Lymphatic tumour burden

It has been suggested that the accurate identification of the SLN by lymphatic mapping could be compromised if there is extensive tumour infiltration of afferent lymphatic channels or draining lymph nodes. Distal obstruction of the lymphatics by tumour and extensive tumour infiltration of the draining lymph nodes may prevent the migration of blue dye and radioisotope to the SLN, adversely affecting SLN identification. Lymph fluid re-routing may cause an alternative non-sentinel node to become "sentinel", increasing the risk of false-negative biopsy (26). We found that in the individual SLN, the percentage replacement by tumour and extranodal invasion of tumour are markers of lymphatic obstruction and are significantly associated with reduced radioisotope uptake (27). More than 50% replacement of the node by tumour will compromise the lymphatic flow and may lead to failed localisation of the node if the radioisotope is used alone (Figure 5). However, SLN identification using blue dye is not compromised by increased SLN tumour burden. The afferent lymphatic leading to the blocked node may be patent. The surgeon can identify the tumour-replaced node by following the blue lymphatic leading to the node. This result further supports combination of blue de and radioisotope being used to optimise the localisation rate.

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