Periareolar Injection for Localization of Sentinel Nodes in Breast Cancer Patients

Abstract

The goal of this study was to evaluate the periareolar injection of technetium 99m sulfur colloid to identify axillary sentinel nodes and compare the number of sentinel lymph nodes identified with preoperative lymphoscintigraphy to intraoperative biopsy using a handheld gamma probe. A total of 104 consecutive patients diagnosed with invasive breast cancer participated in this prospective study, with 81 patients receiving an intradermal periareolar injection and 23 patients receiving an intradermal peritumoral injection of filtered technetium 99m sulfur colloid. Preoperative lymphoscintigraphy was performed for sentinel node mapping and localization. In addition to selective sentinel node biopsy, axillary dissection was performed on all patients to determine false-negative rates. Routine histologic staining was performed on all identified nodes, along with immunohistochemical staining of sentinel nodes negative on initial routine staining. With an intradermal periareolar injection, the sentinel node identification rate was 91.4% (74/81), axillary metastatic rate 35.1% (26/74), sentinel node positive only 61.5% (16/26), and false negative 3.8% (1/26). With an intradermal peritumoral injection, the sentinel node identification rate was 91.3% (21/23), axillary metastatic rate 42.9% (9/21), sentinel node positive only 88.9% (8/9), and false negative 0% (0/9). A total of 241 sentinel nodes were identified with biplanar lymphoscintigraphy and 173 sentinel nodes were harvested during surgery, yielding a 28.2% increase in sentinel nodes identified with lymphoscintigraphy. This study demonstrates that intradermal periareolar injection of filtered technetium 99m sulfur colloid is successful in identifying axillary sentinel nodes with a low false-negative rate. Preoperative lymphoscintigraphy aids in the identification and surgical planning of sentinel node biopsy and provides an objective measure of surgical performance.

Molecular markers of breast axillary lymph node metastasis

“…They are also not able to detect micrometastasis or isolated tumor cells (ITCs) in the SLN, although the clinical significance of their presence is controversial (for review [67]). In fact, a substantial number of lymph node-negative breast cancer cases are found with micrometastasis [68][69][70], which is significantly associated with the development of distant metastasis in patients with early-stage breast cancer, despite earlier diagnosis and better management of locally confined breast cancer [71][72][73]. Therefore, alternative methods are needed to better select patients for SLN dissection.…”

Le ganglion sentinelle sans curage systématique dans le cancer du sein : bilan d'une expérience de 1000 interventions

“…Trois sites d'injection sont habituellement utilisés : l'injection péritumorale, intraparenchymateuse autour de la tumeur, l'injection sousdermique en regard de la tumeur et l'injection sous-aréolaire. Différentes études comparatives non randomisées ont comparé l'injection péritumorale versus sous-dermique [9][10][11][12][13], l'injection péritumorale versus sous-aréolaire [14][15][16], l'injection sous-dermique versus sous-aréolaire [17][18][19], l'injection péritumorale versus sous-ou intradermique [20]. Les résultats en TFN ne permettent pas de privilégier l'un ou l'autre de ces sites, il apparaît simplement une « tendance » pour un TD plus élevé avec la voie sous-aréolaire et un plus grand nombre de marquage extra-axillaire avec la voie péri-tumorale.…”

“Breast Cancers” Recommendations for clinical practice from Saint Paul de Vence

“…Le site et la profondeur d'injection ne sont pas actuellement consensuels : les sites intradermiques, souscutanés (en regard de la tumeur ou périaréolaire), péritumoral ou intratumoral ont été décrits et utilisés, isolément ou en association (niveau 2) [51, 101,167,237,238,278]. L'injection superficielle du traceur radioactif, qu'elle soit périaréolaire, souscutanée ou sous-dermique ne permet d'identifier que les GS axillaires (niveau 2) [34].…”

“…Les injections périaréolaires donnent également d'excellents résultats en termes de taux d'identification, mais sont mal documentées en termes de faux négatifs (niveau 2) [51, 101,167,237,238,278].…”