Diagnostic accuracy of sentinel node identification is maintained with the addition of local lidocaine and subareolar radioactive colloid injection

Abstract

Preoperative sentinel node localization (SNL) using a subareolar injection of radiotracer technetium-99m-sulfur colloid (Tc99mSC) is associated with significant pain. Lidocaine use during SNL is not widely adopted partly due to a concern that it can obscure sentinel node identification and reduce its diagnostic accuracy. We prospectively identified women with a biopsy-proven infiltrating breast cancer who were awaiting a SNL. The women completed the McGill pain questionnaire, Visual Analog Scale, and Wong–Baker FACES Pain Rating Scale prior to and following SNL. We identified a retrospective cohort of women with similar demographic and tumor characteristics who did not receive lidocaine before SNL. We compared sentinel lymph node identification rates in the two cohorts. We used Wilcoxon rank sum tests to compare continuous measures and Fisher's exact test for categorical measures. Between January 2011 to July 2012, 110 women consented, and 105 were eligible for and received lidocaine prior to Tc99mSC injection. The post-lidocaine identification rate of SNL was 95 % with Tc99mSC, and 100 % with the addition of intraoperative methylene blue dye/saline. Pain range prior to and following the SNL was unchanged (P = 0.703). We identified 187 women from 2005 to 2009 who did not receive lidocaine during preoperative SNL. There was no significant difference in the success rate of SNL, with or without lidocaine (P = 0.194). The administration of lidocaine during SNL prevents pain related to isotope injection while maintaining the success rate. We have changed our practice at our center to incorporate the use of lidocaine during all SNL.

Buffering the Suffering of Breast Lymphoscintigraphy

“…First, there has been concern that a buffered lidocaine injection before lymphoscintigraphy might diminish visualization of lymph nodes by potentially decreasing lymph node uptake (10). However, similar to reports of other studies (4,11,12), examinations from both groups in our study were deemed to be of diagnostic quality, and all examinations demonstrated 100% rate of intraoperative sentinel node detection. Second, it had been assumed that any benefit gained from local anesthesia may be offset by the increase in pain from additional needle sticks or pain from the lidocaine itself (4).…”

Pain Control in Breast Surgery: Survey of Current Practice and Recommendations for Optimizing Management—American Society of Breast Surgeons Opioid/Pain Control Workgroup

“…3,4 Injection of local anesthesia does not compromise the diagnostic accuracy of radiotracer utilized for sentinel node biopsy. 5 Liposomal bupivacaine is increasingly used in breast surgery, and anecdotally is reported to be a very effective medication. However, there is a lack of randomized, prospective studies comparing this modality to traditional local anesthetics.…”

“…However, there is a lack of randomized, prospective studies comparing this modality to traditional local anesthetics. Many of the published studies contain small numbers of patients and show that liposomal bupivacaine is equivalent, and maybe better, than traditional local anesthetics [4][5][6][7][8] Most of these studies report on lower patient reported pain scores and decreased opioid use. 6 A Cochrane review of 1377 patients undergoing all surgery types concluded that "Liposomal bupivacaine at the surgical site does appear to reduce postoperative pain compared to placebo; however, at present the limited evidence does not demonstrate superiority to bupivacaine hydrochloride."…”