Optimal imaging time for Tc-99m phytate lymphoscintigraphy for sentinel lymph node mapping in patients with breast cancer

Abstract

Objectives: Sentinel lymph node (SLN) sampling has become a standard practice in managing early-stage breast cancer. Lymphoscintigraphy is one of the major methods used. The radioactive tracer used in Taiwan is Tc-99m phytate. However, this agent is not commonly used around the world and the optimal imaging time has not been studied. Thus, we investigated the optimal imaging time of Tc-99m phytate lymphoscintigraphy for SLN mapping in patients with breast cancer. Materials and Methods: We retrospectively reviewed SLN Tc-99m phytate lymphoscintigraphies in 135 patients with breast cancer between August 2013 and November 2017. The time for the first SLN to be visualized after radiotracer injection was recorded to determine the optimal imaging time. If no SLN was identified on imaging, the scan was continued to 60 min. We also recorded the presurgical technical and clinical factors to analyze the risk factors for nonvisualization of SLN. Each patient's postoperative axillary lymph node status was also recorded. Results: Axillary SLNs were identified on imaging in 94.8% of the patients. All first SLNs presented within 30 min. In 6 of 7 patients with negative imaging, SLNs were identified during surgery using either blue dye or a hand-held gamma probe. Nonvisualization of SLNs on lymphoscintigraphy was significantly associated with a lower injection dose (1.0 mCi vs. 2.0 mCi), 4-injection protocol (compared to 2-injection), and injection around an outer upper quadrant tumor. In addition, patients with axillary lymph node metastasis had a higher percentage of SLN image mapping failure, with a marginally significant difference. Conclusion: Based on our study, 30 min after Tc-99m phytate injection is the optimal time for lymphoscintigraphy and delayed imaging beyond 30 min is not necessary. In addition, a lower injection dose, the 4-injection method, and an injection near the outer upper quadrant tumor should be avoided to minimize nonvisualization of SLNs.