18F-FDG PET/CT as a staging procedure in primary stage II and III breast cancer: comparison with conventional imaging techniques.

The aim of the present study was to investigate if 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) outperforms conventional imaging techniques for excluding distant metastases prior to neoadjuvant chemotherapy (NAC) treatment in patients with stage II and III breast cancer. Second, we assessed the clinical importance of false positive findings. One hundred and fifty four patients with stage II or III breast cancer, scheduled to receive NAC, underwent an 18F-FDG PET/CT scan and conventional imaging, consisting of bone scintigraphy, ultrasound of the liver, and chest radiography. Suspect additional lesions at staging examination were confirmed by biopsy and histopathology and/or additional imaging. Metastases that were detected within 6 months after the PET/CT scan were considered evidence of occult metastasis, missed by staging examination. Forty-two additional distant lesions were seen in 25 patients with PET/CT and could be confirmed in 20 (13%) of 154 patients. PET/CT was false positive for 8 additional lesions (19%) and misclassified the presence of metastatic disease in 5 (3%) of 154 patients. In 16 (80%) of 20 patients, additional lesions were exclusively seen with PET/CT, leading to a change in treatment in 13 (8%) of 154 patients. In 129 patients with a negative staging PET/CT, no metastases developed during the follow-up of 9.0 months. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of PET/CT in the detection of additional distant lesions in patients with stage II or III breast cancer are 100, 96, 80, 100, and 97%, respectively. FDG PET/CT is superior to conventional imaging techniques in the detection of distant metastases in patients with untreated stage II or III breast cancer and is associated with a low false positive rate. PET/CT may be of additional value in the staging of breast cancer prior to NAC.

The yield of SPECT/CT for anatomical lymphatic mapping in patients with melanoma.

BACKGROUND: The hybrid single-photon emission computed tomography camera with integrated CT (SPECT/CT) fuses tomographic lymphoscintigrams with anatomical CT data. SPECT/CT shows the exact anatomical location of a sentinel node and may detect additional drainage. The purpose of this study was to explore its potential in patients with melanoma. METHODS: We studied 85 patients with melanoma with conventional lymphoscintigrams that were difficult to interpret (51 patients), that showed an unusual drainage pattern (33 patients), or with nonvisualization (1 patient). Forty-one patients had melanoma on an extremity, 31 on the trunk, and 14 in the head and neck region. SPECT/CT was performed following late conventional imaging without reinjection of the radiopharmaceutical. RESULTS: Conventional imaging suggested 214 sentinel nodes in 84 of the 85 patients (99%). SPECT/CT showed these same nodes and 12 extra sentinel nodes in seven patients (8%). Ten of these additional nodes were harvested, of which three nodes of two patients harbored metastases. There was a clear advantage of SPECT/CT in 30 patients (35%), resulting in a different incision in 17 patients, an incision at another site in 8, and an extra incision in 5 patients. The value was questionable in 19 patients (22%) in whom sentinel nodes were more clearly visualized by SPECT/CT, although the incision remained unchanged. There was no additional value of SPECT/CT in 36 patients (42%). CONCLUSIONS: SPECT/CT detects additional drainage and shows the exact anatomical location of sentinel nodes in patients with inconclusive conventional lymphoscintigrams. SPECT/CT facilitates surgical exploration in difficult cases and may improve staging.

The yield of SPECT/CT for anatomical lymphatic mapping in patients with breast cancer.

