Implications of lymphatic drainage to unusual sentinel lymph node sites in patients with primary cutaneous melanoma

BACKGROUND: Sentinel lymphadenectomy reliably identifies the first site(s) of regional lymphatic drainage and, therefore, the most likely lymph nodes to contain occult metastasis in patients with primary cutaneous melanoma. Although in most patients lymphatic drainage from the primary melanoma first reaches a standard lymph node basin, a sentinel lymph node (SLN) may be identified in an unusual location. The objective of this study was to determine the frequency and significance of unusual sentinel lymph node drainage patterns in a large cohort of patients with primary melanoma. METHODS: The records of 1145 consecutive primary melanoma patients who underwent SLN biopsy were reviewed. Preoperative lymphoscintigraphy was performed in all patients with truncal melanoma and in many patients with distal extremity lesions. Unusual lymph node sites were defined as epitrochlear, popliteal, or ectopic/interval (in-transit or any other nonstandard lymph node-bearing area). RESULTS: At least one SLN was harvested in 1117 patients (98%). SLN biopsy of an unusual lymph node site was attempted in 59 patients (5%). Successful intraoperative localization and biopsy was performed in 54 (92%) of 59 patients for a total of 56 unusual sites. Of these, 7 (13%) were popliteal, 8 (14%) were epitrochlear, and 41 (73%) were ectopic/interval. Preoperative lymphoscintigraphy was performed in 41 of these 54 patients and correctly identified unusual SLN locations in 12 (29%); the majority of unusual SLNs were identified only with the assistance of the intraoperative gamma probe. In four patients (7%), the unusual lymph node site was the only site from which SLNs were harvested. In the remaining 50 patients (93%), biopsies were performed on SLNs from both unusual sites and from a standard lymph node basin. Among the 54 patients who underwent a SLN biopsy of an unusual nodal site, 7 (13%) had lymph node metastases in that location. In four of the seven patients, the only positive SLN was from the unusual site. CONCLUSIONS: Sentinel lymphatic drainage patterns include lymph node-bearing areas that may be outside established standard lymph node basins and may represent the only site of regional lymph node metastases. Although preoperative lymphoscintigraphy may assist in the identification of unusual SLN drainage patterns, intraoperative use of the gamma probe is recommended to identify accurately and completely all sites of regional lymph node drainage.     

Relevance and practicability of internal mammary sentinel node biopsy for breast cancer

OBJECTIVES AND METHOD: Recent observations in breast cancer patients undergoing sentinel lymph node (SLN) mapping, in which drainage can be traced to the internal mammary node (IMN) chain, have renewed interest in the staging and treatment of the disease. This paper discusses the relevance of internal mammary SLN biopsy and suggests an optimal procedure for the identification of the SLN in the IMN chain. RESULTS: Axillary lymph node (AX) and IMN status have similar predictive relevance for survival, while the involvement of IMNs has prognostic value for AX-negative as well as AX-positive patients. Although parasternal recurrence is fortunately rare after modified radical mastectomy or breast conserving surgery, if left untreated it not infrequently develops as clinically evident disease in patients with histologic involvement of IMNs. "Hot" internal mammary SLNs can be identified by means of lymphoscintigraphy and gamma-detection probe after peritumoral injection of radioisotopes. A positive internal mammary SLN biopsy would be an indication for internal mammary radiotherapy as well as adjuvant systemic treatment. However, the reported incidence of positive internal mammary SLNs is still lower than expected because the spread of radioactivity does not necessarily coincide with nodal involvement. CONCLUSION: Internal mammary SLN biopsy has proven to be relevant but not yet fully practical because more data are needed on the collection of a "Hot" internal mammary SLN and on pathologic involvement. This means that internal mammary SLN biopsy should be regarded as still investigative.     

Sentinel lymph node biopsy in breast cancer: an overview of the Japanese experience

This paper reviews the Japanese literature regarding sentinel lymph node (SLN) biopsy in an attempt to provide an overview of existing controversies and to suggest a method for the identification of the SLN and the detection of micrometastases in the SLN to eliminate unnecessary axillary lymph node dissection (ALND). The combined dye- and gamma probe-guided method resulted in the accurate identification of the SLN in 96% of patients, compared with 80% when the dye-guided method alone was used. Although neither 99m-Tc sulfur colloid nor 99m-Tc colloidal albumin is commercially available in Japan, 99m-Tc stannous phytate and 99m-Tc rhenium colloid appear to be ideal tracers for identifying SLNs. Moreover, subdermal injection over the primary tumor or subareolar injection was found to enhance SLN identification, although these injection routes do not lead to detection of internal mammary SLNs. Furthermore, the accuracy of SLN diagnosis using frozen sections as well as imprint cytology improved with an increase in the number of sections, and could attain a sensitivity comparable to that obtained with routine histologic examination of permanent sections. As a result, several surgeons have begun to offer the option of forgoing ALND to patients with negative SLN. Although subsequent relapse in the axilla has not yet been reported, longer follow-up periods are needed to assess accurately the incidence of axillary failure in these negative SLN patients.     

