Of the 69 lesions, 62 (89.9%) had SLNs located with the blue dye and 65 (94.2%) had SLNs located with the radiopharmaceutical. Thirty-two percent of the patients had history of previous excisional breast biopsies. In another study, patients were injected with 1.0 mCi of Tc-99m-sulfur colloid (unfiltered) in the subareolar area of the tumor-bearing breast and an injection of 2 to 5cc of isosulfan blue was performed around the tumor. The authors concluded that intradermal injections are complementary to peritumoral injections ( Figure 11) for patients with breast cancer. Internal mammary nodes, visualized after peritumoral injection in nine patients, were not visualized by the intradermal technique. In 30 patients, only peritumoral identification of the axillary nodes was successful and in nine patients, only intradermal identification of the axillary nodes was successful. Fifty-two patients had complete concordance with axillary nodal uptake. Ninety-four patients had positive peritumoral and/or intradermal accumulations. Intradermal injections were performed either in the skin overlying the tumor or periareolar in the quadrant of the tumor. In a study comparing two different injection techniques (peritumoral and intradermal), lymphoscintigraphy was performed on 99 patients who underwent peritumoral and intradermal injections on separate days. Prior reports have described a high degree of accuracy for intradermal injections of the isotope at the superolateral aspect of the tumor, probably secondary to communication between intraparenchymal and overlying dermal lymphatics. The SLNB only group did not show inferior survival rates compared to the axillary lymph node dissection group. The other group was randomized to SLNB followed by completion axillary dissection. One group was randomized to SLNB without axillary dissection. The patients were treated with lumpectomy and opposing tangential field radiation therapy and adjuvant systemic therapy at the discretion of the treating physician. The American College of Surgeons Oncology Group (ACOSOG) Z011 trial compared two groups of clinical T1–2 N0 M0 breast cancer patients with a positive SLN. Originally proposed in the management of penile cancer by Cabanas in 1977, the SLN concept has been applied in patients with malignant melanoma with considerable success. The SLNs can be located by injecting blue dye and/or radioactive material at the tumor site and subsequently, identifying a blue ( Figure 3) and/or a radioactive lymph node in the axilla. Sentinel lymph nodes (SLNs) are defined as the first group of lymph nodes draining the tumor bed. The sentinel lymph node (SLN) concept ( Figure 2), which states that the histologic status of the SLN is predictive of the status of the regional lymph nodes, is based on the orderly spread of tumor from the tumor bed to the regional lymph nodes. Sentinel lymph node biopsy (SLNB) has become standard in patients being treated for breast cancer with clinically negative lymph nodes.
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