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Lymphoscintigraphy and SPECT/CT in multicentric and multifocal breast cancer: does each tumour have a separate drainage pattern?

Results of a Dutch multicentre study (MULTISENT)

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European Journal of Nuclear Medicine and Molecular Imaging Aims and scope Submit manuscript

Abstract

Purpose

To investigate whether lymphoscintigraphy and SPECT/CT after intralesional injection of radiopharmaceutical into each tumour separately in patients with multiple malignancies in one breast yields additional sentinel nodes compared to intralesional injection of the largest tumour only.

Methods

Patients were included prospectively at four centres in The Netherlands. Lymphatic flow was studied using planar lymphoscintigraphy and SPECT/CT until 4 h after administration of 99mTc-nanocolloid in the largest tumour. Subsequently, the smaller tumour(s) was injected intratumorally followed by the same imaging sequence. Sentinel nodes were intraoperatively localized using a gamma ray detection probe and vital blue dye.

Results

Included in the study were 50 patients. Additional lymphatic drainage was depicted after the second and/or third injection in 32 patients (64 %). Comparison of planar images and SPECT/CT images after consecutive injections enabled visualization of the number and location of additional sentinel nodes (32 axillary, 11 internal mammary chain, 2 intramammary, and 1 interpectoral. A sentinel node contained metastases in 17 patients (34 %). In five patients with a tumour-positive node in the axilla that was visualized after the first injection, an additional involved axillary node was found after the second injection. In two patients, isolated tumour cells were found in sentinel nodes that were only visualized after the second injection, whilst the sentinel nodes identified after the first injection were tumour-negative.

Conclusion

Lymphoscintigraphy and SPECT/CT after consecutive intratumoral injections of tracer enable lymphatic mapping of each tumour separately in patients with multiple malignancies within one breast. The high incidence of additional sentinel nodes draining from tumours other than the largest one suggests that separate tumour-related tracer injections may be a more accurate approach to mapping and sampling of sentinel nodes in patients with multicentric or multifocal breast cancer.

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References

  1. Sobin LH, Wittekind C. TNM classification of malignant tumours. 5th ed. New York: Wiley; 1997.

    Google Scholar 

  2. Sobin LH, Gospodarowicz MK, Wittekind C. TNM classification of malignant tumours. 7th ed. New York: Wiley; 2009.

    Google Scholar 

  3. Tousimis E, Van Zee KJ, Fey JV, Hoque LW, Tan LK, Cody 3rd HS, et al. The accuracy of sentinel lymph node biopsy in multicentric and multifocal invasive breast cancers. J Am Coll Surg. 2003;197:529–35.

    Article  PubMed  Google Scholar 

  4. Ferrari A, Dionigi P, Rovera F, Boni L, Limonta G, Garancini S, et al. Multifocality and multicentricity are not contraindications for sentinel lymph node biopsy in breast cancer surgery. World J Surg Oncol. 2006;4:79.

    Article  PubMed  Google Scholar 

  5. Knauer M, Konstantiniuk P, Haid A, Wenzl E, Riegler-Keil M, Pöstlberger S, et al. Multicentric breast cancer: a new indication for sentinel node biopsy – a multi-institutional validation study. J Clin Oncol. 2006;24:3374–80.

    Article  PubMed  Google Scholar 

  6. Kim HJ, Lee JS, Park EH, Choi SL, Lim WS, Chang MA, et al. Sentinel node biopsy in patients with multiple breast cancer. Breast Cancer Res Treat. 2008;109:503–6.

    Article  PubMed  CAS  Google Scholar 

  7. Giard S, Chauvet M-P, Penel N, Mignotte H, Martel P, Tunon de Lara C, et al. Feasibility of sentinel lymph node biopsy in multiple unilateral synchronous breast cancer: results of a French prospective multi-institutional study (IGASSU 0502). Ann Oncol. 2010;21:1630–5.

    Article  PubMed  CAS  Google Scholar 

  8. Tanis PJ, Nieweg OE, Valdés Olmos RA, Kroon BB. Anatomy and physiology of lymphatic drainage of the breast from the perspective of sentinel node biopsy. J Am Coll Surg. 2001;192:399–409.