Multidisciplinary approach to selective sentinel lymph node mapping in breast cancer

Although the role of axillary lymph node dissection is controversial with respect to survival benefits, its role as a staging procedure has been well established since nodal involvement is the most reliable prognostic indicator for patients with breast cancer. Selective sentinel lymph node (SLN) dissection is gaining acceptance as a useful staging procedure because it is minimally invasive and spares approximately 70-80% of the patients a more extensive axillary lymph node dissection. The evolving techniques for selective SLN dissection using blue dye and radiotracer methods are reviewed in this article. Based on the classic definition of the breast lymphatic drainage and recently published articles addressing the issue of peritumoral and intradermal injections, a possible new and simplified approach using intradermal injection may identify the axillary SLN more quickly and reliably. This article emphasizes the importance of a multidisciplinary approach in the identification of SLNs by preoperative lymphoscintigraphy performed by expert nuclear medicine physicians, the intraoperative mapping and harvesting of SLNs by well trained surgeons and the meticulous examination of SLNs by experienced pathologists. Therefore, to achieve the highest rate of accuracy regarding SLN status, it is imperative that a multidisciplinary team with close communication and cooperation be formed. The clinical significance of SLNs will be determined by results from follow-up and clinical trials.     

Can axillary dissection be avoided in patients with sentinel lymph node metastasis?

BACKGROUND: Who should undergo a completion dissection following identification of a +sentinel lymph node (SLN) is controversial. METHODS: The records of 1,133 patients who underwent SLN mapping were reviewed. The association between patient, tumor, and treatment characteristics and the presence of +SLNs and +nonSLNs was analyzed using two-way tables of frequency counts and Pearson chi2 test. Possible predictors of +SLNs and +nonSLNs were analyzed using simple and multiple logistic regression. RESULTS: One thousand one hundred forty-eight SLN procedures were performed. 367 procedures (32%) yielded +SLNs. For patients with a +SLN, on multiple logistic regression analysis LVSI, increasing numbers of +SLNs, decreasing numbers of negative SLNs, and increasing size of the largest SLN metastasis were statistically significantly associated with increased likelihood of nonSLN involvement. No subgroup was identified that did not have a significant rate of nonSLN involvement on completion axillary dissection, except those who had a large number of negative SLNs (> or =3) and small size of the largest SLN metastasis (<10 mm). CONCLUSIONS: A definitive answer to the question of who needs a completion axillary dissection awaits the results of ongoing trials. In the interim, our data does not support eliminating dissection for any subgroup of patients with +SLNs.     

Lymphatic mapping and lymphatic endothelial cell isolation in colorectal cancer patients

Background: Sentinel lymph node (SLN) biopsy has already been established as a common procedure with malignant lymphoma and breast cancer. In colorectal cancer, however, the application of the SLN theory remains uncommon and its clinical significance is also unclear. In addition, the characteristics of the lymphatic vessels that connect SLNs or the lymphatic endothelial cells have been unclear. Our purpose is to determine the feasibility and accuracy of SLN mapping by intraoperative subserosal dye injection and to develop a novel method for the isolation of anatomically defined lymphatic endothelial cells. Methods: SLN biopsy by the subserous dye injection method (patent blue) was conducted in 36 patients with colorectal cancer for which curative resection was possible (stage 0: two cases, stage I: 18 cases, stage II: four cases, stage III: 12 cases), with additional systematic lymph node dissection. Endothelial cells were isolated from lymphatic vessels identified at the time of the SLN biopsy by the collagenase II perfusion method, and we tried to transfer them into a culture system with an endothelial cell‐specific medium. Results: SLNs could be identified in 34 cases, providing a 94.4% detection rate. The total number of resected lymph nodes was 705 and 72 of those nodes were confirmed as SLNs (10.2%). Ten metastasis‐positive nodes were found in SLNs (13.9%), and the mean number of identified SLNs per case was 2.0. No complications or toxicity associated with the dye injection were observed. In addition, cells isolated from the lymphatic vessels removed formed some colonies and the expression of lymphatic endothelial cell‐specific VEGFR‐3 was observed. Conclusion: SLNs mapping using subserosal dye injection is a feasible technique that would make the range of lymph node dissection appropriate for colorectal cancer, which is applicable to cases with advanced cancer. This new method was established to isolate lymphatic endothelial cells from resected lymphatic vessels and to culture them, which may contribute to further study of the molecular mechanisms of lymphangiogenesis.     

