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PubMed2006

Pearls and pitfalls of radionuclide imaging of the lymphatic system. Part 1: sentinel node lymphoscintigraphy in malignant melanoma.

Radionuclide imaging of the lymphatic system has a major role in the management of two main patient groups. First, pre-operative lymphoscintigraphy is a highly accurate method of sentinel node localization and can help guide minimally invasive surgery in a variety of tumour groups. Second, lymphoscintigraphy can play a pivotal role in assessing the cause of extremity swelling. This is the first of two pictorial essays on radionuclide imaging of the lymphatic system and will focus on sentinel node imaging in malignant melanoma. Regional nodal sampling is routinely performed in an increasing number of tumour groups and is well established in malignant melanoma and breast carcinoma. Careful attention to technical performance and image interpretation is essential to maximize the clinical utility of the test. This article provides a pictorial review of the interpretative pearls and pitfalls of sentinel node lymphoscintigraphy in malignant melanoma patients.

Adult↗
PubMed2004

Reverse echelon node and a lymphatic ectasia in the same patient during breast lymphoscintigraphy: the importance of injection and imaging technique.

Lymphoscintigraphy, along with triangulated patient body marking, can serve as a guide for surgeons during sentinel lymph node harvesting. Unique drainage patterns have been noted, especially with areolar or intradermal based injections, which are becoming increasingly popular. The images lymphoscintigraphy provide have been invaluable in delineating these patterns. The authors present a case that simultaneously illustrates two separate points in the same patient, a reverse echelon node and a lymphatic ectasia. To our knowledge, this combination has never been described in the same patient. Perilesional and areolar-cutaneous junction injections were performed sequentially and generated these patterns that could potentially have resulted in added morbidity and a false-negative sentinel node if not realised before surgery. Lymphoscintigraphy added valuable information in the management of this patient, which can occasionally present with complex patterns of activity during sentinel node harvesting.

Adult↗
PubMedDate not supplied

Interstitial lymphoscintigraphy for lymphatic mapping in surgical practice and research.

Lymphoscintigraphy is a nuclear medicine technique that gives morphologic and functional information about the lymphatic system. The size of radiopharmaceutical used is a critical factor for it to have acceptable characteristics of uptake by the lymphatics and migration to lymph nodes. A small particle (10-100 nm) with opsonins or a unique surface is required for uptake by lymph-node macrophages. It can be prepared for application with a simple filtering process producing a predictable size distribution and number of particles for the scan. The radiation dose is safe for the patient and staff. Technetium-99m sulfur colloid is readily available and approved for use. The injection can be performed by anyone with certification in handling radiopharmaceuticals. Imaging is done with standard gamma cameras available in any nuclear medicine department. The addition of the hand-held gamma probe adds a new dimension to application of the technique of lymphatic mapping and identification of areas that retain radiopharmaceuticals. Its use is simple and reproducible. The application of lymphoscintigraphy and gamma-probe localization techniques in clinical medicine is best exemplified with the now commonly used sentinel node approach to staging and treating intermediate-thickness malignant melanoma. A number of other malignant diseases such as breast cancer may have their treatments altered with these techniques as well. As a research and diagnostic tool, the creative application of interstitial lymphoscintigraphy can give important qualitative information regarding the morphology and physiology of the lymphatic system. The development of these techniques for surgical research and practice is reviewed.

Breast Neoplasms↗
PubMed2004

[Efficacy of three-dimensional image fusion of lymphoscintigraphy and MDCT data sets in breast cancer].

The aim of this study was to evaluate the clinical usefulness of image fusion of lymphoscintigraphy with (99m)Tc phytate and volume-rendering images generated by multidetector-row CT (MDCT) in patients with breast cancer. The subjects were 25 patients with clinically negative nodes. Data from the two imaging modalities were fused on a personal computer. Thirty-five axillary sentinel nodes were identified by lymphoscintigraphy. The anatomical locations of sentinel nodes in 27 patients were clearly demonstrated by 3D-fusion imaging (84%). Image fusion of lymphoscintigraphy with (99m)Tc phytate and volume-rendering images is helpful for sentinel node biopsy in breast cancer.

