Sentinel-lymph node biopsy in breast cancer.
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Axilla↗
Biomedical subjects
R F Uren
Publications and source records attributed to R F Uren.
Lymphatic drainage from the skin of the back to retroperitoneal and paravertebral lymph nodes in melanoma patients.
BACKGROUND: Preoperative lymphoscintigraphy (LS) with 99mTc antimony sulphide colloid is now part of the routine management of patients with intermediate thickness melanoma at the Sydney Melanoma Unit. Over a 13-year period, 1375 patients have been examined using LS, and we have observed many unusual lymphatic drainage pathways, including direct drainage through the body wall to retroperitoneal and paravertebral lymph nodes from the skin of the back. The aim of this study was to determine the incidence of such drainage in the 542 patients who had primary melanoma sites on the posterior trunk. METHODS: The lymphoscintigrams performed on these patients were examined for the presence of direct lymphatic drainage through the posterior body wall to sentinel nodes in the retroperitoneal and paravertebral regions. RESULTS: Lymphatic drainage directly through the body wall to such lymph nodes occurred in 14 of these 542 patients. CONCLUSIONS: Preoperative knowledge of the presence of this lymph drainage pattern may influence surgical management, and follow-up investigations in these patients can be tailored to ensure that the relevant areas are examined with anatomic imaging or F18-FDG PET scans.
Back↗
Demonstration of second-tier lymph nodes during preoperative lymphoscintigraphy for melanoma: incidence varies with primary tumor site.
BACKGROUND: Preoperative cutaneous lymphoscintigraphy (LS) to identify sentinel (first-tier) lymph nodes was performed in 250 consecutive melanoma patients before wide local excision only or wide local excision with sentinel node biopsy. METHODS: The location of the sentinel nodes was marked on the overlying skin in all patients. Whether or not tracer was present in second-tier lymph nodes on the delayed scans was recorded for each patient and related to the lesion site at which the tracer had initially been injected. For 100 consecutive patients the rate of tracer movement through the lymphatic channels was compared to the incidence of second-tier drainage. RESULTS: Second-tier nodes were visualized in all patients with melanomas on the leg and thigh, and in almost all patients with melanomas on the forearm and hand, but were seen less often in patients with more centrally located melanomas. There was a significant correlation between the rate of lymph flow and the incidence of demonstrable second-tier drainage. CONCLUSION: The results suggest that the physiology of the lymphatic system varies depending on the origin of the lymphatic vessel. These findings have important implications for application of the sentinel node biopsy technique in individual patients.
Antimony↗
The value of pre-operative lymphoscintigraphy in breast cancer treatment.
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Breast Neoplasms↗
Exclusive lymphatic drainage from a melanoma on the back to intraabdominal lymph nodes.
Preoperative lymphoscintigraphy with Tc-99m antimony sulphide colloid was performed for a patient with a cutaneous melanoma on the left back. There was direct lymphatic drainage to retroperitoneal and paravertebral nodes but no drainage whatsoever to the axillary, inguinal, or triangular intermuscular space node fields, which would normally be expected to drain this area of the skin. Any attempt at sentinel lymph node biopsy in the axilla, groin, or triangular intermuscular space would have failed in this patient.
Abdomen↗
Variability of cutaneous lymphatic flow rates in melanoma patients.
Preoperative lymphoscintigraphy was performed in 198 consecutive patients with cutaneous melanoma prior to their definitive surgical treatment. After intradermal injection of antimony sulphide colloid labelled with technetium-99m, lymphatic flow rates were measured in each patient and found to vary according to the location of the primary tumour. The fastest flow rates occurred from melanoma sites on the distal limbs, particularly the lower limbs. The slowest flow rates were from the head and neck region and the proximal limbs, especially the upper arms and shoulders. Lack of flow in the early dynamic images occurred most commonly for tumours on the upper arms and shoulders. These results can be used to optimize the timing of blue dye injection prior to surgery and may influence the sentinel node biopsy method to be used in individuals who show no early drainage.
Antimony↗
Variability in the interpretation of dimercaptosuccinic acid scintigraphy after urinary tract infection in children.
