LYMPH NODE – MAJOR IMPORTANCE PREDICTIVEFACTOR IN BREAST CANCER

145

Journal of Experimental Medical & Surgical Research

Cercetãri Experimentale & Medico-Chirurgicale

Year XV · Nr.4/2008 · Pag. 145-151E x p e r i m e n t a l

M e d i c a l S u r g i c a l

R E S E A R C H

J O U R N A L o f

Correspondence to: Dr, P. Matusz, Departamentul de Anatomie, Universitatea de Medicinã ºi Farmacie "Victor Babeº", Timiºoara, Str. Col. Enescu nr. 2, Timisoara

SUMMARY: Information about the lymph node status is an important prognostic factor,influencing breast cancer staging and treatment options. The primary tumor drains along alymph trajectory in a first regional lymphatic node, called sentinel node (SN), whichcaptures the disseminated tumoral cells. Breast’s lymph drainage is complex; together withthe main axillary drainage pathway there are also secondary pathways, with significantpractical importance in case of breast cancer. The study material was represented by 35female patients, aged between 31 and 74 years, with palpable breast malignant tumor. Weanalyzed primary tumor size and location, and injected radiopharmaceutical (RP)substances. The RP substances used were 99mTc–Hepatate and 99mTc–Nanocoll, in doses of15-30 MBq, by intradermal or peritumoral injection. The scintigraphic detection of the SNwas possible in 34 cases (97.14%), with the following locations: axillary SN – 28 cases(82.36%); internal mammary SN – 4 cases (11.76%); infraclavicular SN – 1 case (2.94%);both axillary and internal mammary SN – 1 case (2.94%). All the four breast quadrants drainmostly towards the axillary SN. Tumors located medially and centrally drain towards theinternal mammary and infraclavicular SN. In case of intradermal RP injecting we detectedthe SN after 15-20 minutes when using 99mTc-Nanocoll, respectively after 45 minutes with99mTc-Hepatate, independently of primary tumor size (T<2.0 cm or 2.0 cm<T<5.0 cm) andlocation. On the study lot, the most frequent location of the SN was those located in axilla (Supported by CNMP 4.1-058/2007).

Key Words: sentinel lymph node, breast cancer, radiopharmaceutical substances

NODULUL SANTINELÃ - FACTOR PREDICTIV MAJOR ÎN CANCERUL DE SÂN

Rezumat:. Statusul limfonodulului santinelã este un factor de prognostic important înstadializarea neoplasmului de sân ºi opþiunile terapeutice. Tumora primarã dreneazã de-alungul traiectului limfatic în primul limfonodul regional, numit nodul santinelã, ce capteazãcelulele tumorale diseminate. Drenajul limfatic al sânului este complex ; împreunã cudrenajul limfatic axilar sunt cãi secundare cu importanþã practicã în neoplasmul de sân. Înstudiu au fost incluse 35 de femei cu vârsta între 31- 74 ani cu tumori maligne palpabile. Amanalizat dimensiunile ºi localizarea tumorii ºi am injectat substanþe radiofarmaceutice (RF).Substanþele RF utilizate au fost 99m Tc- Hepatate ºi 99m Tc- Nanocoll, în dozã de 15-30MBq injectate intradermic ºi peritumoral. Detectarea scintigraficã a nodulului santinelã afost posibilã în 34 cazuri (97,14%) cu urmãtoarele localizãri: axilarã - 28 cazuri (82,36%),mamarã internã - 4 cazuri (11,76%), infraclavicularã -1 caz (2,94%), axilarã ºi mamarãinternã -1 caz (2,94%). Cele patru cadrane ale sânului dreneazã frecvent în nodululsantinelã axilar. Tumorile cu localizare centralã ºi medialã dreneazã în limfonodulii mamariinterni ºi infraclaviculari. În cazul injectãrii intradermice s-a detectat nodulul santinelã dupã15- 20 de minute utilizând 99m Tc- Nanocoll, respectiv 45 de minute cu 99m Tc- Hepatate,independent de dimensiunea ºi localizarea tumorii primare (T< 2 cm sau 99m Tc- Hepatate2-5cm). În studiul analizat localizarea frecventã a nodulului santinelã a fost în axilã.

