British Journal of Radiology (2004) 77, 1053-1056
© 2004 British Institute of Radiology
doi: 10.1259/bjr/65044256
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
Correspondence: Dr Borys R Krynyckyi, Department of Radiology, Division of Nuclear Medicine, Box 1141, The Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029-6574, USA
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Abstract
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Lymphoscintigraphy, along with triangulated patient body marking, can serve as a guide for surgeons during sentinel lymph node harvesting. Unique drainage patterns have been noted, especially with areolar or intradermal based injections, which are becoming increasingly popular. The images lymphoscintigraphy provide have been invaluable in delineating these patterns. The authors present a case that simultaneously illustrates two separate points in the same patient, a reverse echelon node and a lymphatic ectasia. To our knowledge, this combination has never been described in the same patient. Perilesional and areolar–cutaneous junction injections were performed sequentially and generated these patterns that could potentially have resulted in added morbidity and a false-negative sentinel node if not realised before surgery. Lymphoscintigraphy added valuable information in the management of this patient, which can occasionally present with complex patterns of activity during sentinel node harvesting.
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Introduction
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Sentinel lymph node biopsy is increasingly being practiced in a routinely clinical manner. Controversies continue to exist concerning the optimal methods of injection to delineate the sentinel nodes (SNs) as well as the need for lymphoscintigraphy itself [1]. In the USA, perilesional injections were initially commonly used, but more recently, intradermal injections above the lesion and areolar/periareolar injections have been gaining ground. Most studies suggest an equivalence of these methods compared with perilesional injections as far as delineating the true SN [2–4]. However, unusual patterns may be produced that do not always bear this out. A case is presented that illustrates patterns that can occur with non-perilesional injections that could influence patient management if not identified before surgery by lymphoscintigraphy.
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Case report
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A 43-year-old woman presented with a mass in the upper outer quadrant of the left breast found by self-breast exam. A mammogram revealed a diffusely increased density in the superior left breast. A diagnosis of infiltrating lobular carcinoma and lobular carcinoma in situ was made by needle biopsy. Oestrogen receptors and progesterone receptors were strongly positive (3+), and HER-2/neu was negative. The patient was scheduled for a modified radical mastectomy with a microvascular tram flap reconstruction.
Lymphoscintigraphy was performed before surgery consisting of perilesional injections of 19.0 MBq (513 uCi) of 99Tcm sulphur colloid in 3 ml infiltrated into the region around the lesion site. After performing the perilesional injections, a single faint focus of activity was noted (Figure 1
). Immediately thereafter, additional injections were performed consisting of very shallow injections of 13.4 MBq (363 uCi) of 99Tcm sulphur colloid in 1 ml volumes at the areolar–cutaneous junction closest to the original lesion as previously described [5]. Immediately after the areolar–cutaneous junction injection, a bright focus was seen between the injection sites and the first focus that was originally due to the perilesional injection, in effect "upstream" from the original node noted from the perilesional injection (Figure 1). This focus faded over time while a secondary focus appeared, also "upstream" from the original focus due to the perilesional injection. A delayed view the next day before surgery revealed two nodes. The patient's body was marked corresponding to foci that represented the nodes (Figure 1). A sentinel lymph node dissection was then performed and two sentinel nodes were removed, both negative for disease.
