Identifying Somatic Lymph Nodes for VLNT Using Technetium-99m Sulfur Colloid

Abstract

Vascularized lymph node transplant (VLNT) is one of the treatment options for chronic lymphedema following both breast cancer-related lymphoedema and lower extremity lymphoedema. VLNT is a safe and effective treatment for lymphedema with significant benefits fully manifesting at 2 years postoperatively. This involves the microvascular transfer of lymph nodes to the affected limb. The transferred lymph nodes then act as a sump to drain the excessive lymphatic fluid in the interstitial space. One of the challenges in VLNT is to include an adequate number of lymph nodes in the flap, which requires some way of identifying them before harvesting. In order to transfer lymph nodes along with their vascularity, we have relied on anatomic studies. However, using Technetium-99m sulfur colloid as used in sentinel lymph node harvest, we can identify lymph nodes in the transferred tissue, giving greater reliability to the procedure. It involves identifying the lymph node area before incision, guiding surgerons during harvest of the lymph nodes along with the vascularity, confirming the presence of lymph nodes after harvest, and confirming the presence after microvascular transfer to the affected site. It can be used along with methylene blue dye and indocyanine green (ICG) to confirm the presence of lymph nodes. In our pilot study of eight cases, we have found the presence of lymph nodes in all the transferred tissue. This is in comparison to certain studies on sentinel lymph node studies that indicate that the use of radiotracer and ICG is comparable in localizing lymph nodes.

Keywords

Technetium-99m - vascularized lymph node - lymphoedema - localizing lymph nodes

• References

• 1 Brown S, Mehrara BJ, Coriddi M, McGrath L, Cavalli M, Dayan JH. A prospective study on the safety and efficacy of vascularized lymph node transplant. Ann Surg 2022; 276 (04) 635-653
• 2 Salvo G, Ramirez PT, Levenback CF. et al. Sensitivity and negative predictive value for sentinel lymph node biopsy in women with early-stage cervical cancer. Gynecol Oncol 2017; 145 (01) 96-101
• 3 Chang EI, Chu CK, Hanson SE, Selber JC, Hanasono MM, Schaverien MV. Comprehensive overview of available donor sites for vascularized lymph node transfer. Plast Reconstr Surg Glob Open 2020; 8 (03) e2675
• 4 Dauphine CE, Khalkhali I, Vargas MP, Isaac NM, Haukoos J, Vargas HI. Intraoperative injection of Technetium-99m sulfur colloid is effective in the detection of sentinel lymph nodes in breast cancer. Am J Surg 2006; 192 (04) 423-426
• 5 Goodman S, O'Connor A, Kandil D, Khan A. The ever-changing role of sentinel lymph node biopsy in the management of breast cancer. Arch Pathol Lab Med 2014; 138 (01) 57-64
• 6 Chung A, Yu J, Stempel M, Patil S, Cody H, Montgomery L. Is the “10% rule” equally valid for all subsets of sentinel-node-positive breast cancer patients?. Ann Surg Oncol 2008; 15 (10) 2728-2733
• 7 Goonawardena J, Yong C, Law M. Use of indocyanine green fluorescence compared to radioisotope for sentinel lymph node biopsy in early-stage breast cancer: systematic review and meta-analysis. Am J Surg 2020; 220 (03) 665-676
• 8 White KP, Sinagra D, Dip F. et al. Indocyanine green fluorescence versus blue dye, Technetium-99m, and the dual-marker combination of Technetium-99m + blue dye for sentinel lymph node detection in early breast cancer-meta-analysis including consistency analysis. Surgery 2024; 175 (04) 963-973
• 9 Emile SH, Elfeki H, Shalaby M. et al. Sensitivity and specificity of indocyanine green near-infrared fluorescence imaging in detection of metastatic lymph nodes in colorectal cancer: Systematic review and meta-analysis. J Surg Oncol 2017; 116 (06) 730-740