Annals of Surgical Oncology

, Volume 10, Issue 8, pp 942–947 | Cite as

Subareolar Injection May Be More Accurate Than Other Techniques for Sentinel Lymph Node Biopsy in Breast Cancer

  • Giovanni D’Eredita’Email author
  • Filippo Ferrarese
  • Vincenzo Cecere
  • Sara Tiziana Massa
  • Francesco de Carne
  • Gennaro Fabiano
Original Articles


Background: The aims of this study were to compare peritumoral injection of 99mTc-labeled albumin and subdermal injection of blue dye with subareolar (SA) injection of blue dye alone in terms of success of the sentinel lymph node identification rate, false negative (FN) rate, overall accuracy, and sensitivity of the two procedures.

Methods: From January 1999 to October 2002, 155 patients with localized breast cancer were treated. Patients were subdivided into two groups. In patients in group 1 (n = 115; January 1999 to December 2001), lymphoscintigraphy together with injection of vital dye was performed. In patients in group 2 (n = 40; January 2002 to October 2002), SA injection of blue dye alone was performed.

Results: In patients in group 1, the overall successful identification rate was 94.8%. The success rate of identifying a sentinel lymph node by a combination of the two techniques was 95%. With blue dye alone, the successful identification rate was 94.6% in patients in group 1 (subdermal) and 97.5% in group 2 (SA). The FN rate was 9% in group 1 and 0% in group 2. The overall accuracy of lymphatic mapping was 97% in group 1 and 100% in group 2. Sensitivity was 91% in group 1 and 100% in group 2.

Conclusions: This study of dye-only injection into the SA plexus demonstrates a high sentinel node identification rate, absent FN rate, and rapid learning curve. On the basis of these findings, we propose that injections into the SA lymphatic plexus are the optimal way to perform dye-only lymphatic mapping of the breast.

