Selective approach to radionuclide-guided sentinel lymph node biopsy in high-risk ductal carcinoma in situ of the breast.

PURPOSE: Ductal carcinoma in situ (DCIS) currently represents approximately 15-25% of all breast cancers detected. Although inherently a noninvasive disease, occult invasive disease can be found at definitive histology. The role of sentinel lymph node (SLN) biopsy in DCIS is still unclear. The aim of this study was to evaluate the clinical usefulness of SLN biopsy and the incidence of SLN metastases in selected patients with high-risk DCIS, who are at highest risk for being upstaged to invasive carcinoma. MATERIALS AND METHODS: Twenty-three high-risk patients with DCIS proven on core biopsy (mean age, 50 years; median age, 48 years; age range, 37-78 years) were included in the study. SLN scintigraphy was performed 2-4 h before surgery by injecting Tc-99m-labeled nanocolloid intradermally in the periareolar region. The first lymph node to appear on the scan was labeled as SLN and was marked on the skin by using a γ probe. The lymph node was explored in the axilla using a γ probe. RESULTS: The SLN was identified in all patients (100% success rate). Of 23 cases of DCIS on core biopsy, seven patients (30%) were shown to have invasive ductal carcinoma on final histological specimen. Among these seven patients, three had minimal invasive carcinoma (<1 cm) and none of these patients had positive SLN for metastases. Among 23 cases, only one patient with (4%) SLN was positive for metastasis despite histopathological diagnosis of pure DCIS. CONCLUSION: Although the study population is small, our findings suggest that patients with high-risk DCIS have an increased risk of invasive disease, as approximately one-third of these patients had invasive component at the time of definitive operative procedure. Furthermore, the study also suggests that SLNB appears to be reliable in identifying axillary lymph nodes status of these patients.

Incremental diagnostic value and impact on patient management of somatostatin receptor scintigraphy with indium-111-pentetreotide in gastroenteropancreatic neuroendocrine tumors.

OBJECTIVE: To evaluate the efficacy of somatostatin analog scintigraphy with indium-111-pentetreotide and its overall impact on management in patients with gastroenteropancreatic neuroendocrine tumors (GEP-NET). SUBJECTS AND METHODS: Twenty-two consecutive patients with a proven or clinically suspected GEP-NET with or without proven metastases were imaged at 24 and 48 h after injection of (111)In-pentetreotide. The scintigraphic findings were compared with results from conventional imaging methods. The final diagnosis was based on histopathological and surgical findings and complementary radiology. RESULTS: Somatostatin receptor-positive lesions were found in 20 of the patients, whereas conventional methods were positive in 18 patients. Additionally, 13 new tumor sites were discovered by somatostatin receptor scintigraphy in 5 patients (liver: 6; chest: 2; bone: 1; abdomen: 4). The surgical therapeutic strategy was changed in 7 patients (32%). CONCLUSIONS: Our data reinforced that scintigraphy with (111)In-pentetreotide represents the imaging modality of choice in the initial evaluation of GEP-NET. It is highly accurate and can identify clinically unsuspected lesions and optimize the overall staging. It also guides optimal therapy choice and most importantly identifies patients with inoperable or metastatic disease who might be candidates for high-dose targeted therapy.

Evaluation of the gamma probe guided sentinel lymph node biopsy and the blue dye technique in the management of breast cancer.

The aim of this study was to evaluate the efficacy of lymphoscintigraphy, gamma probe guided sentinel lymph node biopsy (GP-SLNB) in the management of breast cancer and study the follow-up results. Fifty two patients (mean age 47.28+/-9.7; range 23-69yr) with operable breast carcinoma and clinically negative axilla were studied. Scintigraphy for the detection of SLN was performed 2-4h before surgery by injecting technetium-99m labeled nanocolloid intradermally in the peritumoral region. First lymph node (LN) to appear on the scan was labeled as SLN and by using the GP was marked on the skin. Blue dye was also injected in all patients intraoperatively and hot and/or blue LN were studied in the axilla using the GP. The SLN was identified in 50 patients (96% success rate) while in 2 patients SLN was not visualized on imaging. The blue dye successfully localized SLN in 45/52 (87%) of the cases. Of the 52 patients, 16 had axillary lymph node dissection (ALND), including 14 SLNB positive for lymph node metastases cases and the two cases in which no SLN was imaged. In the remaining 36/52 cases SLN were negative for metastases and patients on the follow-up remained disease free (NPV 100% for a follow-up period of 12-36 months). The success rate, sensitivity, negative predictive value, and accuracy were 96%, 93%, 100%, and 98% using the GP-SLNB, 87%, 80%, 100%, and 93% using blue dye, and 98%, 100%, 100%, and 98% using combined methods, respectively. In conclusion, lymphoscintigraphy, GP-SLNB has a higher success rate and sensitivity versus the dye technique and when combined with the blue dye technique its sensitivity increases to 100%. We found a high negative predictive value for SLNB and the recurrence rate in these negative SLNB was comparable to the ALND.

Minimally invasive radionuclide-guided parathyroidectomy using 99mTc-sestamibi in patients with primary hyperparathyroidism: a single-institution experience.

OBJECTIVE: To evaluate the efficacy and usefulness of (99m)Tc-sestamibi scintigraphy and gamma probe localization of parathyroid glands in patients with primary hyperparathyroidism and establish radio-guided minimally invasive parathyroidectomy at Hussain Makki Al Jumma Center for Specialized Surgery, Kuwait. SUBJECTS AND METHODS: Twelve patients with primary hyperparathyroidism (mean age: 48 +/- 14 years; median age: 46 years; age range: 29-68 years) were evaluated. The diagnosis of hyperparathyroidism was established by elevated serum calcium and parathyroid hormone levels. All patients had a well-defined parathyroid lesion on previous standard (99m)Tc-sestamibi scintigraphy with or without ultrasound study. All had a normal thyroid gland, no history of familial hyperparathyroidism or multiple endocrine neoplasia nor any history of previous neck irradiation. On the day of surgery, patients were injected with 740 MBq (20 mCi) of (99m)Tc -sestamibi followed by a half-hour-delayed single standard pinhole view of the neck. A skin marker was placed on the basis of maximum count intensity during gamma probe localization. Patients were then sent for radio-guided minimally invasive parathyroidectomy. RESULTS: The preoperative localization of the affected gland was successful in all cases using a gamma probe and (99m)Tc -sestamibi scintigraphy. The pathological parathyroid tissue was localized and successfully removed with the gamma probe. The histopathological diagnosis was parathyroid adenoma in 11 cases and hyperplasia in the remaining one. All patients remained disease and symptom free at 12-month follow-up. CONCLUSIONS: Our initial experience with intraoperative use of a gamma probe to carry out minimally invasive parathyroidectomy was a useful, easy and safe procedure for treating patients with primary hyperparathyroidism.