OBJECTIVES Lymphoscintigraphy is considered a useful tool to optimize sentinel lymph node (SLN) identification. Nonvisualization of the SLN is associated with a lower SLN identification rate. The aim of this study was to identify preoperative factors associated with SLN nonvisualization on lymphoscintigraphy. PATIENTS AND METHODS A total of 2050 consecutive SLN procedures were evaluated from clinically node-negative breast cancer patients. Planar lymphoscintigraphy was performed at 3 h after an intratumoral injection of technetium-99m-nanocolloid. This technique was used for extra-axillary SLN identification. Patient, tumor, and treatment characteristics were analyzed for association with SLN nonvisualization. Factors with a P-value less than 0.1 in univariate analysis were included in a multivariate logistic regression model. RESULTS The SLN visualization rate was 86.7%. In multivariate logistic regression, age of at least 70 years [odds ratio (OR): 3.24; 95% confidence interval (CI): 2.14-4.91)], BMI of at least 30 (OR: 1.93; 95% CI: 1.39-2.69), T3/T4-tumors (OR: 2.70; 95% CI: 1.37-5.32), medially/centrally located tumors (OR: 1.52; 95% CI: 1.17-1.99), previous mantle field radiation (OR: 4.04; 95% CI: 1.74-9.35), nonpalpable tumors (OR: 1.88; 95% CI: 1.36-2.60), and presence of iodine seeds (OR: 1.35; 95% CI: 1.02-1.78) were associated significantly with nonvisualization on lymphoscintigraphy. Nonvisualization was the strongest independent predictor of unsuccessful intraoperative SLN identification (P<0.001). Overall, the SLN identification rate was 97.7% because of the use of additional imaging and blue dye. CONCLUSION This study reports new tumor and treatment-related risk factors for nonvisualization on lymphoscintigraphy by using an intratumoral injection in primary breast cancer. We recommend a periareolar subcutaneous injection to improve SLN visualization in patients with limited prognostic and therapeutic relevance of internal mammary chain SLN identification.

Predictive risk factors for sentinel lymph node nonvisualization on planar lymphoscintigraphy using an intratumoral injection in patients with primary breast cancer.

Background: Accurate sentinel lymph node (SLN) staging is essential for both prognosis and treatment in patients with breast cancer. However, the preoperative lymphoscintigraphy may fail to visualize the SLN in some patients. The purpose of this retrospective study was to identify risk factors associated with SLN nonvisualization on lymphoscintigraphy. For this single-center retrospective study, all data of lymphoscintigraphy of SLN procedures from March 2011 to April 2021 were collected and reviewed from the Amsterdam UMC database. Results: A total of 1886 SLN procedures were included in this study. The SLN nonvisualization rate was 25.1% on lymphoscintigraphy at 4 h post-injection. The SLN nonvisualization rate decreased to 9.4% after reinjection. Multivariable analysis showed that age ≥ 70 years (P < 0.001; OR: 2.27; 95% CI: 1.46–3.53), BMI ≥ 30 kg/m 2 (P = 0.031; OR: 1.48; 95% CI: 1.04–2.12) and nonpalpable tumors (P = 0.004; OR: 1.54; 95% CI: 1.15–2.07) were independent predictors of SLN nonvisualization. Tumor location, brand of radiopharmaceutical, injected dose and volume, experience of preparer and administrator were not associated with SLN nonvisualization. None of the patient, tumor or tracer characteristics were associated with SLN nonvisualization after radiotracer reinjection. Conclusions: This study shows that risk factors for SLN nonvisualization in breast cancer patients during preoperative lymphoscintigraphy are age ≥ 70 years, BMI ≥ 30 kg/m 2 and nonpalpable tumors. Our results support the notion that SLN lymphoscintigraphy is a very robust technique that does not depend on the experience of the preparer or administrator of the radiotracer.

/pdf/risk-factors-for-nonvisualization-of-the-sentinel-lymph-node-531wqpoccq.pdf

Risk factors for nonvisualization of the sentinel lymph node on lymphoscintigraphy in breast cancer patients.