Agneta Maria Pusztai 1,3

Daciana Grujic 2

Lucia Patrascu 1

Mihaela Boit 1

Mihaela Mastacaneanu 2

P. Matusz 2,3

Received for publication: 05.06.2008

Revised: 01.08.2008

1 - Nuclear Medicine Laboratory, Emergency County Clinical Hospital Timisoara2 - Division of Plastic and Reconstructive Surgery, Emergency County Clinical Hospital Timisoara3 - Anatomy-Embryology Discipline, University of Medicine and Pharmacy “Victor Babes” Timisoara

INTRODUCTION

Breast cancer is a serious disease, with severe

prognosis, affecting a large number of people of

increasingly younger age. The survival rate at 5 years for

all stages has a mean of up to 85%. Localized breast

cancer has a 5 years survival rate of 96%, diminishing to

75% in case of regional dissemination and to 20% in case

of distant metastasis (KESHTGAR et al, 1999). It is well

known that patients with positive axillary lymph nodes

present a high probability to develop distant metastasis,

with a poorer prognosis. Postoperative chemotherapy

significantly reduces the risk of spreading. Because of all

that, information about sentinel node status has an

outmost prognostic significance, determining breast

cancer staging and therapeutic management.

Sentinel node biopsy developed as a method of

mammary carcinoma staging . Lack of metastatic

invasion of the sentinel node avoids dissection of axillary

lymph nodes, increasing patients’ quality of life

(VERONESI et al, 2006; BLIDARU et al, 2006).

Sentinel node detection in breast cancer is

theoretically based on the premises that the lymph

drainage is specific and predictable, and that malignant

cells spread sequentially: local, regional and distance

metastasis. The primary tumor drains along a lymphatic

trajectory in a first regional lymph node, called sentinel

node, which captures disseminated tumoral cells (VIALE

et al, 2005; HUANG et al, 2007).

Detection and biopsy of the axillary lymph nodes is a

standard procedure of the oncologic protocol. It is well

known that the breast has complex lymph drainage;

besides the main axillary pathway there are also

secondary pathways, of practical importance in case of

skin invasive cancer:

l internal thoracic pathway (internal mammary);

l supraclavicular pathway, anterior to the

clavicle;

l pathway towards the opposite side.

Between the cutaneous vessels of the two mammary

regions there is a communication on the median line. This

is one of the main pathways of extension from one

mammary region to another of a breast cancer that

invaded the skin. The lymphatic trunks themselves cross

the median line to extend from the skin of a mammary

region to the controlateral axillary region. These are

mainly the retro-pectoral trunks (BASTIAN, 1995).

MATERIAL AND METHOD

The study was done in the Nuclear Medicine

Laboratory, in the Plastic and Reconstructive Clinic of the

Emergency County Clinical Hospital Timisoara and the

University of Medicine and Pharmacy “Victor Babes”

Timisoara.

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Fig.1 - Graphic representation of the breast lymph drainage, showing a lymphatic duct from the inferior-externalquadrant towards the axillary lymph nodes – nodi lymphatici pectorales, where there appears a sentinel lymph node.

The study lot was constituted by 35 female patients,

aged between 31 and 74 years, that presented the

eligibility criteria for sentinel node detection in case of

breast cancer:

l positive diagnosis following clinical

examination, imaging studies and

anatomopathology;

l palpable malignant breast tumor.

We excluded from the study the patients with

multifocal breast cancer, palpable axillary lymph nodes,

previous surgery of the affected breast, pregnant and

post-partum patients.

