Sentinel Node Biopsy

There is considerable argument concerning the number of sentinel node biopsy cases with axillary dissection that surgeons should perform before they are eligible on abandoning axillary dissection in negative sentinel node patients. Papers that (1) address directly or indirectly the subject of credentialing or of learning curve, (2) report on a surgeon's performance, (3) are reported as feasibility or learning curve studies, or both, (4) discuss the learning curve issue, and (5) express an expert's opinion on the learning curve. The number of procedures of the learning curve can not be fixed for all surgeons. Only surgeons in specialized breast cancer centers can succeed in meeting current recommendations with 20 to 30 cases. Surgeons from affiliated community hospitals will need more than 30 cases, whereas broad-based surgeons might need as many as 60 cases with their current caseload. Not all surgeons will be able to offer the procedure to their patients by the current reco...

Background Nipple-sparing mastectomy (NSM) via an inframammary (IM) incision has been described for selected patients with breast cancer. However, the application of sentinel lymph node (SLN) mapping via an IM incision for NSM has yet to be reported. The objective of this study is to determine the technical feasibility of performing SLN through an IM incision without making an axillary counterincision. Methods We retrospectively reviewed our single-institutional experience with SLN biopsy and NSM through IM incisions between January 2006 and March 2008. Clinicopathologic factors were analyzed regarding indications, technical details, postoperative morbidity, and follow-up. Results Fifty-two patients underwent 87 NSM through an IM incision (17 unilateral, 35 bilateral) with immediate reconstruction and SLN biopsy. Indications for surgery included invasive breast cancer (n = 21), ductal carcinoma in situ (DCIS) (n = 18), and prophylactic (n = 48). Mean tumor size of invasive carcinoma was 2.1 cm. The mean mastectomy specimen weight was 437 g. Subareolar injection consisted of blue dye (n = 43), technetium sulfur colloid (n = 2), or combination injection (n = 42). SLN biopsy through an IM incision was successfully performed in 84 of 87 cases (96.6%). A mean of 2.8 SLN were removed with a positive sentinel node encountered in 8 of 21 patients (38%) with invasive cancer. No complications were observed regarding the SLN portion of the operation. With a median follow-up of 6.5 months (range, 0.4–23 months), there have been no axillary local recurrences. Conclusion SLN biopsy can be performed through an IM incision during a NSM, avoiding a secondary axillary incision.

Lymphoscintigraphy in breast cancer usually shows lymphatic drainage to the ipsilateral axilla. Drainage to extraaxillary or contralateral axillary regions is rare and there is still controversy about its management. Due to the significant clinical impact of an accurate staging, a literature research is made based on a case of a patient with recurrence of left breast cancer with contralateral axillary sentinel lymph node detection, without evidence of lymphatic drainage to other locations. © 2018 Published by Elsevier Espã na, S.L.U. on behalf of Sociedad Espã nola de Medicina Nuclear e Imagen Molecular. Drenaje del ganglio centinela a axila contralateral en cáncer de mama: controversias y manejo según la literatura. A propósito de un caso Palabras clave: Cáncer de mama Linfogammagrafía Ganglio centinela Contralateral Drenaje extraaxilar r e s u m e n En el cáncer de mama la linfogammagrafía muestra generalmente drenaje linfático hacia axila ipsilateral. De manera infrecuente, se observa drenaje hacia regiones extraaxilares o axilar contralateral, y su manejo aún genera controversias. Dado el impacto clínico que supone una correcta estadificación, se realiza una revisión bibliográfica a raíz del caso de una paciente con recidiva de cáncer de mama izquierda con detección de ganglio centinela axilar contralateral, sin evidencia de drenaje linfático hacia otras localizaciones.

