Delayed dual-tracer sentinel lymph node biopsy after nipple-sparing mastectomy with implant-based reconstruction

Objective: to present a clinical case of delayed dual-tracer sentinel lymph node biopsy using technetium-99m radiocolloid and indocyanine green fluorescence in a patient who previously underwent nipple-sparing mastectomy with immediate implant-based breast reconstruction, and to analyze the technical feasibility and early perioperative safety of the procedure. Material and Methods. This article presents a clinical case of delayed sentinel lymph node biopsy after previous nipple-sparing mastectomy with immediate implant-based breast reconstruction. The report is descriptive and was not intended to assess diagnostic accuracy, sensitivity, specificity, or the false-negative rate of the technique. A 40-year-old woman with a history of right nipple-sparing mastectomy and immediate implant-based reconstruction underwent delayed axillary sentinel lymph node biopsy for staging regional lymphatic basin. Preoperative lymphatic mapping was performed using periareolar subcutaneous injection of 50 MBq ^99mTc-Nanocoll, followed by lymphoscintigraphy and SPECT-CT. On the day of surgery, indocyanine green was injected intradermally at four periareolar points. intraoperative detection was performed using a near-infrared fluorescence imaging system, MARS, version 2.0.0.7, 2024, and a handheld gamma probe. The primary procedural endpoint was technical success, defined as intraoperative identification and excision of at least one sentinel lymph node. Results. Preoperative lymphoscintigraphy and SPECT-CT demonstrated radiotracer uptake in two right axillary lymph nodes. Intraoperatively, both sentinel lymph nodes were successfully identified and excised using combined gamma-probe detection and fluorescence guidance. Concordance between radioactive and fluorescent signals was observed in both removed nodes. Histological examination showed no metastatic involvement. No intraoperative or early postoperative complications were recorded. The implant, mastectomy flaps and nipple-areolar complex remained viable, with no evidence of ischemia, infection, implant exposure or reconstructive failure. Conclusion. In this clinical case, delayed dual-tracer sentinel lymph node biopsy was technically successful and was not associated with early perioperative complications. These findings indicate the principal technical feasibility of the procedure in this specific clinical situation, but they do not allow assessment of diagnostic accuracy, reproducibility, or oncological safety.

1. Park K.U., Somerfield M.R., Anne N., Brackstone M., Conlin A.K., Couto H.L., Dengel L.T., Eisen A., Harvey B.E., Hawley J., Kim J.N., Lasebikan N., McDonald E.S., Pradhan D., Shams S., Vega R.M., Thompson A.M., Torres M.A. Sentinel Lymph Node Biopsy in Early-Stage Breast Cancer: ASCO Guideline Update. J Clin Oncol. 2025; 43(14): 1720–41. doi: 10.1200/JCO-25-00099.

2. Yoon C.I., Ahn S.G., Kim D., Choi J.E., Bae S.J., Cha C.H., Park S., Jeong J. Repeat Sentinel Lymph Node Biopsy for Ipsilateral Breast Tumor Recurrence After Breast Conserving Surgery With Sentinel Lymph Node Biopsy: Pooled Analysis Using Data From a Systematic Review and Two Institutions. Front Oncol. 2020; 10: 518568. doi: 10.3389/fonc.2020.518568.

3. Intra M., Veronesi P., Gentilini O.D., Trifirò G., Berrettini A., Cecilio R., Colleoni M., Rietjens M., Luini A., Paganelli G., Veronesi U. Sentinel lymph node biopsy is feasible even after total mastectomy. J Surg Oncol. 2007; 95(2): 175–79. doi: 10.1002/jso.20670.

4. Karakatsanis A., Eriksson S., Pistiolis L., Olofsson Bagge R., Nagy G., Man V., Kwong A., Wärnberg F.; SentiNot Trialists Group. Delayed Sentinel Lymph Node Dissection in Patients with a Preoperative Diagnosis of Ductal Cancer In Situ by Preoperative Injection with Super-paramagnetic Iron Oxide (SPIO) Nanoparticles: The SentiNot Study. Ann Surg Oncol. 2023; 30(7): 4064–72. doi: 10.1245/s10434-022-13064-0.

5. Tanis P.J., Nieweg O.E., Valdés Olmos R.A., Kroon B.B. Anatomy and physiology of lymphatic drainage of the breast from the perspective of sentinel node biopsy. J Am Coll Surg. 2001; 192(3): 399–409. doi: 10.1016/s1072-7515(00)00776-6.