Three individual variables were analyzed:

l Primary tumor location

l Primary tumor size

l Injected radiopharmaceutical substance

The method consists of intradermal, peritumoral or

intratumoral injection of radiopharmaceutical substance,

followed by detection at skin surface of the gamma

radiation emission of the sentinel node.

Most often, the radiopharmaceutical substance was

injected intradermally; in subjects with large breasts and

deep located tumor we preferred peri- or intratumoral

injection.

The intradermal injection is justified by the fact that

breast’s embryologic origin is ectodermal. Lymph ducts

from breast skin and parenchyma merge in the subareolar

lymphatic plexus, from where the lymph is drained

towards the axilla through one or two main lymphatic

trunks (GRANT et al, 1959: HALSELL et al, 1965; KETT et

al, 1970; BORGSTEIN et al, 1998).

The intradermal injection consists of a unique dose of

15-30 MBq in 0.2-0.5 ml solution 99mTc-Hepatate /99mTc-Nanocoll, at the level of tumor’s skin projection, the

subject being placed in dorsal decubitus and with the

ipsilateral upper limb in extreme abduction.

Radiopharmaceutical substance aspiration in the syringe

is preceded by aspiration of 0.2 ml air, to avoid

contamination after injection and to favor colloid

dispersion into the subcutaneous tissue. After radiotracer

injection the puncture site is covered with a small

impermeable plaster and the patient is invited to rub it for

a few minutes.

In case of primary tumors T>5.0 cm, the radiotracer is

injected peritumoral, in 4 injection points (1 ml

solution/point) (KESHTGAR et al, 1999).

The radiotracers used were colloids – HEPATATE and

NANOCOLL – radioactively labeled with 99mTc. 99mTc is

constantly provided by a molybdenum generator from the

Nuclear Medicine Laboratory.

In 10 cases patients were injected with99mTc-Hepatate, respectively with 99mTc-Nanocoll in 25

cases.

The radiotracer particles that reach the interstitial level

cross the endothelium of the lymph capillary to the first

lymph node, where they are captured.

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PRIMARY TUMOR SIZE NR. SUBJECTS PERCENTAGE (%)

T < 2.0 cm 11 31.43

2.0 cm <T< 5.0 cm 16 45.71

T > 5.0 cm 8 22.86

TOTAL 35 100.00

Table 2. Distribution of clinical cases according to primary tumor size

PRIMARY TUMOR LOCATION NR. SUBJECTS PERCENTAGE (%)

LATERAL – EXTERNAL QUADRANTS 18 51.43

CENTRAL - PERIAREOLAR 5 14.28

MEDIAL – INTERNAL QUADRANTS 12 34.29

TOTAL 35 100.00

Table 1. Distribution of clinical cases according to primary tumor location.

Scintigraphic data acquisition, the result of gamma

radiation emission from the sentinel node, was done with

a planar gamma camera with the following parameters:

l Collimator Low Energy High Resolution (LEHR),

l Matrix: 256 x 256 pixel,

l Energetic window: 140 keV for 99mTc,

l Dynamic acquisition from oblique-anterior

position with a duration of 20 minutes (40

frames x 30s),

l Static acquisition from oblique-anterior and

lateral position with duration of 5 minutes, at 20

minutes, 45 minutes and 2-3 hours after

injection.

The scintigraphic image of the sentinel node appears

as a focal zone with intense hyper fixation.

After preoperative lymphoscintigraphic detection of

the sentinel node, it is identified and excised

intraoperatively, followed by anatomopathology

examination that establishes the diagnosis of certitude of

metastases in the lymph node.

RESULTS

After intradermal or peritumoral injection of the

radiopharmaceutical substance (99mTc-Hepatate /99mTc-Nanocoll) and after dynamic (20 minutes – 40

frames x 30 s) and static (5 minutes – at 20 minutes, 45

minutes and 2 hours from injection) acquisition, we

obtained the scintigraphic detection of the sentinel node

in 34 cases (97.14%).

