Additional tracer injection to improve the technical success rate of lymphoscintigraphy for sentinel node biopsy in breast cancer.

BACKGROUND: Sentinel node (SN) biopsy has become the standard of care in the treatment of breast cancer. The aim of this study is to determine the value of additional tracer injection to increase the technical success rate of the SN procedure and to identify factors that influence the ability to visualize hotspots. METHODS: From February 1997 to August 2007, 1,208 clinically node-negative breast cancer patients underwent lymphatic mapping for SN biopsy. The technique involved the injection of 370 MBq (10 mCi) Tc-99 m-nanocolloid peritumorally. In case of insufficient or absent visualization of hotspots 37 MBq (1 mCi) of additional tracer was given intracutaneously above the tumor. RESULTS: In 93 patients (7.7%) visualization of hotspots on initial lymphoscintigraphy was insufficient (41 patients) or absent (52 patients). The first 14 patients did not receive additional tracer injection. In five patients, additional tracer did not result in successful lymphoscintigraphy, which is correlated with massive nodal tumor infiltration. In 33 patients with negative initial lymphoscintigraphy, additional tracer injection resulted in secondary SN visualization. In 41 patients with faint hotspots on initial lymphoscintigraphy, additional tracer injection, by increasing nodal uptake, simplified accurate SN biopsy. Decreased radiotracer uptake in this group was associated with older age and high body mass index (BMI). CONCLUSIONS: Additional tracer injection following initial scan failure increases the success rate of lymphoscintigraphy during lymphatic mapping in breast cancer, without compromising accuracy. If additional tracer injection does not result in secondary SN visualization, gross nodal tumor involvement is often present and axillary lymph node dissection (ALND) is mandatory.

Results of sentinel node biopsy not affected by previous excisional biopsy.

AIMS: Sentinel lymph node (SN) biopsy has been validated in the treatment of breast carcinoma. Patients with previous excisional biopsy are regarded as ineligible for SN biopsy. We evaluated the results of SN biopsy for this group of patients based on confirmatory axillary lymph node dissection. PATIENTS AND METHODS: From April 1997 all 88 patients with stage T(1-3) breast cancer who had previously undergone diagnostic excisional biopsy followed by complete axillary lymph node dissection, were enrolled into a prospective study to determine the validity of the sentinel node procedure. RESULTS: Lymphoscintigraphy visualized one or more axillary hot spots in 84/88 patients. A successful SN biopsy was performed in 87 patients. Complete axillary lymph-node dissection showed no false-negative SN biopsy among the 87 SN procedures. CONCLUSION: SN biopsy is a reliable and safe method following excisional biopsy as is confirmed by completion axillary lymph node dissection. Therefore, patients with previous excisional biopsy are eligible for sentinel node procedure and can be spared unnecessary axillary lymph node dissection.

Interpretation of captopril renography by nuclear medicine physicians.

UNLABELLED: This study was designed to assess intra- and interobserver variability and diagnostic accuracy of nuclear medicine physicians in their evaluation of baseline and captopril renograms. METHODS: The diagnostic performance of three experienced nuclear medicine physicians according to their interpretation of baseline, captopril and paired renograms was assessed. To this end, the readers evaluated the renograms of 28 hypertensive patients in whom a diagnosis of renovascular hypertension was suspected on the basis of clinical clues. All patients also underwent angiography. The readers were unaware of the angiographic diagnosis. RESULTS: Thirteen of 28 patients proved to have renal artery stenosis (8 unilateral, 5 bilateral) on renal angiography. The concordance in the renographic diagnoses between the three readers was reasonably good, with an intraobserver agreement and kappa (observed agreement corrected for chance) ranging from 64% to 89% and from 0.52 to 0.75, respectively, and an interobserver agreement and kappa ranging from 68% to 86% and from 0.61 to 0.82. The sensitivity of their interpretation of paired baseline plus captopril renograms in relation to the angiographic diagnosis is poor and below 50%. The post-test probability of RAS in case of a negative renographic study was found to be rather similar to the pre-test probability (prevalence) of 46%. Blinding readers to which renogram was obtained after captopril imaging increased their accuracy. CONCLUSION: The intra- and interobserver agreement between experienced nuclear medicine physicians who evaluate renograms was found to be reasonably good. Blinding readers as to which renogram is the pre- and post-captopril image seems to enhance their diagnostic accuracy in instances of positive scans.