UNLABELLED: Technetium-99m-dimercaptosuccinic acid (DMSA) scintigraphy is a frequently used diagnostic test in pediatric practice to assess the presence and severity of renal damage. Most commonly it is performed after urinary tract infection. The aim of this study was to investigate the variability in the interpretation of DMSA scans by pediatric nuclear medicine physicians in this clinical setting. METHODS: We selected all 441 scans from children with first-time urinary tract infection who presented between 1993 and 1995 to a pediatric casualty department and who are participants in a prospective cohort study. Two hundred and ninety-four scans were performed at a median time of 7 days after diagnosis, and 147 scans were from children who were free from further infection over a 1-yr follow-up period. Two experienced nuclear medicine physicians independently interpreted the 441 scans according to whether renal damage was present or absent and using the modified 4-level grading system for DMSA abnormality of Goldraich. Apart from being informed that urinary tract infection was the indication for DMSA scintigraphy, no other clinical information was given to the nuclear medicine physicians. The indices of variability used were the percentage of agreement and the kappa statistic. For the grading scale used, both measures were weighted with integers representing the number of categories from perfect agreement. Disagreement was analyzed for children, kidneys and kidney zones. RESULTS: There was agreement in 86% (kappa = 69%) for the normal-abnormal DMSA scan dichotomy, and the weighted agreement was 94% (weighted kappa = 82%) for the grading of abnormality. Disagreement of DMSA scan interpretation of > or =2 grades was present in three cases (0.7%). The same high level of agreement was present for patient, kidney and kidney zone comparisons. Agreement was not influenced by age or timing of scintigraphy after urinary tract infection. CONCLUSION: Two experienced nuclear medicine physicians showed good agreement in the interpretation of DMSA scintigraphy in children after urinary tract infection and using the grading system of Goldraich.
Child↗
Patterns of abnormality on bone scans in acute childhood leukemia.
Bone scintigraphy is not performed routinely in the diagnostic work-up of children with leukemia; however, the initial diagnosis of childhood leukemia is often difficult to make and may be delayed. Patients may present with fever and skeletal symptoms and, in such cases, bone scintigraphy may be requested in the early search for a diagnosis. Recognition of the potential scintigraphic abnormalities that result from leukemic infiltration of bone and bone marrow will often facilitate an early diagnosis of leukemia. Bone scans also play a role in detecting osteomyelitis in the immunosuppressed leukemic child with fever and bone pain. This article presents four patients illustrating the salient features of bone scintigraphy in these clinical settings.
Arthritis, Infectious↗
Failure to detect drainage to the popliteal and epitrochlear lymph nodes on cutaneous lymphoscintigraphy in melanoma patients.
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Antimony↗
Contralateral groin node metastasis from lower limb melanoma.
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Aged↗
Single-dose isotope injection for both preoperative lymphoscintigraphy and intraoperative sentinel lymph node identification in melanoma patients.
For patients with melanoma the 'sentinel' lymph node biopsy technique, although simple in concept, has the potential to provide misleading information if great care is not taken to ensure accurate sentinel node (SN) identification. The method initially reported involved lymphatic mapping by injection of blue dye around the primary melanoma site. Preoperative lymphoscintigraphy was subsequently shown to improve both the speed and accuracy of SN identification. More recently, intraoperative use of a hand-held gamma probe has been recommended, and it is likely that maximum reliability of SN biopsy will be achieved if all three manoeuvres are undertaken. As originally described, use of a gamma probe intraoperatively followed injection of tracer a short time before the surgical procedure. We report a simpler method of confirming SN identity with a gamma probe, using residual activity in the node following lymphoscintigraphy the previous day. In 21 patients close concordance with preoperative lymphoscintigram results and intraoperative findings after blue dye injection confirmed the reliability of the technique. Avoiding the need for repeat isotope administration on the day of surgery simplifies logistics, reduces costs, minimizes inconvenience and radiation dose for patients, and eliminates potential health and safety problems for operating theatre staff.
Antimony↗
Direct lymphatic drainage from the skin of the forearm to a supraclavicular node.