Objetive To assess the safety and efficacy of FDG-PET in breast cancer in the diagnostic of primary tumours, lymph node staging, the detection of recurrent disease/metastases, and the assessment of chemotherapy treatment. Methods A systematic review was undertaken. A search was made for primary studies, other systematic reviews, and health technology assessment reports in different databases. Results A total of 73 reports were included. FDG-PET does not appear to be sufficiently accurate to be used in isolation for ruling out the presence of a primary tumour. In lymph gland staging, FDG-PET does not appear to be accurate enough to detect occult axillary metastases or micrometastases (sensitivity 20 and 50%, respectively); sentinel node biopsy is required for confirmation. In the detection of bone metastases, FDG-PET should be complemented with other tests such as bone gammagraphy or SPECT. The assessment of response to chemotherapy, there seems to be no uniform criterion for establishing a standardized uptake value (SUV) for FDG that would allow responders and non-responders to be distinguished. Conclusions FDG-PET is insufficiently sensitive to rule out small primary tumours. Due to the high number of false positives returned, it cannot replace axillary dissection in axillary lymph gland staging. A complete biochemical response identified by FDG-PET should not be relied upon to mean an absence of disease since the technique cannot detect residual microscopic elements.

LYMPHATIC MAPPING IN BREAST CANCER


PURPOSE: To evaluate the use of Lymphatic mapping in the management of Breast Cáncer Between October 1998 to May 2001.

METHOD: We evaluated 25 patients with breast cáncer in clinical stages T1N0M0 and T2N0M0, we used blue dye 5 cc peri-tumoral inside the gland; 5 minutes later we initiated the procedure looking for the Sentinel Node, all the patients had an axillary dissection in levels I and II, and the results were correlated the status of the sentinel node
And the status of the axillary dissection.

RESULTS: In 22 patients was possible identified the sentinel node. In 3 patients the result of the sentinel node do not correlated with the status of the rest of the nodes in level I and II. The predictive value of the sentinel node biopsy is 90%.

CONCLUSION: The sentinel node biopsy allows accurate determination of axillary status and is a good alternative in the conservative management of the Breast Cáncer.

STUDY OBJECTIVE:
To report the detection rate (DR) of sentinel lymph nodes (SLNs) in endometrial cancer (EC) patients after hysteroscopic injection of indocyanine green (ICG) and laparoscopic near-infrared (L-NIR) fluorescence mapping.
DESIGN:
Prospectively collected data (Canadian Task Force classification II-2).
SETTING:
Gynecologic oncology referral center.
PATIENTS:
Consecutive patients with apparent early-stage endometrioid EC scheduled for surgical treatment: total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, SLN mapping.
INTERVENTIONS:
The mapping technique consisted in an intraoperative hysteroscopic peritumoral injection of 5 mg ICG followed by L-NIR fluorescence mapping. Evaluations of the SLN DR and sites of mapping were performed.
MEASUREMENTS AND MAIN RESULTS:
A total of 57 procedures was performed. Patient mean age was 60 years (range, 28-80) and mean body mass index was 28.2 kg/m2 (range, 19-43). At least 1 SLN was detected in 89.5% of the whole population (51/57). After the first 16 cases, L-NIR camera technical improvement led to a 95% DR (39/41). The mean number of harvested SLNs was 4.1 (range. 1-8), and in 47% of cases SLNs mapped to aortic nodes (24/51). Bilateral pelvic mapping was found in 74.5% of cases (38/51). Three patients had SLN metastases: 1 in the pelvic area only, 1 both in the pelvic and aortic area, and 1 presented with 2 metastatic aortic SLNs with negative pelvic SLNs. Overall, 2 of 3 node-positive patients (67%) had aortic SLN involvement. No adverse events were reported.
CONCLUSIONS:
Laparoscopic SLN mapping after the hysteroscopic injection of ICG has comparable DRs with both radioactive tracer series and ICG series with cervical injection, overcoming the need for radioactive substances. Hysteroscopic injection leads to a higher mapping in the aortic area compared with cervical injection. Further investigation is warranted on this topic