The location of the sentinel node was as follows:

l Axillary lymph nodes – 28 cases (82.36%),

l Internal mammary lymph nodes – 4 cases

(11.76%),

l Infraclavicular lymph nodes – 1 case (2.94%),

l Axillary and internal thoracic (internal

mammary) – 1 case (2.94%).

The drainage towards the axillary lymph node is done

from all the four quadrants.

In cases where the sentinel node was found at the

level of the internal thoracic (internal mammary) lymph

duct (11.76 cases), the primary tumor was located

periareolar (1 case) and in the medial quadrants (3

cases).

The lymph drainage towards the infraclavicular lymph

nodes was encountered in a single case (2.94%), in

which the primary tumor (T>5.0 cm) was located in the

superior-medial quadrant.

The primary tumor (T>5.0 cm) with two lymph

drainage trajectories, with simultaneous visualization of

two sentinel nodes, axillary and internal thoracic (internal

mammary) (2.94%) was located in the inferior-medial

quadrant.

In case of intradermal injection of the

radiopharmaceutical substance we noticed the quick

visualization of the sentinel node, at 15-20 minutes when

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Fig.2 - Lymphoscintigraphic image, showing a unique focal area with intense collecting located in the right axilla - increasedprobability of sentinel lymph node (SN).The scintigraphic study was performed at 20 minutes after intradermal injection of 0.8 mCi/0.5 mL of 99mTc-Hepatate andstatic acquisition (5 min / 500000 counts), from right oblique-anterior position, using a planar gamma-camera with thefollowing parameters: LEHR Collimator, matrix 256 x 256 pixel; energetic window – 140 KeV for 99mTc

using 99mTc-Nanocoll and at 45 minutes with99mTc-Hepatate, independently from the sizes (T<2.0 cm

or 2.0 cm<T<5.0 cm) or location (lateral, central or

medial) of the primary tumor.

In case of peritumoral injection, visualization of the

sentinel node was done by late static acquisitions (during

5 minutes, at 2 or 3 hours after injection).

DISCUSSIONS

The oncologic protocol requires preoperative

scintigraphic visualization of the sentinel node, surgical

identification and excision, followed by

anatomopathological examination, sentinel node status

being a major predictive factor in breast cancer.

Although breast lymph drainage is mainly axillary,

there are also secondary pathways, of considerable

practical significance for breast cancer; there is a

possibility for the sentinel node to be located on the

internal thoracic (internal mammary) or supraclavicular

pathway, or at controlateral level.

Breast’s lymph ducts spread along the whole gland,

achieving both deep and superficial drainage. There are

separate lymph vessels for each lobe or lactifer duct. The

lymphatic vessels communicate with the periareolar

lymphatic plexus and are associated in this area with the

venous plexus. The connections of direct deep lymph

ducts perforate the deep fascia towards the underlying

muscles. Primary lymphatic outflow crosses the

superior-lateral quadrant along the pectoralis major

muscle, towards the deep pectoral lymph nodes. Other

lymph vessels communicate directly with the

subscapular nodes. Thus, the lymph flows towards the

central axillary group, then the apical axillary group and

then towards the supraclavicular nodes. The internal

thoracic (internal mammary) perforators are

accompanied by medial lymphatic ducts draining into the

parasternal nodes. The whole breast lymph network is

tributary to these medial lymph nodes (BOSTWICK,

1983).

In the present study we succeeded the scintigraphic

detection of the sentinel node in 34 out of 35 cases

(97.14%), results similar to those obtained by other

authors:

l UREN et al (1999) – 99%

l COX et al (1998) – 94%

l BORGSTEIN (1998) – 89%

l VERONESI et al (1997) – 98%

l ALBERTINI et al (1996) – 92%.

The most frequent location of the sentinel node at the

level of axillary lymph nodes was sustained and

demonstrated by numerous authors. Sentinel node

biopsy developed into a method of staging for the

mammary carcinoma (VERONESI et al, 1997;

BORGSTEIN, 1998; DIXON, 1998; KUEHN et al, 2004;

VIALE et al, 2005; HUANG et al, 2007).