PURPOSE: The recently introduced hybrid single-photon emission computed tomography camera with integrated CT (SPECT/CT) fuses tomographic lymphoscintigrams with anatomical data from CT. The purpose of this study was to explore this sophisticated technique in lymphatic mapping in breast cancer patients. METHODS: We studied 134 patients who underwent SPECT/CT immediately after late planar imaging when these images showed an unusual drainage pattern (85 patients), a pattern that was difficult to interpret (27 patients), or nonvisualization (22 patients). RESULTS: Planar imaging suggested 271 sentinel nodes in 112 of the 134 patients (84%). SPECT/CT showed 269 of these same nodes and indicated that two sites of radioactivity were caused by skin contamination. SPECT/CT visualized 19 additional sentinel nodes in 15 patients, of whom 11 had non-visualization on planar images. One or more tumour-positive sentinel nodes were seen in 27 patients, and in 4 of these patients (15%), these were visualized only by SPECT/CT. SPECT/CT had no additional value for the surgical approach in 11 patients with persisting nonvisualization (8%), and was of questionable value in 67 other patients (50%). Based on the SPECT/CT images, a more precise incision was made in 48 patients (36%), an extra incision was made in 6 (4%), and an incision was omitted in 2 (1.5%). CONCLUSION: SPECT/CT detected additional sentinel nodes and showed the exact anatomical location of sentinel nodes in breast cancer patients with inconclusive planar images. SPECT/CT was able to visualize drainage in patients whose planar images did not reveal a sentinel node. Therefore, SPECT/CT facilitates surgical exploration in difficult cases and may improve staging.

Prospective evaluation of hybrid 18F-fluorodeoxyglucose positron emission tomography/computed tomography in staging clinically node-negative patients with penile carcinoma.

OBJECTIVE: To prospectively evaluate the performance of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) to detect occult metastasis in patients with clinically node-negative (cN0) penile carcinoma, as there is little information on the use of (18)F-FDG-PET/CT in penile carcinoma. PATIENTS AND METHODS: In 24 patients, scheduled to undergo dynamic sentinel-node biopsy, hybrid PET/CT was used before surgery to assess the nodal status of the cN0-groins. Six of the 24 patients were unilaterally cN0. Thus, 42 cN0-groins were evaluated for occult metastasis using PET/CT. All scans were assessed by two experienced nuclear physicians. The histopathological tumour status of the removed sentinel node was used as the standard of care to evaluate the PET/CT-results. RESULTS: Histopathology was tumour-positive in five of the 42 (12%) evaluated cN0-groins, two of which contained only micrometastases (<2 mm). One of the five tumour-positive cN0-groins was correctly predicted on the PET/CT-images. All false-negative PET/CT scans contained metastasis of

The additional value of SPECT/CT in lymphatic mapping in breast cancer and melanoma.

UNLABELLED: The recently introduced SPECT/CT integrates the physiologic data of SPECT with the anatomic data of CT into a single image. The purpose of this pilot study was to explore the additional value of SPECT/CT in breast cancer patients and melanoma patients with inconclusive planar image findings. METHODS: Thirty-one patients had planar lymphoscintigrams showing unexpected lymphatic drainage, 6 had lymphoscintigrams that were difficult to interpret, and 3 showed no drainage on planar imaging. SPECT/CT was performed immediately after delayed planar imaging. RESULTS: In 4 patients, SPECT/CT showed 6 additional sentinel nodes, of which 2 were tumor-positive and led to upstaging and tailored management in 5% of patients. SPECT/CT depicted sentinel nodes in 3 patients whose delayed planar imaging had shown no drainage. CONCLUSION: SPECT/CT was of additional value in finding the exact anatomic location of sentinel nodes in patients with inconclusive planar image findings. SPECT/CT also detected sentinel nodes in addition to those found on planar images, and SPECT/CT detected sentinel nodes in patients whose planar images had shown none.

Thallium-201-chloride scintigraphy in staging and monitoring radiotherapy response in follicular lymphoma patients.

