Intradermal Radiocolloid Injection

Current recommended guidelines for performance ofradioguided sentinel lymphnode biopsy include intradermal injection of 0.5 mCi of 0.2 micron filtered technetium-99 sulfur colloid in a volume of 6 mL at least 1 h prior to operation. For intradermal injection, filtered technetium sulfur colloid is injected in four or five locations into the skin (raise a wheal) overlying the tumor. For tumor locations in which it is not possible to identify the area of skin overlying the tumor, peritumoral injection is recommended. It is important to use the larger volume (6 mL) for peritumoral injection. However, the smaller volume for skin injection is preferable. Intradermal injection appears to reflect accurately the lymphatic drainage of the breast tissue beneath it and results in much more radioactivity reaching the sentinel nodes. Therefore, sentinel node identification is often easier. The other advantage is that the radiocolloid is not diffused throughout the breast tissue, which in upper outer quadrant lesions can often lead to a very difficult time in identifying the sentinel lymph nodes, especially percutaneously.

It has been shown that preoperative lymphoscintigraphy is not necessary in the preoperative evaluation and adds significant expense. In a series of patients we found no difference in the identification of the SLN with or without lymphoscintigraphy. We no longer recommend its routine use in breast SLN localization.

Intraoperative Injection with 5 mL Iymphazurin Dye

Blue dye is injected peritumoral with of 5 mL lymphazurin dye (1% isosulfan blue). The dye should be injected within 5-10 minutes of making the incision to search for the sentinel nodes. Gentle massage of the breast after injection for 5 minutes seems to speed the flow of dye through the afferent lymphatics.

There are several options for injection of the blue dye. For palpable tumors, the dye may be injected around the palpable tumor directly. Ultrasound guidance may be used to inject the dye around the tumor or biopsy cavity if prior excisional biopsy was performed. For nonpalpable lesions for which wire localization has been performed, the entire 5 mL of dye may be injected down the needle, which has been left in place.

Alternatively, the blue dye may be injected under direct vision. If lumpectomy is performed, the dye can be injected into the normal breast tissue following removal of the specimen. For women who have had an excisional biopsy and have elected to have a mastectomy, the previous biopsy cavity can be opened and the vital blue dye injected under direct vision. The biopsy cavity should then be closed and gloves and instruments changed.

The location of the sentinel node should be determined, if possible, by transcu-taneous scanning using a hand-held gamma counter. A "hot spot" in the axilla indicates the location of the sentinel node.

Sentinel Node Biopsy

A small incision will be made in the axilla over the suspected location of the sentinel node. If no hot spot is identified, a curved transverse (anterior to posterior) incision in the lower axilla will give excellent exposure. After incising the clavipectoral fascia to gain access to the axillary contents, the gamma counter is again used to pinpoint the location of the sentinel node. If the tumor is in the upper outer quadrant, the background radioactivity from the tumor injection may make it difficult to detect the sentinel node. Blue stained afferent lymphatic channels should be sought and dissected to the blue-staining sentinel nodes.

All blue lymph nodes should be removed. Similarly, any node with significant radioactivity over background should be removed. Usually, the blue nodes are also the most radioactive, indicating that both techniques identify the same sentinel node. It is possible; however, to have radioactive lymph nodes that are not blue, or blue lymph nodes that are not excessively radioactive. The number of counts per second (cps) should be recorded for each sentinel node in situ, and after removal from the patient. The latter is best performed by placing the node on top of the gamma probe, pointed toward the ceiling.

After removal of each sentinel node, the background activity in the axilla should be examined with the probe and recorded. Background activity less than 10 times the activity of the hottest lymph node indicates that all sentinel nodes have been removed. If no sentinel node is identified, axillary dissection should be carried out in standard fashion.

Each sentinel node should be placed in formalin and labeled separately as sentinel node #1, #2, #3, etc. It is also helpful to record the number of cps for each sentinel node on the pathology sheet.