Breast Neoplasms↗
PubMed1999

[Sentinel lymph node detection with lymphoscintigraphy and intraoperative probe in malignant melanoma patients].

BACKGROUND: The sentinel lymph node is the first node in a lymphatic basin to receive lymphatic drainage from a tumor site. If this node is free of tumor, then radical lymphadenectomy may be avoided. The goal of this study was to assess the usefulness of lymphoscintigraphy and intraoperative gamma probe in the sentinel node detection in patients with malignant melanoma. METHOD: We prospectively studied 40 patients with malignant melanoma (24 in I/II stages and 16 in III stage). The day before surgery a lymphoscintigraphy with 99mTc-nanocolloid was performed and the first lymph node identified was considered as sentinel node. For intra-operative mapping a hand-held gamma probe was used. RESULTS: Sentinel nodes were identified in 39/40 (97.5%) patients. In 24 patients with I/II stages 34 sentinel nodes were demonstrated (six positive and 28 negative for malignant melanoma). A total amount of 161 regional lymph nodes was harvested, all of them being negative for malignant melanoma. In 16 patients with III stage, 22 sentinel nodes were located (14 positive and eight negative for malignant melanoma). A total of 89 regional lymph nodes were excised in sentinel nodes positive patients (44 positive and 45 negative for malignant melanoma) and 36 lymph nodes in sentinel node negative, all of them negative for malignant melanoma. CONCLUSIONS: In patients with malignant melanoma, lymphoscintigraphy with 99Tc-nanocolloid is useful for the detection of sentinel lymph node. Biopsy of this node is useful for the selection of patients to undertake a lymphadenectomy.

Adult↗
PubMed1999

Lymphoscintigraphy in malignant melanoma and breast cancer.

Lymphoscintigraphy is the injection of radioactive particles that are then imaged as they pass through lymphatic vessels to their respective lymph nodal drainage basins. Lymphoscintigraphy is receiving increasing interest as a means to stage regional lymph nodes in early stage malignancy. Injection and imaging techniques for performing breast and melanoma lymphoscintigraphy are discussed in this article.

Breast Neoplasms↗
PubMed1999

Timing of sentinel lymph node mapping after lymphoscintigraphy.

BACKGROUND: Sentinel lymph node (SLN) mapping is an effective technique for staging patients with melanoma. In an attempt to avoid reinjection of radiolabeled colloid and facilitate SLN mapping at the time of surgery, we examined whether residual radioactivity from preoperative lymphoscintigraphy could be used to accurately identify SLNs during surgery 18 to 24 hours later. METHODS: Forty-six patients with newly diagnosed melanoma underwent injection of 0.22-micron filtered technetium 99m-labeled sulfur colloid followed by lymphoscintigraphy. Patients returned the next day for SLN biopsy with Isosulfan blue dye and the hand-held gamma-probe to identify SLNs. Thirty of 46 patients underwent repeat imaging before operation. No patient had reinjection of radiocolloid. RESULTS: Ninety-five SLNs were identified on initial lymphoscintigraphy, and repeat imaging on the day of surgery confirmed all SLNs previously identified. A total of 122 SLNs (2.65 per patient) were resected from 58 basins. Eighty-four (69%) of 122 SLNs stained blue, and 118 (97%) of 122 SLNs had in vivo gamma-counts greater than 4 times background. Microscopic metastases were present in 13 (10.7%) of 122 SLNs in 12 (26.1%) of 46 patients. There have been no recurrences over a mean follow-up time of 320 days. CONCLUSIONS: Intraoperative gamma-probe detection combined with blue dye injection is highly effective in identifying SLNs 18 to 24 hours after injection of 0.22-micron filtered 99mTc-sulfur colloid. Reinjection of radiocolloid is not required. This technique avoids radiopharmaceutical administration in the operating room, minimizes radiation exposure, and increases scheduling flexibility.

Adult↗
PubMed2000

Factors affecting sentinel node localization during preoperative breast lymphoscintigraphy.