Sentinel node biopsy in 70 unselected patients with breast cancer: increased feasibility by using 10 mCi radiocolloid in combination with a blue dye tracer.

AIMS: Lymphatic mapping and sentinel node (SN) biopsy in breast cancer contribute to more accurate staging, while using less invasive techniques. The aim of this study is to improve the accuracy and feasibility of this concept, increasing the identification rate of the SN, by using an alternative technique. METHODS: In 70 unselected patients with primary breast cancer, of whom 51% had undergone previous excisional biopsy, lymphatic mapping was performed using 10 mCi (370 MBq) 99mTc-nanocolloid peritumorally, combined with an intradermal blue dye tracer. RESULTS: Lymphoscintigraphy showed one or more SN in 97% and harvest of the SN was possible in all patients (identification rate 100%). Axillary metastases were found in 39%. Sensitivity of the SN biopsy was high, both after primary surgery (93%) and after previous surgery (100%). Internal mammary lymph node biopsy following lymphatic mapping was attempted in all 24 patients (34%) with parasternal SN visible on the scan and was successful in 15 patients, revealing metastatic involvement in five patients. CONCLUSIONS: We conclude that SN biopsy, using a higher dose of peritumoral radiocolloid tracer, combined with intradermal blue dye tracer, increases feasibility in breast cancer, making this concept applicable for all patients with primary breast cancer.

Reversible migratory osteoporosis in renal oncocytoma mimicking renal cell carcinoma with bone metastases.

We report a case in which initially the wrong diagnosis of renal cell carcinoma with bone metastases was made. Nephrectomy and bone biopsy led to the right diagnosis of oncocytoma with transient osteoporosis. This report stresses the importance of pathological investigation and points to oncocytoma in the differential diagnosis of solid renal masses. In addition, the possible relationship between this tumour and migratory osteoporosis, which disappeared after surgery, is described.

Sucralphate-technetium scintigraphy in inflammatory bowel disease: experience in 23 patients.

Serial abdominal scanning after the oral administration of sucralphate-99mTc was performed in order to determine the extent of active inflammatory bowel disease in 15 patients with Crohn's disease and in 8 patients with ulcerative colitis. Scintigraphic data were compared with those obtained by endoscopy and radiology in all patients. True positive scans were obtained in 6 (40%) patients with Crohn's disease and in 3 (38%) patients with ulcerative colitis. Overall, sensitivity was higher in colonic disease than that in ileal disease. In 4 (17%) patients, false negative scans were obtained and in the remaining 10 (44%) patients, localisation of the inflammatory bowel disease by the isotope was completely inaccurate. Since sensitivity of the sucralphate-99mTc scintigraphy appears to be low, its widespread use in the screening for inflammatory bowel disease or in assessing the extent of disease involvement cannot be advocated at this moment.

Radionuclide-guided biopsy of bone lesions in cancer patients; a reliable, well-tolerated technique.

OBJECTIVES: In follow up or primary analysis of malignant disease, use of nuclear medicine imaging techniques is increasing. The lesions, detected by these modalities, do not always present with a matching radiological abnormality suitable for radiological biopsy. A method to confirm, or rule out, metastatic disease in these cases is radionuclide-guided surgical biopsy. PATIENTS AND METHODS: The technique consists of injecting a Technetium-99m labelled diphosphonate, performing a bone scan and marking the lesion; under general anaesthetic a surgical biopsy is taken through a small incision guided by a gamma-probe. We evaluated the combined experience of two teaching hospitals, by conducting retrospective chart review, over a period of 5.5 years. Sixty-nine procedures with 79 biopsies were performed. The patients previously had breast cancer in 42%, lung cancer in 32%, both gastrointestinal and urological malignancies in 13%, miscellaneous or unknown origin were reported in 9%. In 68% a rib biopsy was taken, in 15% a pelvis biopsy and in 11% a sternum or clavicle biopsy. RESULTS: In 46.8% metastatic disease was confirmed and in 2.6% a new malignancy (M Kahler) was identified. During a median clinical follow up period of 31 months (1-70), 1 initially negative biopsy site was found to contain a metastasis. Apart from local pain in 3% of cases, no complications were mentioned. CONCLUSION: In conclusion we can state that, in this retrospective series, radionuclide-guided bone biopsy is a reliable, well-tolerated technique to determine the diagnosis of these lesions with a sensitivity of 97% and specificity of 100%.

