Does Failure to Visualize a Sentinel Node on Preoperative Lymphoscintigraphy Predict a Greater Likelihood of Axillary Lymph Node Positivity? Soran A, Falk J, Bonaventura M, et al (Univ of Pittsburgh Med Ctr, Pa) J Am Coll Surg 205:66-71, 2007 Background.—Sentinel lymph node (SLN) mapping has become the standard of care for axillary staging in women with early-stage breast cancer. The pur- pose of the study was to investigate the hypothesis that nonvisualization of SLN on lymphoscintigraphy (LSG) predicts a subset of patients at risk of having a sub- stantial burden of axillary tumor as evi- denced by higher rate of lymph node in- volvement. Study Design.—We retrospectively reviewed the records of 1,500 patients who underwent dual-tracer SLN map- ping for breast cancer between 1999 and 2004. LSG were reported as negative or positive. Results.—Ninety-one percent had axillary SLN(s) identified on LSG imag- ing. In 133 of 134 (99.3%) patients with a negative LSG, SLN(s) was identified intraoperatively either by blue dye or hand-held γ detection. SLN was positive in 28.4% of LSG nonvisualized group and was positive in 29.1% of LSG visu- alized group (p > 0.05). A significantly higher percentage of women older than 50 years of age had nonvisualization of SLN (p < 0.0001). Body mass index (calculated as kg/m 2 ) was > 30 in 42.5% of LSG nonvisualized group and in 26.3% in LSG visualized group (p < 0.0001). Conclusions.—Failure to demon- strate axillary uptake by LSG appears to be related to technical factors and patient-related factors, such as body mass index and older age, but does not adversely affect SLN identification. The equivalent rate of positive SLNs in pa- tients with a positive or negative LSG supports the null hypothesis that “failure to visualize” on LSG does not identify a subset of patients at higher risk of being axillary lymph node positive. In this article, Soran and colleagues evaluated the use of preoperative lym- phoscintigraphy to predict the patholog- ic status of the sentinel lymph nodes (SLNs). The authors found that failure to visualize an SLN on preoperative lym- phoscintigraphy was not associated with the presence of lymph node metastases. They also found that even if an SLN was not detected on preoperative lympho- scintigraphy, the surgeons were still able to localize an SLN intraoperatively in 99% of the patients with the use of either blue dye or hand-held γ probes. Although preoperative lymphoscintigraphy is a useful imaging tool for identifying aber- rant lymphatic drainage patterns in pa- tients with melanoma, it has little use in breast cancer management. Preoperative lymphoscintigraphy does not improve the accuracy or identification rates of breast SLN biopsy. 1 Moreover, Dupont and col- leagues 2 demonstrated that intraopera- tive localization with hand-held γ probes is more sensitive than preoperative lym- phoscintigraphy in identifying internal mammary SLNs. So, even if one believes that internal mammary SLNs should be removed, preoperative lymphoscintigra- phy is not required for localization. Thus, the additional cost and time associated with preoperative lymphoscintigraphy for nodal staging of breast cancer do not seem warranted in an era of limited health care resources. T. M. Tuttle, MD References 1. McMasters KM, Wong SL, Tuttle TM, et al. Preoperative lymphoscintigraphy for breast cancer does not improve the ability to identify sentinel lymph nodes. Ann Surg. 2000;231:724-731. 2. Dupont E, Cox CE, Nguyen K, et al. Utility of internal mammary lymph node removal when noted by intraop- erative γ probe detection. Ann Surg Oncol. 2001;8:833-836. Breast Diseases: A Year Book ® Quarterly 63 Vol 19 No 1 2008 63 Multifocal Breast Cancer in Women ≤35 Years Old Litton JK, Eralp Y, Gonzalez-Angulo AM, et al (Univ of Texas M. D. Anderson Cancer Ctr, Houston; Istanbul Univ, Turkey) Cancer 110:1445-1450, 2007 Background. —The relation that mul- tifocality at diagnosis had to survival in women < 35 years of age was evaluated. Methods.—Three hundred women seen at the M. D. Anderson Cancer Center between 1990 and 2002 were identified. Multifocality was defined as the presence of 2 or more foci of the same tumor clearly separated in the same breast. Patient characteristics and out- comes were tabulated and compared be- tween uni- and multifocality. Survival outcomes were estimated with the Kaplan-Meier product limit method and compared between groups with the log- rank statistic. Cox proportional hazards models were fit to determine the associa- tion between multifocality and survival outcomes. Results.—The median age was 32 years (range, 17–35). There were 58 pa- tients (19%) with multifocal disease. At a median follow-up of 43.9 months there have been 101 deaths and 138 recur- rences. Five-year overall survival (OS) estimates were 69.7% (95% confidence interval [CI], 63.1%, 77.1%) for patients with unifocal disease and 67.3% (95% CI, 54.6%, 83.0%) for patients with multifocal disease (P = .70). Five-year recurrence-free survival (RFS) was 44.4% (95% CI, 37.1%, 53.2%) for pa- tients with unifocal disease and 57.1% (5% CI, 43.3%, 75.4%) for patients with multifocal disease, (P = .36). Nuclear