PURPOSE: To study thallium-201-chloride scintigraphy (201Tl-S) in staging and monitoring response after radiotherapy in follicular lymphoma (FL) patients. PATIENTS AND METHODS: Forty-one consecutive and unselected FL patients were examined by 'Conventional Standard Staging' (CSS) procedures (history and physical examination, ultrasound, CT scans, biopsies and fine needle aspiration cytology) prior to irradiation. Eight standardized potentially affected lymphoma localizations (neck, axilla, mediastinum, spleen, paraaortic, parailiac, femoral and extranodal) per patient were separately studied, resulting in the investigation of 328 localizations. Thirty minutes after the intravenous administration of a tracer dose of 150 MBq thallium-201-chloride total body images were made, immediately followed by single photon emission computed tomography acquisition. All lymphoma localizations were subsequently irradiated. Patients were re-examined after a median of 4 weeks (range 3-6 weeks) by all CSS modalities and 201Tl-S. Diagnostic performance was evaluated both per site and per patient, both in the diagnostic phase of the study as well as in the post-treatment re-evaluation phase. RESULTS: In staging, 201Tl-S was positive in 82 of the 129 initial positive regions by CSS (64%). This percentage increased to 70% when eliminating upper abdominal lymph nodes from the analysis. In 24 patients all lesions were visualized by 201Tl-S, in 11 patients some but not all lesions were detected. In six patients none of the lesions were detected by 201Tl-S. In four patients, four additional lesions were initially found by 201Tl-S only. After irradiation, 83 of the total 86 positive regions reached a complete or partial remission by CSS. Eighty-one of these were also diagnosed as remission by 201Tl-S and two as stable disease. In 31 out of 35 patients (89%; 95% CI: 73-97%) the overall response in all irradiated sites was identical by 201Tl-S and CSS. Only two patients, in remission on CSS modalities, showed stable disease on 201Tl-S, while two others were diagnosed as CR by CSS and PR by 201Tl-S. CONCLUSIONS: 201Tl-S has limited additional value in staging FL patients, since only two-thirds of all localizations are detected. However, 201Tl-S is accurate in monitoring radiation treatment response in FL patients. If an FL patient with a positive 201Tl-S at diagnosis is treated by irradiation, the treatment response can be reliably ascertained by only performing a 201Tl-S.

FDG-avid sclerotic bone metastases in breast cancer patients: a PET/CT case series.

Distant metastases from breast cancer most frequently occur in the skeleton. Although 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET), with or without computed tomography (CT), is superior to bone scintigraphy for the detection of osteolytic bone metastases, it has been reported that sclerotic bone metastases frequently show no or only a low degree of FDG uptake on PET and PET/CT. Since both lytic and sclerotic metastases can occur in breast cancer patients, bone scintigraphy may remain of additional value in these patients. In this case series, we describe four breast cancer patients in whom FDG PET/CT has clearly visualized sclerotic bone metastases because of increased FDG uptake. Not so much the type of metastasis (sclerotic or lytic), but possibly the characteristics of the primary tumor or treatments prior to the FDG PET/CT scan might influence the degree of FDG uptake of bone metastases. The ability to detect sclerotic bone metastases based on increased FDG uptake supports the use of FDG PET/CT as a staging procedure in breast cancer patients, but knowledge of factors determining the visibility of bone metastases with FDG PET/CT is crucial.

SPECT/CT and a portable gamma-camera for image-guided laparoscopic sentinel node biopsy in testicular cancer.

UNLABELLED: The purpose of this study was to evaluate the utility of SPECT/CT and real-time intraoperative imaging with a portable γ-camera for laparoscopic sentinel node (SN) localization in stage I testicular cancer. METHODS: Ten patients with clinical stage I testicular cancer were studied between November 2006 and November 2010. Their mean age was 37 y (range, 25-50 y). The primary tumors were situated on the right side in 5 patients and on the left side in 5. After a funicular block with 2% lidocaine, an average dose of 80 MBq (range, 59-98 MBq) of (99m)Tc-nanocolloid in a volume of 0.2 mL was injected into the testicular parenchyma. Shortly after injection, a 10-min dynamic study was performed, followed by the acquisition of static planar images at 15 min and 2 h. SPECT/CT was performed at 2 h. After image fusion, SNs were visualized, and their exact anatomic location was determined. The SPECT/CT images were displayed in the operation room to guide SN detection using a laparoscopic γ-ray probe and a portable γ-camera. RESULTS: Lymphatic drainage to the retroperitoneum was seen in all patients. SPECT/CT identified interaortocaval or paracaval SNs in the 5 patients with right-sided tumors, one of whom had an additional SN adjacent to the testicular vessels. In all 5 patients with left-sided tumors, paraaortic SNs were visualized; a node along the testicular vessels was visualized in 2 of these 5. Twenty-six SNs were laparoscopically removed (range, 1-4 per patient). An SN contained metastases in 1 case. No recurrences developed in the 9 patients with a tumor-free SN during a median follow-up of 21 mo (range, 2-50 mo). CONCLUSION: SPECT/CT enables accurate anatomic localization of retroperitoneal SNs in patients with testicular cancer, facilitating their laparoscopic retrieval. Real-time image guidance by a portable γ-camera improves intraoperative SN detection and appears to identify (20%) additional SNs.