Aims: The clinical significance of nonvisualized sentinel lymph nodes (non-vSLNs) is unknown. The authors sought to determine the incidence of non-vSLNs on lymphoscintigraphy, the identification rate during surgery, factors associated with non-vSLNs and related axillary management. Patients & methods: A total of 30,508 consecutive SLN procedures performed at a single institution from 2000 to 2017 were retrospectively studied. Associations between clinicopathological factors and the identification of SLNs during surgery were assessed. Results: Non-vSLN occurred in 525 of the procedures (1.7%). In 73.3%, at least one SLN was identified intraoperatively. Nodal involvement was only significantly associated with SLN nonidentification (p < 0.001). Conclusion: Patients with non-vSLN had an increased risk for SLN metastasis. The detection rate during surgery was consistent, reducing the amount of unnecessary axillary dissection.Lay abstract To study the clinical significance of nonvisualized sentinel lymph nodes (non-vSLNs) in axillary surgery for breast cancer, 30,508 consecutive SLN procedures performed at a single institution from 2000 to 2017 were retrospectively reviewed with the aim to analyze the incidence of non-vSLNs on lymphoscintigraphy, the identification rate during surgery, factors associated with non-vSLNs and related axillary management. Associations between clinicopathological factors and the identification of SLNs during surgery were assessed. Non-vSLN occurred in 525 of the procedures (1.7%). In 73.3%, at least one SLN was identified intraoperatively. Nodal involvement was only significantly associated with SLN nonidentification (p < 0.001). Patients with non-vSLN had an increased risk for SLN metastasis. The detection rate during surgery was consistent, reducing the amount of unnecessary axillary dissection. 

Does failed mapping predict sentinel lymph node metastasis in cN0 breast cancer?

BACKGROUND AND OBJECTIVES Preoperative lymphoscintigraphy does not always visualize a sentinel lymph node (SLN). The study aim was to investigate whether persistent nonvisualization after additional single-photon emission computed tomography (SPECT)/CT or a second radiotracer injection in breast cancer patients is associated with nodal metastases or worse outcome due to potential understaging and consequently undertreatment. METHODS Altogether 2042 consecutive SLN procedures were evaluated. All patients were clinically node-negative, underwent axillary ultrasound and fine-needle aspiration cytology (US/FNAC) of suspicious nodes. Lymphoscintigraphy was performed at 3 to 4 hours after intratumoral injection of 99mTc-nanocolloid. SPECT/CT or a reinjection was performed when initial lymphoscintigraphy showed nonvisualization. RESULTS Persistent nonvisualization was seen in 170 of 2042 procedures (8.3%). The nodal metastasis rate was 16.0% vs 18.0% for procedures with nonvisualization vs SLN visualization, respectively (P = 0.593). The regional recurrence rate of tumor-negative SLN biopsy procedures was equal between the visualization (0.7%, 11 of 1535) vs nonvisualization (0.7%, 1 of 144) group. Median follow-up was 48 months. Distant-metastasis free interval and overall survival was not significantly different between both groups ( P = 0.164 and 0.208, respectively). CONCLUSIONS Persistent nonvisualization after lymphoscintigraphy plus SPECT/CT or radiotracer reinjection is not associated with a higher nodal metastasis rate or worse long term outcome when preoperative US/FNAC is performed.

Sentinel lymph node nonvisualization after intratumoral radioisotope tracer injection in breast cancer is not associated with a higher nodal metastasis rate or worse outcomes

Resumen Objetivo Revisar la aplicabilidad de la biopsia selectiva del ganglio centinela en pacientes con cancer de mama y antecedente de cirugia mamaria previa, y examinar los factores que podrian influir en la deteccion del ganglio centinela. Material y metodos Revisamos retrospectivamente la biopsia selectiva del ganglio centinela en 91 pacientes con cancer de mama dividiendolas en 2 grupos segun el antecedente quirurgico de la mama: cirugia estetica en 30 (grupo I ) y conservadora en 61 (grupo II ). Se realizo linfogammagrafia prequirurgica tras inyeccion intratumoral en 21 casos y periareolar en 70. Se analizaron los patrones de drenaje linfatico y la deteccion global del ganglio centinela segun caracteristicas clinicas, patologicas y quirurgicas. Resultados La deteccion global del ganglio centinela en la linfogammagrafia fue del 92,3%, con un 7,7% de drenajes extraaxilares. La deteccion fue similar en el grupo I (93,3%) y grupo II (91,8%). En 2 pacientes (2,2%) detectamos ganglios centinelas en la axila contralateral, estando afectados en el estudio anatomopatologico. El porcentaje de no deteccion del ganglio centinela en la gammagrafia fue del 7,7%. Se encontro una proporcion de no deteccion significativamente mayor en tumores con mayor grado histologico (28,6% grado III , 4,5% grado I y 3,6% grado II ). Conclusion Se puede realizar la biopsia selectiva del ganglio centinela en pacientes con antecedente de cirugia mamaria previa, pero serian necesarios mas estudios para valorar la influencia en la deteccion del ganglio centinela de diferentes aspectos en este escenario clinico. Un elevado grado histologico se relaciona significativamente con una menor deteccion.

Influencia de la cirugía mamaria previa en la biopsia selectiva del ganglio centinela en pacientes con cáncer de mama

Objective
To evaluate factors associated with non identification of the sentinel lymph node (SLN) in lymphoscintigraphy of breast cancer patients and analyze the relationship with SLN metastases.

Breast cancer lymphoscintigraphy: Factors associated with sentinel lymph node non visualization.

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Breast cancer lymphoscintigraphy: Factors associated with sentinel lymph node non visualization.