After the sentinel node(s) are removed, completion level I and II axillary lymph node dissection should be performed. This includes the lymph nodes lying beneath the pectoralis minor muscle, to the axillary vein superiorly, the latissimus dorsi

laterally, and the serratus anterior medially. The long thoracic and thoracodorsal nerves should be identified and preserved. The axillary dissection specimen should be sent separate from the sentinel nodes and clearly marked.

Pathology

Because we know that more intensive pathologic investigation of the sentinel nodes will detect micrometastatic disease and that such micrometastases correlate with worse prognosis, it makes little sense to perform sentinel lymph node biopsy and submit the nodes for routine histology. Each sentinel node should be processed by cutting the lymph node at 2-3 mm intervals ("bread loafing") for paraffin embedding of each piece. At least one section should be taken from each piece (about 5 sections for a 1.0 cm lymph node). For smaller lymph nodes, multiple pieces can be embedded in a single block. Routine H&E stains are performed. The axillary dissection specimen should be examined using routine histologic methods.

References

1. Giuliano AE, Kirgan DM, Guenther JM et al. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg 1994; 220:391-401.

2. Krag DN, Weaver DL, Alex JC et al. Surgical resection and radiolocalization of the sentinel lymph node in breast cancer using a gamma probe. Surg Oncol 1993; 2:335-340.

3. Albertini JJ, Lyman GH, Cox C et al. Lymphatic mapping and sentinel node biopsy in the patient with breast cancer [see comments]. JAMA 1996; 276:1818-22.

4. Veronesi U, Paganelli G, Galimberti V et al. Sentinel-node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph-nodes. Lancet 1997;

349:1864-67.

5. Morton DL, Wen D-R, Wong JH et al. Technical details of intraoperative lymphatic mapping for early-stage melanoma. Arch Surg 1992; 127:392-399.

6. Alex JC, Krag DN. The gamma-probe-guided resection of radiolabeled primary lymph nodes. Surg Oncol Clin N Am 1996; 5:33-41.

7. Giuliano AE, Kirgan DM, Guenther JM et al. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg 1994; 220:391-8; discussion 398-401.

8. Giuliano AE, Dale PS, Turner RR et al. Improved axillary staging of breast cancer with sentinel lymphadenectomy. Ann Surg 1995; 222:394-9; discussion 399-401.

9. Giuliano AE, Jones RC, Brennan M et al. Sentinel lymphadenectomy in breast cancer. J Clin Oncol 1997; 15:2345-2350.

10. Giuliano AE. Sentinel lymphadenectomy in primary breast carcinoma: An alternative to routine axillary dissection [editorial]. J Surg Oncol 1996; 62:75-7.

11. Nathanson SD, Anaya P, Karvelis KC et al. Sentinel lymph node uptake of two different technetium-labeled radiocolloids. Ann Surg Oncol 1997; 4:104-10.

12. Statman R, Giuliano AE. The role of the sentinel lymph node in the management of patients with breast cancer. Adv Surg 1996; 30:209-21.

13. Rosen PP, Lesser ML, Kinne DW et al. Discontinuous or "skip" metastases in breast carcinoma. Analysis of 1228 axillary dissections. Ann Surg 1983; 197:276-83.

14. Van Lancker M, Goor C, Sacre R et al. Patterns of axillary lymph node metastasis in breast cancer. Am J Clin Oncol 1995; 18:267-272.

15. Dowlatshahi K, Fan M, Snider HC et al. Lymph node micrometastases from breast carcinoma. Reviewing the dilemma. Cancer 1997; 80:1188-1197.

16. Clare SE, Sener SF, Wilkens W et al. Prognostic significance of occult lymph node metastases in node-negative breast cancer. Ann Surg Onc 1997; 4:447-451.

17. Burak, William Jr E, Walker et al. Routine preoperative lymphoscintigraphy is not necessary prior to sentinel node biopsy for breast cancer. Am J Surg 1999; 177(6):445-449.

Chapter 9

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