Scanning with 18F-FDG-PET/CT for detection of pelvic nodal involvement in inguinal node-positive penile carcinoma.

BACKGROUND: Penile carcinoma patients with inguinal lymph node involvement (LNI) have an increased risk for pelvic nodal involvement with or without distant metastases. OBJECTIVE: To evaluate the diagnostic accuracy of fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) with computed tomography (CT; 18F-FDG PET/CT) scanning in determining further metastatic spread in patients with tumour-positive inguinal nodes. DESIGN, SETTING, AND PARTICIPANTS: Eighteen patients with penile squamous cell carcinoma with unilateral or bilateral cytologically tumour-positive inguinal disease underwent whole-body 18F-FDG-PET/CT scanning for tumour staging. MEASUREMENTS: Images were blindly assessed by two nuclear medicine physicians. All scans were evaluated for pelvic nodal involvement per basin and for distant metastases. Histopathology (when available), radiologic imaging, and clinical follow-up (with a minimum of 1 yr) served as a reference standard. The diagnostic value of PET/CT scanning for predicting pelvic nodal involvement was evaluated using standard statistical methods. RESULTS AND LIMITATIONS: The reference was available in 28 of the 36 pelvic basins. Of the 11 tumour-positive pelvic basins, 10 were correctly predicted by PET/CT scan, as were all 17 tumour-negative pelvic basins. PET/CT scan showed a sensitivity of 91%, a specificity of 100%, a diagnostic accuracy of 96%, a positive predictive value of 100%, and a negative predictive value of 94% in detecting pelvic nodal involvement. Additionally, PET/CT scans showed distant metastases in five patients. In four patients, the presence of distant metastases could be confirmed, while in one patient, no radiologic confirmation was found for that particular lesion. A potential limitation is that the diagnostic accuracy of PET/CT scanning was calculated on 28 pelvic basins only. Furthermore, no comparison was made with conventional CT scans, as not all patients had undergone contrast-enhanced CT scans. CONCLUSIONS: PET/CT scanning appears promising for detecting pelvic lymph node metastases with great accuracy, and it identifies distant metastases in penile carcinoma patients with inguinal LNI. In our practice, PET/CT scanning has become part of routine staging in such patients.

A simple and safe method for 131I radiolabeling of rituximab for myeloablative high-dose radioimmunotherapy.

The aim of this study was to develop a safe and simple radiolabeling and purification procedure for high-dose (131)I-rituximab for treatment of patients with non-Hodgkin's lymphoma. As the starting point, the conventional Iodogen-coated vial method was applied. After the iodogen-coated monoclonal antibody (mAb) method, a labeling method involving much lower amounts of iodogen was assessed. Subsequently, (131)I-rituximab was purified with a tangential flow filtration system. Quality control of the final product was performed by using size-exclusion chromatography with ultraviolet detection and by instant high-performance thin-layer chromatography. Immunoreactivity was determined by using a cell-binding assay. During the labeling procedure, radiation exposure was monitored. The coated vial method resulted in a low radiation exposure, but immunoreactivity was highly compromised (37%). Also, formation of aggregates was observed. The maximal observed effective dose was 18 microSv, finger thermoluminescence dosemeters revealed a hand-dose measurement of 0.8 mSv. The second method resulted in an immunoreactivity of 70%. Radiochemical purity was >97% after purification. The maximal measured effective dose was 31 microSv, and detected exposure to the hands was 1.9 mSv. We have developed a simple labeling technique for the preparation of high-dose (131)I-rituximab. The method offers a high purity and retained immunoreactivity with minimal radiation exposure for involved personnel.

