Kern Kenneth A
Department of Surgery, Hartford Hospital and University of Connecticut School of Medicine, USA.
J Am Coll Surg. 2002 Oct;195(4):467-75. doi: 10.1016/s1072-7515(02)01312-1.
We have previously demonstrated the utility, accuracy, and advantages of a subareolar (SA) site of injection for blue dye compared with an intraparenchymal site. In later studies we advocated the additional use of preoperative SA-injected technetium 99m-labeled sulfur colloid as a directional aid in finding blue-stained sentinel lymph nodes (SLNs). Paramount to the usefulness of this dual-tracer, same-site technique is the degree to which SA-injected blue dye and SA-injected radiocolloid migrate concordantly and are deposited within the same sentinel nodes. The purpose of this study was to document the correlation and accuracy of SLN biopsy using blue dye and radiocolloid when both nodal markers are injected by the same SA route.
Between September 1999 and February 2002 (29 months), 185 consecutive patients with 187 operable breast cancers underwent 187 attempted SLN biopsies by a dual-tracer, same-site injection technique using the SA approach for both agents. Unfiltered technetium 99m-labeled sulfur colloid (1 mCi [37 MBq]) was SA-injected 30 to 45 minutes preoperatively; and just after anesthetic induction, 3 mL of 1% isosulfan blue dye was injected by the same SA route. SLN biopsies or complete axillary dissections were carried out, and SLNs identified during these procedures were classified as containing both blue dye and radioactivity ("blue-hot" nodes), radioactivity alone ("hot-only" nodes), or blue dye alone ("blue-only" nodes). Cases were categorized and tabulated based on the presence or absence of these three types of SLNs.
Of the 187 procedures, a SLN was identified successfully in 184 cases, indicating an SLN identification rate of 98.4% (95% confidence interval, 96.6% to 100.2%). In these 184 cases, a blue-hot node was present in 94.5% (n = 174 of 184). An SLN was positive in 50 cases, or 27.2% of the total group (n = 50 of 184). A blue-hot node was the only positive SLN in 43 of these 50 cases, or 86% of the node-positive cases. There were no false negatives in 20 confirmatory axillary node dissections carried out to document the findings of a negative SLN. A correlation analysis revealed that in 98.9% of cases (174 of 176), blue nodes were also radioactive ("blue-hot" case concordance = 98.9%). In 95.1% of cases (174 of 183), hot nodes had also taken up blue dye ("hot-blue" case concordance = 95.1%).
Using SA injections of both blue dye and radiocolloid, we achieved an SLN identification rate of 98.4% (184 of 187 cases), a false-negative rate of 0% (0 of 20 cases), and an accuracy in predicting the malignant status of the axilla of 100% (70 of 70 cases). The case concordance rate ranged between 98.9% ("blue-hot concordance") and 95.1% ("hot-blue concordance"). The present study is the first to evaluate dual-tracer, same-site SA injections of blue dye and radiocolloid. By demonstrating a high case concordance rate, a high SLN identification rate, and a 0% false-negative rate, this study adds further support to the validity and accuracy of same-site SA injections of both blue dye and radiocolloid during SLN biopsy in breast cancer.
我们之前已经证明，与实质内注射部位相比，乳晕下（SA）注射部位用于注射蓝色染料具有实用性、准确性和优势。在后续研究中，我们主张术前额外使用经SA注射的99m锝标记硫胶体作为寻找蓝色染色前哨淋巴结（SLN）的定向辅助手段。这种双示踪剂同部位技术的有效性的关键在于经SA注射的蓝色染料和经SA注射的放射性胶体的迁移一致性以及它们在同一前哨淋巴结内的沉积程度。本研究的目的是记录当两种淋巴结标记物均通过相同的SA途径注射时，使用蓝色染料和放射性胶体进行SLN活检的相关性和准确性。
在1999年9月至2002年2月（29个月）期间，185例连续患有187例可手术乳腺癌的患者通过双示踪剂同部位注射技术进行了187次SLN活检尝试，两种制剂均采用SA途径。术前30至45分钟经SA注射未过滤的99m锝标记硫胶体（1毫居里[37兆贝可]）；麻醉诱导后，立即通过相同的SA途径注射3毫升1%的异硫蓝染料。进行SLN活检或完整腋窝清扫，并将在这些操作中识别出的SLN分类为同时含有蓝色染料和放射性（“蓝热”淋巴结）、仅含有放射性（“仅热”淋巴结）或仅含有蓝色染料（“仅蓝”淋巴结）。根据这三种类型的SLN的有无对病例进行分类和列表。
在187例操作中，184例成功识别出SLN，SLN识别率为98.4%（95%置信区间，96.6%至100.2%）。在这
