Arguments have been made in favour of preoperative lymphoscinti-graphy as a 'road map' for surgeons (Figure 4). SLN visualisation on pre-operative lymphoscintigraphy significantly improves the intraoperative SLN identification rate (22, 23). If a SLN takes up enough radiocolloid to image with a camera, it should be easily detected with the intraoperative probe.

The question is whether lymphoscintigraphy should be done at all since SLNs are still identified in the majority of image negative patients (22-25) and most surgeons are concerned with mapping only to the axilla. In addition, the demonstration of extraaxillary lymphatic drainage only becomes important when a treatment decision is to be made based on the finding. Given the time and cost required to perform preoperative lymphoscintigra-phy its routine use does not appear to be justified. It may be valuable for surgeons in the learning phase to decrease the learning curve and in patients who have an increased risk of intraoperative failed localisation (obese or old patients). A negative preoperative lymphoscintiscan predicts inability to localise with the hand held gamma probe. Therefore, if SLN is not visualised on lymphoscintigraphy then the addition of intraoperative blue dye is recommended to increase the likelihood of SLN identification (23).

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