UNLABELLED: Variable success rates for identifying axillary (AX) sentinel nodes in breast cancer patients using preoperative lymphoscintigraphy have been reported. We evaluated the effects of age, weight, breast size, method of biopsy, interval after biopsy, and imaging view on the success of sentinel node identification and on the kinetics of radiopharmaceutical migration. METHODS: Preoperative breast lymphoscintigraphy was performed in consecutive breast cancer patients from February 1998 to December 1998. The ipsilateral shoulder was elevated on a foam wedge and the arm was abducted and elevated overhead. Imaging using this modified oblique view of the axilla (MOVA) started immediately after peritumoral injection of Millipore-filtered 99mTc-sulfur colloid and continued until AX sentinel nodes were identified. Anterior views were obtained after MOVA. AX, internal mammary (IM), and clavicular (CL) basins were monitored in all patients. MOVA was compared with the anterior view for sentinel node identification. Age, weight, breast size, method of biopsy, interval after biopsy, and primary tumor location were evaluated for their effects on sentinel node localization and transit times from injection to arrival at the sentinel nodes. RESULTS: Seventy-six lymphoscintigrams were obtained for 75 patients. AX sentinel nodes were revealed in 75 (99%) cases. IM or CL sentinel nodes were found in 19 (25%) cases and were not related to tumor location; exclusive IM drainage was present in 1 (1%) case. Identification of AX sentinel nodes was equivalent with MOVA and anterior views in 18 (24%) patients, was better with MOVA in 20 (26%) patients, and was accomplished only with MOVA in 38 (50%) patients. Median transit time was 17.5 min (range, 1 min to 18 h) after injection, and larger breast size was associated with increased transit time. No effect of age, weight, biopsy method, interval from biopsy, or tumor location on transit time was found. CONCLUSION: Use of MOVA can improve identification of AX sentinel nodes. Although AX drainage is the predominant pattern, a tumor in any portion of the breast can drain to IM sentinel nodes. Transit time was influenced by breast size. Overall short arrival times with this technique allow sentinel lymph node dissection to be performed on the same day as lymphoscintigraphy.

Axilla↗
PubMed2000

Lymphoscintigraphy in staging and management of breast cancer.

Internal mammary lymphoscintigraphy (IML) is a simple non-invasive and reproducible technique to determine the extent of the parasternal node invasion in patients suffering from breast cancer. A total forty four patients--37 before surgery or any sort of treatment and seven patients after having undergone surgery, chemotherapy and/or radiotherapy were included in this study to assess the potential role of lymphoscintigraphy in the context of the present 'state of the art' of staging and management of breast cancer patients in Bangladesh. The scintigraphic test was done using Technetium 99m (Tc-99m) Antimony sulfide colloid in a dose of 500 microCi injected interstitially into the sub-costal space. Images were obtained after two to three hours on a Gamma Camera and the study findings were then interpreted as normal, abnormal and equivocal. The scintigraphic images obtained in patients who had undergone surgery, chemotherapy and/or radiotherapy were difficult and more challenging to interpret than those images obtained from patients before surgery or other therapy. This was evidenced by the high number (71%) equivocal cases of IML findings in patients after treatment as compared to only 22% equivocal cases in patients studied before surgery or other therapy. Parasternal lymph node involvement was found to occur regardless of the site or size of the primary tumour. Thirty three percent of tumours located in the outer quadrant showed abnormal nodes on IML. When the size was considered, IML was found abnormal in 22.20% patients with tumour size less than 2 cm in diameter. Correlation of IML with clinically palpable lymph nodes showed abnormal scan findings in 18% patients without clinically demonstrable axillary lymph nodes. These findings are in agreement with previously published data and suggests that conventionally classified stage I patients may in effect be in stage II or even in stage III of the disease. In conclusion, when the technique of lymphoscintigraphy is done with a comprehensive overview of the patient, and when the interstitial injection site is correct, it will generally lead to a logical and clinically useful interpretation of the data for more efficient management of the patient with breast cancer.