MR间质淋巴造影在VX2兔乳腺癌内乳前哨淋巴结显像中的初步研究

背景与目的：内乳淋巴结(internal mammary lymph node,IMLN)对乳腺癌远处转移及远期复发的预测价值与腋窝淋巴结的价值相当。IMLN在改良根治术下不能被清除,目前临床上只能对内乳区可能存在转移的患者盲目追加放疗;如何选取适合IMLN活检或切除手术的乳腺癌患者,则是目前临床急需解决的问题。该研究初步探讨MR间质淋巴造影(MR lymphography,MR-LG)检查在显示VX2兔乳腺癌内乳前哨淋巴结(sentinel lymph node,SLN)的可行性。方法：选取纯种雌性新西兰大白兔55只建立VX2兔乳腺癌动物模型,并行MR-LG检查。图像传至ISP(Philips Intellispace Portal)工作站进行后处理,自注射部位至内乳或腋窝方向的引流淋巴管上最先显像的1个或数个淋巴结定义为SLN,记录SLN及引流淋巴管显示情况,并与前哨淋巴结活检(sentinel lymph node biopsy,SLNB)结果对照。结果：55只实验兔建模成功率为98.2%(54/55),最终51只荷瘤兔成功入组。在MR-LG图像上,对比剂注射后5 min扫描较注射后即刻扫描可显示更多的内乳区淋巴管(36 vs 25),且同时显示腋窝SLN及引流淋巴管效果进一步提高(45 vs 37),两者差异均有统计学意义(P=0.021和P=0.040)。在内乳区MR-LG图像上,显像SLN长径为(2.64±0.59)mm,短径为(2.24±0.54)mm,引流淋巴管直径平均值为2.18 mm;肿瘤大小及腋淋巴结数目对内乳淋巴管的显示差异均有统计学意义(P=0.032和P=0.040)。11只荷瘤兔内乳区SLNB共检出内乳区SLN 15枚,位于第2~3肋间者6枚,1~2肋间者5枚,3~4肋间者2枚,而位于第10肋间和剑突旁者各1枚;对照MR-LG,共9只荷瘤兔共显示11枚内乳区SLN,其中7只(77.8%,7/9)与SLNB显示结果一致;SLNB检出的SLN长短径均大于MR-LG图像上显示的SLN,差异均有统计学意义(P<0.05)。结论：MR-LG可显像VX2兔乳腺癌内乳区SLN,但显像率的提高有待进一步研究。     

Indocyanine green guidance for combined robotic pelvic and para-aortic sentinel node mapping in cervical cancer

BackgroundIndocyanine green (ICG) for pelvic sentinel lymph node (SLN) mapping is well established in endometrial cancer (Persson et al., 2019 Jul). However, the application for para-aortic SLNs is less reported; and the detection rate of para-aortic SLNs, mainly after cervical injection of ICG, varies between 14% and 71% (Rossi et al., 2013 Nov; Kim et al., 2020 Mar; Gallotta et al., 2019 Mar). One recent report differentiates between lower and upper para-aortic SLNs in endometrial cancer (Kim et al., 2020 Mar). Here we describe a technique using ICG for identifying pelvic SLNs, lower and upper para-aortic SLNs in cervical cancer.VideoA 46-year old female presented with high grade cervical dysplasia/carcinoma in situ on cervical smear. Cervical cone biopsy revealed a grade two squamous cell carcinoma (depth of invasion 6.8mm, width 20.8mm). Clinically she was staged as an early FIGO-stage IB2 cervical cancer. NMR revealed bilaterally enlarged iliac lymph nodes. Additional PET-CT revealed FDG-uptake in the enlarged pelvic lymph nodes. In view of the imaging findings a staging Robotic pelvic and para-aortic SLN procedure was planned, prior to select the primary treatment (radical hysterectomy or chemo-radiation). ICG was injected into the cervical stroma, and a robotic pelvic and para-aortic SLN dissection (using Firefly System ®, Intuitive Surgical Inc.) was initiated 15 minutes and 35 minutes, respectively, after cervical injection.ResultsThis video demonstrates the application of ICG for mapping bilateral primary pelvic SLNs, secondary and tertiary para-aortic SLNs in the lower and upper para-aortic region respectively, in cervical cancer. Pathology revealed one metastatic pelvic SLN on the left side, other four pelvic SLNs were negative; both the secondary/lower (n = 3) and tertiary/upper (n = 5) para-aortic SLNs were negative, as well as the non-SLNs (n = 8).ConclusionThe application of ICG for para-aortic SLN mapping should further be investigated and validated in staging surgically locally advanced cervical cancer and those with suspicious lymph nodes on imaging.     

