Intraoperative Injection of Subareolar or Dermal Radioisotope Results in Predictable Identification of Sentinel Lymph Node in Breast Cancer
Chad B Johnson, MD*, Cristiano Boneti, MD*, Soheila Korourian, MD*, Yara Robertson, MD*, Laura Adkins, MD*, Suzanne Klimberg, MD
University of Arkansas for Medical Sciences, Little Rock, AR
Preoperative injection of technetium-99m sulfur colloid(Tc99) and lymphoscintigraphy is standardly performed before sentinel lymph node biopsy(SLNB) for breast cancer(BC). Blue dye is often used to help guide and confirm the localization but tattoos the breast. This methodology results in painful injections, variable identification rates, added costs and unnecessary scheduling delays. We hypothesized that lymphoscintigraphy is unnecessary and that intraoperative injection alone by the surgeon of dermal or subareolar Tc99 that migrates within minutes is practical for SLNB.
This is an IRB-approved prospective study of operable BC seen from October 2002-2010. After induction 1 mCi of Tc-99 unfiltered was administered by a subareolar or 0.25 mCi for dermal injection. Confirmatory blue dye was injected at the discretion of the surgeon. Site and type of injection, injection time, incision time, and extraction time along with nodal positivity were recorded.
699 patients were accrued for 775 intraoperative Tc-99 injections. The SLN was localized in 98.6%(419 of 425) with subareolar radiotracer alone, 94.8%(326 of 244) in dual injection and 100%(6 of 6) in dermal injection. Median time from injection to incision including bilateral procedures was 30min for subareolar radiotracer, 26min for dermal injections and 26min for dual injection. The average ex-vivo count and nodal positivity were similar for all groups. Radiotracer alone was least expense.
Intraoperative injection of Tc99 alone with a subareolar or dermal injection technique rapidly localizes the SLN in BC, is most humane for the patient, avoids tattooing, is cost effective and facilitates operative room time management.
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