131I-MIBG therapy in metastatic phaeochromocytoma and paraganglioma.

PURPOSE: (131)Iodine metaiodobenzylguanidine ((131)I-MIBG) is a radiopharmaceutical used for scintigraphic localisation of phaeochromocytomas and paragangliomas. The experience with its therapeutic use is limited. We report our experience for the treatment of malignant phaeochromocytoma and paraganglioma. MATERIALS AND METHODS: The charts of 19 patients with malignant phaeochromocytoma (n = 12) or paraganglioma (n = 7), who were treated with (131)I-MIBG, were retrospectively reviewed. Four patients (21%) received radiotherapy, three (16%) chemotherapy, and in one patient (5%), both chemotherapy and radiotherapy was given before (131)I-MIBG therapy. Response to (131)I-MIBG treatment was evaluated by objective as tumour response, biochemical and subjective response. RESULTS: Of the 19 patients, 13 (68%) were men, 6 (32%) were women. Ages ranged from 22 to 68 years (median, 47). The median initial dose was 7.4 GBq (200 mCi; range, 6.7 GBq-25.9 GBq, 180-700 mCi); median cumulative dose was 22.2 GBq (600 mCi; range, 6.8 GBq-81.4 GBq, 183-2200 mCi). Objective tumour response was achieved in 47% of the patients. Biochemical response rate was 67%, and symptomatic response was seen in 89% of the patients. Overall median follow-up was 29 months, with a range of 3-93 months. Haematologic complications were the most common side effects and were observed in 26% of the patients. CONCLUSION: Our data support that symptomatic and biochemical response can be reached with (131)I-MIBG therapy in patients with metastatic phaeochromocytoma and paraganglioma. Although complete tumour response was not observed, the palliation and control of tumour function by (131)I-MIBG therapy may be valuable for the patients.

Sentinel node biopsy and concomitant probe-guided tumor excision of nonpalpable breast cancer.

BACKGROUND: Preliminary data have shown encouraging results of a single intratumoral radiopharmaceutical injection that enables both sentinel node biopsy and probe-guided excision of the primary tumor in patients with nonpalpable breast cancer. The aim of the study was to evaluate this approach in a large group of patients. METHODS: Lymphoscintigraphy was performed in 368 patients with nonpalpable breast cancer after intratumoral injection of (99m)Tc-nanocolloid (.2 mL, 123 MBq, 3.3 mCi) guided by ultrasound or stereotaxis. The sentinel node was pursued with the aid of vital blue dye (1.0 mL, intratumoral) and a gamma ray detection probe. In case of breast-conserving surgery, the probe was used to guide the excision. RESULTS: At least one sentinel node could be identified intraoperatively in 357 patients (97%), of whom 69 had involved nodes (19%). Age over 60 years was associated with less frequent nonaxillary lymphatic drainage and absence of internal mammary chain dissemination. Tumor-free margins were obtained in 262 (89%) of the 293 patients who underwent segmental excision. Re-excision of the primary tumor bed was performed in six patients (2%). During a median follow-up of 22 months, one breast recurrence and one axillary recurrence were observed. CONCLUSIONS: Lymphatic mapping and probe-guided tumor excision of nonpalpable breast cancer by intralesional administration of a single dose of (99m)Tc-nanocolloid and blue dye resulted in 97% identification of the sentinel node and in tumor-free margins in 89% of the patients who underwent breast-conserving surgery. Longer follow-up is needed to substantiate the accuracy and safety of this technique.

Clinical implications of sentinel nodes outside the axilla and internal mammary chain in patients with breast cancer.