Key Words

Sentinel lymph node biopsy Lymphatic mapping Subareolar injection Breast cancer 


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  1. 1.
    NIH consensus conference. Treatment of early-stage breast cancer. JAMA 1991;265:391–5.CrossRefGoogle Scholar
  2. 2.
    Veronesi U, Luini A, Galimberti V. Extent of metastatic involvement in 1446 cases of breast cancer. Eur J Oncol 1990;16:127–33.Google Scholar
  3. 3.
    Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg 1994;220:391–401.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Albertini JJ, Lyman GH, Cox C, et al. Lymphatic mapping and sentinel node biopsy in the patient with breast cancer. JAMA 1996;276:1818–22.CrossRefPubMedGoogle Scholar
  5. 5.
    Linehan DC, Hill AD, Akhrust T, et al. Intradermal radiocolloid and intraparenchymal blue dye injection optimize sentinel node identification in breast cancer patients. Ann Surg Oncol 1999;6:450–4.CrossRefPubMedGoogle Scholar
  6. 6.
    Cox CE. Lymphatic mapping in breast cancer: combination tech-nique. Ann Surg Oncol 2001;8(9 Suppl):67–70.Google Scholar
  7. 7.
    Crossin JA, Johnson AC, Stewart PB, Turner WW Jr. Gamma-probe-guided resection of the sentinel lymph node in breast cancer. Am Surg 1998;64:666–8.PubMedGoogle Scholar
  8. 8.
    Krag DN, Weaver D, Alex JC, Fairbank JT. Surgical resection and radiolocalization of the sentinel lymph node in breast cancer using a gamma probe. Surg Oncol 1993;2:335–40.CrossRefPubMedGoogle Scholar
  9. 9.
    McMasters KM, Wong SL, Martin RC, et al. Dermal injection of radioactive colloid is superior to peritumoral injection for breast cancer sentinel lymph node biopsy: results of a multiinstitutional study. Ann Surg 2001;233:676–87.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Veronesi U, Paganelli G, Galimberti V, et al. Sentinel-node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph-nodes. Lancet 1997;349:1864–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Cox CE, Pendas S, Cox JM, et al. Guidelines for sentinel node biopsy and lymphatic mapping of patients with breast cancer. Ann Surg 1998;227:645–51.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Borgstein PJ, Meijer S, Pijpers R. Intradermal blue dye to identify sentinel lymph-node in breast cancer. Lancet 1997;349:1668–9.CrossRefPubMedGoogle Scholar
  13. 13.
    Borgstein PJ, Meijer S, Pijpers RJ, van Diest PJ. Functional lymphatic anatomy for sentinel node biopsy in breast cancer. Ann Surg 2000;232:81–9.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Sappey MPC. Traité d’Anatomie Descriptive. 2nd ed. Paris:: Labé, 1888.Google Scholar
  15. 15.
    Rouviere H. Anatomy of the Human Lymphatic System: A Compendium. Ann Arbor, MI:: Edwards Brothers, 1938.Google Scholar
  16. 16.
    Grant RN, Tabah EJ, Adair FE. The surgical significance of the subareolar lymph plexus in cancer of the breast. Surgery 1953;33:71–8.PubMedGoogle Scholar
  17. 17.
    Turner-Warwick RT. The lymphatics of the breast. Br J Surg 1959;46:574–82.CrossRefPubMedGoogle Scholar
  18. 18.
    Gray J. The relation of the lymphatic vessels to the spread of cancer. Br J Cancer 1939;26:462–95.Google Scholar
  19. 19.
    Kern KA. Sentinel lymph node mapping in breast cancer using subareolar injection of blue dye. J Am Coll Surg 1999;189:539–45.CrossRefPubMedGoogle Scholar
  20. 20.
    Klimberg VS, Rubio IT, Henri R, Cowan C, Colvert M, Korourian S. Subareolar versus peritumoral injection for location of the sentinel lymph node. Ann Surg 1999;229:860–5.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Smith LF, Cross MJ, Klimberg VS. Subareolar injection is a better technique for sentinel lymph node biopsy. Am J Surg 2000;180:434–7.CrossRefPubMedGoogle Scholar
  22. 22.
    Hsu SM, Raine L, Fauger H. Use of avidin-biotin peroxidase complex (ABC) in immunoperoxidase techniques: a comparison between ABC and unlabelled antibody (PAP procedures). J. Histochem Cytochem 1981;29:577–80.CrossRefPubMedGoogle Scholar
  23. 23.
    Cody HS, Hill ADK, Tran KN, et al. Credentialing for breast lymphatic mapping: how many cases are enough? Ann Surg 1999;229:723–8.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Faries MB, Bedrosian I, Reynolds C, Nguyen HQ, Alavi A, Czerniecki BJ. Active macromolecule uptake by lymph node antigen-presenting cells: a novel mechanism in determining sentinel lymph node status. Ann Surg Oncol 2000;7:98–105.CrossRefPubMedGoogle Scholar
  25. 25.
    Mertz L, Mathelin C, Marin C, et al. Subareolar injection of 99m-Tc sulfur colloid for sentinel node identification in multifocal invasive breast cancer. Bull Cancer 1999;86:939–45.PubMedGoogle Scholar
  26. 26.
    Kern KA, Rosenberg RJ. Preoperative lymphoscintigraphy during lymphatic mapping for breast cancer: improved sentinel node imaging using subareolar injection of technetium 99m sulfur colloid. J Am Coll Surg 2000;191:479–89.CrossRefPubMedGoogle Scholar
  27. 27.
    Donahue EJ. Sentinel node imaging and biopsy in breast cancer patients. Am J Surg 2001;182:426–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Beitsch PD, Clifford E, Whitworth P, Abarca A. Improved lymphatic mapping technique for breast cancer. Breast J 2001;7:219–23.CrossRefPubMedGoogle Scholar
  29. 29.
    Tuttle TM, Colbert M, Christensen R, et al. Subareolar injection of 99m-Tc facilitates sentinel lymph node identification. Ann Surg Oncol 2002;9:77–81.CrossRefPubMedGoogle Scholar
  30. 30.
    Bauer TW, Spitz FR, Callans LS, et al. Subareolar and peritumoral injection identify similar sentinel nodes for breast cancer. Ann Surg Oncol 2002;9:169–76.CrossRefPubMedGoogle Scholar
  31. 31.
    Kern KA. Concordance and validation study of sentinel lymph node biopsy for breast cancer using subareolar injection of blue dye and technetium 99m sulfur colloid. J Am Coll Surg 2002;195:467–75.CrossRefPubMedGoogle Scholar

Copyright information

© The Society of Surgical Oncology, Inc. 2003

Authors and Affiliations

  • Giovanni D’Eredita’
    • 1
    • 2
    Email author
  • Filippo Ferrarese
    • 1
  • Vincenzo Cecere
    • 1
  • Sara Tiziana Massa
    • 1
  • Francesco de Carne
    • 1
  • Gennaro Fabiano
    • 1
  1. 1.Department of General and Special SurgeryUniversity of BariBariItaly
  2. 2.BariItaly

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