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Concordance of Peritumoral Technetium 99M Colloid and Subareolar Blue Dye Injection in Breast Cancer Sentinel Lymph Node Biopsy

      Introduction

      Sentinel lymph node (SLN) mapping has emerged as a less invasive method for axillary lymph node staging in patients with breast cancer. Blue dye and radioisotopes are commonly used agents to localize SLNs, but the optimal site for the injection of these agents continues to be debated. In this study, we evaluated whether subareolar injection of blue dye led to the identification of the same SLNs as peritumoral injection of technetium colloid.

      Methods

      From March 2003 to August 2006, 124 patients with invasive breast cancer, diagnosed by core needle biopsy, were included in this study. Demographic and clinical data were abstracted from medical records. Approximately 1 h prior to surgery, all patients had peritumoral injection of 37 Mbq of Tc-99m-sulfur colloid. In the operating room, 3 to 5 mL of 1% lymphazurin was injected into the subareolar area. SLNs were categorized as radio-labeled-only, blue-only, or radio-labeled + blue. Data were analyzed with 95% exact confidence intervals, Spearman rank coefficient and κ coefficient.

      Results

      The mean number of SLNs identified was 1.9 (range 1–5). With the combination of two methods 122 out of 124 patients (98.4%) had successful identification of SLNs. One hundred fifteen patients (92.7%) had SLNs that were blue and 121 patients (97.6%) had radio-labeled SLNs. One hundred fourteen patients had at least one SLN that was both blue and radio-labeled, yielding a concordance rate of 91.9% (95% CI, 0.88–0.98). Metastatic disease was identified in SLNs of 28 patients. All lymph nodes with evidence of metastasis were both blue and radio-labeled.

      Conclusions

      Our study showed a high degree of concordance between subareolar blue dye and peritumoral radiocolloid in identification of SLNs. These results further support that the breast parenchyma and subareolar plexus drain to similar SLNs within the axilla. These two techniques can complement each other in localizing SLNs with a high success rate.

      Key Words

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      References

        • Morton D.L.
        • Wen D.R.
        • Wong J.H.
        • et al.
        Technical details of intraoperative lymphatic mapping for early stage melanoma.
        Arch Surg. 1992; 127: 392
        • Krag D.N.
        • Weaver D.L.
        • Alex J.C.
        • et al.
        Surgical resection and radio localization of the sentinel lymph node in breast cancer using a gamma probe.
        Surg Oncol. 1993; 2: 335
        • Guiliano A.E.
        • Kirgan D.M.
        • Guenther J.M.
        • et al.
        Lymphatic mapping and sentinel lymphadenectomy for breast cancer.
        Ann Surg. 1994; 220: 391
        • Burak W.E.
        • Hollenbeck S.T.
        • Zervos E.E.
        • et al.
        Sentinel lymph node biopsy results in less postoperative morbidity compared with axillary lymph node dissection for breast cancer.
        Am J Surg. 2002; 183: 23
        • Keramopoulos A.
        • Tsionou C.
        • Minaretzis D.
        • et al.
        Arm morbidity following treatment of breast cancer with total axillary dissection: A multivariate approach.
        Oncology. 1993; 50: 445
        • Albertini J.J.
        • Lyman G.H.
        • Cox C.
        • et al.
        Lymphatic mapping and sentinel node biopsy in the patient with breast cancer.
        JAMA. 1996; 276: 1818
        • Sappey M.P.C.
        Injection Preparation et Conservation des Vais-Seaux Lymphatiques.
        Thesis for a doctorate in medicine, no 241. Rignoux Imprimeur de la Faculte de Medecine, Paris1834
        • Turner-Warwick R.T.
        The lymphatics of the breast.
        Br. J. surg. 1959; 46: 574-582
        • Spratt J.S.
        Anatomy of the breast.
        Clin Surg. 1979; 5: 1
        • Tanis P.J.
        • Nieweg O.E.
        • Olmos R.A.
        • et al.
        Anatomy and physiology of lymphatic drainage of the breast from the perspective of sentinel node biopsy.
        J Am Coll Surg. 2001; 192: 399
        • Borgstein P.F.
        • Meijer S.
        • Pijpers R.J.
        • et al.
        Functional lymphatic anatomy for sentinel node biopsy in breast cancer: Echoes from the past and the periareolar blue method.
        Ann Surg. 2000; 232: 81
      1. Borgstein PJ, Meijer S, Pijpers R. Intradermal blue dye to identify the sentinel lymph node in breast cancer. Eur J Surg Oncol 998;24:427.

