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Identification of sentinel lymph nodes in breast cancer by lymphoscintigraphy and gamma probe guidance: Dependence on route of injection and tumour location

Identifizierung des Wächterlymphknotens beim Mammakarzinom mittels Lymphoszintigraphie und Gammasonde: Abhängigkeit von der Applikationsmethode und der Lokalisation des Primärtumors

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Summary

Background: Sentinel lymph node detection with radiocolloids is confronted with the same problem as the blue dye (BL) method: Even now there is no standardized procedure as regards the application method, the amount of radioactivity and injected volume of the radiocolloid (RC). Therefore, our aim was to find out the most reliable application method and to evaluate a possible tumour-site dependence of detectability.

Methods: Until 1 November 2001, 1567 patients with primarily diagnosed breast cancer and SNB were collected in a nationwide multicentric database (MCDBP, Multicentre Database Project) of the Austrian Sentinel Node Biopsy Study Group (ASNSG). 1116 patients (71.2 %) with radiocolloid detection of the sentinel node (SN), either alone or in combination with blue dye, were included in this evaluation. Exclusion criteria were tumour size >3 cm, multicentric carcinoma, previous chemotherapy or extensive surgical intervention, enlarged axillary lymph nodes, pregnancy, and lactation. The influence of the injection technique (peritumoral [PT], subdermal [SD] application) and tumour location on the lymphatic drainage pathway and the detection rates were evaluated.

Results: On lymphoscintigraphy, drainage to axillary lymph nodes could be detected in 86 % (468/544) using PT, and in 80.1 % (273/341) using SD. Lymphatic drainage to parasternal SNs could be primarily observed using PT in 3.7 % (20/544). Intraoperatively, slightly higher detection rates could be observed only in tumours located in the inner-upper quadrants using PT (73/83; 88 %) as compared with SD (98/124; 79 %). Intraoperative detection rates for medially and laterally located tumours were comparable for PT (89.5 % vs. 90.5 %), but demonstrated inferior results for medially (68.4 %) vs. laterally (80.7 %) located tumours for SD.

Conclusions: In conclusion, as regards axillary SNs, the detection rates of PT and SD seem to be comparable, whereas parasternal SNs seem to be detected more frequently by PT. A dependence on the primary tumour site could be demonstrated only for the inner quadrants, with detection rates being higher with PT than with SD. As a consequence, PT demonstrates advantages in terms of complete lymphatic mapping, independent of tumour location, and would be the method of choice for sentinel node biopsy.

Zusammenfassung

Grundlagen: Analog zur Blaufarbstoffmethode (BL) existiert auch für den nuklearmedizinischen Nachweis des Sentinellymphknoten (SN) beim Mammakarzinom bislang kein standardisiertes Vorgehen bezüglich Injektionsart, -ort, verabreichter Aktivität und Volumen des Radiokolloids (RC). Die Fragestellung dieser Arbeit war, welche Injektionsmethode die höchste Detektionsrate aufweist und ob eine Abhängigkeit vom Sitz des Primärtumors besteht.

Methodik: Bis 1.11.2001 wurden 1567 Patientinnen mit erstdiagnostiziertem Mammakarzinom und durchgeführter SNB (Sentinel node biopsy) in eine zentrale Datenbank (MCDBP, Multicenter Database Project) der Österreichischen Arbeitsgruppe für Sentinel Node Biopsy eingegeben. 1116 Patientinnen (71,2 %), bei welchen zur SN-Markierung ein RC entweder exklusiv oder in Kombination mit BL verabreicht wurde, wurden in diese Auswertung einbezogen. Als Ausschlußkriterien galten Tumorgröße >3 cm, multizentrische Karzinome, Zustand nach Chemotherapie oder ausgedehnter Voroperation, klinisch positive Axilla, Gravidität sowie Laktation. Untersucht wurde der Lymphabfluß in Abhängigkeit von Injektionstechnik (peritumorale [PT], subdermale [SD] Injektion) und der Tumorlokalisation.

Ergebnisse: Insgesamt konnte szintigraphisch nach PT bei 86 % (468/544), sowie nach SD bei 80,1 % (273/341) der Patientinnen zumindest ein axillärer SN detektiert werden, wobei parasternale SN vorzugsweise mittels PT in 3,7 % (20/544) zur Darstellung kamen. Hinsichtlich der Abhängigkeit von der Tumorlokalisation zeigte sich lediglich bei Tumorsitz im inneren oberen Quadranten eine gering höhere Detektionsrate mittels PT (73/83; 88 %) gegenüber SD (98/124; 79 %). Die intraoperativen Detektionsraten für laterale und mediale Tumoren waren mit PT vergleichbar (89,5 % vs. 90,5 %), zeigten jedoch mittels SD bessere Resultate bei lateralem Tumorsitz (80,7 %) gegenüber medial gelegenen Tumoren (68,4 %).

Schlußfolgerungen: Insgesamt scheinen die Detektionsraten von PT und SD hinsichtlich des Nachweises axillärer SN vergleichbar, während parasternale SN vorzugsweise mittels PT erkannt werden. Eine Abhängigkeit vom Tumorsitz zeigt sich lediglich bei medialen Tumoren, wobei hier höhere Detektionsraten mittels PT erzielt werden. Dementsprechend muß PT wegen der umfassenden Darstellung des lymphatischen Abstroms und der Unabhängigkeit von der Tumorlokalisation gegenüber SD der Vorzug gegeben werden.

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Authors and Affiliations

  1. From the Department of Nuclear Medicine, Landeskrankenhaus Klagenfurt, Austria

    H. J. Gallowitsch

  2. Second Department of Surgery, Landeskrankenhaus Graz, Austria

    P. Konstantiniuk

  3. Department of Nuclear Medicine, Barmherzige Schwestern Hospital, Linz

    L. Jörg

  4. Department of Surgery, Landeskrankenhaus Klagenfurt, Austria

    A. Urbania

  5. Department of Surgery, Barmherzige Schwestern Hospital, Linz

    F. Kugler

  6. Department of Nuclear Medicine, Landeskrankenhaus Feldkirch, Austria

    W. Peschina

  7. Department of Nuclear Medicine, Allgemein Öffentliches Krankenhaus, Linz

    M. Hatzl-Griesenhofer

  8. Department of Nuclear Medicine, University of Vienna, for the Austrian Sentinel Node Biopsy Study Group of the ABCSG, Austria

    G. Zettinig

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  1. H. J. Gallowitsch
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Gallowitsch, H.J., Konstantiniuk, P., Jörg, L. et al. Identification of sentinel lymph nodes in breast cancer by lymphoscintigraphy and gamma probe guidance: Dependence on route of injection and tumour location. Eur. Surg. 34, 267–271 (2002). https://doi.org/10.1046/j.1563-2563.2002.02072.x

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