Unenhanced Chest Computerized Tomography Assisted Sentinel Lymph Node Biopsy Could be a Highly Reliable Option for Only Methylene Blue Available Breast Cancer Patients

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Background: Blue dye and radioisotope (RI) combined SLNB is the “best” protocol. However, RI is not available worldwide. This study is to evaluate the feasibility of unenhanced chest Computerized Tomography (CT) with three criteria for suspicious nodal metastasis assisted SLNB using only methylene blue (MB) as an alternative reliable option.

Patients and Methods: A total of 1771 consecutive patients with clinically node negative breast cancer were enrolled. For limiting FNR and surgical complications, the number of removed Sentinel Lymph Nodes (SLNs) was suggested to be 3~5. Unenhanced chest CT is mandatory to locate SLNs, which were graded from 1 to 3 according to suspicious criteria for metastasis. Three doctors adopted three SLNB methods. Periareolar sub-dermal injection using 4ml of 0.5% MB alone or in combination with a radioisotope was individually employed by two doctors. The third doctor used 2ml of 1% MB to inject into parenchyma to map SLNs.

Results: Both FNR and outcomes of patients showed no difference between three methods. We also confirmed that Lymph Vascular Invasion (LVI) and CT grade were both significantly correlated with SLN status (coefficients were0.68 and 0.25, p<0.001). Although there was no difference found in complications, but parenchymal injection did never cause skin necrosis.

Conclusion: Unenhanced chest CT could be are liable assistance to improve SLNB using only MB via parenchymal injection. This technique might be the safest and convenient option for SLNB in the study and RI could be safely spared.

Keywords: Breast cancer; Sentinel lymph node biopsy; Methylene blue; Computerized tomography

Unenhanced Chest Computerized Tomography Assisted Sentinel Lymph Node Biopsy Could be a Highly Reliable Option for Only Methylene Blue Available Breast Cancer Patients

                      http://austinpublishinggroup.com/obstetrics-gynecology/onlinefirst.php

Chinese incidence of breast cancer has increased remarkably with the socioeconomic development, particularly in eastern coastal areas, and it has been expected to approach more than 100 cases per 100000 women aged 55~69 years by 2021. Whereas, benefitting from systemic therapy, the invasiveness of surgical treatment has been largely controlled. Clinical trials have revolutionized the pattern of clinical practice. Mastectomy and Axillary Lymph Node Dissection (ALND) were both profoundly proven not to improve survival and Quality of Life (QOL) when comparing with Breast-Conserving Therapy (BCT) and Sentinel Lymph Node Biopsy (SLNB) [3,4]. National Surgical Adjuvant Breast and Bowel Project (NSABP) B-32 and other trials identified that SLNB could not only reduce the surgical morbidities, but could also be reliable for axillary staging of clinically lymph node negative (cN0) breast cancer.

SNB has become the standard of care in patients with cN0 disease. Although blue dye and radioisotope (RI) combined lymphatic mapping was well established as a standard procedure to limit FNR  but the optimal protocol for SLNB is still under investigation. In many Japanese hospitals, due to the lack of RI, contrast enhanced CT Lymphography (CT-LG) has been routinely used to stage the axilla accurately with dye-only SLNB. It was concluded that using the only size criterion by CT-LGor MRI alone to diagnose SLNs was not sufficient. No matter what contrast regimen used, the cost and procedure of the technique they used were not practical in China.

Based on previous studies on ultrasonography and CT-LG, metastatic nodes have several abnormal signs. In our daily wok, US-guided Core Needle Biopsy (CNB) and unenhanced chest CT have routinely been preoperatively adopted to evaluate node status and triage the patients. Because of unavailable RI and limited financial support in our country, most of patients, especially who live in remote rural areas, must receive more unnecessary ALND. In this context, we conduct this research to evaluate an unenhanced chest CT assisted method for SLNB and provide an alternative option for the given population.