Intraoperative probes have been employed to assist in the detection and removal of tumors for more than 50 years. For a period of about 40 years, essentially every detector type that could be miniaturized had been tested or at least suggested for use as an intraoperative probe. These detectors included basic Geiger-Müller (GM) tubes, scintillation detectors, and even state-of-the-art solid state detectors. The radiopharmaceuticals have progressed from 32PO4- injections for brain tumors to sophisticated monoclonal antibodies labeled with iodine-125 for colorectal cancers. The early work was mostly anecdotal, primarily interdisciplinary collaborations between surgeons and physical scientists. These collaborations produced a few publications, but never seemed to result in an ongoing clinical practice. In the mid 1980s, several companies offered basic gamma-detecting intraoperative probes as products. This led to the rapid development of radioimmunoguided surgery (RIGS) and sentinel node detection as regularly practiced procedures to assist in the diagnosis and treatment of cancer. In recent years intraoperative imaging probes have been developed. These devices add the ability to see the details of the detected activity, giving the potential of using the technique in a low-contrast environment. Intraoperative probes are now established as clinical devices, they have a commercial infrastructure to support their continued use, and there is ongoing research, both commercial and academic, that would seem to ensure continued progress and renewed interest in this slowly developing field.

Sentinel node biopsy (SNB) for melanoma, with its intradermal (ID) injection, has a higher success rate than SNB for breast cancer, which is typically performed with a subcutaneous (SC) or peritumor injection. It is hypothesized that this is in part due to a slower transit time of lymphatic mapping agents through the parenchymal lymphatics of the breast. No study has investigated differences in transit time between different tissues to account for this clinical observation. The goal of the study was to compare transit time between ID and SC injections with common agents used in lymphatic mapping. Four injection sites on five domestic pigs were used. Sites were bilateral and included cervical, forelimb, hindlimb, and flank areas. Agents included technetium sulfur colloid (Tc99, filtered and unfiltered), isosulfan blue (IB) dye, and fluorescein (FL) dye. At each site both ID and SC injections were made and the transit time to reach the sentinel node was recorded. The transit time differences were calculated per centimeter distance from the draining lymph node basin. Sentinel nodes were identified draining all sites and found to be hot, blue, or fluorescent (using a Wood's lamp for identification). The cervical and forelimb injection sites drained to the same cervical lymph node basin and both SC and ID injection sites drained to the same sentinel node. Similarly, the hindlimb and flank injection sites both drained to inguinal lymph node basins. The slowest transit time occurred with Tc99 injected SC and the fastest occurred with Tc99 injected ID, whereas both FL dye and IB traveled rapidly to the sentinel node whether injected SC or ID. Large differences were found using unfiltered Tc99 depending on its injection ID (2.7 s/cm +/- 0.5) vs SC (249 s/cm +/- 14.7, P = 0.008). Tc99 ID injections were significantly faster than SC injection. The slowest and fastest SC injection agents were unfiltered Tc99 and IB, respectively. Dermal injections provide faster transit of lymphatic agents and may improve the identification rate when applied to patients with breast cancer.

Location of the sentinel lymph node in malignant melanoma and early breast cancer patients requires separate injections of radiocolloid and blue dye. These agents are administered at alternative times because of their different rates of transit. This study has elucidated why particular dyes are absorbed by the lymphatic system from an investigation of dye molecular structure as a function of protein binding ability. A dye-protein binding assay was developed using size-exclusion chromatography and ultraviolet spectrophotometry and applied to a series of 20 sulfonic acid group-containing dyes. Radiochemical analyses were also used with 3 99mTc-labeled dyes to rationalize which functional groups are involved in the protein binding reaction. Methylene blue resulted in no protein affinity at 37 degrees C, whereas disulfonate dyes separated by 1 atom such as Patent blue or Indigo carmine gave <30% binding. Optimum protein binding (84%-100%) was achieved with those dyes containing at le...

