Bone Metastases
Tumors arising primarily in bone are relatively rare while bony metastases are rather common, especially in patients over the age of 45. Metastases tend to arise in areas of persistent red marrow, especially in the axial skeleton, presumably because of increased blood flow 4 . From a series of 2001 patients 5 , the most frequent sites of bony metastases are shown in Table 1 5 . Malignancies with the highest frequency of osseous metastases include breast cancer and prostate cancer, with cancers...
Lymphoscintigraphy Jpq
A dose of 15 MBq 0.4 mCi of 99mTc antimony sulphide colloid was injected intradermally around the excision biopsy site. On the early dynamic image, several lymphatic vessels were observed passing up the right arm from the injection sites around the excision-biopsy scar Fig. 11 . Two nodes were observed on the early image, one in the right epitrochlear region and the other an interval node medially in the arm at midhumeral level. These nodes were again evident on the delayed scan performed 2...
References Qkm
1. H Snow. Melanotic cancerous disease. Lancet 2 872, 1892. 2. DS Reintgen, EB Cox, KS McCarty Jr, RT Vollmer, HF Seigler. Efficacy of elective lymph node dissection in patients with intermediate thickness primary melanoma. Ann Surg 198 379-385, 1983. 3. WH McCarthy, HM Shaw, GW Milton. Efficacy of elective lymph node dissection in 2,347 patients with clinical stage I malignant melanoma. Surg Gynecol Obstet 161 575-580, 1985. 4. DL Morton, L Wanek, JA Nizze, RM Elashoff, JH Wong. Improved...
Conclusions Iud
At the present time, the standard of care for definitive staging of clinically early-stage invasive breast cancer is axillary node dissection. Because of the morbidity of this procedure, sentinel lymphadenectomy has been suggested as a means of identifying patients without lymphatic metastases, allowing them to forego the more morbid axillary dissection. Sentinel nodes have been identified using both vital stains and radiocolloid injection, with the highest success achieved by the combination...
Surgery Xiy
The operation was performed the next day with the aid of blue dye and a gamma-ray detection probe. One milliliter of patent blue dye was administered around the original melanoma site on the right shoulder. A blue, hot node was removed from the right axilla. A repeat dose of 1 ml of blue dye was administered before Figure 16 The lateral view shows one supraclavicular node in addition to the node in the right axilla. The anterior view depicts one hot spot in the right axilla and two in the...
Melanoma
Lymphatic mapping with sentinel node biopsy for cutaneous melanoma was originally described by Morton and colleagues in 1990 as a potential solution to the controversy surrounding elective lymph node dissection 4 . The manuscript took 2 years to publish because of the reviewers' skepticism to the validity of the technique. However, since Morton's original article, approximately 300 reports on this approach have appeared in the literature. All major centers use presurgical cutaneous...
Limitations
There are several reasons why sometimes no sentinel node is identified on the lymphoscintigraphy images. Rarely, there is no drainage of the agent from the injection site 11,23,49 . This risk is greater after a wide therapeutic excision has been performed 3,58 , and it is the rule after a skin graft has been applied to cover the defect 59 . Injection of the radiocolloid into the scar of the excisional biopsy may also be associated with no flow from the primary site. Visualization of the liver...
Vulvectomy
Recent publications offer a still growing body of evidence that especially smaller primary vulvar tumors can be managed with hemivulvectomy or radical local excision instead of radical vulvectomy. An important factor to take into account when determining the management of the vulvar lesion is the condition of the remainder of the vulva. The presence of multifocal invasive lesions or widespread in situ neoplasia may preclude management by radical local excision 3 . Radical local excision implies...
Discussion Cbx
Cabanas developed the sentinel node concept in an attempt to solve the controversy surrounding inguinal lymph node dissection in clinically node-negative patients with penile carcinoma 6 . The original procedure was based on identification of a specific lymph node by lymphangiography of the dorsal lymphatics of the penis and did not take into account the individual drainage pattern of each tumor and the diversity of the anatomy of lymphatic drainage 7 . This original sentinel node concept for...
BLUE DYE MAPPING The Concept
The use of colored substances to demonstrate lymphatic vessels and lymph nodes is not a new concept. It was the technique employed by a number of the earliest anatomists who sought to map human cutaneous lymphatic drainage pathways see Chapter 2 . By injecting materials such as Prussian Blue dye and Chinese ink, they confirmed that lymphatics and blood vessels were distinctly separate entities and produced the first recorded maps of cutaneous lymphatic drainage pathways. In more recent times,...