    Article  PubMed  CAS  Google Scholar 

  9. Paganelli G, Galimberti V, Trifirò G, Travaini L, De Cicco C, Mazzarol G, et al. Internal mammary node lymphoscintigraphy and biopsy in breast cancer. Q J Nucl Med. 2002;46:138–44.

    PubMed  CAS  Google Scholar 

  10. Estourgie SH, Nieweg OE, Olmos RA, Rutgers EJ, Kroon BB. Lymphatic drainage patterns from the breast. Ann Surg. 2004;239:232–7.

    Article  PubMed  Google Scholar 

  11. Suami H, Pan WR, Mann GB, Taylor GI. The lymphatic anatomy of the breast and its implications for sentinel lymph node biopsy: a human cadaver study. Ann Surg Oncol. 2008;15:863–71.

    Article  PubMed  Google Scholar 

  12. Schrenk P, Wayand W. Sentinel-node biopsy in axillary lymph-node staging for patients with multicentric breast cancer. Lancet. 2001;13:122.

    Article  Google Scholar 

  13. Kern KA. Concordance and validation study of sentinel lymph node biopsy for breast cancer using subareolar injection of blue dye and technetium 99m sulfur colloid. J Am Coll Surg. 2002;195:467–75.

    Article  PubMed  Google Scholar 

  14. Kumar R, Jana S, Heiba SI, Dakhel M, Axelrod D, Siegel B, et al. Retrospective analysis of sentinel node localization in multifocal, multicentric, palpable, or nonpalpable breast cancer. J Nucl Med. 2003;44:7–10.

    PubMed  Google Scholar 

  15. Klimberg VS, Rubio IT, Henry R, Cowan C, Colvert M, Korourian S. Subareolar versus peritumoral injection for location of the sentinel lymph node. Ann Surg. 1999;229:860–4.

    Article  PubMed  CAS  Google Scholar 

  16. Pelosi E, Bellò M, Giors M, Ala A, Giani R, Bussone R, et al. Sentinel lymph node detection in patients with early-stage breast cancer: comparison of periareolar and subdermal/peritumoral injection techniques. J Nucl Med. 2004;45:220–5.

    PubMed  Google Scholar 

  17. Valdés-Olmos RA, Jansen L, Hoefnagel CA, Nieweg OE, Muller SH, Rutgers EJ, et al. Evaluation of mammary lymphoscintigraphy by a single intratumoral injection for sentinel node identification. J Nucl Med. 2000;41:1500–6.

    PubMed  Google Scholar 

  18. Andea AA, Wallis T, Newman LA, Bouwman D, Dey J, Visscher DW. Pathologic analysis of tumour size and lymph node status in multifocal/multicentric breast carcinoma. Cancer. 2002;94:1383–90.

    Article  PubMed  Google Scholar 

  19. Layeeque R, Henry-Tillman R, Korourian S, Kass R, Klimberg VS. Subareolar sentinel node biopsy for multiple breast cancers. Am J Surg. 2003;186:730–5.

    Article  PubMed  Google Scholar 

  20. Andea AA, Bouwman D, Wallis T, Visscher DW. Correlation of tumour volume and surface area with lymph node status in patients with multifocal/multicentric breast carcinoma. Cancer. 2004;100:20–7.

    Article  PubMed  Google Scholar 

  21. Goyal A, Newcombe RG, Mansel RE, Chetty U, Ell P, Fallowfield L, et al. Sentinel lymph node biopsy in patients with multifocal breast cancer. Eur J Surg Oncol. 2004;30:475–9.

    Article  PubMed  CAS  Google Scholar 

  22. Gentilini O, Trifiro G, Soteldo J, Luini A, Intra M, Galimberti V, et al. Sentinel lymph node biopsy in multicentric breast cancer. The experience of the European Institute of Oncology. Eur J Surg Oncol. 2006;32:507–10.

    Article  PubMed  CAS  Google Scholar 

  23. Coombs NJ, Boyages J. Multifocal and multicentric breast cancer: does each focus matter? J Clin Oncol. 2005;23:7497–502.

