In this presentation the most important controversies in breast cancer lymphatic mapping and sentinel node biopsy have been discussed based on NCCN guideline.

1. Sentinel node
mapping in
breast cancer:
controversies
Ramin Sadeghi, MD
Associate Professor of Nuclear
Medicine,
Nuclear Medicine Research Center,
Mashhad University of Medical
Sciences

2. Major indication

3. F-18 FDG can not replace sentinel
node mapping for axillary staging

4. Negative axilla on
FDG PET/CT
Sentinel node not
visualized:
During surgery
several involved
axillary nodes were
removed

5. Mapping material
 Usually radiotracer and/or blue dye are used.
 In case of sentinel node visualization on
lymphoscintigraphy added value of blue dye is
disputed:
 Int J Surg. 2014;12(4):325-8. doi:
10.1016/j.ijsu.2014.01.014. Epub 2014 Jan 29.
Added value of blue dye injection in sentinel node
biopsy of breast cancer patients: do all patients need
blue dye? Sadeghi R, Alesheikh G, Zakavi SR,
Fattahi A, Abdollahi A, Assadi M, Jangjoo A,
Keshtgar M.

6.  CONCLUSIONS:
 The use of blue dye should be reserved for
inexperienced surgeons during their learning
phase and for those patients in whom
lymphoscintigraphy failed to show any uptake
in the axilla.

7. Type of radiotracer
 Various types of radiotracers are in use.
 All works well.
 In our country
 Tc-99m Phytate
 Tc-99m Antimony Sulfide Colloid

8. Injection site and depth
 The best location of injection is peri-areolar
and best depth is intradermal
 Raising a wheal is a key sign of successful
injection
 Very fast and efficient movement of the tracer.

9. Deep vs. superficial injections
 Internal mammary nodes are visualized
mostly by deep injections.
 Overall, the two methods are concordant
 Axillary concordance between superficial and deep sentinel node mapping
material injections in breast cancer patients: systematic review and meta-
analysis of the literature. Sadeghi R, Asadi M, Treglia G, Zakavi SR, Fattahi A,
Krag DN. Breast Cancer Res Treat. 2014 Apr;144(2):213-22. doi:
10.1007/s10549-014-2866-1

10. Deep vs. superficial injections
 Conclusion
 Axillary lymphatic
drainage concordance between superficial
and deep sentinel node mapping material in
breast cancer patients is fairly high and
clinically acceptable.

11. How long to wait after injection
 In case of intradermal injection, movement of
the tracer is very fast and peak count would
be reached at about 12 minutes most injection

12. How long to continue delayed
imaging
 Imaging past 15-30 minutes is futile.
 Zarifmahmoudi, L., Shabahang, H., Dabbagh Kakhki, V., Sadeghi, R. Time frame of sentinel
node visualization in early breast cancer patients using intradermal injection of Tc-99m
phytate: Imaging beyond 45 minutes does not yield more information. Iranian Journal of
Nuclear Medicine, 2018; 26(1): 30-34.
 How long the lymphoscintigraphy imaging should be continued for sentinel lymph node
mapping? Sadeghi R, Forghani MN, Memar B, Rajabi Mashhadi MT, Dabbagh Kakhki VR,
Abdollahi A, Zakavi SR. Ann Nucl Med. 2009 Aug;23(6):507-10. doi: 10.1007/s12149-009-
0284-y. Epub 2009 Jul 9.

16. 1 day or 2 day protocol
 Both works well
 The dose should be adjusted for 2 day protocol
 Hell J Nucl Med. 2011 Sep-Dec;14(3):313-5. Comparison between
one day and two days protocols for sentinel node mapping of
breast cancer patients. Ali J1, Alireza R, Mostafa M, Naser
FM, Bahram M, Ramin S.
 Nucl Med Commun. 2010 Jun;31(6):521-5. Comparison of early and
delayed lymphoscintigraphy images of early breast cancer
patients undergoing sentinel node mapping. Jangjoo A1, Forghani
MN, Mehrabibahar M, Rezapanah A, Kakhki VR, Zakavi
SR, Ghavamnasiri MR, Kashani I, Hashemian F, Sadeghi R.

17. 1 day or 2 day protocol
 CONCLUSION:
 Our study showed that a delay of up to 20 h in
sentinel lymph node biopsy using intradermal
injection of (99m)Tc-antimony sulfide colloid
does not result in washout of the tracer from
the true sentinel node or migration of the
radiotracer into second-echelon nodes.

18. 1 day or 2 day protocols
 In conclusion, two days protocol gives the
sentinel node biopsy team considerable
flexibility and lymphoscintigrpahy imaging can
be completed before surgery. Finding of the
axillary sentinel node during surgery is also
being easier. False negative rates as well as
the detection rate for one day and two days
protocols are comparable.

19. Volume of injection
 Lower injection volume causes less pain with
comparable results to higher volumes
 Nucl Med Commun. 2013 Jul;34(7):660-3. doi:
10.1097/MNM.0b013e3283619d07. Effect of radiotracer injection volume on
the success of sentinel node biopsy in early-stage breast cancer patients.
Dabbagh Kakhki VR1, Aliakbarian H, Fattahi A, Jangjoo A, Assadi M, Khajeh
M, Sadeghi R.