        • Reitsamer R.
        • Peintinger F.
        • Rettenbacher L.
        • et al.
        Subareolar subcutaneous injection of blue dye versus peritumoral injection of technetium-labeled human albumin to identify sentinel lymph nodes in breast cancer patients.
        World J Surg. 2003; 27: 1291
        • Bauer T.W.
        • Spitz F.R.
        • Callans L.S.
        • et al.
        Subareolar and peritumoral injection identify similar nodes for breast cancer.
        Ann Surg Oncol. 2002; 9: 169
        • Tuttle T.M.
        • Colbert M.
        • Christensen R.
        • et al.
        Subareolar injection of 99m Tc facilitates sentinel lymph node identification.
        Ann Surg Oncol. 2002; 9: 77
        • Klimberg V.S.
        • Rubio I.T.
        • Henry R.
        • et al.
        Subareolar versus peritumoral injection for location of the sentinel lymph node.
        Ann Surg. 1999; 6: 860
        • Nathanson S.D.
        • Wachna D.L.
        • Gilman D.
        • et al.
        Pathways of Lymphatic drainage from the breast.
        Ann Surg Oncol. 2001; 8: 837
        • Gray R.J.
        • Pockaj B.A.
        A concordance study of subareolar and subdermal injections for breast cancer sentinel lymph node mapping.
        Am J Surg. 2004; 188: 423
        • Martin R.C.
        • Chagpar A.
        • Scoggins C.R.
        • et al.
        Clinicopathologic factors associated with false-negative sentinel lymph-node biopsy in breast cancer.
        Ann Surg. 2005; 241: 1005
        • Chagpar A.B.
        • Martin R.C.
        • Scoggins C.R.
        • et al.
        Factors predicting failure to identify sentinel lymph node in breast cancer.
        Surgery. 2005; 138: 56
        • Chagpar A.
        • Martin R.C.
        • Chao C.
        • et al.
        Validation of subareolar and periareolar injection techniques for breast sentinel lymph node biopsy.
        Arch Surg. 2004; 139: 614
        • Linehan D.C.
        • Hill A.D.
        • Akhurst T.
        • et al.
        Intradermal radiocolloid and intraparenchymal blue dye injection optimizes sentinel node identification in breast cancer patients.
        Ann Surg Oncol. 1999; 6: 450
        • Radovanovic Z.
        • Golubovic A.
        • Plzak A.
        • et al.
        Blue dye versus combined blue dye-radioactive tracer technique in detection of sentinel lymph node in breast cancer.
        EJSO. 2004; 30: 913
        • Kern K.A.
        Concordance and validation study of sentinel lymph node biopsy for breast cancer using subareolar injection of blue dye and technetium 99m sulfur colloid.
        J Am Coll Surg. 2002; 195: 467
        • Estourgie S.H.
        • Nieweg O.E.
        • Olmos R.A.
        • et al.
        Eight false negative sentinel node procedures in breast cancer: What went wrong?.
        EJSO. 2002; 29: 336
        • Guenther J.M.
        Axillary dissection after unsuccessful sentinel lymphadenectomy for breast cancer.
        Am Surg. 1999; 65: 991
        • Stearns V.
        • Ewing C.A.
        • Slack R.
        • et al.
        Sentinel lymphadenectomy after neoadjuvant chemotherapy for breast cancer may reliably represent the axilla except for inflammatory breast cancer.
        Ann Surg Oncol. 2002; 9: 235
        • Tafra L.
        • Verbanac K.M.
        • Lannin D.R.
        Preoperative chemotherapy and sentinel lymphadenectomy for breast cancer.
        Am J Surg. 2001; 182: 312