[Female infant mortality in Batia]. / La mortalite infantile feminine a Bafia

PIP: In 1986, a researcher of the Institute for Demographic Research and Training IFORD) applied the Brass, and the Hill-Trussel indirect estimation technics to the estimation of female adult mortality in the urban part of Bafia (25,845 inhabitants), Cameroon. He used the only available data: the 10,464 questionnaires on mothers' survivorship administered in the census completed by the IFORD in urban Bafia, in 1986. The administration of these questionnaires met several difficulties on the field: some questionnaires were presented to uneligible people, and on the other hand, eligible people were not addressed the questionnaire; meanwhile some adopted motherless children said their mother was alive, causing underestimates of mortality. Nevertheless, applied to the data on motherless children resulting from these questionnaires, both technics gave almost identical results: both estimates show a mortality rate decline. Life expectancy in urban Bafia (50 to 52.5 years in 1973-1974; level 13-14 in Coale-Demeny's life table) is superior to the average life expectancy in Cameroon. This difference could be explained by the existence, in Bafia, of well developed health services. Then, the Brass-Bamgboye technic was applied to the retrospective estimation of the dates of reference, and results compared with those of the empirical technic used by the CELADE in Honduras and Costa-Rica. The latter appeared more promising after experiment. The results of this comparison confirmed the decline of mortality in Bafia (every 2 years, life expectation raises of 1 degree in Coale-Demeny's life table).^ieng

[Female infant mortality in Bafia]. / La mortalite infantile feminine a Bafia.

PIP: The Brass and Hill-Trussell methods were applied to data on survival of mothers from the 1986 census of Bafia, Cameroon, to obtain estimates of adult female mortality. 25,845 persons were enumerated, but only 10,464 urban residents whose mothers were born in Bafia were included in this study. The Brass and Hill-Trussell methods gave very similar results, especially after age 30. A more detailed analysis of results from the Hill-Trussell method demonstrates that mortality in Bafia has declined. The mortality levels for ages 20 and 25 were probably underestimated. The levels according to the Coale and Demeny north type tables of 18.6 for age 20 and 16.3 for age 25 would correspond to life expectancies at birth in excess of 57.5-62.5 years. Life expectancy in Cameroon was estimated at 45.6 years in 1976. Given the better health and sanitary conditions enjoyed by urban residents of Bafia, the Coale and Demeny level of 13-14 corresponding to a life expectancy of 50.0-52.5 seems acceptable for 1973-74 and is in agreement with results of the Hill-Trussell technique. Reference dates calculated by the Brass-Bamgboye method appear less satisfactory than those obtained with the empirical method used by the Latin American Demographic Center. It is therefore recommended that a question on the date of death of the mother or father be added to the question on survival of the mother or father. In the case of Bafia, the data indicate a very strong though not impossible mortality decline equivalent to addition of 1 degree in the Coale and Demeny framework each 2 years, or to a gain of 1.25 years of life expectancy at birth each year for about 6 years. The question on survival of the mother was the source of numerous problems during the census enumeration, but the information obtained gave quite satisfactory results.^ieng

[An analytical approach to migration using data from population censuses in francophone Africa south of the Sahara: the case of Cameroon]. / Approche analytique du phenomene migratoire a partir des donnees issues de recensement demographique en Afrique francophone au sud du Sahara: le cas du Cameroun.

PIP: Using the Cameroon census of April 1987, the authors outline the basics of the study of recent internal migration using censal data. Particular attention is given to the value of such data for studying the socioeconomic characteristics of migrants, the most recent migrations, and for predicting future trends.^ieng

[Level of maternal education and mortality: a critical evaluation]. / Niveau d'instruction de la mere et mortalite: une evaluation critique.

