Rimma Danielsson

Lymph Drainage Studied by Lymphoscintigraphy in the Arms after Sentinel Node Biopsy Compared with Axillary Lymph Node Dissection Following Conservative Breast Cancer Surgery

Purpose: To investigate lymphatic drainage as measured by lymphoscintigraphy in the arms of patients undergoing either sentinel lymph node biopsy (SNB) or axillary lymph node dissection (ALND). Material and Methods: From January 2001 to December 2002, 30 patients with unilateral invasive breast carcinoma underwent breast-conserving surgery with SNB and 30 patients with ALND. All patients received radiotherapy to the breast. Lymphoscintigraphy was performed, and skin circulation, skin temperature, and arm volume were measured 2–3 years after radiotherapy. Results: None of the 30 patients who underwent SNB showed any clinical manifestation of lymphedema. Of the 30 patients undergoing ALND, six (20%) had clinical lymphedema, with an arm volume that was >10% larger on the operated than on the non-operated side (P<0.01). Scintigraphically, visual analysis revealed lymphatic dysfunction in three patients, manifested as forearm dermal back flow. Two of these patients also had an increased arm volume. Quantitative analysis showed no differences between the groups, apart from a smaller amount of isotope in the axilla in the ALND group. There was no difference in skin circulation or skin temperature. Conclusion: Our study shows that lymph drainage in the operated arm compared with the non-operated arm was less affected by SNB than by ALND, and that morbidity associated with SNB was lower than with ALND. However, the results do not confirm our hypothesis that lymphoscintigraphy can reveal differences in lymph circulation that are not evident clinically in the form of manifest lymphedema. The most sensitive clinical method of assessing lymph drainage seems to be measurement of arm volume.

Sensitivity and Specificity of Planar Scintimammography with 99mTc-Sestamibi

Purpose: The aim of our prospective study was to determine the diagnostic accuracy of planar breast imaging with 99mTc-MIBI in detecting malignant disease. Material and Methods: Ninety-six consecutive patients with 121 clinically-and/or mammographically-detected breast lesions underwent preoperative planar scintimammography. Ten minutes after injection of 700 MBq 99mTc-MIBI, two lateral prone and one anterior supine projections with an acquisition time of 8 minutes each were obtained. Interpretation of scintimammographic results was made blindly and any focal accumulation of MIBI in the breasts was the criterion for an abnormal scintigram. All lesions were operated on and histologically verified. Results: Histologically, 86 malignant and 35 benign lesions were found in 121 breast lesions. A sensitivity of 83.7% and a specificity of 74.2% for malignancy was achieved at planar scintimammography. Conclusion: Scintimammography with 99mTc-MIBI is an imaging modality of modest usefulness in the investigation of breast lesions. The method has a low sensitivity in lesions smaller than 10 mm in diameter, which decreases the clinical use of the method.

The role of scintimammography with 99mtc-sestamibi as a complementary diagnostic technique in the detection of breast cancer

Purpose: To prospectively determine the clinical value of scintimammography (Sc) with 99mTc-sestamibi as a complementary method to triple diagnosis (TD) in detecting malignant disease of the breast. Material and Methods: Ninety-six patients with 119 clinically or mammographically detected breast lesions underwent TD procedures, including clinical examination, mammography and fine-needle aspiration cytology. Prone planar Sc with 99mTc-sestamibi was performed in all 96 patients. Five groups were defined for diagnosis: 1 = normal; 2 = benign; 3 = probably benign; 4 = highly suspect of malignancy; and 5 = malignant. All lesions were histopathologically examined. The results of each method per se and the combination of TD with Sc (TD + Sc) were analyzed. Results: Histopathology of the 119 surgically excised breast lesions found 83 malignant and 36 benign lesions. TD missed 6 of 83 carcinomas, resulting in a sensitivity of 92.7%. Sc alone showed sensitivity of 85.5%. The combination TD + Sc missed 1 of 83 carcinomas, and thus had a sensitivity of 98.7%. In mammographically dense breasts both TD and Sc detected 16 of 18 carcinomas, while the combination TD + Sc led to detection of all 18 carcinomas. Conclusion: Adding Sc to TD increases the sensitivity for detection of breast carcinomas. Sc with 99mTc-sestamibi is recommended as a complimentary method to TD in selected cases such as mammographically dense breasts.