Adult↗
PubMed2001

Pilot study comparing the accuracy of lymphoscintigraphy sentinel lymph node localisation with axillary node dissection in women with operable breast cancer.

AIM: To evaluate the use of lymphoscintigraphy sentinel lymph node mapping with scintillation gamma probe detection and blue dye assisted sentinel lymph node biopsy in patients with invasive breast cancer. To compare the lymph nodes detected lymphosintigraphically and at surgery for invasive breast cancer and the accuracy of sentinel node prediction of axillary status. METHODS: A prospective pilot study was performed on 36 women diagnosed with invasive breast cancer requiring axillary node dissection. Lymphoscintigraphy involving peritumoral injection of 99mTechnetium antimony sulphide or rhenium sulphur colloid was performed prior to surgery. Sentinel lymph node biopsy was then performed using gamma probe and blue dye localisation. RESULTS: Sentinel lymph nodes were identified on lymphoscintigrams in 100% of cases, and sentinel nodes located surgically in 34/36 (94.4%) of patients. All women with positive axillary lymph nodes on axillary dissection were correctly identified on sentinel node biopsy. Eight patients demonstrated internal mammary (IM) node radiocolloid uptake, one returning positive IM histology in the presence of positive axillary sentinel node metastasis. CONCLUSION: A high proportion of sentinel nodes were demonstrated by lymphoscintigraphy and were subsequently removed surgically. When internal mammary nodes are identified surgical removal should be considered. In this small series sentinel lymph node status correctly predicted axillary node status in 100% of patients for whom sentinel nodes were retrieved supporting the concept of sentinel node biopsy only for women with normal sentinel lymph nodes. Evidence from randomised trials that sentinel node based management does not compromise regional control of breast cancer or survival, is awaited.

Adult↗
PubMed2001

Accuracy of the intra-operative radioguided localization of the sentinel lymph node (SLN) 24 hours after lymphoscintigraphy in patients with malignant melanoma.

AIM: For optimized logistics for the sentinel lymphadenectomy (SL) it might be helpful for the clinics involved if a longer time period between the lymphoscintigraphy (LS) and surgery is possible. Therefore, we investigated if a precise localization of the sentinel lymph node is possible 24 hours after LS. METHODS: 78 patients with primary malignant melanoma (MM; n = 44) or with MM pre-operated by excisional biopsy (n = 34) were investigated. In 40 cases the tumor was localized on the trunk and in 38 cases on the extremities. Mean MM thickness was 2.68 mm (range: 0.29 to 12 mm). In all patients a lymphoscintigraphy (LS) with an average of 85 MBq of Tc-99m nanocolloid was performed one day prior to surgery. Immediately after tracer application dynamic data acquisition was started at a LFOV gamma camera followed by a whole body scan. With a hand-held gamma detector (C-Trak) 2, 4, 6, 8, and 24 hours after tracer administration the SLN was identified and the counts registered. RESULTS: 94 SLNs were identified in 87 lymphatic basins from which 86 could be resected. Nine MM showed two draining channels. After 24 hours 15.5% (as an average) of the initial counts could be measured in the SLN. The uptake in the SLN in pre-operated versus patients with primary tumor was statistically not significant (p = 0.4). In 16 cases (20.5%) the SLN was tumor positive. Four of those patients developed distant metastases and two died within the first year. None of the patients with negative SLN developed distant metastases or died. CONCLUSION: The remaining activity in the SLN up to 24 hours after administration is sufficient for their intra operative localization. The method of lymphoscintigraphy and localization of the SLN by a hand-held gamma detector optimizes the intra operative identification of the SLN in patients with malignant melanoma.

Adult↗
PubMedDate not supplied

Case report: complete lymphatic staging in breast cancer by lymphoscintigraphy and sentinel node biopsy.

