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University of Florida surgeons have simplified the way they identify which lymph node is reached first by breast cancer cells that escape from a tumor. The refined approach improves the accuracy of sentinel node biopsy, an increasingly popular method of gauging whether the disease has spread.

Physicians using the technique, which involves injecting a radioactive tracer into sites above and adjacent to breast tumors, also could better tailor the way they deliver radiation because the approach identifies the small percentage of patients whose sentinel node is actually located in the chest, not the armpit. UF surgeons reported findings from a retrospective study of the dual-injection method in the August issue of the journal American Surgeon.

In the past few years, many surgeons seeking to determine how advanced a patient鈥檚 cancer is have switched from removing 10 to 15 lymph nodes from under the arm鈥攖he traditional procedure known as axillary node dissection鈥攖o sentinel node biopsy because the method is associated with less pain and fewer complications, and has proved just as accurate, said cancer surgeon D. Scott Lind, M.D., who is affiliated with the UF Shands Cancer Center.

If the sentinel node is free of cancer, patients often can avoid having additional nodes surgically removed, a practice that can lead to nerve damage, chronic swelling, restricted shoulder movement and pain.

Yet the optimal way of performing sentinel node biopsy remains controversial, Lind said, and techniques vary widely from institution to institution and among individual surgeons.

鈥淲ith respect to treating breast cancer, we have become much, much less invasive and less radical,鈥� said Lind, a professor of surgery at UF鈥檚 College of Medicine. 鈥淚n the last century we went from radical mastectomy to learning that you can do breast-conserving therapy and can spare the patient the morbidity of taking the whole breast off, with equivalent outcomes. In the last 10 years, nearly every patient who previously would have undergone axillary dissection undergoes sentinel node biopsy. The problem is that鈥檚 rapidly becoming the standard of care without a standard technique. A lot of people are doing it in different ways.鈥�

Typically, a surgeon injects a small amount of a radioactive tracer around the patient鈥檚 tumor, then locates the sentinel node with a hand-held device used to detect the tracer鈥檚 path. A blue dye also is injected into the breast tissue to help visually confirm the node鈥檚 location.

But surgeons continue to debate the ideal site for injecting the tracer and whether using the blue dye is even needed, Lind said. The dilemma has centered on whether it is necessary to inject the marker drug directly into the area where the original tumor was located, technically very difficult.

One in every eight American women will develop breast cancer at some point in their lifetime, the National Cancer Institute estimates. UF surgeons retrospectively studied 118 patients who were grouped into three categories. Sixty-five had the radioactive tracer injected into the skin over the tumor, six had the injection into the breast tissue around the tumor and 47 had both. Overall, at least one sentinel node was identified in 98.3 percent of the patients. A sentinel node was identified in 98.5 percent of patients receiving an injection in the skin above the tumor, 83.3 percent of those receiving an injection around the tumor and 100 percent of those receiving both.

Although the results showed that injection into the skin overlying the area of the tumor is an accurate localizing technique, using both injection sites helped increase the accuracy of identifying the sentinel node by detecting abnormal patterns of lymph fluid drainage, which are noted in up to 20 percent of breast cancer patients, Lind said. Practitioners then could target radiation treatments accordingly, he said, and spare other women radiation to areas where they don鈥檛 really need it.

The study鈥檚 authors also questioned the need for using blue dye, which is associated with rare but serious allergic reactions. UF surgeons have abandoned its use, though it continues to be popular among practitioners nationwide.

鈥淲e found that using the two injection sites allows us to reliably identify the sentinel node in the most effective fashion,鈥� he said. 鈥淎nd it probably has some advantages because we won鈥檛 have to worry about patients having reactions to blue dye, and we can identify nonaxillary sites of disease that may affect treatment planning. This is particularly important with the new breast cancer staging system coming out in January, which will incorporate sentinel node results.鈥�

The UF findings provide unique insight into the care of women with breast cancer, said Michael Edwards, M.D., a professor and chairman of the department of surgery at the University of Arkansas.

鈥淲hile most of the experts have been narrowly focused on which single site of injection is superior, Dr. Lind and his group have split the dose and shown that injecting at two sites is superior to the 鈥榦ne-site injection鈥� approach,鈥� Edwards said. 鈥淚t sounds simple, but so much of the highest quality care is just that鈥攕imple, and better. They are to be complimented for thinking clearly and considering techniques that other experts and leading centers have overlooked.鈥