Clinical relevance of internal mammary node mapping as a guide to radiation therapy.

BACKGROUND: The surgical management of breast cancer has changed markedly with the development of lymphatic mapping and sentinel lymph node (SLN) biopsy. Lymphatic mapping technique varies with respect to injection method, mapping agent, and surgical technique. The decision to pursue the internal mammary nodes (IMN) is another source of controversy. METHODS: From April 1998 to November 2000, 1,470 patients underwent lymphatic mapping for breast cancer and were prospectively entered into the breast database. The combined technique method was used, consisting of both isosulfan blue dye and technetium-99 labeled sulfur colloid. Patients with inner quadrant lesions and suspicion for internal mammary metastasis had preoperative lymphoscintigraphy. Those with internal mammary radioactivity noted by either lymphoscintigraphy or gamma probe underwent removal of the internal mammary sentinel nodes. RESULTS: Thirty-six of the 1,470 (2.4%) patients mapped had at least 1 internal mammary lymph node removed. Inner quadrant lesions were present in 24 of the 36 (67%) IMN mapped patients. Of the 36 patients mapping to the IM area, 5 (14%) had at least 1 IM node positive. Two of the 5 (40%) had only IM metastasis, with 1 of these patients having 5 of 5 IMN positive and no disease detected in her axilla. A total of 2 of the 5 (40%) IM positive patients had more than 1 IMN positive. Twenty-eight of the 36 (78%) IM node harvested patients had preoperative lymphoscintigraphy, with 18 (64%) IMN appearing on imaging. Complications occurred in 3 of the 36 (8%) IMN mapped patients, without clinical significance. CONCLUSIONS: Mapping to the IMN basin with the finding of metastasis results in N3 disease by the current staging system. The consequence for these patients is radiation therapy to the IMN basin. It is significant to note that 14% (5 of 36) were upstaged as result of IMN detection and 40% (2 of 5) had multiple positive IMNs. Substantial disease was detected in these 5 patients necessitating additional radiation therapy while avoiding IM radiation and its attendant complications in 86% of patients mapping to the IM basin.

The role of lymphoscintigraphy in the management of the patient with breast cancer.

INTRODUCTION: Regional nodal status is the most powerful predictor of recurrence and survival in women with breast cancer. Lymphatic mapping and sentinel lymph node (SLN) biopsy have been found to accurately predict the regional nodal status. Preoperative lymphoscintigraphy has been used in melanoma patients to identify the basins at risk for metastases when primary sites are located in watershed areas of the body. This study was performed to define the role of lymphoscintigraphy for axillary nodal staging in women with breast cancer. Specifically, can preoperative lymphoscintigraphy define a population of women with breast cancer who have multidirectional drainage or who do not drain to the axilla and need no axillary dissection? METHODS: 516 patients with invasive breast cancer were accrued in a national breast lymphatic mapping trial sponsored by the U.S. Department of Defense. Preoperative lymphoscintigraphy images were produced using filtered technetium-99 sulfur colloid. Lymphatic drainage to axillary and internal mammary sites was noted. RESULTS: Drainage to an axillary SLN was found in 335 (65%) patients, and internal mammary or extra-axillary drainage was noted in 52 (10%) patients. By using sensitive hand-held probes and vital blue dye intraoperatively, the overall success rate of finding an axillary SLN was 85%. Of the 335 patients who had an axillary SLN identified with imaging, all had successful SLN biopsy procedures. Although no SLNs could be imaged in 181 patients, 153 (85%) of these patients had an axillary SLN identified with intraoperative mapping. For 28 patients in which lymphoscintigraphy was negative and intraoperative mapping was unsuccessful, complete axillary node dissection was performed, and 13 (46%) of these patients were found to have metastatic disease in the basin. CONCLUSIONS: Preoperative lymphoscintigraphy can identify those women with primary breast cancers who have extra-axillary regional basin drainage such as internal mammary. The ability to image an axillary SLN was associated with a high success rate of being able to find the node intraoperatively with a combination mapping technique. In a high percentage of patients with negative lymphoscintigraphy, the SLN was identified with more sensitive hand-held probes. Therefore, patients who have a negative preoperative lymphoscintigraphy and intraoperatively are found to have no "hot" spot in the axilla with the hand-held probe still need an axillary node dissection, because 46% of these patients contain metastatic disease in the axilla.

