Sentinel node mapping in Marjolin's ulcers: is it feasible?

INTRODUCTION: This study evaluated the feasibility of sentinel node biopsy in Marjolin's ulcers using peritumoral injection of the radiotracer and blue dye. MATERIALS AND METHODS: Ten patients with Marjolin's ulcers (5 male and 5 females) ranging in age from 39-65 years, and who were candidates for surgical removal of their tumors, were included in this study. The patients received 2 mCi technetium 99m (99mTc) antimony sulfide colloid in 2 divided doses subcutaneously in the peritumoral region. Immediately after anesthesia induction, 1 cc patent blue V in 2 divided doses was also injected in the same fashion as the radiotracer. Lymphatic mapping and sentinel node biopsy was performed using a gamma probe. Any hot and/or blue lymph nodes were harvested as a sentinel node. Primary lesions were then excised and wounds grafted with a splitthickness skin graft. RESULTS: A sentinel node could be identified on the lymphoscintigraphy images in only 2 patients. Sentinel node mapping was successful during surgery in these 2 patients. None of the harvested sentinel nodes were blue. CONCLUSION: Lymphatic mapping and sentinel node biopsy do not seem feasible in Marjolin's ulcers located in areas of extensive burn scarring due to a low detection rate. Larger studies are needed to validate the results of this study.

Lymphatic mapping and sentinel node biopsy in endometrial cancer--a feasibility study using cervical injection of radiotracer and blue dye.

BACKGROUND: The aim of this study was to evaluate the feasibility and accuracy of sentinel lymph node (SLN) detection using preoperative lymphoscintigraphy and intra-operative gamma probe/blue dye for endometrial cancer patients. MATERIAL AND METHODS: Twenty four consecutive patients with endometrial cancer were recruited. All patients underwent lymphatic mapping and sentinel node biopsy using combined intracervical radiotracer and blue dye injections. Pelvic lymph node dissection was performed for all patients. Para-aortic lymphadenectomy was done in high risk patients. All SLNs were examined by frozen section and Hematoxylin and Eosin (H&E) permanent sections. RESULTS: Pre-operative lymphoscintigraphy showed at least one SLN in 21/24 patients. Intra-operatively, at least one SLN could be harvested by gamma probe and/or blue dye methods. A total of 95 SLNs were detected. Four SLNs were detected only by blue dye, 42 only by radiotracer, and 49 were hot/blue. Median number of SLN per patient was 3. Three patients had positive pelvic lymph nodes. All of them had positive SLN (no false negative case). Frozen section could identify SLN involvement in two of three patients with positive pathology. CONCLUSION: Lymphatic mapping and sentinel node biopsy is feasible and accurate in endometrial cancer patients using combined radiotracer and blue dye methods. Frozen section accuracy was lower and underscores the importance of expert pathologists for SLN mapping technique.

Disabilities and activities of daily living among veterans with old hip disarticulation and transpelvic amputation.

BACKGROUND: The Iran-Iraq imposed war lasted eight years and was one of the longest wars of the last century. Twenty-three years have passed since the war ended, but little has been discussed about the long-term results of war amputations in the literature. OBJECTIVES: In this long-term study, we have evaluated the activities of daily living among veterans with hip or hemipelvis amputations. PATIENTS AND METHODS: A cross-sectional study was performed on Iran-Iraq war veterans with hip or hemipelvis amputations in Iran. Eighty-four (96.5%) veterans out of 87 registered veterans with hip or hemipelvis amputations participated in the study. The degree of independence for activities of daily living (ADL) was assessed by the Barthel index. The degree of independence for instrumental activities of daily living (IADL) was assessed by the Lawton-Brody scale. RESULTS: The average follow-up time was 26.6 ± 3.7 years. The average age of veterans was 44.1±7 years old. Of 84 amputees, 57 (67.85%) had limitations in at least one domain of the ADL. The most common single item that affected the patients was ascending and descending stairs seen in 45 (78.9%) veterans, followed by eating seen in 4 (7.01%) veterans. In addition, 70 (83.33%) had limitations in at least one domain of the IADL. The most common single item that affected the veterans was shopping seen in 56 (80%), followed by responsibility for own medications seen in 13 (18.57%) veterans. Spearman correlation coefficient of the sum scores of ADL and IADL showed an intermediate to strong correlation (r = 0.58). CONCLUSIONS: Increasing dependency in ADL is accompanied by increasing dependency in IADL. In the past, the duty of health care providers was saving the life of veterans due to injuries while at present, because these injuries occurred in young and healthy individuals, the need for increased function is being highlighted.

Diagnostic value of 99mTc-bombesin scintigraphy for differentiation of malignant from benign breast lesions.

