Excision biopsy of breast lesions changes the pattern of lymphatic drainage.

BACKGROUND: The aim was to validate the sentinel node biopsy procedure in women who had previous breast excision biopsy by means of determining the reproducibility of lymphoscintigraphy after surgery. METHODS: Twenty-five women scheduled for excision biopsy of a breast lesion were investigated. The day before surgery, (99m)Tc-labelled nanocolloid was injected into the tumour. Lymphoscintigraphy was repeated a minimum of 2 weeks after surgery. RESULTS: Preoperative lymphoscintigraphy visualized at least one sentinel node in all 25 women. Discrepancy in the drainage patterns after surgery was noted in 17 of 25 patients. A change in the drainage pattern in the axilla after excision biopsy was seen in 11 women. Drainage to the internal mammary chain was noted before surgery in 13 women, but only three had the same drainage pathways after excision biopsy. CONCLUSION: After breast excision biopsy lymphoscintigraphy usually showed a different drainage pattern. This implies that sentinel node biopsy should be performed before excision biopsy to ensure optimal sensitivity.

High incidence of in-transit metastases after sentinel node biopsy in patients with melanoma.

BACKGROUND: The occurrence of in-transit metastases in patients with a tumour-positive sentinel node varies greatly between centres and it has been suggested that the incidence is high in this patient group. METHODS: The incidence of in-transit metastases in 61 patients who had lymph node dissection because of a tumour-positive sentinel node was compared with that in 60 patients who had palpable nodal metastases dissected. RESULTS: The incidence of in-transit metastases was 23 per cent in patients with a positive sentinel node and 8 per cent in those with palpable nodes (P = 0.027). CONCLUSION: Sentinel node biopsy was associated with a higher risk of in-transit metastases. This finding does not support the routine use of sentinel node biopsy in the management of melanoma.

How to avoid false-negative dynamic sentinel node procedures in penile carcinoma.

PURPOSE: Evaluation of the false-negative dynamic sentinel node procedures in penile carcinoma at our institute. MATERIALS AND METHODS: Between January 1994 and February 2003, 123 patients with penile squamous cell carcinoma underwent dynamic sentinel node biopsy. RESULTS: The sentinel node revealed metastasis in 28 (23%) of 123 patients. Regional recurrence after excision of a tumor-negative sentinel node or after nonvisualization was seen in 6 patients resulting in a false-negative rate of 18% (6 of 34). We assume that 1 false-negative case was due to tumor blockage, 3 to tumor blockage and rerouting, 1 to a pathological sampling error and 1 to a low radioactivity level in the sentinel node during surgery. CONCLUSIONS: Based on the false-negative results, important adaptations have been made in the dynamic sentinel node biopsy procedure for penile carcinoma at our institute. Pathological analysis was extended by serial sectioning and immunohistochemical staining, and preoperative ultrasonography with fine needle aspiration cytology has been added. Furthermore, exploration of groin without visualized sentinel nodes and intraoperative palpation of the wound have been introduced.

Eight false negative sentinel node procedures in breast cancer: what went wrong?

AIMS: The purpose of the study was to evaluate the false negative sentinel node procedures in patients with breast cancer at our institution. METHODS: A total of 606 sentinel node biopsies were performed on 599 clinical N0 breast cancer patients between January 1997 and November 2001. RESULTS: The axillary sentinel node revealed metastasis in 204 (36.1%) of the 565 patients in whom it was identified and was false negative in eight patients. Two false negative results came to light by confirmatory axillary lymph node dissection during the learning phase. Tumour-positive lymph nodes were incidentally found in the axillary tail of the simple mastectomy specimen in two patients. Excision of a firm, non-radioactive, unstained but tumour-positive non-sentinel node occurred in three other patients. One patient developed an axillary recurrence 22 months postoperatively. Presumptive causes were surgical delay, pathological sampling error and tumour blocking. CONCLUSION: Intra-operative palpation of the axilla to identify suspicious lymph nodes is recommended. In a two-day protocol, surgery should be performed first thing in the morning. Seven slices of 50-150-micro m strike an acceptable balance between sensitivity and work load for the pathologist.

Lymphatic mapping with tracer administration into the primary breast cancer.

There is an ongoing debate over the best tracer injection technique in lymphatic mapping for breast cancer. The technique of low tracer volume administration into the primary breast cancer is presented. The reasons that led to this approach are explained as well as its advantages. Excision of radioactivity that remains at the injection site in the breast cancer prevents the gamma ray scatter that may hamper retrieval of a sentinel node. The intralesional injection technique avoids potential injection of tracer fluid across a lymphatic watershed, it enables identification of extra-axillary sentinel nodes and allows probe-guided excision of non-palpable tumours.

Status of lymph node staging.

Sentinel node biopsy has the potential to provide more accurate staging information than axillary node dissection. Given the considerable morbidity of axillary node dissection this less invasive approach is attractive. However, there are a number of issues to be resolved before the best technique of sentinel node biopsy is determined. When large studies with long-term follow up demonstrate that lymphatic mapping to identify clinically occult lymph node metastases is as effective as we hope, then full axillary node dissection can be reserved to treat patients who indeed have lymph node metastases. Around 60% of the patients could then be spared an axillary node dissection that they do not need because they do not have metastases there. Modern technology is providing more accurate prognostic information based on primary tumor characteristics. Applying these technologies to sentinel lymph nodes may render the lymph node status even more relevant than it currently is.