* Corresponding author: Ramin Sadeghi, Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran. Tel: +985118012202; Fax: +985118933186; Email: sadeghir@mums.ac.ir; raminsadeghi1355@yahoo.com
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Inappropriate
Intra
‐
cervical
Injection
of
Radiotracer
for
Sentinel
Lymph
Node
Mapping
in
a
Uterine
Cervix
Cancer
Patient:
Importance
of
Lymphoscintigraphy
and
Blue
Dye
Injection
Sima Kadkhodayan , Elham (osseini Farahabadi , Zohreh Yousefi , Malihe
(asanzadeh , Ramin Sadeghi *
Women’s (ealth Research Center, Mashhad University of Medical Sciences, Mashhad, )ran Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, )ran
ARTICLE INFO ABSTRACT
Articletype:
Case report (erein, we report a case of sentinel lymph node mapping in a uterine cervix cancer patient, referring to the nuclear medicine department of our institute. Lymphoscintigraphy images showed inappropriate intra‐cervical injection of radiotracer. Blue dye technique was applied for sentinel lymph node mapping, using intra‐cervical injection of methylene blue. Two blue/cold sentinel lymph nodes, with no pathological involvement, were intra‐operatively identified, and the patient was spared pelvic lymph node dissection. The present case underscores the importance of lymphoscintigraphy imaging in sentinel lymph node mapping and demonstrates the added value of blue dye injection in selected patients. )t is suggested that pre‐ operative lymphoscintigraphy imaging be considered as an integral part of sentinel lymph node mapping in surgical oncology. Detailed results of lymphoscintigraphy images should be provided for surgeons prior to surgery, and in case the sentinel lymph nodes are not visualized, use of blue dye for sentinel node mapping should be encouraged.
Articlehistory: Received: Mar Revised: Apr Accepted: May
Keywords:
mTc‐Phytate
Cervical cancer Lymphoscintigraphy Methylene blue Sentinel node
►Pleasecitethispaperas:
Kadkhodayan S, (osseini Farahabadi E, Yousefi Z, (asanzadeh M, Sadeghi R. )nappropriate )ntra‐cervical )njection of Radiotracer for Sentinel Lymph Node Mapping in a Uterine Cervix Cancer Patient: )mportance of Lymphoscintigraphy and Blue Dye )njection.Asia Oceania J Nucl Med Biol. ; : ‐ .
Introduction
Sentinel node mapping, as a useful method for regional lymph node staging, minimizes the morbidity associated with lymph node dissection in patients with solid tumors.
The concept of sentinel node mapping relies on an orderly and predictable pattern of lymphatic flow from tumors. Sentinel nodes are the first lymph nodes in the lymphatic drainage system of tumors, and can be considered as surrogates for regional lymph nodes, regarding the pathological involvement , .
Two conventional methods for sentinel lymph node mapping are injection of radiotracer and blue dye. A combination of radiotracer and
blue dye injection for lymphatic mapping is found to increase the detection rate and decrease the false‐negative rate of sentinel node
biopsy . (owever, several authors have
proposed a more restricted use of blue dye injection due to potential life‐threatening complications, associated with this method ‐
.
Case
report
A ‐year‐old female patient with a
Kadkhoday
136
Figure1.E
the patient blue large
Figure 2.
images of t the injectio
nuclear The pat hysterec oophore Eight patient r
mTc‐ P
mCi /
Lympho posterio min aft variable‐ as previ was equ collimato photope the hue o
Lymp imprope as most vagina seen on t
yan S et al
Early lymphosci t’s hue in the lo e arrows . No sen
Delayed anter the patient. No s on sites in the ce
medicine de tient was p
ctomy and
ectomy. teen hours received two Phytate at
/ . cc
scintigraphy r and latera ter the inje ‐angle gamm ously specifi uipped with
or and imag ak and scatte of the patient phoscintigrap er injection o of the radio Figure ; al the lymphosc
ntigraphy image ower row. Note
ntinel node coul
ior/posterior ly sentinel node is ervix
epartment of planned to
d bilatera
before the o intra‐cervic
and o’cloc
for each
images w al views wer ection, using ma camera EC
ed . The g
low‐energy h ges were ta er photopeak t image /
phy imag
of radiotracer oactivity was lso, no sentin cintigraphy im
es of the patient. minimal activity d be visualized i
ymphoscintigrap visible. Arrows
f our institu undergo to
al salping
surgery, t cal injections ck positions
h injection
with anterio re obtained g a dual‐he
CAM, Siemen gamma came high‐resoluti
aken by m
ks for imagi min .
ges show
r in the cerv s visible in t nel nodes we
mages.
. The original im y in the cervix in the pelvis
phy are ute. tal go‐ the of n . or‐ ead ns , era on mTc ng wed vix, the ere ra ly sa ly tw pe Fr in re de ex fo ly
D
se by be ne in se w an so us )n th br ex Asia O mages are shownblack arrows a
The patien adiotracer ymphoscintig
ame finding ymph nodes wo intra‐cerv
. cc/injecti erformed usi rance and bl Two blue ntra‐operative
egions. (owe etected by th xamination o or pathologic ymph node di
Discussion
The impor entinel node y many res ehind blue d egative rate ncrease the entinel nodes (owever, a with some
naphylactic ome authors
se of blue dy n an importa hat the margi reast cance xperience of
Lymphoscin
Oceania J Nucl M n in the upper ro and extension o
nt refused to injection raphy image s without
Figure . vical injection ion , and lym ing a gamma lue dye techn e sentinel no
ely in the rig ever, no hot he gamma p of the sentine cal involvem issection was
rtance of blu mapping ha searchers
ye technique of sentinel intra‐oper s.
addition of b risks includ reactions
have propos ye in sentine ant study, De inal benefit o er patients surgeons inc
ntigraphy in Cerv
Med Biol. 2014; 2( w and the scatte of radiotracer in
undergo an
n. Pre‐o
es also sho any visible The patient ns of methyl mphatic mapp a probe EUR nique.
odes were i ght and left o
sentinel nod probe. Frozen el nodes was ment, and n s performed.
ue dye tech as been demo
, . The
e is to decrea node mapp rative detec
blue dye is a ding life‐thr
, , . T
sed a more r l node mapp erossis et al. f blue dye inj
decreases
creases .
vical Cancer
(2):135-137. erograms of n the vagina
y further operative owed the sentinel received lene blue ping was ROPROBE,
identified obturator des were n section negative no pelvic
hnique in onstrated rationale ase false‐ ping and ction of
ssociated reatening Therefore, restricted
ping .
Lymphoscintigraphy in Cervical Cancer Kadkhodayan S et al
Asia Oceania J Nucl Med Biol. 2014; 2(2):135-137. 137
study by Sadeghi et al. reported similar findings, and showed the marginal benefits of blue dye technique in case of sentinel node visualization on lymphoscintigraphy images .
The present case shows the importance of lymphoscintigraphy imaging as an integral part of sentinel node mapping. Lymphoscintigraphy images indicated the inappropriate injection of radiotracer in our case, failure to inject the air bubble behind the radiotracer in syringes , and the surgeon was informed about the results before the surgery. Blue dye technique was successful for lymphatic mapping and the patient was spared pelvic lymph node dissection.
Therefore, non‐visualization of sentinel nodes on lymphoscintigraphy images should be reported to surgical oncologists, and use of blue dye technique should be promoted in similar clinical situations.
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