The role of sentinel lymph node biopsy in women undergoing prophylactic mastectomy.

BACKGROUND: Indications for prophylactic mastectomy (PM) range from LCIS to BRCA 1-2 positive, cosmesis, and cancer phobia. Occult cancers have been found in up to 5% of PM cases. Consequently, consideration must be given to the role of sentinel lymph node (SLN) biopsy as a diagnostic procedure in these patients as PM excludes the subsequent option of SLN biopsy. METHODS: From April 1994 to November 1999, all patients undergoing PM had SLN biopsy after four quadrant periareolar injections of radiocolloid (450 mci) and blue dye (5 cc). All patients were prospectively accrued to the computerized database of breast patients. The SLN were all evaluated with hematoxylin and eosin (H&E) as well as CAM5.2 cytokeratin immunohistochemical (CK-IHC) stains. RESULTS: Over a 67-month period, 1,356 patients were mapped; 57 patients underwent PM in which 148 nodes (2.6 nodes per patient) were evaluated. Nodes were examined by routine H&E and CK-IHC staining. Two patients, neither of whom was found to have a cancer in the prophylactic mastectomy breast, were found to have a positive SLN by CK-IHC staining. Infiltrating carcinoma was discovered within the PM breasts of 2 additional patients. Sentinel lymph node biopsy was negative for malignancy by H&E as well as CK-IHC stains. No lymphedema has been detected in PM patients. CONCLUSIONS: Sentinel node biopsy has been shown to be an accurate and minimally invasive method of evaluating the lymphatic basin. This study shows that the absence of known disease within the breast does not preclude the presence of occult cancer or metastatic nodal disease. Four patients (7%) had a significant change in their surgical management as a direct result of sentinel lymph node biopsy. Two patients were spared the complications of a complete axillary node dissection. This minimally invasive procedure accurately evaluated the known disease status and provided new diagnostic information. Most important, once a mastectomy is performed, the opportunity for SLN biopsy is lost should a cancer be found within the breast specimen.

Case report: recurrent pneumothorax in a patient with rheumatoid arthritis.

Rheumatoid arthritis is a multi-system disease. Pulmonary manifestations and complications include pleural disease, pulmonary infections, pneumonitis and interstitial pulmonary fibrosis, bronchogenic carcinoma, arteritis with pulmonary hypertension, obliterative bronchiolitis, bronchiectasis, and amyloidosis. Pulmonary rheumatoid nodules, including rheumatoid pneumoconiosis (Caplan's Syndrome), can result in spontaneous pneumothorax. In this article, the authors present a patient with rheumatoid arthritis and recurrent spontaneous pneumothorax. Through investigation, a bronchopleural fistula caused by a rheumatoid nodule was revealed. The authors also discuss the potential pitfalls caused by a lung nodule in a patient with rheumatoid arthritis, including the overlap with bronchogenic carcinoma and confusion with tuberculosis.

Potential of overuse of the inferior vena cava filter.

To examine indications for, and morbidity and mortality rate of, inferior vena cava filter insertion at a community hospital, the records of 69 patients who received inferior vena cava filters were reviewed. Patients were assigned to three groups--group 1, 45 patients with pulmonary embolism or deep venous thrombosis and a contraindication to anticoagulation; group 2, 14 patients with a diagnosis as in group 1, who received filters without consideration to anticoagulation, and group 3, ten patients with clinically suspected deep venous thrombosis and no objective assessment of the process. Indications for filter placement were recorded. Morbidity and in-hospital mortality rates were 29 and 49 percent, 43 and 36 percent and 10 and 30 percent for groups 1, 2 and 3, respectively (29 and 43 percent overall). Only patients in group 1 had documented indications for caval interruption. Results compared unfavorably with complication and mortality rates reported previously. Non-selective use of inferior vena cava filters is associated with unacceptable morbidity and mortality rates. Strict indications for filters must be well documented.