Histologic changes associated with false‐negative sentinel lymph nodes after preoperative chemotherapy in patients with confirmed lymph node‐positive breast cancer before treatment

BACKGROUND:

A wide range of false‐negative rates has been reported for sentinel lymph node (SLN) biopsy after preoperative chemotherapy. The purpose of this study was to determine whether histologic findings in negative SLNs after preoperative chemotherapy are helpful in assessing the accuracy of SLN biopsy in patients with confirmed lymph node‐positive disease before treatment.

METHODS:

Eighty‐six patients with confirmed lymph node‐positive disease at presentation underwent successful SLN biopsy and axillary dissection after preoperative chemotherapy at a single institution between 1994 and 2007. Available hematoxylin and eosin‐stained sections from patients with negative SLNs were reviewed, and associations between histologic findings in the negative SLNs and SLN status (true negative vs false negative) were evaluated.

RESULTS:

Forty‐seven (55%) patients had at least 1 positive SLN, and 39 (45%) patients had negative SLNs. The false‐negative rate was 22%, and the negative predictive value was 67%. The negative SLNs from 17 of 34 patients with available slides had focal areas of fibrosis, some with associated foamy parenchymal histiocytes, fat necrosis, or calcification. These histologic findings occurred in 15 (65%) of 23 patients with true‐negative SLNs and in only 2 (18%) of 11 patients with false‐negative SLNs (P = .03, Fisher exact test, 2‐tailed). The lack of these histologic changes had a sensitivity and specificity for identifying a false‐negative SLN of 82% and 65%, respectively.

CONCLUSIONS:

Absence of treatment effect in SLNs after chemotherapy in patients with lymph node‐positive disease at initial presentation has good sensitivity but low specificity for identifying a false‐negative SLN. Cancer 2010. © 2010 American Cancer Society.     

前哨淋巴结活检在皮肤型和肢端型黑色素瘤临床诊疗中的价值

背景与目的：前哨淋巴结活检（sentinel lymph node biopsy,SLNB）是评估皮肤型和肢端型黑色素瘤区域淋巴结转移情况及病理学分期的重要手段。SLNB作为外科诊疗规范的重要环节,已在各大诊疗指南中被推荐,也已在中国临床应用近10年。自2017年靶向和免疫治疗应用于中国黑色素瘤治疗领域,患者预后得到显著改善。本研究旨在分析复旦大学附属肿瘤医院近5年恶性黑色素瘤患者的临床资料,评估在新药治疗时代前哨淋巴结（sentinel lymph node,SLN）状态在临床应用的价值和对预后的影响。方法：对2017—2021年在复旦大学附属肿瘤医院黑色素瘤诊治中心接受诊治的381例恶性黑色素瘤患者的临床资料进行回顾性分析。每例患者均接受原发灶扩大切除和相应的SLNB,手术后随访至少6个月。SLN定位使用美兰染色或同位素示踪。结果：本研究共入组381例恶性黑色素瘤患者,平均Breslow浸润深度为3.10 mm,69.8%为肢端型,溃疡率为57.1%,SLN阳性率为34.6%,中位无复发生存率（relapse-free survival,RFS）为17个月。SLN状态是显著影响患者预后的独立危险因素。在N_1a和T₄亚组,SLN活检数>2枚的患者具有更好的RFS。接受完整的区域淋巴结清扫（complete lymph node dissection,CLND）和未清扫患者的RFS差异无统计学意义,在SLN活检数>2枚和SLN微转移直径<1 mm的亚组未清扫者反而具有更优的RFS。结论：SLN状态仍是影响临床无显性转移的黑色素瘤预后的重要因素,对于恶性黑色素瘤患者应常规开展SLNB,在保证微创的前提下,提高SLN定位的准确性,保证SLNB充分。SLN阳性后行即刻CLND对于皮肤型和肢端型黑色素瘤患者未能带来进一步的预后改善。     

Sentinel node biopsy in primary breast cancer: radioactive detection and metastatic disease.