Percutaneous Needle Biopsy
Sometimes it is possible to perform a percutaneous needle biopsy of a suspected bony metastasis for histological confirmation of tumor when there is a soft-tissue mass or large lytic lesion in the bone. A computed tomographic CT -guided biopsy of a spine lesion is also possible on occasion. Nevertheless, there is always the possibility of a sampling error when the needle biopsy is nondiagnostic. An open surgical biopsy may be needed when the staging and ultimate treatment recommendation hinge...
Discussion Dhr
Lymph drainage from the right epigastric region across the midline to the opposite axilla without concomitant drainage to the ipsilateral axilla is unusual. Drainage from the skin to the internal mammary lymph nodes is also rare but occurs via a costal margin node in approximately 20 of patients with melanoma in the superior periumbilical area 1 . The unlikely drainage pattern in this patient can be explained by the prior operation on the ipsilateral breast. Tumors in the epigastric region...
References Uhw
1. DI Morton, D-R Wen, JH Wong, JS Economou, LA Cagle, FK Storm, LJ Foshag, AJ Cochran. Technical details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg 127 392-399, 1992. 2. OE Nieweg, BAE Kapteijn, JF Thompson, BBR Kroon. Lymphatic mapping and selective lymphadenectomy for melanoma not yet standard therapy. Eur J Surg Oncol 23 397-398, 1997. 3. U Veronese J Adamus, DC Bandera, O Brtnnhwvn, E Caceres, N CascrnelM, F Claudio, RL Ikwnwpiswv, VV Javorski, S Kirov, A...
Results
The images are usually easy to interpret. The above-described technique depicts the lymphatic duct s in 80-98 of patients. In our hands, it hardly ever fails to visualize the sentinel node s 42,44-48 . Lymphatic drainage is complex in the neck and this is the most difficult lymphatic field for the interpretation of lymphoscintigraphy. We could not identify a sentinel node in 3 of 25 12 patients with a melanoma in the head and neck region 49 . O'Brien and coworkers faced this problem in 2 out of...
References Lqu
1. H Rouviere MJ Tobias, transl. . Anatomy of the Human Lymphatic System. Ann Arbor, MI Edwards Bros., 1938. 2. E Daseler, B Anson, A Riemann. Radical excision of the inguinal and iliac lymph glands. Surg Gynecol Obstet 87 679-694, 1948. 3. S Horenblas, H Van Tinteren, JFM Delemarre, LMF Moonen, V Lustig, R Kroger. Squamous cell carcinoma of the penis accuracy of tumor, nodes and metastasis classification system, and role of lymphangiography, computerized tomography scan and fine needle...
Comments
An important prognostic variable in colorectal cancer is the presence or absence of tumor in lymph nodes 28 . However, the clinical assessment of lymph node involvement is not easy because size and consistency, the two parameters used by the surgeon in traditional exploration, are not reliable indicators for the presence of metastasis 29 . RIGS has proven to be a technology capable of detecting lymph node metastasis in areas such as along the vena cava and hepatoduodenal ligament 3,4,30 ....
Reproductive Organs
In the male, testicular lymphatic vessels begin as a superficial plexus under the tunica vaginalis, and as a deep plexus within the substance of the testis and the epididymis 7 . These drain into four to eight collecting lymphatics which ascend in the spermatic cord and end in the lateral aortic and pre-aortic nodes. Collecting lymphatic vessels from the ductus deferens end in the external iliac nodes, whereas those from the seminal vesicles drain into both the internal and external iliac...
Contents
Foreword Donald L. Morton and Alistair J. Cochran iii 1. Microanatomy and Physiology of the Lymphatic System 1 Peter C. A. Kam, John F. Thompson, and Roger F. Uren 2. The History of Lymphatic Mapping 23 Roger F. Uren, John F. Thompson, and Robert Howman-Giles 3. Cutaneous Lymphoscintigraphy 43 Omgo E. Nieweg, Renato A. Valdes Olmos, Liesbeth Jansen, B. Acca E. Kapteijn, and Cornelis A. Hoefnagel 4. Operative Technique for Sentinel Lymphadenectomy Blue Dye Identification and Use of a Gamma Probe...