PURPOSE: The aim of this study was to determine the incidence, location, surgical identification rate, tumor status, and clinical implications of sentinel nodes outside the axilla and internal mammary chain. PATIENTS AND METHODS: In 785 breast cancer patients, pre-operative lymphoscintigraphy was performed after intratumoral injection of 116 MBq 99mTc-labeled nanocolloid (0.2 ml; 3.1 mCi). Sentinel nodes were pursued using a gamma-ray detection probe and vital blue dye. RESULTS: Lymphoscintigraphy visualized sentinel nodes outside the axilla and internal mammary chain in 91 of the 785 patients (12%). Sentinel nodes (106) were identified in 80 patients. These nodes were found in the following locations: 50 in the breast, 31 in the infraclavicular fossa, 19 between the pectoral muscles, and 6 within the supraclavicular bed. Eighteen nodes contained a metastasis (17%) and were removed from 16 patients. The treatment strategy was adjusted in 12 of them with the addition of adjuvant local or systemic therapy. Two additional patients with an unusually situated tumor-negative sentinel node were spared an axillary node dissection that would otherwise have been performed. CONCLUSION: Unusually situated sentinel nodes were visualized in 12% of the patients. The treatment was adjusted in 18% of patients in whom these nodes were identified.

Ultrasonography and fine-needle aspiration cytology in the preoperative evaluation of melanoma patients eligible for sentinel node biopsy.

BACKGROUND: Ultrasonography with fine-needle aspiration cytology (FNAC) has proven to be a valuable diagnostic tool in the preoperative workup of patients with breast cancer or penile cancer eligible for sentinel lymph node biopsy. The aim of this study was to evaluate the use of this technique in the initial assessment of patients with primary cutaneous melanoma. METHODS: A total of 107 patients with cutaneous melanoma eligible for sentinel node biopsy with clinically negative nodes were studied prospectively. Patients underwent ultrasonography of potentially involved basins and FNAC in case of a suspicious lymph node. The sentinel node procedure was omitted in patients with tumour-positive lymph nodes in lieu of lymph node dissection. RESULTS: Ultrasonography with FNAC correctly identified disease preoperatively in two of the 107 patients (2%). Thirteen of the 22 patients (59%) with a suspicious node on ultrasonographic imaging but a tumour-negative fine-needle aspirate were shown to have involved nodes. Of the 85 patients with ultrasonographically normal nodes, 25 (29%) were shown to have metastases. Of the total of 43 involved basins, 16 contained metastases > 2 mm and 25 < or = 2 mm. CONCLUSIONS: In our hands, the sensitivity and specificity of preoperative ultrasonography to detect lymph node involvement in patients with melanoma are 34% and 87%, respectively. In combination with FNAC, this is 4.7% and 100%, respectively. This yield is insufficient for this technique to be used as a routine diagnostic tool in the selection of patients eligible for sentinel node biopsy.

Sentinel node biopsy before neoadjuvant chemotherapy spares breast cancer patients axillary lymph node dissection.

BACKGROUND: Neoadjuvant chemotherapy in breast cancer patients is a valuable method to determine the efficacy of chemotherapy and potentially downsize the primary tumor, which facilitates breast-conserving therapy. In 18 studies published about sentinel node biopsy after neoadjuvant chemotherapy, the sentinel node was identified in on average 89%, and the false-negative rate was on average 10%. Because of these mediocre results, no author dares to omit axillary clearance just yet. In our institute, sentinel lymph node biopsy is performed before neoadjuvant chemotherapy. The aim of this study was to evaluate our experience with this approach. METHODS: Sentinel node biopsy was performed before neoadjuvant chemotherapy in 25 T2N0 patients by using lymphoscintigraphy, a gamma ray detection probe, and patent blue dye. Axillary lymph node dissection was performed after chemotherapy if the sentinel node contained metastases. RESULTS: Ten patients had a tumor-positive axillary sentinel node, and one patient had an involved lateral intramammary node. Four patients had additional involved nodes in the completion lymph node dissection specimen. The other 14 patients (56%) had a tumor-negative sentinel node and did not undergo axillary lymph node dissection. No recurrences have been observed after a median follow-up of 18 months. CONCLUSIONS: Fourteen (56%) of the 25 patients were spared axillary lymph node dissection when the sentinel node was found to be disease free. Performing sentinel node biopsy before neoadjuvant chemotherapy seems successful and reliable in patients with T2N0 breast cancer.