AIM: To examine the relationship between the intensity of the radioactive counts and the presence of tumor metastasis in sentinel lymph nodes (SLNs) in order to correctly identify the number of SLNs to be removed. PATIENTS AND METHODS: Five hundred three breast cancer patients with successful radioisotope localization of SLNs using the combined blue dye and radioisotope method were analyzed. SLN biopsy was continued until all the blue-stained and radioactive nodes were removed. RESULTS: The mean number of harvested SLNs was 1.7+/-0.9, and the number of radioactive SLNs among the harvested nodes was 1.6+/-0.8. SLN metastasis was found in 123 of the 503 cases. The metastasis was detected in the SLN with the highest radioactive count (the hottest SLN) in 94 of the 123 cases with positive SLNs. The positive rate in the hottest SLN was 89% in 61 cases with a single radioactive SLN, and 65% in 62 cases with multiple radioactive SLNs. Of the 29 cases with positivity in other than the hottest SLNs, the metastasis was detected in the second hottest SLN in 16 cases, in the third hottest SLN in one case, in a mixture of negative radioactive SLNs and blue-dye-stained in four cases, and in the negative SLNs and positive non-SLNs (false-negative) in eight cases. Of 123 node-positive cases, 111 cases had metastasis that was detected within the first three hottest SLNs. CONCLUSIONS: These data suggest that lymph node metastasis may not always be detected in the hottest SLN. Thus, in practice, all radioactive and/or blue-dye-stained nodes should be removed for further examination.     

Which Treatment When?

Sentinel lymph node (SLN) biopsy is rapidly emerging as an alternative to axillary lymph node dissection (ALND) for many female breast cancer patients. In contrast, ALND remains the standard of care for male breast cancer patients with similar tumors. We evaluated the results of SLN biopsy in male breast cancer patients with clinically negative axillae. This study included all male breast cancer patients who underwent SLN biopsy at our institution between October 1999 and 2000. All patients had negative axillae on clinical examination and sonography. All patients underwent preoperative lymphoscintigraphy followed by SLN biopsy performed using a combination of isosulfan blue dye and technetium Tc 99m sulfur colloid. Tc 99m sulfur colloid was injected at a dose of 2.5 mCi 24 h before surgery (four patients) or 0.5 mCi 2–4 h before surgery (three patients). Intraoperatively, 5 ml of 1% isosulfan blue was injected adjacent to the breast tumor or biopsy cavity prior to SLN biopsy. A gamma probe was used intraoperatively in order to localize SLNs. Any node that was blue or associated with ex vivo radioactivity counts at least 10 times higher than the axillary background counts was defined as a SLN. SLNs were assessed intraoperatively using touch preparation cytologic examination. Completion ALND was performed if nodal metastases were identified. Seven patients, 44–76 years of age, were included in the study. Preoperative lymphoscintigraphy identified SLNs in five patients. Intraoperatively, SLNs were identified in all seven patients. SLNs were identified in six patients using the gamma probe and in all seven patients using blue dye. The mean number of SLNs encountered was 2.9. Findings on touch preparation cytology correlated with findings on the final pathological analysis examination in all patients. One patient had a positive SLN, this patient had three additional positive nodes identified in his completion ALND specimen. Three patients with negative SLNs had been elected preoperatively to undergo ALND regardless of findings on SLN biopsy, no positive lymph nodes were identified in the ALND specimens from these patients. These findings compare favorably with findings reported in the literature regarding SLN biopsy in female breast cancer patients. Blue dye injection and radioisotope injection were complementary. SLN biopsy should be considered for axillary staging in male breast cancer patients with clinically negative axillae.     