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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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Discussion
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Great variation exists in the methods and sites of injection used to delineate the SN. Perilesional based injections were initially the most popular, followed by intradermal injections above the lesion. More recently, areolar/periareolar injections are becoming more frequently used. Our own initial dissatisfaction with perilesional injections led us to develop a combination injection technique in 1999 that consisted of perilesional injections of 50:50 filtered and unfiltered 99Tcm sulphur colloid followed sequentially by intradermal injections over the lesion in one imaging session. This markedly improved our visualization of SNs during lymphoscintigraphy [6]. This technique was eventually refined to also include very shallow injections at the areolar–cutaneous junction, still combined with perilesional and dermal injections over the tumour. The areolar–cutaneous junction injection has been dubbed by us as LymphoBoost (LB) [5]. The marked improvement achieved by the addition of the LB injections at the areolar–cutaneous junction in delineating the SN over that achieved with dermal injections over the tumour, led us to abandon the intradermal injections over the lesion. We currently perform perilesional injections sequentially followed by LB injections. The ability to markedly increase the activity in the SN compared with perilesional only injections, on the average by many times, and by up to 50–100 times in some cases when using LB, is extremely important when surgery is planned for the next day and decay of activity has occurred. In addition, increased levels of activity in the SN tend to make it easier to find with the probe during surgery, which leads to less dissection and potentially less morbidity.
We dynamically monitor all injections with the gamma camera and very unusual patterns have been noted, two of which occurred simultaneously in the same patient as presented in this case report. The case illustrates the advantages of dynamically monitoring the patients with lymphoscintigraphy during studies. Similar patterns were noted by Roumen who described patterns of discongruence when comparing perilesional injections with areolar injections in the same patient. However, these injections were performed on different days [7].
The pseudosentinel node (PSN), which probably represents a lymphatic dilation that allows pooling of activity, is seen occasionally (in less than 10% of our cases), and can cause confusion with the probe during surgery when surgery is performed right after non-perilesional injections [8]. Appearing as a "true" SN to the probe because of focally concentrated activity, the PSN will result in additional, unproductive dissection of the patients tissues, potentially increasing morbidity (Figures 1 and 2
). Lymphoscintigraphy can identify this entity because of its signature pattern of decreasing activity over time. This would not occur with a true SN (after accounting for decay), as also evidenced by successes with 2 day lymphoscintigraphy and next day surgery protocols throughout the literature [9–12]. This information can then be relayed to the surgeon ahead of time.
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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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This case illustrates the importance of recognizing patterns of changing activity on early dynamic/sequential imaging. The bright "focus" started to fade right away which alerted us that it most likely did not represent a SN. However, it remained focal for some time (which would appear to the probe as a node), so we continued to take images to further verify that this was an PSN, and this prevented us from marking the patient's body to a "node" that was not going to be there the next day. If surgery was to have been on the same day, we would have alerted the surgeon that it was most likely not a node but an ectasia.
The reverse echelon node (REN), represents a partial discongruence pattern, and signifies a lymph node "supplied" by only the non-perilesional injection and not directly by the perilesional injection (Figures 1 and 2). The flow of lymphatic fluid is generally away from any lesion "downstream" towards the axillary nodes. Since the non-perilesional areolar injection site can be further away from the axillary nodes than the perilesional injection site, it can use lymphatic pathways that are "before/upstream" to those that the perilesional injection uses. These pathways can contain a lymph node that will appear "upstream". This pattern is rarer than the PSN and would cause one to miss the "true" SN drained to by the perilesional injection if only the REN is harvested (assuming that the perilesional injections are the gold standard). In almost all cases of REN findings, we have seen the "true" SN (from the original perilesional injection) also eventually receiving activity from the non-perilesional injections as activity travels "downstream" towards the nodes. As long as more than one visualized node is removed during surgery when using the probe, the chances of missing the critical nodes are eliminated.
Nodes that are first or the brightest are not necessarily the ones that contain disease in up to 28% of studies; and if two SNs are present, both should be removed [13]. If a great multitude of nodes is seen, then the information depicted by the lymphoscintigraphy images regarding their distance from the primary lesion, order of appearance, and sequential position along the lymphatic channel, can be used to tailor the number of nodes removed. The very distant echelon nodes do not have to be removed in the interest of morbidity reduction in appropriate patients [1, 13–15].