Removal Of Particulate Matter By Lymphatics
Several pathways through the walls of the initial lymphatics lymphatic capillaries have been identified. These include pores through the plasma membrane, vesicles, fenestrations of the basement membrane, and interendothelial junctions. The open junctions are the most important pathways in the walls of the initial lymphatics and are most numerous in the lymphatics of the intestine and peritoneal surface of the diaphragm. Vesicular transport across the endothelial cells can occur, but it is...
I
Figure 1 Early and late static images of a 43-year-old man with a melanoma in the right parasternal region. The early images a, b show the lymphatic channel running from the primary lesion site to the sentinel node in the right axilla. On the late images c, d , the radioactivity has largely cleared the lymphatic duct. The sentinel node and remaining radioactivity at the injection site are depicted. The lateral views b, d also depict a second-tier node. contour can be displayed by moving a...
Radiopharmaceuticals
The agents come in kits and are labeled with the radionuclide just before use. Noncolloidal macromolecules such as 99mTc-labeled human serum albumin HSA or dextran can be used to delineate lymphatic channels and to study flow kinetics. In lymphatic mapping, lymphatic channels as well as lymph nodes need to be visualized. Labeled colloids are used when lymph nodes need to be depicted. Colloid particles are 5-1000 nm in size. The behavior of colloids injected intersti-tially is dependent on their...
Phantom Measurements
The dose calculations were based on the assumption that 10 megabecquerels MBq of tracer is retained at the injection depot at the moment of surgery. The effects of two variables were estimated the depth of the depot, which was placed in tissue equivalent material i.e., water , and the distance from the depot to the dose-rate monitor. A sphere with a diameter of 2 cm was filled with 10 MBq of 99mTc pertech-netate and submersed in water at a depth of 1, 2, and 4 cm as a model for peritu-moral...
Surgery Jev
The patient was taken to the operating room 24 hours after lymphoscintigraphy. One milliliter of patent blue dye was administered around the biopsy site on the right buttock. The gamma detection probe confirmed that the sentinel node was situated exactly underneath the skin mark placed by the nuclear medicine physician. A 4-cm incision was made over the skin mark, and three lymphatic vessels were identified underneath Scarpa's fascia. The vessels were observed converging on one blue radioactive...
Surgery Ftv
The operation was performed the next day. Patent blue dye 1 mL was administered into the tumor in the left breast. A 4-cm incision was made along the lateral Figure 28 The late anterior view shows one hot spot in the right axilla and another that is less bright. A sentinel node and several second-tier nodes are depicted in the ipsilateral internal mammary node chain. Figure 28 The late anterior view shows one hot spot in the right axilla and another that is less bright. A sentinel node and...
Intraoperative Use Of A Gamma Probe 1
Although definite blue staining of a sentinel node with identification of at least one blue-stained afferent lymphatic channel entering the node currently remains the gold standard for assessment of whether a lymph node is or is not a true sentinel node, intraoperative use of a gamma detection probe can provide valuable confirmatory evidence. A number of compact, lightweight gamma probes are now available which can be used intraoperatively to assist with the sentinel lymphadenectomy procedure....
Pressure Resistance And Flow In Peripheral Lymphatics
There are considerable variations in the intralymphatic pressures which have been reported, apparently due to differences in methodology. The pressures in the pre-nodal lymphatics depend on the intrinsic contractility of lymphangion and active or passive movements of neighboring muscles Table 1 . Unlike the venous system, hydrostatic pressures are not important in affecting peripheral lymphatic pressures. The pressure in the collecting lymphatics of the leg ranges between 0 and 5 mmHg during...
Use Of Immunohistochemistry
It is absolutely essential that all lymph nodes be examined by immunohistology using antibodies to S-100 protein and HMB-45, unless the node contains overt tumor on gross inspection or review of H amp E-stained slides. The antibody MART-1 melanoma-associated antigen recognized by T lymphocytes Melan-A can be substituted for HMB-45. Immunohistology will always increase the frequency of sentinel lymph nodes found to contain tumor. The proportion of sentinel nodes that require immunohistology to...