6. Parks L. Nipple-Sparing Mastectomy in Breast Cancer: Impact on Surgical Resection, Oncologic Safety, and Psychological Well-Being. JAdv Pract Oncol. 2021; 12(5): 499–506. doi: 10.6004/jadpro.2021.12.5.5.

7. Kim J.H., Ryu J.M., Bae S.J., Ko B.S., Choi J.E., Kim K.S., Cha C., Choi Y.J., Lee H.Y., Nam S.E., Kim Z., Kang Y.J., Lee M.H., Lee J.E., Park E., Shin H.J., Kim M.K., Choi H.J., Kwon S.U., Son N.H., Park H.S., Lee J; Korea Robot-endoscopy Minimal Access Breast Surgery Study Group. Minimal Access vs Conventional Nipple-Sparing Mastectomy. JAMASurg. 2024; 159(10): 1177–86. doi: 10.1001/jamasurg.2024.2977.

8. Cavalcante F.P., Zerwes F.P., Millen E.C., Garcia G.N. Nipple-Sparing Mastectomy for Early Breast Cancer: Less is More? Ann Surg Oncol. 2023; 30(12): 7155–56. doi: 10.1245/s10434-023-14210-y.

9. Pestana I.A., Jones V.M., Velazquez C. Breast Reconstruction and Nipple-Sparing Mastectomy: Technical Modifications and Their Outcomes Over Time at an Academic Breast Center. Ann Plast Surg. 2021; 86(6S Suppl 5): 521–25. doi: 10.1097/SAP.0000000000002701.

10. Bargon C.A., Huibers A., Young-Afat D.A., Jansen B.A.M., Borel-Rinkes I.H.M., Lavalaye J., van Slooten H.J., Verkooijen H.M., van Swol C.F.P., Doeksen A. Sentinel Lymph Node Mapping in Breast Cancer Patients Through Fluorescent Imaging Using Indocyanine Green: The INFLUENCE Trial. Ann Surg. 2022; 276(5): 913–20. doi: 10.1097/SLA.0000000000005633.

11. Kedrzycki M.S., Leiloglou M., Ashrafian H., Jiwa N., Thiruchelvam P.T.R., Elson D.S., Leff D.R. Meta-analysis Comparing Fluorescence Imaging with Radioisotope and Blue Dye-Guided Sentinel Node Identification for Breast Cancer Surgery. Ann Surg Oncol. 2021; 28(7): 3738–48. doi: 10.1245/s10434-020-09288-7.

12. Bae S.J., Kook Y., Jang J.S., Baek S.H., Moon S., Kim J.H., Lee S.E., Kim M.J., Ahn S.G., Jeong J. Selective omission of sentinel lymph node biopsy in mastectomy for ductal carcinoma in situ: identifying eligible candidates. Breast Cancer Res. 2024; 26(1): 65. doi: 10.1186/s13058-024-01816-7.

13. Kim B.K., Woo J., Lee J., Kang E., Baek S.Y., Lee S., Lee H.J., Lee J., Sun W.Y.; Korean Breast Cancer Society. Survival Outcomes Based on Axillary Surgery in Ductal Carcinoma In Situ: A Nationwide Study From the Korean Breast Cancer Society. J Breast Cancer. 2024; 27(1): 1–13. doi: 10.4048/jbc.2023.0221.

14. Fat S.C., Weed C., Samaha Y., Chung A., Boyle M.K., Giuliano A., Ray E., Amersi F. Incidence of Cancer and Role of Sentinel Lymph Node Biopsy in BRCA Mutation Carriers Undergoing Prophylactic Mastectomies. Am Surg. 2023; 89(10): 4066–71. doi: 10.1177/00031348231175498.

15. Wong S.M., Ferroum A., Apostolova C., Alhassan B., Prakash I., Basik M., Boileau J.F., Meterissian S., Aleynikova O., Wong N., Foulkes W.D. Incidence of Occult Breast Cancer in Carriers of BRCA1/2 or Other High-Penetrance Pathogenic Variants Undergoing Prophylactic Mastectomy: When is Sentinel Lymph Node Biopsy Indicated? Ann Surg Oncol. 2022; 29(11): 6660–68. doi: 10.1245/s10434-022-11916-3.

16. Thompson J.L., Sinco B.R., McCaffrey R.L., ChangA.E., Sabel M.S., Dossett L.A., Hughes T.M., Jeruss J.S. Prophylactic mastectomy and occult malignancy: Surgical and imaging considerations. J Surg Oncol. 2023; 127(1): 18–27. doi: 10.1002/jso.27088.

17. