title: Intraoperative subareolar injection of 99mTc-labeled sulfur colloid results in consistent sentinel lymph node identification.
abstract: BACKGROUND
  Preoperative parenchymal or peritumoral (PT) injection of (99m)Tc-labeled sulfur colloid (TcSC) is the standard method for sentinel lymph node (SLN) identification in patients with breast cancer. Limitations of this method include variable identification rates, slow transit times, and painful injections. We hypothesize that TcSC will travel to the SLN within minutes after injection into the subareolar (SA) lymphatics, thus making an intraoperative injection technique feasible.
  
  
  METHODS
  One hundred twenty-two women with invasive breast cancer were enrolled onto this prospective study. Immediately after the induction of general anesthesia, patients were injected with 1 to 2 mCi of filtered TcSC in the SA location. Then, 5 mL of 1% isosulfan blue dye was injected into the PT location. The SLN or SLNs were identified as radioactive, blue, or both and removed for pathologic evaluation.
  
  
  RESULTS
  The mean patient age was 56 years. The mean tumor size was 1.5 cm. In 86.1% of patients, a transcutaneous axillary "hot spot" was identified by handheld gamma probe. The mean time from TcSC injection to axillary incision was 17.6 minutes. At least one SLN was identified in 99.2% of patients. The mean number of SLNs identified per patient was 1.83. The mean count of radioactive SLNs was 2715 cps. In 97.2% of patients, blue SLNs were also radioactive.
  
  
  CONCLUSIONS
  TcSC injected into the SA lymphatics rapidly drains to the SLN. The radioactive SLN is easily and quickly identified after an intraoperative SA TcSC injection. The simplicity of this method eliminates the inherent problems associated with standard PT injection.
authors.affiliation: John Wayne Cancer Institute, 2200 Santa Monica Boulevard, Santa Monica, California 90404, USA.
authors.forename: Theresa G
authors.initials: TG
authors.lastname: Zogakis
authors.forename: Robert E
authors.initials: RE
authors.lastname: Wetherille
authors.forename: Robert D
authors.initials: RD
authors.lastname: Christensen
authors.forename: Kevin J
authors.initials: KJ
authors.lastname: Ose
authors.forename: Joel D
authors.initials: JD
authors.lastname: Friedman
authors.forename: Marybeth
authors.initials: M
authors.lastname: Colbert
authors.forename: Charles A
authors.initials: CA
authors.lastname: Svendsen
authors.forename: Omer K
authors.initials: OK
authors.lastname: Sanan
authors.forename: Todd M
authors.initials: TM
authors.lastname: Tuttle
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000473:pathology* / Q000601:surgery; D018270:Carcinoma, Ductal, Breast / Q000473:pathology* / Q000601:surgery; D018275:Carcinoma, Lobular / Q000473:pathology* / Q000601:surgery; D004396:Coloring Agents / Q000008:administration & dosage; D005260:Female; D006801:Humans; D007279:Injections, Subcutaneous; D007432:Intraoperative Period; D008207:Lymphatic Metastasis; D008875:Middle Aged; D019275:Radiopharmaceuticals / Q000008:administration & dosage*; D012394:Rosaniline Dyes / Q000008:administration & dosage; D021701:Sentinel Lymph Node Biopsy / Q000379:methods*; D013671:Technetium Tc 99m Sulfur Colloid / Q000008:administration & dosage*
chemical_list: D004396:Coloring Agents; D019275:Radiopharmaceuticals; D012394:Rosaniline Dyes; C025484:iso-sulfan blue; D013671:Technetium Tc 99m Sulfur Colloid