Bone Scintigraphy
The most sensitive indicator of metastatic disease is bone scintigraphy, which appears positive when as little as 5-15 of the trabecular bone is destroyed by tumor 4 . This technique is much more sensitive than plain bone radiographs and shows metastases to bone much earlier. Indeed, only 3 of bone metastases will be seen on plain bone radiographs in the face of a normal bone scan. The mechanism involved in the uptake of the radiopharmaceutical used in bone scin-tigraphy is not well understood....
Discussion Kmd
In one series, a sentinel node between the pectoralis muscles was found in two of 113 patients with breast cancer 1 , and in one of 92 patients with breast cancer in another series 2 . This location is difficult to determine beforehand examining the lymphoscintigraphy images. In retrospect, one of the hot nodes may be located somewhat more anteriorly than is usual on the lateral view. The larger tracer volumes and the popularity of injection over greater areas of the breast may explain why...
Physiology Of Lymph Formation
Lymph formation, which is essentially the filling of the lymphatic capillaries initial lymphatics , is the main determinant of lymph flow. Once lymphatic fluid enters the lymphatic collecting vessels, it is propelled along either by active contractions or external forces, and flow is unidirectional. The rate of movement of fluid and protein out of blood passing through capillaries see Fig. 8 into the interstitial space 1-3 can be summarized by where Vc is the volume of the capillary filtrate,...
Contributors
Jan G. Aalders, M.D., Ph.D. Department of Gynecologic Oncology, Groningen University Hospital, Groningen, the Netherlands Albert Jan Arends, M.Sc. Department of Medical Physics, Catharina Hospital, Eindhoven, the Netherlands Shmuel Avital, M.D. Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel Claudia G. Berman, M.D. Department of Radiology, University of South Florida, Tampa, Florida Paul J. Borgstein, M.D., Ph.D. Department of Surgical Oncology, Vrije Uni-versiteit...
Technique Of Intraoperative Gammaray Detection Probe Localization
The development of the hand-held, high-resolution gamma-ray detection probe, which provides real-time, rapid counting in the surgery room, has allowed the development of a much simpler technique for localizing bone lesions for biopsy. The gamma probe has been quite successfully used intraoperatively for ra-dioguided identification of sentinel lymph nodes in melanoma and breast cancer 13,14 . The gamma probe has been subsequently adapted for use at the H. Lee Moffitt Cancer Center for...
References Cqg
1. B Selverstone, WH Sweet, CV Robinson. The clinical use of radioactive phosphorus in the surgery of brain tumors. Ann Surg 136 643-651, 1949. 2. AC Morris, TR Barclay, R Tanida, JV Nemeck. A miniaturized probe for detecting radioactivity at thyroid surgery. Phys Med Biol 16 397-404, 1971. 3. JA Kim, PL Triozzi, EW Martin. Radioimmunoguided surgery for colorectal cancer. Oncology 7 55-64, 1993. 4. AC Perkins, JG Hardy. Intraoperative nuclear medicine in surgical practice. Nucl Med Commun 17...
Index
Adjuvant therapy, 88, 102, 117, 141, 148, 153, 168, 177, 339, 342, 361, 364 Albumin, 99mTc-colloid, 31, 102, 106, 115, 173 99mTc-labeled human serum, 47, 48, 102, 106, 108, 115, 362 Allergic reaction, 46, 62, 75 Antibody, 34, 63, 168, 245, 249, 360, 364 Antimony trisulfide colloid, 31, 47, 48, 158, 161, 220, 362 Bartholin, 23 Bladder, 36 Blood, 151 Blue dye, 24, 73, 76, 115, 116, 169, 192, 205, 209, 274 allergic reaction, 75 injection technique, 74, 104, 172, 205, 329 lymphangiography, 29 side...
Surgery Pgx
The operation was performed the next day. The gamma detection probe could not locate the sentinel node through the intact skin. One milliliter of patent blue dye was administered into the lesion before preparing and draping the left breast. The cranial flap for the mastectomy was partially raised, and the pectoralis major muscle fibers were split to get to level III of the axilla. No blue duct was observed in this area. After massaging the breast tissue from the tumor in the direction of the...
Detection In The Vicinity Of An Injection Site Shielding And Energy
Radiation from an injection site close to a node may be considerably stronger than that from the node. As long as the probe is not pointed in the direction of the injection site, its radiation may be blocked quite efficiently with side shielding. If necessary, an add-on shield or collimator can be used to improve side shielding. A 100-1000-fold reduction of the direct radiation can easily be obtained in this way, which is quite sufficient for the typical situation in which not more than 4 MBq...
