Annals of Surgical Oncology

, Volume 20, Issue 8, pp 2548–2555

Technical Effects of Adding 1 % Lidocaine to Technetium Sulfur Colloid for Sentinel Lymphatic Mapping in Early Breast Cancer: Analysis of Data from a Double-blind Randomized Controlled Trial

  • Cletus A. Arciero
  • Leonard R. Henry
  • Robin S. Howard
  • George E. Peoples
  • Anton J. Bilchik
  • Itzhak Avital
  • Chester C. Buckenmaier III
  • Alexander Stojadinovic
Breast Oncology



A practice standard in sentinel lymph node (SLN) mapping in breast cancer is intradermal injection of technetium-99m sulfur colloid (Tc-99m), resulting in significant patient discomfort and pain. A previous randomized controlled trial showed that adding lidocaine to Tc-99m significantly reduced radioisotope injection-related pain. We tested whether 1 % lidocaine admixed with Tc-99m affects feasibility of SLN mapping.


Between January 2006 and April 2009, 140 patients with early breast cancer were randomly assigned (1:1:1:1) to receive standard topical 4 % lidocaine cream and intradermal Tc-99m (control) or to one of three other study groups: topical placebo cream and injection of Tc-99m containing sodium bicarbonate (NaHCO3), 1 % lidocaine, or both. All SLN data were collected prospectively.


Study groups were comparable for clinicopathological parameters. As previously reported, the addition of 1 % lidocaine to the radioisotope solution significantly improved patient comfort. Overall SLN identification rate in the trial was 93 %. Technical aspects of SLN biopsy were similar for all groups, including time from injection to operation, first SLN (SLN 1) gamma probe counts, ex vivo counts for SLN 1 and SLN 2, and axillary bed counts. SLN identification rates were comparable statistically: control (96 %), lidocaine (90 %), sodium bicarbonate (97 %), and sodium bicarbonate–lidocaine (90 %). The control group had a significantly higher SLN 2/SLN 1 ex vivo count ratio, and the number of SLNs detected was significantly reduced in the lidocaine versus no-lidocaine groups (p < 0.05).


Addition of 1 % lidocaine to standard radioisotope solution for SLN mapping in breast cancer is associated with fewer SLNs detected, but it does not appear to compromise SLN identification.