The internal mammary basin is not drained to by intradermal injections as extensively noted in the literature [1]. A similar pattern of complete discongruence, though much rarer, can also occur in the axilla with non-perilesional injections (Figure 2). In this type of scenario, completely different axillary lymph nodes receive drainage from the different injection locations. This can seriously raise the possibility of a false negative SN result in the axilla if only non-perilesional injections are performed. Fortunately, this pattern is very rare, and is seen less than 2% of the time in our experience of over 600 cases with our ongoing protocol, and would only be an issue if no perilesional injection were being performed. Since both types of injections are being performed, "all bases are covered". Given that the false negative rate in detecting disease with sentinel lymph node biopsy does not usually reach 0% with even the best of techniques, any additional increments towards that goal are deemed worthwhile by us.
The enthusiasm in the literature for areolar injections must be accompanied by a thorough understanding of the various patters that can arise and their implications for the technique of sentinel lymph node biopsy to minimize the false negative rate and maximize morbidity reduction. For those centres interested in delineating the internal mammary nodes, including perilesional injections as part of the injection protocol is the only real option [1]. Even if the internal mammary nodes are not harvested, their presence might influence the management of the patient concerning irradiation of the chest.
Sentinel lymph node biopsy reliability can be problematic when lesions are very large (palpable). This is because the chances are increased that metastatic disease has largely replaced/obliterated the normal reticuloendothelial system in the SN that is responsible for phagocytosis of the radiocolloid, or cutoff lymphatic flow. With no reticuloendothelial system in the node or no lymphatic flow, the node will be cold or very faint even though it is full of disease, a "missed" SN. Because of the "clogged" nature of this node, collateral lymphatic flow to other nodes can occur, which appear hot. These "other" nodes have been called false SN, false negative nodes and neosentinel nodes, as the potential exists that disease has not spread to them, and false negative SN biopsies can result [1, 14, 15].
The importance of proper lymphoscintigraphy technique and the optimal display and printing of images cannot be overstressed. Multiple details in the dynamic acquisition of images and their display and printing must be attended to. Additional details involving patient body marking, outlining, standing views and arm position also exist. These are critical if the whole process is to accurately communicate to the surgeons the number and locations of the SNs, and is to facilitate the detection of the various patterns that are potential "issues" as noted above [1, 5, 14–21]. This case is interesting because the two potentially confusing patterns (REN and ectasia) occurred simultaneously. However, careful acquisition and analysis of the images allowed this previously unreported combination to be resolved successfully.
In summary, non-perilesional injections can occasionally create unique patterns of activity distribution during lymphoscintigraphy. When these patterns are properly identified and acted upon, lymphoscintigraphy, with triangulated patient body marking, can prevent unnecessary morbidity by limiting the extent of dissections. It can also assist in lowering the false negative rate when additionally combined with perilesional injections.
Received for publication January 5, 2004.
Revision received June 11, 2004.
Accepted for publication July 12, 2004.
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References
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- Krynyckyi BR, Kim CK, Shafir MK, Mosci K, Machac J. Breast cancer and its management, the utility and technique of lymphoscintigraphy. In: Freeman LM (editor). Nuclear medicine annual. Philadelphia: Lippincot William & Wilkins, 2003;131–69.