Non-axillary breast cancer recurrences after sentinel node biopsy.

BACKGROUND AND OBJECTIVES: The primary lymphatic pathway of patients with breast cancer is toward the axilla, but lymph drainage is also possible towards the internal mammary chain and the supraclavicular fossa. In the current article, the development of breast cancer recurrences at these two sites after sentinel lymph node biopsy is reviewed. METHODS: Since 1997, 803 patients underwent sentinel lymph node biopsy with intratumoral injection of 99mTc-nanocolloid and patent blue dye in The Netherlands Cancer Institute. All sentinel nodes as visualized on the lymphoscintigraphy images were pursued. The patients were followed prospectively for a median period of 34 months. Patients with a lymph node recurrence outside the axilla were identified and their lymphatic mapping procedures were reviewed. RESULTS: Four of the 803 patients (0.5%) developed regional lymph node recurrences outside the axilla. One recurrence was located in the internal mammary chain, the other three in the supraclavicular bed. One or two of these patients also had an axillary recurrence. The sentinel node procedure had failed in two of the four patients. CONCLUSION: The incidence of nodal recurrences outside the axilla is low. Although all extra-axillary sentinel nodes were pursued, some of these recurrences concern missed sentinel nodes that harbor metastasis. Identification of all sentinel nodes and subsequent treatment of the involved basins may reduce the risk of breast cancer recurrences in these unusual locations.

Review and evaluation of sentinel node procedures in 250 melanoma patients with a median follow-up of 6 years.

BACKGROUND: The aim of this study was to evaluate the results of sentinel node biopsy in cutaneous melanoma at our institute. METHODS: A total of 250 patients with cutaneous melanoma were studied prospectively. Preoperative lymphoscintigraphy was performed after injection of (99m)Tc-nanocolloid intradermally around the primary tumor or biopsy site (.32 mL, 65.5 MBq [1.8 mCi]). The sentinel node was surgically identified with the aid of patent blue dye and a gamma ray detection probe. The median follow-up was 72 months. RESULTS: Lymphoscintigraphic visualization was 100%, and surgical identification was 99.6%. In 60 patients (24%), 1 or more sentinel nodes were tumor positive at initial pathology evaluation. Late complications after sentinel node biopsy of the remaining 190 patients were seen in 35 patients (18%). The false-negative rate was 9%. In-transit metastases were seen in 7% of sentinel node-negative and 23% of sentinel node-positive patients. The estimated 5-year overall survival rates were 89% and 64%, respectively (P <.001). CONCLUSIONS: This study confirms that the status of the sentinel node is a strong independent prognostic factor. The false-negative rate and the incidence of in-transit metastases in sentinel node-positive patients are high and have to be weighed against the possible survival benefit of early removal of nodal metastases.

Feasibility of sentinel node lymphoscintigraphy in stage I testicular cancer.

The aim of this study was to investigate the feasibility of lymphoscintigraphy for sentinel node identification in testicular cancer. Five patients with clinical stage I testicular cancer were prospectively included. A single dose of technetium-99m nanocolloid (mean dose 99 MBq, volume 0.2 ml) was injected into the funiculus in the first patient and into the testicular parenchyma in the following four patients. Dynamic lymphoscintigraphy was performed over 10 min, followed by early and late static images after 15 min and 2 to 24 h, respectively. Lymphoscintigraphy was followed by laparoscopic sentinel node biopsy on the same day in the last two patients using patent blue dye and an endoscopic gamma probe. The funicular administration route showed five hot spots in the right inguinal region after 2 h. Intratesticular administration resulted in sentinel node visualisation in three of the four patients. Dynamic images showed afferent lymphatic vessels to one sentinel node in the left para-aortic region in two patients and two sentinel nodes in the left para-aortic region in another patient. Sentinel nodes were intraoperatively identified in one of two patients who underwent laparoscopic exploration. It is concluded that lymphoscintigraphy for sentinel node identification is feasible in stage I testicular cancer using intratesticular radiocolloid administration.