Intraoperative radiocolloid injection for sentinel node biopsy postneoadjuvant chemotherapy.

BACKGROUND: This study sought to determine significance of radiocolloid injection timing for sentinel node biopsy (SNB) after neoadjuvant chemotherapy (NAC). MATERIAL AND METHODS: A retrospective comparison of intraoperative (IRCI) and preoperative (PRCI) radiocolloid injection for SNB was performed in breast cancer patients who had completed NAC. The sentinel node identification rate (SNIDR) was tested for noninferiority by a two-proportion z-test. The differences between clinical demographics, pathologic demographics, and SNIDR were evaluated by Fisher exact test. The difference in the number of sentinel nodes removed was analyzed by two-sample t-test. RESULTS: In the 6-y study period, 120 SNB were performed after NAC: 84 received PRCI and 36 received IRCI. The two groups were similar except there were fewer clinical T2 and more clinical T3 and T4 with IRCI (P = 0.0008). The SNIDR was 92.9% with PRCI and 80.6% with IRCI. By two-proportion z-test, IRCI was not "noninferior" (P = 0.5179). By Fisher exact test, the SNIDR of the two groups did not differ. The SNIDR differs only in patients who experience T downstaging (100% versus 80%, P = 0.0173). The mean number of lymph nodes removed was higher with IRCI: 3.38 versus 2.49 nodes (P = 0.0068). There were more positive SNB with IRCI: 32.1% versus 55.2%, (P = 0.0432). The incidence of nontherapeutic axillary dissection was similar between the two groups (3.6% for PRCI versus 5.6% for IRCI). CONCLUSIONS: IRCI for SNB after NAC may be inferior to PRCI.

Clinical decisions associated with positron emission tomography in a prospective cohort of patients with suspected or known cancer at one United States center.

PURPOSE: In 2001, Medicare approved reimbursement of F-18 fluorodeoxyglucose positron emission tomography (PET) for a variety of cancers. PET has been observed to be more accurate than other imaging in cancer patients, but the impact of PET on management in routine practice is uncertain. PATIENTS AND METHODS: We studied a prospective cohort having noninvestigational PET at one university center. Before and after PET, a questionnaire was administered to solicit information regarding each physician's preceding actions, intended management, and probability estimates. RESULTS: Seventy-one physicians provided data on 248 patients, of whom 40% had new or suspected cancer and 60% were undergoing restaging or had suspected recurrence. Lung, lymphoma, and head/neck cancers accounted for two thirds of cases. Sixteen physicians made 64% of requests. Physicians changed their intended management in 61% of patients (95% CI, 54% to 66%). For individual physicians ordering at least 10 scans, the average kappa was 0.16 (range, -0.04 to 0.36), reflecting only slight level of agreement between their before and after PET plan. PET was associated with a change in 90 (79%) of 114 patients if the pre-PET intended plan involved more testing or biopsy. In 32% of cases, physicians changed to a treatment from a nontreatment strategy. The therapeutic goal and mode changed in 22 (7%) and 21 cases (8%), respectively. CONCLUSION: This study confirms that physicians often change their decision making based on PET. This impact is likely due to combined effects of PET's improved accuracy and reduced physician uncertainty. Physicians may also be overconfident in interpreting PET and use it as the final arbiter after an extensive evaluation in lieu of tissue biopsy.

Intraoperative injection of radiocolloid for sentinel node biopsy in breast cancer.

UNLABELLED: Preoperative injection of radiocolloid for axillary sentinel node biopsy in breast cancer is uncomfortable for patients. This study evaluated the reliability of radiocolloid injection as determined by sentinel node identification rate and positive sentinel node biopsy rate, after the patient has been anesthetized in the operating room as compared with preoperative injection. METHODS: After institutional review board approval, a retrospective cohort of patients with breast cancer who underwent sentinel node biopsy from January 2005 through December 2010 was evaluated for analysis. Patients who received intraoperative injection of radiocolloid were compared with those who received their injection preoperatively. Patients with incomplete pathologic staging or having received neoadjuvant chemotherapy were excluded. All patients received radiocolloid injections into the retroareolar tissue; some also received intradermal injection directly over the tumor. All injections contained 37 MBq (1 mCi) in 0.5 mL of filtered (0.22-µm) (99m)Tc-sulfur colloid. RESULTS: Over the 6-y study period there were 904 sentinel node biopsy procedures, and 165 patients were excluded from analysis. Of the 739 sentinel node biopsies that were analyzed, 647 had preoperative injection of radiocolloid and 92 had intraoperative injection. The overall sentinel lymph node identification rates were similar for the 2 groups: 93.5% for the preoperative injection group and 94.6% for the intraoperative injection group (not statistically significant). The identification rates remained comparable for both groups when analyzed by T stage of the tumor. The average number of sentinel lymph nodes removed was similar between preoperative and intraoperative injection: 2.60 and 2.70 nodes, respectively. The overall rates of positive sentinel nodes were comparable for the 2 groups: 25.6% for the preoperative injection group and 26.4% for the intraoperative injection group (not statistically significant). When analyzed by T stage, the positive sentinel node rates remained similar between the 2 groups. CONCLUSION: The sentinel lymph node identification rate of 94.6% for the intraoperative injection group was similar to other published sentinel lymph node identification rates (96%-100%). The positive sentinel lymph node rate was also comparable to that of published series. Intraoperative injection of radiocolloid for axillary sentinel node biopsy appears equivalent to preoperative injection and is a less painful experience for breast cancer patients.

Sensitivity of acute rest myocardial perfusion imaging for identifying patients with myocardial infarction based on a troponin definition.

BACKGROUND: Myocardial perfusion imaging (MPI) is often used to identify low-risk chest pain patients who have myocardial infarction (MI). A recent recommendation is that patients with increased troponin levels be diagnosed as having MI. The sensitivity and characteristics of patients who have elevated troponin levels who also underwent early MPI are unknown. METHODS AND RESULTS: Patients considered at low risk for MI underwent rest gated tomographic MPI and serial marker assessment as part of a standard chest pain evaluation protocol. Patients with cardiac troponin I (cTnI) elevations were analyzed further for this study. MPI results were considered positive if there was a perfusion defect in association with abnormal wall motion or thickening. Short-axis images were divided into 17 segments and graded on a 4-point scale (0, normal; 3, high-grade or absent perfusion), and a summed rest score was derived. Of the 319 patients who had MPI and cTnI elevations, 78 had negative MPI results (sensitivity, 75%). Patients with negative MPI results had lower peak creatine kinase (CK)-MB values (15 +/- 25 ng/mL vs 45 +/- 78 ng/mL, P <.0001) and higher ejection fractions (56% +/- 15% vs 47% +/- 13%, P <.0001) and were less likely to have significant disease (55% vs 72%, P =.04) than those with positive MPI results. Increasing summed rest score was associated with larger MIs as estimated by peak CK and CK-MB values. CONCLUSIONS: Patients with negative MPI results have smaller MIs and less extensive coronary disease. MPI and cTnI offer complementary data for assessing patients with possible MI.