Kenneth A. Kern

Sentinel lymph node mapping in breast cancer using subareolar injection of blue dye

BACKGROUND Lymphatic mapping in breast cancer performed solely by intraparenchymal injections of blue dye remains an accepted method of identifying sentinel nodes, largely because of its simplicity. As currently practiced, the technique is associated with a marked learning curve, variable identification rates of sentinel nodes, and high false-negative rates. The purpose of this study is to improve dye-only lymphatic mapping of the breast by using an alternative site for injection of blue dye: the subareolar lymphatic plexus. STUDY DESIGN In the 10 months between August 1998 and May 1999, 40 women with operable breast cancer in stages I and II underwent lymphatic mapping and sentinel node biopsy performed solely by subareolar injections of blue dye, followed by complete axillary node dissection. The technique involved the injection of 5 mL of 1% isosulfan blue into the subareolar plexus, which consists of breast tissue located immediately beneath the areola. No peritumoral injections of blue dye were performed. The ability of subareolar dye injections to identify sentinel nodes and accurately predict the pathologic status of the axilla was determined and compared with published results for dye-only lymphatic mapping using intraparenchymal injections. RESULTS The identification rate of sentinel nodes was 98% (in 39 of 40 patients). Axillary basins harboring positive lymph nodes were found in 15 of these 39 patients (38.5%). Sentinel nodes correctly predicted the status of these 15 positive axillary basins in 100% of the patients. There were no false-negative sentinel node biopsies, indicating a false-negative rate of 0 (in 0 of 15). The overall accuracy, sensitivity, and specificity were 100%. CONCLUSIONS Compared with other series of dye-directed lymphatic mapping, the present study of dye-only injections into the subareolar plexus demonstrates a high sentinel node identification rate, absent false-negative rate, and rapid learning curve. On the basis of these findings, we propose that injections into the subareolar lymphatic plexus are the optimal way to perform dye-only lymphatic mapping of the breast.

Medicolegal analysis of bile duct injury during open cholecystectomy and abdominal surgery

To understand the medicolegal impact of bile duct injury, we analyzed 68 cases of biliary injury resulting from open cholecystectomy and abdominal surgery. Cases were litigated within the US civil justice system between 1970 and 1991. Operations resulting in bile duct complications included cholecystectomy for cholelithiasis in 49 patients (72%), common bile duct exploration in 5 patients (7%), and other abdominal operations in 7 patients (10%); 7 operations were of unknown type. The average delay in recognition of injury was 16 days (range 3 to 42). The mortality rate was 18% (12 of 68). Median jury verdict awards in successfully litigated cases were twice that of out-of-court settlements (

Achieving the Lowest False-Negative Rate in Peritumoral Breast Lymphatic Mapping: The Oncologic Search for the Holy Grail

500,000 versus

Concordance and validation study of sentinel lymph node biopsy for breast cancer using subareolar injection of blue dye and technetium 99m sulfur colloid

250,000, P = 0.01). Bile duct injury after open cholecystectomy and abdominal surgery has a high mortality rate when diagnosed late, and is expensive to litigate. This review may be useful in defining the medicolegal outcome of similar injuries from laparoscopic cholecystectomy.

Lymphoscintigraphic anatomy of sentinel lymphatic channels after subareolar injection of technetium 99m sulfur colloid

The search for the lowest false-negative rate in sentinel node biopsy for breast cancer is an undertaking worthy of all surgical oncologists. This search is particularly vital, however, for those surgeons who continue to use the original method of dye-only, peritumoral (PT) injections as described by Giuliano1 because PT injections must overcome the poor migration characteristics related to the relative paucity of lymphatic channels within the breast parenchyma.2–5 False-negative rates reported after PT injections range as high as 11%, with approximately 5% as an average false-negative rate.6 Whether a consistently low false-negative rate using dye-only, PT injections can ever be achieved by a diverse group of surgeons remains to be seen. This search for the lowest false-negative rate using PT injections may be loosely compared with the 12th century Crusaders’ search for the mythological Holy Grail. Word of the relic’s existence prompted heroic search efforts that in the end came to naught because the Holy Grail existed in the imagination of its seekers, and not in reality. In PT sentinel node biopsy, the search for the Holy Grail, the lowest false-negative rate, may take two forms: either continued adjustments and fine-tuning of the original PT methodology or abandoning the original PT method altogether and seeking a new route to the Holy Grail. I have chosen the latter method and have abandoned PT injections in favor of the subareolar (SA) approach to breast lymphatic mapping. Using combined radiocolloid and blue dye SA injections, I have reported a 98.8% identification (ID) rate, a 0% false-negative rate, and a 96% concordance rate,5 findings supported by the results of other studies.7,8 Nos et al.9 have chosen to persist on the original route to the Holy Grail by advocating a dye-only, PT injection with added modifications to decrease the false-negative rate. The false-negative rate for PT injections before the compensating mechanisms they describe is 11.1%, a finding in line with other dye-only, PT approaches.6,10 Nonetheless, this false-negative rate is clearly an underestimate because the ID rate of sentinel nodes was only 85.5%. This is significantly below the ID rate of the subareolar method of over 98%.5 Using the method of Nos et al. resulted in over 14% of patients never having had the chance to undergo a sentinel node biopsy. Unfortunately, the authors never addressed methods to improve this first step in the sentinel node process, finding the sentinel node in the first place. To decrease this false-negative rate among patients with an identified sentinel node, Nos et al. retrospectively applied three major compensating mechanisms. First, they checked other nonblue nodes, removed during the completion axillary dissection, for blue staining after fixation in an acid-alcohol-formalin (AFA) fixative (called the “pathological color quality assessment”). They labeled any nodes with delayed blue staining “sentinel nodes” (in this article I will call these latent sentinel nodes). Second, they subjected all latent sentinel nodes to 24 step-sections per node. Last, they defined a retrospectively identified “positive” sentinel node as any latent sentinel node with two or more immunohistochemical-positive cells (IHC [ ]), even without the presence of positive hematoxylin and eosin (H&E) cells. By using these sequential postbiopsy maneuvers, Nos et al. were able to state, after the fact, that some latent sentinel nodes were actually positive because they had at least two IHC ( ) cells. These relabeled latent sentinel nodes were used to calculate a lower false-negative rate for this procedure of 2.2%. Although this is an interestReceived April 5, 2003; accepted April 21, 2003. From the Hartford Hospital and the University of Connecticut School of Medicine, Hartford, Connecticut. Address correspondence to: Kenneth A. Kern, MD, FACS, FSSO, Hartford Hospital and the University of Connecticut School of Medicine, 85 Seymour St., Suite 1011, Hartford, CT 06106; Fax: 860-5412299; E-mail: Kennet2521@aol.com.