CASES OF THE WEEK - “First case of cancer breast (left) encountered with visualisation of axillary and infraclavicular sentinel lymph nodes by sln scintigraphy and subsequent gamma probe guided removal. Histopathology showed micro metastatis in both

CASES OF THE WEEK - “First case of cancer breast (left) encountered with visualisation of axillary and infraclavicular sentinel lymph nodes by sln scintigraphy and subsequent gamma probe guided removal. Histopathology showed micro metastatis in both

40-year-old female with history of left breast lump was investigated. Ultrasound breast showed a well-defined, oval, hypoechoic lesion with lobulated margins at 2 clocks on position. Both the axillary regions show few enlarged lymph nodes with preserved fatty hilum. MRI BREAST showed left breast mass (Birads category 4A), Core needle biopsy invasive duct carcinoma left breast.

Patient was planned for left mastectomy & sentinel lymph node biopsy & hence referred for sentinel lymph node scintigraphy for identification and localization of sentinel lymph nodes.

Identification of the SLN(s) is done during the surgery to remove the primary tumor of the breast. Prior to surgery, 99mTc Nano colloid is injected into subareolar location. The technique of injecting the radiolabeled agent and subsequent localization is known as lymphoscintigraphy and is typically performed on the day of surgery to identify the location of the SLN or group of nodes and lymphatic channels.

After two hours of injection- Static and SPECT-CT fused images identified and localized SLN1 in left mid axillary region and SLN 2 in left infraclavicular region medially. Subsequently underwent Gamma probe guided removal of the SLNS (During the tumor removal surgery, a hand-held gamma counter is used to locate the SLN, which will have a high radioactivity count, and under visual inspection. The SLNS is then biopsied and the sample is assessed to determine whether it contains cancer cells.

SLNS BIOPSY SHOWED MICRO METASTASIS IN BOTH THE SENTINEL LYMPH NODES.

The early depiction of the infraclavicular lymph nodes on preoperative lymphoscintigraphy may be associated with an increased incidence of positive ipsilateral axillary lymph node status and recurrence at drainage lymphatic vessel regions. The depiction of SLN outside the axilla on lymphoscintigraphy could provide more accurate lymphatic staging for regional and systemic treatment of breast cancer (Breast cancer patient with ipsilateral infra clavicular lymph node metastasis are defined as IIIc stage (N3) according to the newly published 8th AJCC staging system).

In conclusion, the detection of uptake by infraclavicular SLNs on lymphoscintigraphy may provide additional staging information to tailor individual treatment regimens with regard to the potential risk of recurrence or metastasis of breast cancer.

WE THANK, DR FADI ALNEHLAOUI, ONCO-SURGEON AT ZULEKHA HOSPITAL, SHARJAH FOR REFERRING THIS PATIENT AND GIVING US THE VALUABLE INPUTS.

Unique Cases 062b Unique Cases 062c Unique Cases 062d