Investigation of sentinel lymph nodes of the axillary and cubital regions in upper-extremity malignant skin tumors: a series of 15 patients

Background. Few articles have reported the location of sentinel lymph nodes (SLNs) in relation to skin-tumor location. We examined the location of SLNs in relation to skin-tumor location in the axillary and cubital regions. Methods. We attempted to detect SLNs of the axillary and cubital regions using 1% sulfan blue dye in 15 patients with melanoma and other skin cancers. Results. SLNs were detected in 12 patients: in 10 patients, one SLN was detected; in 2 patients, two SLNs were detected. In 4 patients, tumor metastasis in SLNs was positive. In 69 samples, 16 metastatic lymph nodes were detected: tumor metastasis was recognized in 4 SLNs and in 12 other lymph nodes. In 8 patients, the SLNs were negative for tumor metastasis. Ten SLNs were found in 45 other samples; all lymph nodes were negative for tumor metastasis (false-negative rate, 0%). The SLNs were located in the following regions: central axillary nodes, 6 cases; lateral axillary nodes, 4 cases; subscapular nodes, 1 case; cubital node, 2 cases. Conclusions. Because the lateral and central lymph nodes drain the lymph channels of the upper extremity, the SLNs were mainly located in the central and lateral lymph nodes in the axillary region. However, the ulnar dorsal hand tumors and the dorsal little-finger skin tumors were connected to the cubital lymph node. It is necessary to check both the cubital and axillary regions when dyed lymph vessels are going toward the cubital region.     

Low locoregional failure rates in selected breast cancer patients with tumor-positive sentinel lymph nodes who do not undergo completion axillary dissection

BACKGROUND: The role for completion axillary dissection (CLND) in patients with breast cancer who have tumor-positive sentinel lymph nodes (SLN) has been questioned. The objective of this study was to examine the long-term safety of avoiding CLND in selected patients with positive SLNs. METHODS: Patients with invasive breast cancer who underwent SLN biopsy at the authors' institution between 1993 and July 2005 were reviewed. Of 3366 total patients, 750 patients had a positive SLN. There were 196 patients with a positive SLN who did not undergo CLND based on clinician and patient preference. Clinicopathologic variables and treatment patterns were analyzed along with locoregional, distant recurrence, and survival. RESULTS: Most tumors were infiltrating ductal carcinomas (74%), estrogen receptor-positive tumors (82%), progesterone receptor-positive tumors (70%), HER-2/neu-negative tumors (78.6%), and tumors were classified predominantly as either T1 or T2 (95.4%). The median number of SLNs removed was 3, and the median number of positive SLNs was 1. The median size of the tumor deposit in the SLN was 1.0 mm (range, 0.1-12.9 mm). Most SLNs were positive by on hematoxylin and eosin staining (64.3%), whereas 35.7% of SLNs were positive only by immunohistochemistry. Most patients underwent breast conservation (68.9%), radiation (58.2%), and chemotherapy (neoadjuvant in 14.3%, adjuvant in 55.6%). With a median follow-up of 29.5 months, no patients had an axillary recurrence, 1 patient had a supraclavicular lymph node recurrence, and 3 patients developed distant metastases. The median time to recurrence was 32 months. CONCLUSIONS: In selected patients who had positive SLNs, the locoregional failure rate was low without CLND. Prospective studies will be valuable to corroborate these results and to refine further the optimal selection criteria for this approach.     

Lymphatic mapping and sentinel node identification in squamous cell carcinoma and melanoma of the head and neck

AIM: The aim of our study was to evaluate the role of scintigraphy in lymphatic mapping and in the identification of the sentinel lymph node (SLN) in patients with head and neck cancer. METHODS: Between September 1999 and February 2001 we enrolled 22 consecutive patients with cancer in the head and neck region: five squamous cell carcinomas, one Merkel cell tumor of the cheek, and 16 malignant melanomas. Lymphoscintigraphy was performed three hours before surgery after injection of 30-50 MBq of 99mTc -Nanocoll in 0.3 mL; the dose was fractionated by injecting the radiotracer at two points around the lesion. Static acquisition (anterior and/or lateral views, 512 x 512 matrix, 5 mins pre-set time) was started immediately after the injections so as to visualize the pathways of lymphatic drainage. The skin projection of the SLN was marked with ink. Intraoperative SLN detection was performed with perilesional injection of patent blue. RESULTS: SLNs were found with lymphoscintigraphy in all patients. Thirty-three SLNs were identified: one occipital node, three nodes at the base of the tongue, 10 superficial lateral nodes (external jugular), five submandibular nodes, five submental nodes, three mastoid nodes and six supraclavicular nodes. Biopsy was performed in 21/22 patients. In 20/22 patients the first lymph nodes were visualized in the proximal cranial regions (retroauricular, jugular and submandibular) at five minutes post injection. The SLN positivity rate was 13.6% (three patients). All patients with tumor-positive SLNs were submitted to radical dissection. Poor concordance in the detection of sentinel nodes was observed with patent blue. CONCLUSIONS: The flow of nanocolloid in the lymph vessels of the head is rapid. In our experience immediate scintigraphic imaging was essential to visualize the pathways of lymphatic drainage and the first SLN. Radioguided SLN biopsy is therefore recommended within three hours. Injection of patent blue is inadvisable because of the poor concordance with lymphoscintigraphy and the risk of permanent tattooing of the face.     

前哨淋巴结检测在早期宫颈癌中的临床应用

背景与目的：前哨淋巴结（sentinel lymphnode,SLN）检测已经广泛应用于一些实体肿瘤的治疗方案设计中,特别是乳腺癌和体表恶性黑色素瘤。若SLN阴性,则可视为该淋巴区域无肿瘤转移。本研究的目的是探讨放射性核素定位法、活性染料定位法及二者联合法探测宫颈癌SLN和评价SLN对早期宫颈癌盆腔淋巴结转移状况的预测价值。方法：27例欲行广泛性子宫切除＋盆腔淋巴结清扫术的宫颈癌患者,术前16h注射^99mTc-右旋糖酐,进行SLN显像：手术时．注射亚甲蓝约4ml,寻找监染淋巴结;同时术中用1探针探测放射性热点。SLN全部被切除后,行广泛子宫切除＋盆腔淋巴结清扫术,所有切除的SLN及非SLN（non—sentinel lymph node,NSLN）分别送常规病理检查。结果：染料法、核素法、联合法对27例患者的SLN检出率分别为96.3%（26/27）、100%（27/27）,100%（27/27）;27例患者中染料法、核素法、联合法分别检出SLN61枚、69枚、70枚;核素法中,术前SPECT/CT融合显像较平面显像多检出4枚宫旁淋巴结。病理结果示7例患者有淋巴结转移,占25.9%（7/27）。SLN检测的敏感性,准确性、阴性预测值,假阴性率分别为85.7%（6/7）,96.3%（26/27）,95.2%（20/21）,14.3%（1/7）。结论：术前SPECT/CT三维断层显像检出SLN的敏感性优于平面显像,并且能够对SLN进行准确定位,联合应用放射性核素定位法和活性染料识别法提高了SLN检出的准确性;SLN的病理结果可以准确的预测早期宫颈癌患者盆腔淋巴结的病理状态。     

Sentinel lymph node biopsy for breast cancer: How many nodes are enough?

INTRODUCTION: Sentinel lymph node (SLN) biopsy using blue dye and radioisotope often results in the removal of multiple SLNs. We sought to determine whether there is a point where the surgeon can terminate the procedure without sacrificing accuracy. METHODS: One thousand one hundred ninety-seven patients from University of Michigan and the Mayo Clinic undergoing SLN biopsy formed the study population. Surgeons removed all SLNs until counts within the axilla were less than 10% of the highest node ex vivo and recorded the order in which they were removed. RESULTS: The mean number of SLNs removed per patient was 2.5 (range 1-9). Approximately 42% of patients had three or more lymph nodes removed, while 19% had four or more lymph nodes removed. Eighteen percent of patients (132/725) at University of Michigan and 22% (103/472) at Mayo Clinic had a positive SLN. Ninety-eight percent (231/235) of patients with lymph node metastases were identified by the 3rd SLN while 100% were identified by the 4th SLN. CONCLUSION: Among patients undergoing SLN biopsy for breast cancer, the only positive SLN is rarely identified in the 4th or higher node. Terminating the procedure at the 4th node may lower the cost of the procedure and reduce morbidity.     

Sentinel lymph node biopsy as guidance for central neck dissection in patients with papillary thyroid carcinoma

BACKGROUND.

Occult lymph node metastasis of papillary thyroid carcinoma (PTC) can be detected by sentinel lymph node (SLN) biopsy, but studies in larger patient cohorts undergoing complete central neck dissection may be required to assess the diagnostic accuracy of SLN. Therefore, the authors prospectively assessed the usefulness of SLN biopsy for the detection of central lymph node metastasis in patients with differentiated PTC who had no suspicious cervical lymphadenopathy.

METHODS.