The status of the lymph nodes in the axilla and in the internal mammary chain are the most significant prognostic factors for survival in breast cancer. Lymphoscintigraphy shows lymphatic drainage outside the axilla, most often to the internal mammary nodes, usually in 20% to 30% of breast cancer patients, when intraparenchymal techniques of the radioactive tracer injection are used. Lymphoscintigraphy and sentinel node biopsy are potential tools for more accurate staging in breast cancer, because they provide additional information compared to axillary staging alone. We report a breast cancer case with 10 hot spots in five different lymphatic basins (axilla, internal mammary chain, intramammary, infraclavicular, and high interpectoral) in the lymphoscintigraphy.

Adult↗
PubMed2003

[Three-dimensional fusion imaging of lymphoscintigraphy and MDCT for sentinel node biopsy in breast cancer].

The purpose of this study was to evaluate the clinical usefulness of three-dimensional (3D) fusion imaging of lymphoscintigraphy with 99mTc phytate and MDCT (four-slice CT) for sentinel node biopsy in breast cancer. Volume-rendering images generated by MDCT were fused with lymphoscintigrams on a personal computer. The subjects were 7 patients with clinically negative nodes. In all patients, sentinel nodes were identified by lymphoscintigraphy, and the anatomical locations of sentinel nodes were clearly demonstrated by 3D-fusion imaging. 3D-fusion imaging of lymphoscintigraphy and MDCT is expected to be a promising method for sentinel node biopsy in breast cancer.

Breast Neoplasms↗
PubMed2003

[Contribution of lymphoscintigraphy in the exploration of lymphedema in children].

OBJECTIVES: The objectives of this work were a) to assess the feasibility of lymphoscintigraphy in very young children, and b) to assess its usefulness in understanding the underlying pathophysiology. PATIENTS AND METHODS: Forty-one children (age range 3 months-16 years) with primary lymphedema of the lower and/or upper limbs underwent lymphosinctigraphy using 99mTC-labeled colloid (Nanocis or Nanocol) injected subcutaneous at the foot and/or hand level. Recording time, which depended on the child's age, included at least static images during the thirty minutes following injection and four hours later. RESULTS: Abnormal activity of the lymph collectors, nodes, and interstitial space were analyzed according to age (> or < 2 years). Abnormal findings were classed as simple hypoplasia (n=18) or other type of lymph disease: diffuse lymphatic dysplasia (n=6), mixed vascular dysmorphism (n=5), amniotic bride disease (n=1), and hypoplasia revealed by occurrence of a minor factor (n=11). These observations demonstrate the role of lymphoscintigraphy in the diagnosis and prognostic evaluation of lymphedema in children. CONCLUSION: Lymphoscintigraphy is a useful technique for very young children with lymphedema providing further information contributing to overall exploration.

Adolescent↗
PubMed2004

Preoperative lymphoscintigraphy and internal mammary sentinel lymph node biopsy do not enhance the accuracy of lymphatic mapping for breast cancer.

Lymphoscintigraphy (LS) may identify sentinel lymph nodes (SLNs) outside the axilla. Biopsy of these nodes could improve the accuracy of lymphatic mapping (LM) for breast cancer (BC) if a significant number of tumor-positive extra-axillary sentinel nodes are identified. To address this, we evaluated the impact of the use of preoperative LS and biopsy of axillary and internal mammary SLNs in women with BC. From October 1997 to July 2003, 175 women with breast cancer received technetium sulfur colloid, and images were obtained. Isosulfan blue dye was injected intraoperatively, and LM of the axillary and internal mammary lymph node basins was performed with a hand-held gamma probe. The anatomic location and histologic status of all SLNs identified with LS and LM was recorded, and the impact of the findings on LS and internal mammary LM were evaluated. LS showed SLN in 127/175 (73%) women and "hot spots" were found with the gamma probe in 142/175 (81%). At least one SLN was identified by LM in 168/175 (96%) patients, and 48/168 (29%) had metastases. One hundred sixty-two of 168 (96%) patients had SLN exclusively in the axilla. Only 10 of 175 (6%) women had internal mammary (IM) SLNs seen on LS. LM identified IM sentinel nodes in 6 of these 10 patients, but none were involved with tumor. Preoperative lymphoscintigraphy and biopsy of internal mammary sentinel nodes do not enhance the accuracy of lymphatic mapping for breast cancer. Omitting lymphoscintigraphy reduces the complexity and cost of lymphatic mapping without compromising the identification of tumor-positive sentinel nodes.