- 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.[CrossRef][Medline]
- Maza S, Valencia R, Geworski L, et al. Peritumoural versus subareolar administration of technetium-99m nanocolloid for sentinel lymph node detection in breast cancer: preliminary results of a prospective intra-individual comparative study. Eur J Nucl Med Mol Imaging 2003;30:651–6.[Medline]
- Celliers L, Mann GB. Alternative sites of injection for sentinel lymph node biopsy in breast cancer. ANZ J Surg 2003;73:600–4.[CrossRef][Medline]
- Krynyckyi BR, Kim CK, Mosci K, Fedorciw BJ, Zhang ZY, Lipszyc H, et al. Areolar-cutaneous "junction" injections to augment sentinel node count activity. Clin Nucl Med 2003;28:97–107.[CrossRef][Medline]
- Krynyckyi BR, Miner M, Ragonese JM, Firestone M, Kim CK, Machac J. Technical aspects of performing lymphoscintigraphy: optimization of methods used to obtain images. Clin Nucl Med 2000;25:978–85.[CrossRef][Medline]
- Roumen RMH, Geuskens LM, Valkenburg JGH. In search of the true sentinel node by different injection techniques in breast cancer patients. Eur J Surg Oncol 1999;25:347–51.[CrossRef][Medline]
- Uren RF, Thompson JF, Howman-Giles R. Sentinel nodes. Interval nodes, lymphatic lakes, and accurate sentinel node identification. Clin Nucl Med 2000;25:234–6.[Medline]
- McCarter MD, Yeung H, Yeh S, Fey J, Borgen PI, Cody HS 3rd. Localization of the sentinel node in breast cancer: identical results with same-day and day-before isotope injection. Ann Surg Oncol 2001;8:682–6.[Abstract/Free Full Text]
- Yeung HW, Cody III HS, Turlakow A, et al. Lymphoscintigraphy and sentinel node localization in breast cancer patients: a comparison between 1-day and 2-day protocols. J Nucl Med 2001;42:420–3.[Abstract/Free Full Text]
- Solorzano CC, Ross MI, Delpassand E, et al. Utility of breast sentinel lymph node biopsy using day-before-surgery injection of high-dose 99mTc-labeled sulfur colloid. Ann Surg Oncol 2001;8:821–7.[Abstract/Free Full Text]
- Koizumi M, Nomura E, Yamada Y, Takiguchi T, Tanaka K, Yoshimoto M, et al. Sentinel node detection using 99mTc-rhenium sulphide colloid in breast cancer patients: evaluation of 1day and 2day protocols, and a dose-finding study. Nucl Med Commun 2003;24:663–70.[CrossRef][Medline]
- Bourgeois P, Nogaret JM, Veys I, et al. How ‘hot’ is the pathologically positive sentinel lymph node in breast cancer patients? Nucl Med Commun 2003;24:513–8.[CrossRef][Medline]
- Krynyckyi BR, Kim CK, Goyenechea MR, et al. Clinical breast lymphoscintigraphy: optimal techniques for performing studies, image atlas and analysis of images. Radiographics 2004;24:121–45.[Abstract/Free Full Text]
- Nieweg OE, Estourgie SH. What is a sentinel node and what is a false-negative sentinel node? Ann Surg Oncol 2004;11:169S–73S.[Abstract/Free Full Text]
- Uren RF, Howman-Giles R, Renwick SB, Gillett D. Lymphatic mapping of the breast: locating the sentinel lymph nodes. World J Surg 2001;25:789–93.[CrossRef][Medline]
- Pierini A, Dworkin HJ. Is the upright position more sensitive than the supine position in breast cancer sentinel node lymphoscintigraphy? Clin Nucl Med 2001;26:823–5.[CrossRef][Medline]
- Haigh PI, Hansen NM, Giuliano AE, Edwards GK, Ye W, Glass EC. Factors affecting sentinel node localization during preoperative breast lymphoscintigraphy. J Nucl Med 2000;41:1682–8.[Abstract/Free Full Text]
- Ichihara H, Kinoshita F, Hiyoshi K, Beppu T, Fujigasaki K. Usefulness of imaging posture using modified oblique view of the axilla (MOVA) for sentinel lymph node scintigraphy in patients with breast cancer. Nippon Hoshasen Gijutsu Gakkai Zasshi 2003;59:765–70.[Medline]
- Tsushima H, Yamanaga T, Shimonishi Y, Ochi H. Usefulness of imaging method without using lead plate for sentinel lymph node scintigraphy. Kaku Igaku 2002;39:161–9.[Medline]
- Krynyckyi BR, Sata S, Zolty I, Kim CK, Knesaurek K. Reducing exposure from 57Co sources during breast lymphoscintigraphy by optimizing energy windows and other suggested enhancements of acqusition and the display of images. J Nucl Med Technol 2004;32:198–205.[Abstract/Free Full Text]
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Abstract
Introduction
