High discordance rates between sub-areolar and peri-tumoural breast lymphoscintigraphy.

OBJECTIVE: To test the hypothesis that sub-areolar (SA) lymphoscintigraphy (LSG) identifies the same sentinel node as peri-tumoural (PT) injections. BACKGROUND: It is commonly believed that all LSG techniques will identify the same sentinel lymph nodes (SLN) draining the breast. Hybrid imaging technology (SPECT/CT) allows accurate identification of the exact location of SLNs. Using SPECT/CT SA and PT LSG techniques were compared. METHOD: In a multi-centre trial 39 patients sequentially underwent LSG (SA followed by PT) separated by 2-7 days. Patients were referred by 4 surgeons to 3 LSG centres, with standardization of isotope (99mTc-antimony sulfide colloid), LSG and SPECT/CT evaluation techniques. LSG were evaluated for SLN concordance and degree of discordance in the axilla and internal mammary nodes (IMN). RESULTS: 39 eligible patients, median age 62 years, were recruited. Successful axillary SLN mapping for SA and PT injection techniques was 87% and 95% respectively. Successful internal mammary SLN mapping occurred with SA and PT LSG in 5% and 36% respectively. Discordance was identified in the IMN (39%) and axilla (21%), with an overall rate of discordance between SA and PT LSG of 56%. CONCLUSIONS: There is a high level of discordance in the localization of SLN by these commonly used LSG injection techniques. This discordance has implications for accuracy of axillary and extra-axillary staging and could impact on patient outcome.

Multicentre evaluation of intraoperative molecular analysis of sentinel lymph nodes in breast carcinoma.

BACKGROUND: Ideally, intraoperative sentinel lymph node (SLN) analysis in breast cancer should be automated, have high concordance with extensive histopathology, and be applicable in any hospital setting. A prospective multicentre evaluation of the one-step nucleic acid amplification (OSNA) automated molecular diagnostic system of SLN analysis was undertaken. METHODS: Intraoperative examination of SLNs from 204 patients with breast cancer was performed by OSNA at four sites in the UK. Half of each SLN was assessed by OSNA (for cytokeratin 19 mRNA) and the remaining half was paraffin embedded for intensive histological examination at ten levels. Discordant cases were reanalysed by further molecular biological techniques and by additional histological examination of all remaining nodal material to ascertain whether the discordance was due to an uneven distribution of metastases, known as tissue allocation bias (TAB). RESULTS: After exclusion of samples affected by TAB, the overall concordance rate for OSNA versus histopathology was 96.0 per cent, with a sensitivity of 91.7 per cent and a specificity of 96·9 per cent. The median time to process a single SLN was 32 (range 22-97) min, and that for two nodes 42 (30-73) min. CONCLUSION: OSNA enables accurate automated intraoperative diagnosis and can be used successfully in different UK hospitals. When the SLN is shown to be positive, the patient can undergo immediate axillary clearance under the same anaesthetic rather than having a delayed second procedure.

Angioplasty and stenting in the posterior cerebral circulation.

PURPOSE: To report initial experience with intracranial vertebral artery (VA) and basilar artery (BA) percutaneous transluminal angioplasty (PTA) and stenting. METHODS: Eleven patients (10 men; mean age 66 years, range 56-75) with intracranial 14 VA and 3 BA stenoses were managed from December 1997 through November 1999. All patients presented with vertebrobasilar ischemia (VBI) despite antiplatelet and anticoagulant therapy. Clinical presentations included visual disturbance (n = 8), dysarthria/dysphasia (n = 5), and vertigo (n = 5). RESULTS: Five patients underwent PTA only of 7 lesions with a mean preprocedural stenosis of 80% (range 50%-90%) that was reduced to 54% (range 30%-70%) after dilation. Six patients received 9 stents, 2 for VA dissections, 3 for tandem lesions, and 1 for a BA lesion. There were no embolic strokes. Patients were followed by clinical evaluation and personal or telephone interviews. Over a mean 18-month follow-up (range 12-35), 8 (73%) patients remained asymptomatic, while 3 (27%) had permanent deficits, 2 related to the procedure and 1 owing to distal disease CONCLUSIONS: Intracranial VA or BA angioplasty and stenting alleviated symptoms in patients with vertebrobasilar ischemia despite best medical management and may prevent stroke.