Purposes Of Lymphoscintigraphy Preparations And Injection Technique
The wound edges following a wide excision do not necessarily drain to the same lymph node or even same basin as the original lesion 3,18,19 . The relevant cutaneous lymphatics may be disrupted. Studies have shown that if lymphatic mapping is performed after wide local excision, the mean number of sentinel lymph nodes removed is increased. The number of patients where two or more basins have to be dissected is also increased to suggest that more extensive surgery is performed when compared to...
Patient Dosimetry
Radiolabeled colloids are well suited for sentinel node detection. The amount of injected tracer ranges from 7 MBq 12 up to 60 MBq 8 . Compared with other nuclear medicine studies, these tracer doses are low 22 . Estimation of the patient's radiation dose after intracutaneous or subcutaneous injection of colloidal solutions is difficult. Because only a small fraction of the tracer is transported, the effective dose is largely determined by the amount of tracer that is retained in the injection...
Lymphoscintigraphy
Hultborn and colleagues were among the first to employ a physiologic strategy for radiocolloid imaging of lymph nodes draining breasts with malignant disease 5 . Their technique involved preoperative injection of the breast parenchyma with postoperative ex vivo imaging of the radical or extended radical mastectomy specimen. The gamma camera image directed the pathologist's dissection of the operative specimen. They also utilized a gamma probe for localization within indistinctly visualized...
Case 11 Sentinel Node in Interpectoral Fossa Rotters Sentinel Node
A 50-year-old woman sought medical attention 4 weeks after discovering a lump in the left breast. Her surgeon noticed a 1.5-cm firm nodule in the upper inner quadrant. Physical examination was otherwise unremarkable. The radiologist reported seeing a malignant lesion on the mammograms and ultrasound. Fine-needle aspiration was performed and showed clusters of large atypical epithelial cells consistent with adenocarcinoma. The diagnosis and the various treatment options were discussed with the...
Node Localization Spatial Resolution Sensitivity At A Distance
Spatial resolution describes the ability of the probe to distinguish between two sources that are close together, or to locate the precise position of a source from a distance. The latter is important if we want to locate a sentinel node through the intact skin before the incision is made. Figure 2 shows the relative spatial resolution scanning in a straight line over a source with a closest distance of 26 mm with respect to the front of the probe or collimator for different probe...
Case 2 Merkels Cell Carcinoma
A 34-yeor-old woman was examined at another hospital with a 3 X 4 cm tumor in the right thigh. The tumor was attached to the skin and had developed in the scar of o cut that she suffered 22 years earlier. Physical examination revealed no other abnormalities. Excision with a narrow margin was performed. Pathological evaluation revealed a neuroendocrine tumor of the skin Merkel's cell carcinoma that involved the excision margin. A computed tomography scan of the chest was normal. She was then...
Skin
Studies of the microlymphatics of the skin have shown a widespread subepithelial network Fig. 5 2,4 . A superficial subpapillary layer of prelymphatic capillaries initial lymphatics forms a closely interconnected hexagonal network. These initial lymphatics are connected to deeper layers of lymphatic capillaries in the dermis, and lymph is then transported centrally through subcutaneous lymphatic collecting vessels. The subdermal lymphatics communicate with those below the deep fascia 4 . With...
Microanatomy Of The Lymphatic System
Although there are remarkable similarities in the lymphatic microanatomy within different organs, there are also some essential differences 2 . This review will deal with the common ultrastructural features first and then examine the differences between organs. The lymphatic system Fig. 1 begins as a network of blind ending capillaries which absorb lymph from the interstitial spaces. These capillaries are called initial lymphatics and are also known in the literature as prelymphatics, lymphatic...
Lymphatic Mapping Of The Skin
The first comprehensive descriptions of the lymphatic drainage of the skin were based on the elegant work of the anatomist Sappey, who in the nineteenth century injected mercury into the lymphatics of cadavers to display the lymph channels 3,4 . He reported drainage to the axilla and groin from the skin of the trunk Figs. 1-3 and showed a vertical midline zone anteriorly and posteriorly where drainage tended to overlap. A similar zone was identified passing horizontally around the waist from...