Adult↗
PubMed2004

Lymphoscintigraphy in radical vaginal trachelectomy and pelvic lymphadenectomy.

BACKGROUND: Radical hysterectomy has traditionally been the treatment of choice for early invasive cervical carcinoma. Validation of the sentinel lymph node concept in gynaecology has led to less radical surgery. If preservation of fertility is an issue, then radical trachelectomy is an accepted approach. CASE REPORT: A 29-year-old female presented with stage IB1 cervical cancer was treated by radical vaginal trachelectomy and pelvic lymphadenectomy as definitive treatment. Two obturator nodes visualised on lymphoscintigraphy and one parametrial not visualized on lymphoscintigraphy were "hot" and blue during surgery, and identified as sentinel nodes. All 18 nodes were non-metastatic. CONCLUSION: Preoperative lymphoscintigraphy is a useful tool in the preoperative localisation of sentinel lymph nodes, and should be undertaken in cases of early invasive cervical carcinoma where a radical trachelectomy is performed to preserve fertility.

Adult↗
PubMed2005

Lymphoscintigraphy with intraoperative gamma probe sentinel node detection: clinical impact in patients with head and neck melanomas.

AIM: The aims of this paper were to evaluate the clinical relevance of lymphoscintigraphy with intraoperative gamma-probe detection in identifying sentinel nodes (SNs) and to study the prognostic value of SN biopsy in head and neck melanoma patients. METHODS: Sixty-one patients had lymphoscintigraphy with intradermal injections of 99mTc-Nanocoll (40 MBq), 24 h before surgery. Tumor-positive SNs patients underwent total lymph node dissection. Postoperative histological examination was performed. Patients were followed up for 1 to 5 years (median 3 years). The tumor relapses and the overall survival were evaluated by means of statistical methods. RESULTS: Lymphoscintigraphy showed lymphatic distribution to more than one basin in 45 patients (74%), in 15 patients one basin was visualized and no basin in 1 patient. In 41 patients the SN was negative for metastases, while in 20 was positive. In a high percentage of patients (30%), metastatic involvement occurred in more than one lymph node basin. During follow-up in the negative SN group, 40 patients remained disease free and 1 relapsed. In the positive SN group, 10 patients remained disease free and 10 relapsed. Recurrence time ranged from 6 to 11 months. The overall survival of the SNs negative group was significantly higher than the positive SN group. CONCLUSIONS: This approach was able to distinguish: a) patients with tumor-negative SNs with a favorable clinical course (98% did not relapse, P<0.001); b) patients with tumor-positive SNs with a high rate of tumor relapse (50%, P<0.001). Therefore SN biopsy may give information about prognosis in head and neck melanoma patients.

Adult↗
PubMed1992

[Evaluation of the internal mammary nodes by lymphoscintigraphy and ultrasonography in patients with breast cancer].

The efficacy of lymphoscintigraphy and ultrasonography was evaluated in the detection of internal mammary lymph node (IMN) metastases in patients with breast cancer. On histological examination of IMN, 10 patients had metastases (positive group) and 47 did not (negative group). On lymphoscintigraphy, lack of uptake in the parasternal region of the affected side was classified as abnormal. The frequency of this abnormal finding was not significantly different between both groups. On sonography, the thickness of the sonolucent internal mammary area was measured. The thickness of the affected side was 6 mm or more in two patients of the positive group and only one of the negative group. A thickness of over 6 mm on the affected side was statistically significant (p less than 0.05). The difference in thickness between the affected side and the healthy side was 3 mm or more in four patients of the positive group, and was less than 3 mm in all patients of the negative group. A difference in thickness of more than 3 mm between the two sides was extremely significant (p less than 0.001). In conclusion, sonography is valuable in detecting IMN metastases, while lymphoscintigraphy is not useful. Sonography is recommended as an efficient diagnostic modality for IMN metastases.

Adult↗