title: Using the intraoperative hand held probe without lymphoscintigraphy or using only dye correlates with higher sensory morbidity following sentinel lymph node biopsy in breast cancer: a review of the literature.
abstract: BACKGROUND
  There are no studies that have directly investigated the incremental reduction in sensory morbidity that lymphoscintigraphy images (LS) and triangulated body marking or other skin marking techniques provide during sentinel lymph node biopsy (SLNB) compared to using only the probe without LS and skin marking or using only dye. However, an indirect assessment of this potential for additional sensory morbidity reduction is possible by extracting morbidity data from studies comparing the morbidity of SLNB to that of axillary lymph node dissection.
  
  
  METHODS
  A literature search yielded 13 articles that had data on sensory morbidity at specific time points on pain, numbness or paresthesia from SLNB that used radiotracer and probe or used only dye as a primary method of finding the sentinel node (SN). Of these, 10 utilized LS, while 3 did not utilize LS. By matching the data in studies not employing LS to the studies that did, comparisons regarding the percentage of patients experiencing pain, numbness/paresthesia after SLNB could be reasonably attempted at a cutoff of 9 months.
  
  
  RESULTS
  In the 7 studies reporting on pain after 9 months (> 9 months) that used LS (1347 patients), 13.8% of patients reported these symptoms, while in the one study that did not use LS (143 patients), 28.7% of patients reported these symptoms at > 9 months (P < 0.0001). In the 6 studies reporting on numbness and/or paresthesia at > 9 months that used LS (601 patients), 12.5% of patients reported these symptoms, while in the 3 studies that did not use LS (229 patients), 23.1% of patients reported these symptoms at > 9 months (P = 0.0002). Similar trends were also noted for all these symptoms at < or = 9 months.
  
  
  CONCLUSIONS
  Because of variations in techniques and time of assessing morbidity, direct comparisons between studies are difficult. Nevertheless at a minimum, a clear trend is present: having the LS images and skin markings to assist during SLNB appears to yield more favorable morbidity outcomes for the patients compared to performing SLNB with only the probe or performing SLNB with dye alone. These results are extremely pertinent, as the main reason for performing SLNB itself in the first place is to achieve reduced morbidity.
authors.affiliation: Division of Nuclear Medicine, Department of Radiology, The Mount Sinai School of Medicine, The Mount Sinai Hospital, New York, New York, USA. sukchulkim@gmail.com
authors.forename: Suk Chul
authors.initials: SC
authors.lastname: Kim
authors.forename: Dong Wook
authors.initials: DW
authors.lastname: Kim
authors.forename: Renee M
authors.initials: RM
authors.lastname: Moadel
authors.forename: Chun K
authors.initials: CK
authors.lastname: Kim
authors.forename: Samprit
authors.initials: S
authors.lastname: Chatterjee
authors.forename: Michail K
authors.initials: MK
authors.lastname: Shafir
authors.forename: Arlene
authors.initials: A
authors.lastname: Travis
authors.forename: Josef
authors.initials: J
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authors.forename: Borys R
authors.initials: BR
authors.lastname: Krynyckyi