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The fog clears

¹ Departments of Radiology
² Nuclear Medicine, Box 219, University of Cambridge and Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QQ, UK

A 40-year-old woman presented to the Radiology Department for a pre-operative chest radiograph. The radiographer noted an area of fogging on one corner of the film (Figure 1a). Suspecting that the cassette was faulty, a repeat radiograph was performed 7 min later. A smaller but persistent area of fogging was noted to be situated over the right nipple (Figure 1b). A further radiograph with yet a different cassette was performed 15 min after the second. This was normal (Figure 1c).

View larger version (53K): [in this window] [in a new window]   Figure 1. Pre-operative chest radiograph.

On questioning the patient it was established that she had been admitted for elective lumpectomy of a right subareolar infiltrating ductal carcinoma. She had presented with a serous nipple discharge and an impalpable tumour. During the morning, prior to the chest radiographs being performed, she had received an intratumoral injection of 40 MBq of ⁹⁹T_c^m-labelled nanocolloid for sentinel node detection. When the posteroanterior chest radiographs were performed, her breasts were compressed against the cassette, discharging the radiolabelled colloid.

Radiation safety in sentinel lymph node biopsy has been addressed and guidelines for the technique have been published [1, 2]. Operative instruments and pathology equipment only emit radiation doses equivalent to background radiation and the radiation dose received by operating theatre staff has been quantified and demonstrated to be well within the statutory limits [1, 3]. However, occult contamination from nipple discharge could result in significant localized effective doses being received by medical and paramedical staff [2, 4].

A number of techniques for injecting the radiolabelled nanocolloid, including peritumoral and subdermal routes, have been described [5, 6]. In our department, impalpable tumours are injected directly using ultrasound or stereotactic guidance. In the patient described here, the lactiferous ducts may have been unusually distended by the tumour or by secreted fluid. A direct puncture of the duct would have resulted in most of the colloid being mixed with the secreted fluid. Similar sentinel node labelling can be achieved by a number of injection techniques [5, 6]. It is therefore probably safer to use a peritumoral or subdermal injection rather than an intratumoral injection when labelling the sentinel node of tumours presenting with nipple discharge.

Received for publication August 7, 2000. Accepted for publication August 31, 2000.

References

1. Miner TJ, Shriver CD, Flicek PR, Jaques DP, Maniscalco-Theberge ME, Krag DN. Guidelines for the safe use of radioactive materials during localisation and resection of the sentinel lymph node. Ann Surg Oncol 1999;6:75–82.[Abstract]
2. Glass EC, Basinski JE, Krasne DL, Giuliano AE. Radiation safety considerations for sentinel node techniques. Ann Surg Oncol 1999;6:10–1.[Medline]
3. Stratmann SL, McCarty TM, Kuhn JA. Radiation safety with breast sentinel node biopsy. Am J Surg 1999;178:454–7.[Medline]
4. Bronskill MJ. Radiation dose estimates for interstitial radiocolloid lymphoscintigraphy. Semin Nucl Med 1983;13:20–5.[Medline]
5. Klimberg VS, Rubio IT, Henry R, Cowan C, Colvert M, Korourian S. Subareolar versus peritumoural injection for location of the sentinel lymph node. Ann Surg 1999;229:860–5.[Medline]
6. Roumen RM, Geuskens LM, Valkenburg JG. In search of the true sentinel node by different injection techniques in breast cancer patients. Eur J Surg Oncol 1999;25:347–51.[Medline]

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