In 1995, UREN et al made a study on 34 subjects with

breast cancer and, using colloid small particles (3-12

nm), demonstrated multiple pathways of breast’s lymph

drainage:

l Towards the axillary lymph nodes exclusively

in 58% cases;

l Towards axillary and internal thoracic lymph

nodes in 19.4 cases;

l Towards axillary, internal thoracic and

infraclavicular lymph nodes in 13% cases;

l Towards the axillary and infraclavicular lymph

nodes in 3.2% cases;

l Towards internal mammary lymph nodes in

6.4% cases.

In case of intradermal administration of colloid small

particles, the lymph drainage is fast, requiring early data

acquisition. The smaller the diameter of the colloid

particles, the larger number of visualized lymph nodes.

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Fig.3 - Lymphoscintigraphic image, showing a unique focalarea with intense collecting, located in the left axilla -increased probability of sentinel lymph node (SN).The scintigraphic study was performed after intradermalinjection of 0.8 mCi/0.5 mL of 99mTc-Nanocoll, dynamicacquisition (20 minutes – 40 frames x 30 s) and staticacquisition (5 min / 500000 counts), from left oblique-anteriorposition, using a planar gamma-camera with the followingparameters: LEHR Collimator, matrix 256 x 256 pixel;energetic window – 140 KeV for 99mTc

Larger colloid particles migrate slowly, requiring late

acquisition of data.

The characteristics of the ideal colloid for visualization

of the sentinel node are:

l Particles between 80-200 nm,

l Marked with 99mTc,

l Stable during storage and in the blood flow,

l Quickly carried through lymph drainage

pathways,

l Captured by the sentinel node.

After scintigraphic detection of the sentinel node, it is

identified and excised intraoperatively, and then

undergoes anatomopathological examination. Biopsy of

sentinel lymph node in breast cancer allows evaluation of

its status, leading to axillary staging of the disease,

minimally invasive surgical procedures, diminishing of

postoperative morbidity and improvement in the quality

of patients’ life.

CONCLUSIONS

The primary tumor drains along a lymph trajectory,

into a first regional lymph node, called sentinel node,

which captures disseminated tumoral cells.

Drainage towards the axillary lymph node is done from

all the four quadrants.

Most frequent location of sentinel node in breast

cancer is axillary – 82.36%, the lymph drainage being

mostly towards the axillary lymph nodes.

There are also other locations of the sentinel node, due

to the secondary pathways of drainage with practical

importance in breast cancer: internal thoracic lymph

nodes (11.76%), infraclavicular lymph nodes (2.94%),

axillary and internal thoracic lymph nodes (2.94%).

The drainage towards the sentinel nodes from the

internal thoracic and infraclavicular level was done by

tumors having a medial or central location. Data

acquisition has to be done with a large dimension

detector or using multiple incidences, in order to detect

these less frequent locations of the sentinel node.

In case of intradermal injection of the

radiopharmaceutical substance, the sentinel node is

detected quickly when using 99mTc-Nanocoll (at 15-20

minutes), and later with 99mTc-Hepatate (at 45 minutes),

independently of primary tumor size (T<2.0 cm or 2.0

cm<T<5.0 cm) and location (lateral, central or medial).

150

Fig.4 - Lymphoscintigraphic image, showing a unique focalarea with intense collecting, located in the right axilla -increased probability of sentinel lymph node (SN), situatedmostly in the axillary lymph nodes in case of mammarycarcinoma.The scintigraphic study was performed after intradermalinjection of 0.8 mCi/0.5 mL of 99mTc-Nanocoll, dinamicacquisition (20 minutes – 40 frames x 30 s) and staticacquisition (5 min / 500000 counts), from right oblique-anterior position, using a planar gamma-camera with the followingparameters: LEHR Collimator, matrix 256 x 256 pixel;energetic window – 140 KeV for 99mTc.

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