OBJECTIVE: In this study, we evaluated the diagnostic accuracy of (99m)Tc-bombesin scintigraphy for differentiation of benign from malignant palpable breast lesions. (99m)Tc-Bombesin is a tracer with high affinity for gastrin-releasing peptide receptor, which is overexpressed on a variety of human tumors including breast carcinoma. MATERIALS AND METHODS: We examined 33 consecutive women who were referred to our center with suspicious palpable breast lesions but had no definitive diagnosis in other imaging procedures. A volume of 370-444 MBq of (99m)Tc-bombesin was injected and dynamic 1-min images were taken for 20 min immediately after injection in anterior view. Thereafter, two static images in anterior and prone-lateral views were taken for 5 min. Finally, single-photon emission computed tomography images were taken for each patient. Definitive diagnosis was based on biopsy and histopathological evaluation. RESULTS: The scan findings were positive in 19 patients and negative in 11 on visual assessment of the planar and single-photon emission computed tomography images. Pathologic examination confirmed breast carcinoma in 12 patients with positive scans and benign pathology for 18 patients. The overall sensitivity, specificity, negative and positive predictive values, and accuracy of this radiotracer for diagnosis of breast cancer were 100, 66.1, 100, 63, and 76%, respectively. Semiquantitative analysis improved the specificity of the visual assessment from 66 to 84%. CONCLUSION: Our study showed that (99m)Tc-bombesin scintigraphy has a high sensitivity and negative predictive value for detecting malignant breast lesions, but the specificity and positive predictive value of this radiotracer for differentiation of malignant breast abnormalities from benign ones are relatively low.

Added value of blue dye injection in sentinel node biopsy of breast cancer patients: do all patients need blue dye?

BACKGROUND: In the current study, we evaluated the incremental value of blue dye injection in sentinel node mapping of early breast cancer patients. We specially considered the experience of the surgeons and lymphoscintigraphy results in this regard. METHODS: 605 patients with early stage breast cancer were retrospectively evaluated in the study. Patients underwent sentinel node mapping using combined radiotracer and blue dye techniques. Lymphoscintiraphy was also performed for 590 patients. Blue dye, radioisotope, and overall success rates in identifying the sentinel lymph node were evaluated in different patient groups. The benefit of blue dye and radioisotope in identifying the sentinel lymph nodes was also evaluated. RESULTS: Marginal benefits of both blue dye and isotope for overall sentinel node detection as well as pathologically involved sentinel nodes were statistically higher in inexperienced surgeons and in patients with sentinel node visualization failure. In the patients with sentinel node visualization on lymphoscintigraphy, 6 sentinel nodes were detected by blue dye only. All these six nodes were harvested by inexperienced surgeons. On the other hand 8 sentinel nodes were detected by dye only in the patients with sentinel node non-visualization. All these nodes were harvested by experienced surgeons. CONCLUSIONS: The use of blue dye should be reserved for inexperienced surgeons during their learning phase and for those patients in whom lymphoscintigraphy failed to show any uptake in the axilla.

Axillary concordance between superficial and deep sentinel node mapping material injections in breast cancer patients: systematic review and meta-analysis of the literature.

It is still unclear whether the deep and superficial lymphatics of the breast always drain into the same nodes and which route best simulates the spread of breast cancer. In the current study, we systematically searched the available literature to find the studies evaluated the sentinel node locations of deep and superficial injections in the same patients simultaneously or serially. We searched SCOPUS, and PUBMED for relevant studies. Patient basis concordance rate was defined as the ratio of patients with at least one identified axillary sentinel node by both deep and superficial injections to all patients with identified axillary sentinel nodes using either methods. Sentinel node basis concordance was defined as the ratio of the number of axillary sentinel nodes identified by both deep and superficial injections to the sum of all identified axillary sentinel nodes using either methods. Pooled sentinel node detection rates were 94 % [92.1-95.5], 91.2 % [87.1-94.1], and 97.2 % [96-98] for superficial, deep, and combined (superficial and deep) injections. Pooled patient basis and sentinel node basis concordance rates were 90 % [86.7-92.4] and 73 % [63.3-80.9]. Pooled false negative rates were 9.1 % [5.9-14], 8.6 % [3.7-18.8], and 6.5 % [3.4-11.9] for superficial, deep, and combined (superficial and deep) injections, respectively. Axillary lymphatic drainage concordance between superficial and deep sentinel node mapping material in breast cancer patients is fairly high and clinically acceptable. However, both injection techniques can complement each other and the combined superficial/deep injection technique seems to be more successful clinically and can decrease the overall false negative rate.

Effect of radiotracer injection volume on the success of sentinel node biopsy in early-stage breast cancer patients.

OBJECTIVE: The volume of radiotracer to be injected for sentinel node mapping is a controversial issue in breast cancer patients. In the current study, we evaluated the effect of radiotracer injection volume on the success rate of sentinel node mapping in early-stage breast cancer patients. MATERIALS AND METHODS: A total of 383 patients with early-stage breast cancer (cN0) were included in the study. The patients received an intradermal injection of Tc-antimony sulfide colloid for sentinel node mapping. The volume of injection was 0.1 ml for 102 patients, 0.2 ml for 221 patients, 0.5 ml for 30 patients, and 1 ml for 30 patients. The detection rate of the sentinel nodes during surgery was compared between the different injection volume groups. RESULTS: The overall detection rate was 93.9%. Detection rates were 95.1, 95, 90, and 86.7% for 0.1, 0.2, 0.5, and 1 ml volumes, respectively, which did not show a statistically significant difference despite minimal decrease in detection at higher volumes (P=0.214). The time of sentinel node visualization was not statistically different between the studied groups either (P=0.65). CONCLUSION: Increasing the volume of radiotracer in intradermal injections does not have a statistically significant effect on the sentinel node detection rate (despite minimal decrease in detection at higher volumes), nor on the time of sentinel node visualization. A low volume (0.1 ml) of radiotracer for intradermal injections can be as successful as higher volumes for sentinel node mapping with the added benefit of reduced pain from injections.