%), because no lymphatic tissue was found in pathology analysis in three cases (8%) and in one patient (3%) IMLN was not found during surgery. Ten (26%) metastatic IMLN were located and the remaining 24 IMLN cases (63%) were metastasis-free. During the clinical follow-up, one patient with IMLN+ developed hepatic metastases. The remaining 33 patients did not present any recurrence. No follow-up data were available for three patients. ConclusionsIMLN and axillary sentinel node biopsy are recommended when both are depicted in preoperative lymphoscintigraphy. The axilla treatment will only depend on the axillary sentinel node status. Based on the data from other authors and our own experience, avoiding the axillary lymphadenectomy when a metastatic IMLN without axillary involvement seems reasonable.

Contribution of lymphoscintigraphy to intraoperative sentinel lymph node detection in early cervical cancer: Analysis of the prospective multicenter SENTICOL cohort

PurposeTo evaluate the contribution of preoperative lymphoscintigraphy to intraoperative lymphatic mapping (ILM) in early cervical cancer MethodsWe conducted an ancillary analysis of the multicenter prospective SENTICOL study in early cervical cancer. Radiocolloid was injected intracervically on the day before (long protocol) or morning of (short protocol) surgery, lymphoscintigraphy was performed, and the results of a centralized image review were communicated to the surgeons. ILM was performed on combined radioactivity/patent blue detection. Sentinel lymph nodes (SLNs) were electively sampled before routine bilateral pelvic lymphadenectomy by laparoscopy. ResultsOf 139 patients in the modified intention-to-diagnose analysis, 114 had centrally reviewed lymphoscintigrams, which showed 352 SLNs in 100 patients. Lymphoscintigraphy and ILM detection rates were 87.8% and 97.8%, respectively. Agreement between lymphoscintigraphy and ILM was low for the number of SLNs (κ=0.23; −0.04; 0.49) and bilateral SLNs (κ=0.36; 0.2; 0.52). No patient without SLNs by ILM had SLNs by lymphoscintigraphy. Lymphoscintigraphy identified substantial proportions of unusual drainage pathways. No patients with metastatic nodes had SLNs by lymphoscintigraphy but not by ILM in the relevant territory. In 1 of the 2 patients with false-negative SLN results, SLNs were bilateral by lymphoscintigraphy and unilateral by ILM. ConclusionAlthough the detection rate was lower by lymphoscintigraphy than by ILM, the substantial proportions of SLNs in unusual territories provided valuable guidance for the surgical exploration. Awareness of the limited agreement between lymphoscintigraphic and surgical detection might help surgeons decrease the false-negative rate.

Imaging sentinel lymph nodes.

As the technique of sentinel lymph node (SLN) biopsy has evolved over the last 22 years, it has become increasingly evident that accurate SLN imaging is vital to allow surgical removal of only the true SLN(s) and not other nodes. Identifying the lymphatic collectors draining a tumor site and following them to the draining SLNs defines which nodes need to be removed for careful histologic examination. Current technology allows the exact location of each SLN to be defined. This allows the full benefits of SLN biopsy to be achieved, that is, highly accurate lymph node staging with minimal morbidity. In melanoma and breast cancer, the current practice of preoperative lymphoscintigraphy (LS) using peritumoral injections of tracer or injection adjacent to an excision biopsy site with dynamic imaging to visualize the lymphatic collectors and delayed imaging including single-photon emission computed tomography/computed tomography gives the best results. This information informs the surgical approach and allows rapid excision of the SLNs at surgery.In patients with visceral tumors where the primary cancer site is difficult to access, it appears that using fluorophores that are fluorescent under near-infrared light, injected during surgery, is evolving as the preferred technique.