title: Intraoperative subareolar radioisotope injection for immediate sentinel lymph node biopsy.
abstract: OBJECTIVE
  To determine the identification of sentinel lymph node biopsy (SLNB) in breast cancer patients after intraoperative injection of unfiltered technetium-99m sulfur colloid (Tc-99) and blue dye.
  
  
  BACKGROUND
  SLNB guided by a combination of radioisotope and blue dye injection yields the best identification rates in breast cancer patients. Radioisotope is given preoperatively, without local anesthesia, whereas blue dye is given intraoperatively. We hypothesized that, because of the rapid drainage noted with the subareolar injection technique of radioisotope, intraoperative injection would be feasible and less painful for SLN localization in breast cancer patients.
  
  
  METHODS
  Intraoperative injection of Tc-99 and confirmation blue dye was performed using the subareolar technique for SLNB in patients with operable breast cancer. The time lapse between injection and axillary incision, the background count, the preincision and ex vivo counts of the hot nodes, and the axillary bed counts were documented. The identification rate was recorded.
  
  
  RESULTS
  Ninety-six SLNB procedures were done in 88 patients with breast cancer employing intraoperative subareolar injection technique for both radioisotope (all 96 procedures) and blue dye (93 procedures) injections. Ninety-three (97%) procedures had successful identification; all SLNs were hot; 91 (of 93 procedures with blue dye) were blue and hot. The mean time from radioisotope injection to incision was 19.9 minutes (SD 8.5 minutes). The mean highest 10 second count was 88,544 (SD 55,954). Three of 96 (3%) patients with failure of localization had previous excisional biopsies: 1 circumareolar and 2 upper outer quadrant incisions that may have disrupted the lymphatic flow.
  
  
  CONCLUSIONS
  Intraoperative subareolar injection of radioisotope rapidly drains to the SLNs and allows immediate staging of the axilla, avoiding the need to coordinate diagnostic services and a painful preoperative procedure.
authors.affiliation: Department of Surgery, Division of Breast Surgical Oncology, University of Arkansas for Medical Sciences and the Central Arkansas Veterans Hospital System, Little Rock, AR, USA.
authors.forename: Rakhshanda
authors.initials: R
authors.lastname: Layeeque
authors.forename: Julie
authors.initials: J
authors.lastname: Kepple
authors.forename: Ronda S
authors.initials: RS
authors.lastname: Henry-Tillman
authors.forename: Laura
authors.initials: L
authors.lastname: Adkins
authors.forename: Rena
authors.initials: R
authors.lastname: Kass
authors.forename: Maureen
authors.initials: M
authors.lastname: Colvert
authors.forename: Regina
authors.initials: R
authors.lastname: Gibson
authors.forename: Anne
authors.initials: A
authors.lastname: Mancino
authors.forename: Soheila
authors.initials: S
authors.lastname: Korourian
authors.forename: V Suzanne
authors.initials: VS
authors.lastname: Klimberg
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001707:Biopsy, Needle; D001943:Breast Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology* / Q000601:surgery; D004396:Coloring Agents; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015552:Injections, Intralesional; D008198:Lymph Nodes / Q000473:pathology*; D008408:Mastectomy / Q000379:methods; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods*; D009367:Neoplasm Staging; D009558:Nipples; D011446:Prospective Studies; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals; D018570:Risk Assessment; D012494:Sampling Studies; D012680:Sensitivity and Specificity; D021701:Sentinel Lymph Node Biopsy / Q000379:methods*; D013671:Technetium Tc 99m Sulfur Colloid
chemical_list: D004396:Coloring Agents; D019275:Radiopharmaceuticals; D013671:Technetium Tc 99m Sulfur Colloid