    Article  PubMed  Google Scholar 

  24. Fearmonti RM, Batista LI, Meric-Bernstam F, Bedrosian I, Kuerer HM, Hunt KK, et al. False negative rate of sentinel lymph node biopsy in multicentric and multifocal breast cancers may be higher in cases with large additive tumour burden. Breast J. 2009;15:645–8.

    Article  PubMed  Google Scholar 

  25. Ozmen V, Muslumanoglu M, Cabioglu N, Tuzlali S, Ilhan R, Igci A, et al. Increased false negative rates in sentinel lymph node biopsies in patients with multi-focal breast cancer. Breast Cancer Res Treat. 2002;76:237–44.

    Article  PubMed  CAS  Google Scholar 

  26. Vlastos G, Rubio IT, Mirza NQ, Newman LA, Aurora R, Alderfer J, et al. Impact of multicentricity on clinical outcome in patients with T1-2, N0-1, M0 breast cancer. Ann Surg Oncol. 2000;7:581–7.

    PubMed  CAS  Google Scholar 

  27. Van der Ploeg IM, Nieweg OE, Kroon BB, Rutgers EJ, Baas-Vrancken Peeters MJ, Vogel WV, et al. The yield of SPECT/CT for anatomical mapping in patients with breast cancer. Eur J Nucl Med Mol Imaging. 2009;36:903–6.

    Article  PubMed  Google Scholar 

  28. Vidal-Sicart S, Brouwer OR, Valdés Olmos RA. Evaluation of the sentinel lymph node combining SPECT/CT with the planar image and its importance for the surgical act. Rev Esp Med Nucl. 2011;30:331–7.

    Article  PubMed  CAS  Google Scholar 

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Acknowledgments

The authors thank the surgeons as well as nuclear medicine physicians and technologists at the participating centres for their cooperation. Participating centres in this study were: The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam; Rijnland Hospital, Leiderdorp; Sint Lucas Andreas Hospital, Amsterdam; and Onze Lieve Vrouwe Gasthuis, Amsterdam. This work was nominated for the Marie Curie Award at the 2012 EANM congress.

Conflicts of interest

None.

Author information

Authors and Affiliations

  1. Department of Nuclear Medicine, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands

    O. R. Brouwer, L. Vermeeren & R. A. Valdés Olmos

  2. Department of Surgery, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands

    I. M. C. van der Ploeg, E. J. Th. Rutgers & H. S. A. Oldenburg

  3. Department of Radiology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands

    C. E. Loo

  4. Department of Nuclear Medicine, Rijnland Hospital, Leiderdorp, The Netherlands

    L. M. Pereira-Bouda & F. Smit

  5. Department of Surgery, Rijnland Hospital, Leiderdorp, The Netherlands

    P. Neijenhuis

  6. Department of Surgery, Sint Lucas Andreas Hospital, Amsterdam, The Netherlands

    B. C. Vrouenraets

  7. Department of Nuclear Medicine, Sint Lucas Andreas Hospital, Amsterdam, The Netherlands

    F. Sivro-Prndelj

  8. Department of Nuclear Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands

    S. M. Jap-a-Joe & P. J. Borgstein

  9. Antoni van Leeuwenhoekhospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands

    O. R. Brouwer

Authors
  1. O. R. Brouwer
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  2. L. Vermeeren
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  3. I. M. C. van der Ploeg
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  4. R. A. Valdés Olmos
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  5. C. E. Loo
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  6. L. M. Pereira-Bouda
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  8. P. Neijenhuis
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  9. B. C. Vrouenraets
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  13. E. J. Th. Rutgers
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  14. H. S. A. Oldenburg
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Corresponding author

Correspondence to O. R. Brouwer.

Additional information

O. R. Brouwer and L. Vermeeren contributed equally to this work.

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Brouwer, O.R., Vermeeren, L., van der Ploeg, I.M.C. et al. Lymphoscintigraphy and SPECT/CT in multicentric and multifocal breast cancer: does each tumour have a separate drainage pattern?. Eur J Nucl Med Mol Imaging 39, 1137–1143 (2012). https://doi.org/10.1007/s00259-012-2131-y

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  • DOI: https://doi.org/10.1007/s00259-012-2131-y

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