PIP: Maternal education has been accepted almost unanimously as a major socioeconomic factor in infant and postinfant mortality, but anomalies have been found which call the relationship into question. Considerable evidence points to the existence of other important elements in infant mortality besides maternal education. Survey results from Kenya, Lesotho, and other countries in Africa and elsewhere do not consistently demonstrate higher mortality among children of less educated or illiterate mothers. It is thus important to determine how maternal education influences infant mortality. 3 principal interpretations have been that educational level is an indicator of living standard and consequently determines access to goods and services that influence mortality; that formal education permits acquisition of knowledge and modern standards in the areas of hygiene, child care, health and related domains that affect the level of mortality; and that education measures the degree of breaking with tradition. The relation between maternal education, selected intermediate variables influenced by it, and mortality was analyzed using data from the Survey of Infant and Child Mortality in Yaounde (EMIJ). This survey was conducted on a sample of infants born in 1978 in maternity centers of Yaounde to women residing in the city. The infants were visited at home at 1, 4, 8, 12, 16, 20, and 24 months. Intermediate variables analyzed included the type of milk provided at 8 months, whether meat and eggs were given at 8 months, whether or not water given to infants at 4 months was boiled, what vaccinations the child received by 12 months, the number of prenatal visits, and the source of household water. Infant mortality was found to be lower when the number of prenatal visits increased, when boiled water or mineral water was given to the child, when there was running water in the house, and when the infant was vaccinated. The risk of death increased with bottle feeding. A relationship was also found between the educational level of the mother and the intermediate variables, but the strength of the relationship varied for different variables. The relationship was very weak in the areas of type of foods given and number of vaccinations. The strongest relationship was with the mode of feeding, the very variable that sometimes leads to a positive relationship between maternal education and infant mortality. The factor of ethnic group was found to disturb the normal relationship between maternal education and infant mortality, probably because each ethnic group adopts elements of western culture at its own distinctive pace. The data demonstrated that it is only after 10 years of successful schooling that the changes in habits and customs become significant. A few years of school do not automatically determine a decrease in infant mortality.^ieng

The determination of delta-5-androstenediol and its sulphate in serum and urine by gas chromatography-mass spectrometry.

OBJECTIVES: We developed an assay for delta-5-androstenediol (adiol) and delta-5-androstenediol-3-sulphate (adiol-3S) in serum and adiol and total adiol sulphate (adiol-S) in urine. DESIGN: An analytical procedure using HPLC and gas chromatography-mass spectrometry was devised and tested for its reliability. MEASUREMENTS: After addition of deuterated androstenediol as internal standard, serum and urine samples were extracted. Steroid sulphates were hydrolysed. The extracts and hydrolysates were purified on HPLC, adiol was derivatized using heptafluorobutyric anhydride and finally quantified by gas chromatography-mass spectrometry. RESULTS: The assay is accurate and reproducible. The coefficient of variation (CV) for the determination of adiol in serum samples is 4% (intra-assay) and 9% (interassay) and for urine samples 3 and 8% respectively. The intra-assay CV for the adiol-3S analyses is 5% for serum and 2% for urine samples while the interassay CV values for adiol-3S are 10% for serum and 7% for urine samples. The recovery of adiol and adiol-3S from serum and urine samples is 97%. CONCLUSIONS: The developed assay meets the analytical demands needed for clinical applications.

Halsted revisited: internal mammary sentinel lymph node biopsy in breast cancer.

OBJECTIVE: To investigate the feasibility of internal mammary sentinel lymph node biopsy as a method to refine and thereby improve nodal staging in breast cancer. SUMMARY BACKGROUND DATA: The internal mammary lymph node status is a major prognostic factor in breast cancer. If positive, prognosis is less favorable. However, staging this regional nodal basin is not performed routinely, thus discarding additional staging information. METHODS: In a consecutive series of 256 patients with primary breast cancer, sentinel node biopsy was performed based on lymphoscintigraphy, intraoperative gamma probe detection, and blue dye mapping using 10 mCi (370 MBq) (99m)Tc-nanocolloid injected peritumorally and 0.5 to 1.0 mL Patent Blue V injected intradermally. During surgery, whenever possible, both axillary and internal mammary sentinel nodes were sampled. RESULTS: Lymphoscintigraphy showed axillary sentinel nodes in 95% (243/256) and additional internal mammary sentinel nodes in 25.3% (65/256). The overall success rate of axillary sentinel node biopsy was 97% (249/256). Sampling the internal mammary basin, based on the results of lymphoscintigraphy, was successful in 63% (41/65). In three patients a small pleural lesion resulted from staging this basin. This technique revealed internal mammary metastases in 26.8% (11/41). In 7.3% (3/41), internal mammary nodes showed metastatic involvement without accompanying axillary metastases. CONCLUSIONS: Internal mammary sentinel node biopsy is feasible without serious additional complications. It improves nodal staging in breast cancer by identifying higher-risk subgroups with internal mammary nodal metastases, which might benefit from altered adjuvant treatment regimens.