20. Volume of injection
 CONCLUSION:
 Increasing the volume of radiotracer in
intradermal injections does not have a statistically
significant effect on the sentinel node detection
rate (despite minimal decrease in detection at
higher volumes), nor on the time of sentinel node
visualization. A low volume(0.1 ml) of radiotracer
for intradermal injections can be as successful as
higher volumes for sentinel node mapping with the
added benefit of reduced pain from injections.

21. Definition of sentinel node during surgery and
importance of second echelon nodes
 Any node with count >5-10 fold of background
is sentinel node.
 All hot sentinel nodes should be harvested.
 The hottest sentinel node is not necessarily
the pathologically involved node

22. Second echelon node which was
pathologically involved

23. Imaging (lymphoscintigraphy)
 Imaging can be very useful for detection of
technical failure, determination of number of
sentinel nodes and sentinel node non-
visualization
 Zarifmahmoudi, L., Sadeghi, R. Radiotracer re-injection in case of sentinel
node non-visualization in a breast cancer patient. Iranian Journal of Nuclear
Medicine, 2017; 25(1): 70-72.

25. Re-injection following non-
visualization
 J Surg Oncol. 2010 Nov 1;102(6):649-55. doi: 10.1002/jso.21637.
Safety of sentinel node biopsy in breast cancer patients who rec
eive a second radioisotopeinjection after visualization failure in l
ymphoscintigraphy. Meretoja TJ1, Joensuu H, Heikkilä
PS, Leidenius MH.

26. Immediately following re-
injection: SLN was harvested
and was not pathologically
involved

27. Z011 era

28. IHC: Does it have any role in
clinical decision making

29. Breast cancer in pregnancy

30. Ducatal carcinoma in situ

31. History of excisional biopsy
 Is not contra-indicated
 Am Surg. 2010 Nov;76(11):1232-5. The effect of excisional biopsy on the
accuracy of sentinel lymph node mapping in early stage breast cancer:
comparison with core needle biopsy. Forghani MN1, Memar B, Jangjoo
A, Zakavi R, Mehrabibahar M, Kakhki VR, Kashani I, Hashemian F, Sadeghi R.
 Eur J Surg Oncol. 2012 Feb;38(2):95-109. doi: 10.1016/j.ejso.2011.11.005. Epub 2011 Dec 3.
The accuracy of sentinel node biopsy in breast cancer patients with
the history of previoussurgical biopsy of the primary lesion: systematic review and meta-
analysis of the literature. Javan H1, Gholami H, Assadi M, Pakdel AF, Sadeghi R, Keshtgar M.

32. History of neoadjuvant
chemotherapy

33. Local recurrence

34. Local recurrence
 Risk of Regional Recurrence After Negative Repeat Sentinel Lymph
Node Biopsy in Patients with Ipsilateral Breast Tumor Recurrence.
Poodt IGM, Vugts G, Maaskant-Braat AJG, Schipper RJ, Voogd AC,
Nieuwenhuijzen GAP; SentinelNode and Recurrent Breast Cancer
(SNARB) study group. Ann Surg Oncol. 2018 May;25(5):1312-1321.
doi: 10.1245/s10434-018-6384-y. Epub 2018 Mar 1
 Repeat Sentinel Lymph Node Biopsy for Ipsilateral Breast
Tumor Recurrence: A Systematic Review of the Results and Impact
on Prognosis. Poodt IGM, Vugts G, Schipper RJ, Nieuwenhuijzen
GAP. Ann Surg Oncol. 2018 May;25(5):1329-1339. doi:
10.1245/s10434-018-6358-0. Epub 2018 Feb 21.

35. Local recurrence
 CONCLUSIONS:
 The risk of developing regional recurrence after negative rSLNB is
low. The low relapse rate supports the safety of rSLNB as primary
nodal staging tool in IBTR. The time has come for clinical guidelines to
adopt rSLNB as axillary staging tool in patients with IBTR.
 CONCLUSION:
 The prognostic impact of rSLN-positive versus rSLN-negative
IBTR remains unclear. Further studies are needed to fill in the
gap in the management of lymph nodes for patients with IBTR.
However, based on the current evidence, rSLNB is feasible for
64% of patients, especially after previous SLNB. With a negative
predictive value of 96.5%, rSLNB appears to be highly specific,
with substantial advantages over ipsilateral ALND in IBTR.

36. Local recurrence in a breast
cancer patient with history of
axillary dissection
Note sentinel node in the
contralateral axilla

37. Internal mammary sentinel
nodes: what to do?
 Thus far no role in decision making
 Breast J. 2017 Jul;23(4):410-414. doi: 10.1111/tbj.12754. Epub 2017
Jan 24. Is Sentinel Node Biopsy of
the Internal Mammary Lymph Nodes Relevant in the
Management of Breast Cancer? Tan C1, Caragata R1, Bennett I1.

38. Internal mammary sentinel
nodes: what to do?
 Conclusion:
 Only a small proportion of breast cancer
patients were found to have metastasic
involvement of the IMN chain and which did
not significantly change their adjuvant therapy
management. These findings suggest that the
benefits of exploration of the IMN chain
in breast cancer patients are limited and may
be outweighed by the risk of complications.

39. Example of internal
mammary sentinel node
visualization in a breast
cancer patient

40. Inflammatory breast cancer

41. Paget’s disease

42. Phyllodes tumor