After peritumoral injection of methylene blue, SLN biopsy was performed in 50 patients with newly diagnosed PTC who had no palpable or ultrasound (US)‐detected lymph node involvement. After SLN biopsy, all patients underwent total thyroidectomy and central neck dissection. The diagnostic accuracy of intraoperative SLN sampling was calculated by comparison with the final pathologic diagnosis.

RESULTS.

SLNs were identified in 46 of 50 patients (92%); of these, 14 SLNs were positive and 32 SLNs were negative on intraoperative frozen sections. One patient had a positive SLN in the jugular region and subsequently underwent modified radical neck dissection. Final pathologic examination revealed that 18 patients (36%), including 4 who had negative SLNs, had central lymph node metastasis. Thus, the sensitivity, specificity, accuracy, and positive and negative predictive values of SLN biopsy were 77.8%, 100%, 92%, 100%, and 88.9%, respectively. Temporary and permanent hypocalcemia developed in 19 patients and 1 patient, respectively. There were no direct complications of SLN sampling.

CONCLUSIONS.

SLN biopsy in patients with PTC without gross clinical or US lymph node involvement was able to detect occult metastasis with high accuracy and may have the potential to select patients who require central neck dissection. Cancer 2008. © 2008 American Cancer Society.     

How many sentinel lymph nodes are enough during sentinel lymph node dissection for breast cancer?

BACKGROUND.: It remains unclear how many sentinel lymph nodes (SLNs) must be removed to accurately predict lymph node status during SLN dissection in breast cancer. The objective of this study was to determine how many SLNs need to be removed for accurate lymph node staging and which patient and tumor characteristics influence this number. METHODS.: The authors reviewed data for all patients in their prospective database with clinical tumor, lymph node, metastasis (TNM) T1 through T3, N0, M0 breast cancer who underwent lymphatic mapping at their institution during the years 1994 through 2006. There were 777 patients who had at least 1 SLN that was positive for cancer. Simple and multiple quantile regression analyses were used to determine which patient and tumor characteristics were associated with the number of positive SLNs. The baseline number of SLNs that needed to be dissected for detection of 99% of positive SLNs in the total group of patients also was determined. RESULTS.: The mean number of SLNs removed in the 777 lymph node-positive patients was 2.9 (range, 1-13 SLNs). Greater than 99% of positive SLNs were identified in the first 5 lymph nodes removed. On univariate analysis, tumor histology, patient race, tumor location, and tumor size significantly affected the number of SLNs that needed to be removed to identify 99% of all positive SLNs. On multivariate analysis, mixed ductal and lobular histology, Caucasian race, inner quadrant tumor location, and T1 tumor classification significantly increased the number of SLNs that needed to be removed to achieve 99% recovery of all positive SLNs. CONCLUSIONS.: In general, the removal of a maximum of 5 SLNs at surgery allowed for the recovery of >99% of positive SLNs in patients with breast cancer. The current findings indicated that tumor histology, patient race, and tumor size and location may influence this number.     

Factors affecting false-negative rates on ex vivo sentinel lymph node mapping in colorectal cancer

Purpose

Despite the increasing use of sentinel lymph node (SLN) mapping after colorectal cancer resection, reported node identification and false-negative rates vary considerably. The main aim of this prospective study was to quantify the false-negative rates on SLN mapping after resection and to evaluate factors influencing them.

Methods

Sixty-nine patients with biopsy-proven cancer of the colon and rectum underwent SLN mapping according to a protocol involving the ex vivo submucosal and peritumoral injection of 2–4 ml of Patent Blue V dye. All lymph nodes visualized were marked as SLN and totally embedded, then two 4 μm sections were cut for hematoxylin and eosin staining, and cytokeratin (AE1/AE3) immunostaining. A standard examination of the whole specimen and of the regional non-sentinel lymph nodes was also performed.

Results

SLNs were identified in 97.3% of the evaluable cases. A mean of 5.0 SLNs were removed per patient (SD ± 4.2). Nine false negatives were identified. Rectal cancer, tumor size > 60 mm, number of metastatic non-sentinel lymph nodes, and mucinous tumors were associated with false-negative SLNs. At multivariate analysis, a rectal location and mucinous differentiation were independently associated with false-negative SLNs.

Conclusions

Ex vivo SLN mapping after colorectal cancer surgery is technically feasible with a high identification rate. Tumor size and stage, rectal involvement and a mucinous histology seem to interfere with the reliability of SLN staging. It is mandatory to standardize the procedure and selection criteria in order to deal with the question of the reliability of SLN mapping in colorectal cancer.