... El relieve del nódulo en piel se aprecia a simple vista y no existe telorrea ni telorragia. En la axila izquierda (AI) no se palpan nódulos sospechosos. ... Hum Pathol. 1995;26:965—9. 22. Middleton LP, Vlastos G, Mirza NQ, Eva S, Sahin AA. ...

Aunque la identificación del ganglio centinela (GC) presenta en la actualidad una amplia aplicación en el melanoma y el cáncer de mama, no se utiliza rutinariamente en otras neoplasias, como pueden ser las ginecológicas.Evaluar la aplicabilidad y los resultados de la técnica de localización del GC en pacientes con cánceres ginecológicos.Se estudiaron 155 pacientes con diversas neoplasias ginecológicas (70 vulvares, 50 de cuello uterino y 35 endometriales). Se realizó una linfogammagrafía el día previo a la intervención quirúrgica mediante la inyección de 111 MBq de 99mTc-nanocoloide por diversas vías según el tipo de lesión. La localización intraoperatoria se realizó mediante una sonda detectora y en 100 casos (70 vulvares y 30 de cuello uterino) se administró también un colorante vital pocos minutos antes del inicio de la intervención. Se realizó estudio anatomopatológico del GC. Se practicó linfadenectomía reglada en todas las pacientes con cáncer de cérvix y de endometrio y en las primeras 35 pacientes con cáncer de vulva.La linfogammagrafía prequirúrgica visualizó como mínimo un GC en el 97% de los cánceres de vulva, en el 92% de cérvix y el 64% de tumores de endometrio. Intraoperatoriamente la localización del GC mostró unos porcentajes del 97, del 90 y del 62%, respectivamente. El estudio anatomopatológico demostró metástasis en el 24,2% de las pacientes con lesiones vulvares, el 8,8% en las de cérvix y el 4,5% en las de endometrio. El porcentaje de falsos negativos fue del 5,5% en los cánceres de vulva (1 caso), presentándose 2 casos en el endometrio y ninguno en las pacientes con cáncer de cérvix.La linfogammagrafía es una técnica útil y sencilla para identificar los GC en este tipo de tumores. La biopsia del GC ofrece resultados fiables en los cánceres de vulva y cuello uterino. Sin embargo, en el cáncer de endometrio nuestros resultados no son óptimos y debe valorarse la adecuación de la técnica.Although sentinel lymph node (SLN) identification is widespread used in melanoma and breast cancer some concerns exist in other malignancies, such gynaecologic cancers, and this staging method has not been adopted in many centers due to lack or large validation studies.To evaluate the applicability and results of SLN technique in gynaecological malignancies referred to our institution.We studied 155 patients with different malignancies (70 vulvar, 50 cervical and 35 endometrial cancers). The day before surgery a lymphoscintigraphy was performed by injecting 111 MBq of 99mTc-nanocolloid in several ways depending on the type of cancer studied. Intraoperative detection of the SLN was always performed by using a hand-held gammaprobe and, in 100 cases with the aid of blue dye injection (70 vulvar and 30 in cervical cancer) few minutes before surgical intervention. Pathological study of SLN was performed in all cases. Lymphadenectomy was done in all cervix and endometrial cancer patients and in the first 35 vulvar cancer patients.Pre-surgical lymphoscintigraphy demonstrated one, at least, SLN in 97% of vulvar cancer patients, 92% in the cervical malignancy and 64% in the endometrial cancer patiuents. During surgery, SLN was harvested in 97%, 90% and 62% of patients, respectively. The pathological study showed metastases in 24.2%, 8.8 and 4.5% of patients with vulvar, cervical and endometrial cancer, respectively. The false negative percentage was 5.5% in vulvar cancer patients, with 2 cases in the endometrial cancer and without any case in the cervical cancer patients.Lymphoscintigraphy is a relatively simple and useful technique to identify the SLN in this kind of tumours. However, in endometrial cancer more effort has to be made to reach a suitable result. Sentinel lymphm node biopsy seems to be a reliable technique in vulvar and cervical malignancies.