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British Journal of Radiology (2004) 77, 1053-1056
© 2004 British Institute of Radiology
doi: 10.1259/bjr/65044256
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Reverse echelon node and a lymphatic ectasia in the same patient during breast lymphoscintigraphy: the importance of injection and imaging technique

S H Kim, MD, J Shim, MD, C K Kim, MD, J Machac, MD and B R Krynyckyi, MD

Department of Radiology, Division of Nuclear Medicine, The Mount Sinai School of Medicine, New York, NY, USA



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  		Figure 1. Left lateral dynamic sequence during LymphoBoost (LB) injection: (0 min) Perilesional injection (T=perilesional injection site) was performed approximately 20 min earlier and shows a sentinel node (SN). (1 min) Areolar–cutaneous junction injection (LB) is performed showing activity in syringe during injection. (2 min) Immediately, a very bright focus (pseudosentinel node, PSN) is noted midway between injection sites and the SN from perilesional injection and initially is presumed to be a very bright lymph node. (10 min) An additional focus appears (reverse echelon node, REN), also between the injection sites and the SN from the perilesional injection. (0.6 h to 16 h) The PSN focus fades completely over time while the REN focus persists. End of study view (right image) showing the "sentinel" nodes. The PSN turned out not to represent a node but a lymphatic ectasia (dilation, lake) or possibly even an "end on effect" from a lymphatic channel seen on edge, in effect a "pseudo sentinel node" [5, 14]. The REN persist over time with no fading and most likely represents a node "upstream" and closer to the injection site at the areolar–cutaneous junction, i.e. in effect a "reverse echelon node" [1, 5]. T, perilesional injection site.

 


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  		Figure 2. Potential patterns of merging lymphatics. (A) Perilesional injection with sentinel node (SN) and more distant echelon node. (B) Surface injection augmenting perilesional injection, by far the most common pattern seen. (C) Pseudosentinel node (PSN) i.e. a dilation/ectasia representing focal pooling of activity along the lymphatic channel and a reverse echelon node (REN) representing a node seen "upstream" from the perilesional injection site. The original "true" SN also gets augmented, a pattern of partial discongruence. (D) Surface injection bypassing the true SN and visualizing a distant echelon node that might not contain tumour or another different node altogether, a pattern of complete discongruence. Adapted, modified from Krynycki BR et al [1] and used with permission from Lippincot, Williams & Wilkins, Philadelphia.

 




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