Editorial
Is Preoperative Lymphoscintigraphy Needed for Sentinel
Node Procedures in Breast Cancer?
Seth P. Harlow,MD
Division of Surgical Oncology,University of Vermont,89 Beaumont Avenue,E309C Given Building,Burlington,Vermont 05405
Sentinel node biopsy techniques have gained rapid
acceptance in the medical community as being an
accurate tool for the pathologic staging of regional
lymph nodes in patients with clinically node-negative
breast cancer. Two large multicenter clinical trials,
the National Surgical Adjuvant Breast and Bowel
Project B32 and the American College of Surgeons
Oncology Group Z10 trials,have recently completed
accrual and should give us definitive proof that these
minimally invasive procedures provide regional dis-
ease control and patient survival equivalent to those
with standard axillary node dissection,with less
morbidity. A great deal of attention is now being paid
to determining the most effective methods for per-
forming these procedures and what factors may
influence their success. In this issue of Annals of
Surgical Oncology,Rousseau et al.
1
describe the fac-
tors that may influence the ability to visualize sentinel
nodes on preoperative lymphoscintigraphy and the
effect that nonvisualization has on the outcome of the
sentinel node procedure.
Lymphoscintigraphy has been used routinely in
sentinel node procedures for melanoma and has been
quite useful in this role because of the variability in
lymphatic drainage patterns seen in this disease.
However,lymphoscintigraphy has been met with
mixed enthusiasm for sentinel node identification in
breast cancer. From the surgeonÕs perspective,for
lymphoscintigraphy to be a clinically useful tool,it
should have a high rate of success in identifying the
location of the sentinel node,and there should be
some ambiguity as to which nodal basin the sentinel
node will be located in before the scan is performed.
The track record for lymphoscintigraphy in breast
cancer has been for only moderate success in identi-
fying the sentinel node site (only 78.5% successful in
this study),whereas the presence of unsuspected no-
dal drainage sites is relatively uncommon,especially
if one considers the internal mammary basin as a
known potential drainage site. In this study,
1
the
authors made sure to use a technique that would be
expected to give a high level of success for visualizing
sentinel nodes. All injections were given in the peri-
areolar region,were of small volume (.1 mL),and
were of adequate dose (30–40 MBq). Common
problems identified in the past that have inhibited the
success of lymphoscintigraphy in breast cancer have
been the overlap of injection site activity with nodal
drainage sites and a lack of sufficient tracer reaching
the sentinel nodes. Each of these should have been
avoided by the technique used. The 21.5% nonvisu-
alization rate in this study is in fact better than rates
in many reports in the literature,
2–3
but from the
standpoint of the surgeon,this rate is still relatively
high. This is further borne out by the fact that in
84.6% of patients in whom there was nonvisualization
of a sentinel node by scan,a sentinel node was found
by the surgeon using the gamma detector at the time
of operation. Additional sentinel nodes were also
found when blue dye was included,and this increased
the sentinel node identification rate to 88.4%.As
would be expected,if a sentinel node was identified
on preoperative lymphoscintigraphy,the sentinel
node identification rate was higher (93.2%),but it was
Received March 10,2005; accepted April 17,2005; published
online j.
Address correspondence and reprint requests to: Seth P. Harlow,
MD; E-mail: seth.harlow@uvm.edu.
Published by Springer Science+Business Media,Inc. Ó 2005 The Society of
Surgical Oncology,Inc.
Annals of Surgical Oncology, 12(7): 1)2
DOI: 10.1245/ASO.2005.03.900
1