Lymphoscintigraphy with Tc-99m antimony sulfur colloid was performed on a patient with cutaneous melanoma of the left forearm to define the sentinel nodes before surgery. The patient was found to have direct lymphatic drainage from the left forearm through a clearly seen lymph channel to a sentinel lymph node in the left supraclavicular fossa, and drainage through a separate channel to two sentinel nodes in the left axilla. Surprising patterns of lymphatic drainage can be seen from the forearm, as well as other parts of the skin, and lymphoscintigraphy will enable such patients to be identified before sentinel node biopsy.
Axilla↗
Lymphatic drainage to triangular intermuscular space lymph nodes in melanoma on the back.
METHODS: Lymphoscintigraphy with 99mTc-antimony sulphide colloid was performed on patients with cutaneous melanoma of the back to define draining node fields and sentinel nodes before surgery. RESULTS: One patient was found to have drainage from the back to sentinel lymph nodes in the triangular intermuscular spaces bilaterally, above and lateral to the scapula. Subsequently, drainage to this node field has been found in 26% of 42 consecutive patients who have had lymphoscintigraphy performed for melanoma on the back. CONCLUSION: When performing lymphoscintigraphy to locate draining node fields and sentinel nodes in patients with melanoma on the back, it is important to look for drainage to the triangular intermuscular space node field by obtaining posterior and lateral scans. Any sentinel lymph nodes found in this field should be marked prior to surgery in the same way as nodes in other node fields are delineated so that they may be removed at surgery.
Adult↗
Prediction of potential metastatic sites in cutaneous head and neck melanoma using lymphoscintigraphy.
BACKGROUND: The technique of lymphoscintigraphy may allow a more selective approach to the management of clinically negative neck nodes among patients with cutaneous head and neck melanoma. PATIENTS AND METHODS: A group of 97 patients with cutaneous head and neck melanoma had preoperative lymphoscintigraphy using intradermal injections of technetium 99m antimony trisulfide colloid to identify sentinel nodes. Fifty-one patients were eligible for clinical analysis after initial definitive treatment by wide excision only (n = 11), wide excision and elective dissection of the neck (n = 19) or axilla (n = 1), or wide excision and a sentinel node biopsy procedure (n = 20). RESULTS: Sentinel nodes were identified in 95 of 97 lymphoscintigrams, and 85% of patients had multiple sentinel nodes. In 21 patients (22%), sentinel nodes were identified outside the parotid region and the 5 main neck levels, mostly in postauricular nodes (n = 13). Lymphoscintigrams were discordant with clinical predictions in 33 patients (34%). Lymph nodes were positive in 4 elective dissections and 4 sentinel node biopsies. Among 16 patients evaluable after wide excision and a negative sentinel node biopsy, 4 patients subsequently developed metastatic nodes; however, confident identification of all nodes marked as sentinel nodes on lymphoscintigraphy was not achieved at the original biopsy procedure in 3 of these patients. CONCLUSIONS: Lymphoscintigraphy and sentinel node biopsy are more difficult to perform in the head and neck than in other parts of the body. The reliability of sentinel node biopsy based on lymphoscintigraphy may be improved by identifying and marking all nodes that are considered to receive direct lymphatic drainage from the primary melanoma, and by use of a gamma probe intraoperatively.
Adolescent↗
Lymphatic drainage from peri-umbilical skin to internal mammary nodes.
While performing lymphoscintigraphy to define draining lymph node groups and sentinel nodes in patients with melanoma, the authors have discovered a new lymphatic channel in two patients with tumors in the peri-umbilical area. This channel passes over the right costal margin to an interval node before passing toward the midline, where it passes through the chest wall to reach the internal mammary lymph node chain. Appreciating the possible presence of this channel in patients with periumbilical lesions has important implications for the surgical management and follow-up of these patients.
Antimony↗
Sentinel lymph node status as an indicator of the presence of metastatic melanoma in regional lymph nodes.