  1. 1.
    Cabanas RM. An approach for the treatment of penile carcinoma. Cancer. 1977;39:456–66.PubMedCrossRefGoogle Scholar
  2. 2.
    Morton DL, Wen DR, Wong JH, et al. Technical details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg. 1992;127:392–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Morton DL, Thompson JF, Cochran AJ, et al; MSLT Group. Sentinel-node biopsy or nodal observation in melanoma. N Engl J Med. 2006;355:1307–17.PubMedCrossRefGoogle Scholar
  4. 4.
    Krag DN, Weaver DL, Alex JC, Fairbank JT. Surgical resection and radiolocalization of the sentinel lymph node in breast cancer using a gamma probe. Surg Oncol. 1993;2:335–9.PubMedCrossRefGoogle Scholar
  5. 5.
    Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg. 1994;220:391–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Krag D, Weaver D, Ashikaga T, et al. The sentinel node in breast cancer—a multicenter validation study. N Engl J Med. 1998;339:941–6.PubMedCrossRefGoogle Scholar
  7. 7.
    Giuliano AE, Haigh PI, Brennan MB, et al. Prospective observational study of sentinel lymphadenectomy without further axillary dissection in patients with sentinel node-negative breast cancer. J Clin Oncol. 2000;18:2553–9.PubMedGoogle Scholar
  8. 8.
    Veronesi U, Paganelli G, Viale G, et al. A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer. N Engl J Med. 2003;349:546–53.PubMedCrossRefGoogle Scholar
  9. 9.
    McMasters KM, Wong SL, Martin RC 2nd, Chao C, Tuttle TM, Noyes RD, Carlson DJ, Laidley AL, McGlothin TQ, Ley PB, Brown CM, Glaser RL, Pennington RE, Turk PS, Simpson D, Cerrito PB, Edwards MJ; University of Louisville Breast Cancer Study Group. Dermal injection of radioactive colloid is superior to peritumoral injection for breast cancer sentinel lymph node biopsy: results of a multi-institutional study. Ann Surg. 2001;233(5):676–87.PubMedCrossRefGoogle Scholar
  10. 10.
    Fetzer S, Holmes S. Relieving the pain of sentinel lymph node biopsy tracer injection. Clin J Oncol Nurs. 2008;12:668–70.PubMedCrossRefGoogle Scholar
  11. 11.
    Stojadinovic A, Peoples GE, Jurgens JS, et al. Standard versus pH-adjusted and lidocaine supplemented radiocolloid for patients undergoing sentinel-lymph-node mapping and biopsy for early breast cancer (PASSION-P trial): a double-blind, randomised controlled trial. Lancet Oncol. 2009;10:849–54.PubMedCrossRefGoogle Scholar
  12. 12.
    Dura JV, Hinkle GH. Stability of a mixture of technetium Tc 99m sulfur colloid and lidocaine hydrochloride. Am J Health Syst Pharm. 2007;64:2477–9.PubMedCrossRefGoogle Scholar
  13. 13.
    Wang YF, Chuang MH, Cham TM, Chung MI. Stability of the mixture of technetium-99m human serum albumin and lidocaine hydrochloride for clinical application. Nucl Med Commun. 2009;30:494–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Loveless VS, Surdock CP, Bhattacharjee H. Evaluation of zeta-potential and particle size of technetium 99mTc-sulfur colloid subsequent to the addition of lidocaine and sodium bicarbonate. J Nucl Med Technol. 2010;38:49–52.PubMedCrossRefGoogle Scholar
  15. 15.
    Johnson CB, Boneti C, Korourian S, Adkins L, Klimberg VS. Intraoperative injection of subareolar or dermal radioisotope results in predictable identification of sentinel lymph nodes in breast cancer. Ann Surg. 2010;254:612–8.CrossRefGoogle Scholar
  16. 16.
    Krag DN, Anderson SJ, Julian TB, Brown AM, Harlow SP, Ashikaga T, Weaver DL, Miller BJ, Jalovec LM, Frazier TG, Noyes RD, Robidoux A, Scarth HM, Mammolito DM, McCready DR, Mamounas EP, Costantino JP, Wolmark N, National Surgical Adjuvant Breast and Bowel Project. Technical outcomes of sentinel-lymph-node resection and conventional axillary-lymph-node dissection in patients with clinically node-negative breast cancer: results from the NSABP B-32 randomised phase III trial. Lancet Oncol. 2007;8:881–8.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2013

Authors and Affiliations

  • Cletus A. Arciero
    • 1
  • Leonard R. Henry
    • 2
  • Robin S. Howard
    • 3
  • George E. Peoples
    • 4
    • 5
  • Anton J. Bilchik
    • 5
    • 6
  • Itzhak Avital
    • 7
  • Chester C. Buckenmaier III
    • 8
  • Alexander Stojadinovic
    • 5
    • 9
    • 10
  1. 1.Department of SurgeryDwight D. Eisenhower Army Medical CenterFort GordonUSA
  2. 2.Division of Surgical OncologyIndiana University Health, Goshen Center for CancerGoshenUSA
  3. 3.Department of Research ProgramsBiostatistics Section, Walter Reed National Military Medical CenterBethesdaUSA
  4. 4.Department of SurgeryBrooke Army Medical CenterFort Sam HoustonUSA
  5. 5.United States Military Cancer InstituteClinical Trials GroupWashingtonUSA
  6. 6.John Wayne Cancer Institute and California Oncology Research InstituteSanta MonicaUSA
  7. 7.Bon Secours Cancer InstituteRichmondUSA
  8. 8.Defense and Veterans Center for Integrative Pain ManagementRockvilleUSA
  9. 9.Department of Surgery, Division of Surgical OncologyWalter Reed National Military Medical CenterBethesdaUSA
  10. 10.Uniformed Services University of the Health SciencesBethesdaUSA

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