Sentinel node in breast cancer — a Swedish pilot study of 75 patients

OBJECTIVE To find out if the sentinel node can be detected in sufficient numbers of women with breast cancer to be useful as a prognostic sign, whether it reflects that state of the entire axilla, and whether it detects micrometastases that would otherwise be missed. DESIGN Prospective study. SETTING 3 teaching hospitals, Sweden. SUBJECTS 75 patients with breast cancer who were listed to have axillary dissection as well as resection of their tumour. INTERVENTIONS Injection of 99Tc nanocolloid 0.4 ml and patent blue dye 1 ml around the tumour or under the skin above the tumour, followed by preoperative lymphoscintigraphy and then identification of the sentinel node during operation either because it had turned blue or with a gamma probe. Removal of the sentinel node and complete axillary dissection. MAIN OUTCOME MEASURES Identification of the sentinel node and presence of metastatic nodes in the axilla. RESULTS The sentinel node was identified in 69/75 (92%). It correctly predicted the state of the axilla in 66/69 (96%), and detected metastases in 24 of the 27 with invaded nodes in the axilla (89%). The false negative rate was 11%. In 14/27 with axillary metastases (52%) the sentinel node was the only involved node. In 3/24, metastases were detected by immunohistochemistry alone. CONCLUSION Biopsy of the sentinel node predicted the presence or absence of axillary metastases with acceptable accuracy. However, before axillary node dissection is rejected in favour of sentinel node biopsy alone, large multicentre studies are needed to establish the true false negative rate.

Evaluation of planar scintimammography with 99mTc-MIBI in the detection of axillary lymph node metastases of breast carcinoma.

Purpose: the aim of our prospective study was to evaluate the role of planar scintimammography with 99mTc-MIBI in detecting axillary lymph node metastases in women with primary breast carcinoma. Material and Methods: Fifty-eight patients underwent scintimammography prior to axillary lymph node dissection. Ten minutes after injection of 700 MBq 99mTc-MIBI, two prone lateral projections were obtained, followed by a supine anterior projection. Sixty-one axillae (3 bilateral) were operated upon and the status of the lymph nodes verified with histopathology. the scintigraphic result was compared to the histopathologic findings. Results: A sensitivity of 67% and a specificity of 80% of planar scintimammography in detecting axillary lymph node metastases were achieved. Conclusion: Scintimammography with 99mTc-MIBI is not recommended as a routine method for the detection of axillary lymph node metastases in patients with breast carcinoma.

Comparison of planar and SPECT scintimammography with 99mTc-sestamibi in the diagnosis of breast carcinoma.

Purpose: To compare results of planar and SPECT breast imaging with 99mTc-MIBI in detecting primary breast cancer. Material and Methods: Twenty-six consecutive patients with 34 suspected breast lesions underwent both planar and SPECT scintimammography. Ten minutes after injection of 700 MBq 99mTc-MIBI, 2 prone lateral projections were obtained, followed by a supine anterior projection. Forty minutes after injection, a SPECT study was done. All lesions were operated upon and verified with histopathology. Results: A sensitivity of 85% and specificity of 88% of planar scintimammography in diagnosis of primary breast lesions were achieved. The corresponding values for SPECT were 61% and 64%. Conclusion: The diagnostic accuracy of planar scintimammography was not improved by using SPECT imaging.

Circulation in the breast after radiotherapy and breast conservation.

OBJECTIVE To investigate the breast circulation after radiotherapy and breast conservation. DESIGN Open clinical study. SETTING University hospital, Sweden. SUBJECTS 24 patients with breast cancer (mean age 54 years, range 41-64). INTERVENTIONS The glandular and the subcutaneous circulation in the breast were measured by Xenon (133Xe) clearance and the skin circulation by laser Doppler fluxmetry (LDF) two to five years after radiotherapy (50 Gy) following lumpectomy. The subcutaneous circulation was measured 2 cm above and medial or lateral to the areolar border and the glandular circulation 2 cm below and medial or lateral to the areolar border in the quadrant not previously operated on for carcinoma. The skin circulation was measured at the corresponding sites. MAIN OUTCOME MEASURES Circulation in the subcutaneous and glandular tissue measured by 133Xe clearance and in the skin by LDF. RESULTS The subcutaneous circulation, expressed as the ratio of 133Xe clearance in the operated irradiated: non-operated non-irradiated breast, was 0.88 (0.94) (median, interquartile range) and the glandular circulation 0.93 (0.75). The skin circulation ratios over the corresponding areas were 1.00 (0.37) and 1.00 (0.38), respectively. CONCLUSION Radiotherapy after breast conservation surgery does not lead to long-term changes in basal glandular, subcutaneous, or skin circulation in the breast.