Answer
Injection techniques can be divided into superficial and deep methods. The superficial techniques include intradermal, subcutaneous, subareolar, and periareolar injections. Deep techniques include peritumoral or intratumoral injections. Subcutaneous, periareolar, and subareolar techniques are associated with a low yield of nonaxillary nodes.
The combination of radiocolloid injection and blue-dye injection immediately before surgery gives the highest sensitivity and specificity of the technique. However, numerous studies have also found that SLN biopsy with radiotracer alone is successful. [16, 17] A meta-analysis found that mapping sentinel lymph node locations with methylene blue alone results in an acceptable identification rate but an excessive false-negative rate. [18]
SLN biopsy with near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) has been reported to be a highly sensitive method for SLN detection. In this method, ICG is injected and then tracked through the lymphatic ducts to SLNs using an excitation illumination system and a high-sensitivity camera. [19]
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Injecting syringe.
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Gamma probe with a highly collimated handheld detecting wand, which is covered with a sterile cover for use within the surgical field.
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Injection tray containing the radioactive dose in a syringe shield, alcohol swabs, bandage, and dry cotton.
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Intradermal injection technique. Note that the needle tip is within the skin thickness and a bleb has formed on the skin. The cancer is represented by the black mass.
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Intradermal injection technique. The needle is inserted at a very acute angle with the skin and the bleb forms when the radiocolloid is injected.
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Intraparenchmal injections. Note the needle injects within the parenchyma around the lesion.
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Postinjection massage. Dry cotton is used to massage the injection site to encourage lymph flow with the radiocolloid towards the sentinel node.
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Methylene blue is injected in the operating theater. Note the larger volume and a deeper insertion angle.
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The sentinel node is located using the gamma counter probe in the area with the highest count rate. This is done after sterilization; note that the probe is covered with a sterile sheath.
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With the probe in the proper location, the area is marked on the skin.
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The incision is made over the area identified by the mark on the skin.
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The incision leads to a blue lymph node. Note the blue channel at 1 o'-clock position indicating that this is the sentinel node (to be corroborated by radiation counting).
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The blue node is confirmed to be the sentinel node by counting over it. It should be the "hottest" node.
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The blue and hottest node is excised and ex vivo counts are checked. Note that the probe is directed towards the ceiling to avoid getting extraneous counts from the patient. Note the high counts (acquired over 2 seconds) at the top of the screen.
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After the sentinel node is excised, the nodal bed is checked again for residual counts. If the sentinel node has been removed, the count rate should fall to the background level or 10% of the in vivo count rate.
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Postexcision counts are acquired. In this image, the counts have fallen to very low background rates.