The value of elective lymph node dissection (ELND) for melanoma patients with clinically uninvolved regional nodes remains controversial. However, it has been proposed that selective 'sentinel' lymph node biopsy reliably identifies individuals with micrometastases, who are most likely to benefit from full ELND. The aim of this study was to confirm that metastatic melanoma cells travelling in lymphatics do not bypass the sentinel node. After preoperative lymphoscintigraphy and intraoperative injection of blue dye around the primary melanoma site, sentinel node biopsy was performed in 118 melanoma patients for whom full ELND was planned as part of their definitive surgical treatment. A confidently identified sentinel node was tumour positive in 22 out of 105 regional lymph node fields (21%). In 18 cases the sentinel node was the only node found to be involved and in four cases, additional nodes were positive. In two other patients a positive node was found when the sentinel lymph node had been negative. However, in each case an avoidable error of technique had occurred and definite blue staining indicated that the positive node was in fact another sentinel node. This study thus confirms that sentinel lymph node status reliably indicates whether metastatic melanoma is present in regional lymph nodes.
Adolescent↗
Mammary lymphoscintigraphy in breast cancer.
UNLABELLED: Lymphoscintigraphy has previously been used to define lymph drainage patterns and locate sentinel lymph nodes, prior to surgery, in patients with cutaneous melanoma. The aim of this study was to apply this technique to patients with breast cancer using intramammary injections placed around the primary tumor in the breast. METHODS: Lymphoscintigraphy using 99mTc-labeled antimony sulphide colloid was performed in 34 patients with a suspected primary breast cancer. Images were recorded immediately and at 2.5 hr using a LFOV digital gamma camera. Sentinel lymph node location was marked when possible. RESULTS: Lymphatic drainage patterns were successfully recorded in all but three patients. Lymph drainage was to the axillary, internal mammary, supraclavicular and, in one patient, infraclavicular node fields in various combinations but always on the same side of the body as the breast tumor. There was unexpected drainage across the center line of the breast to axillary or internal mammary nodes in 32% of patients with inner or outer quadrant lesions. Direct drainage to supraclavicular or infraclavicular nodes occurred in 20% of upper quadrant lesions. Drainage to the ipsilateral axilla occurred in 85% of patients, where a single sentinel node was seen in all cases. CONCLUSION: Intramammary lymphoscintigraphy can be used to define the lymphatic drainage patterns of individual breast cancers. The surface location of sentinel lymph nodes in the draining node fields can be marked and in the axilla their depth can be measured. It should therefore be possible to use lymphoscintigraphy, along with a blue dye injection technique or the gamma probe at surgery, to locate sentinel lymph nodes in patients with breast cancer.
Antimony↗
Thallium-201 scintigraphy in pediatric soft-tissue tumors.
UNLABELLED: Thallium-201 has been used as a tumor imaging agent in adults with lymphoma, brain tumors, thyroid carcinoma and bone sarcomas. The application of 201Tl in pediatric oncology has been very limited. METHODS: Whole-body 201Tl studies were incorporated into the imaging protocols of 45 children with solid soft-tissue tumors. Bone and 67Ga scans as well as 131I-MIBG scans for patients with neuroblastoma were obtained. RESULTS: Seventeen children with lymphoma, five with Hodgkin's disease and twelve with non-Hodgkin's lymphoma (NHL) were studied. All of the patients with Hodgkin's disease showed avid uptake of 201Tl and 67Ga. The six patients with B-cell NHL had positive 67Ga scans and four had positive 201Tl scans. There was variable uptake in T-cell and undifferentiated lymphoma with an overall sensitivity of 69% for 201Tl and 85% for 67Ga. In 14 patients with rhabdomyosarcoma, 10 (71%) had positive 201Tl scans and 11 (79%) had positive 67Ga images. Gallium and thallium scans detected lesions equally. There was poor uptake of 201Tl in the six children with neuroblastoma. Primary tumor and metastases were detected more readily with the bone and MIBG scans. Three children with Wilms' tumor had poor or no uptake on 201Tl images, two of three patients with histocytosis had no significant uptake and one patient had mild uptake of 201Tl. One patient with primitive neuroectodermal tumor had positive 201Tl and 67Ga images and one patient with a neurofibrosarcoma had negative 201Tl and 67Ga images. There was no correlation with histological types of tumor or disease staging. CONCLUSION: This study shows significant uptake of 201Tl in many pediatric solid soft-tissue tumors. Additional study is needed to determine 201Tl effects on treatment response and tumor viability. Also, more studies are needed to assess 201Tl delayed images to determine if there is more tracer concentration in the tumors.
3-Iodobenzylguanidine↗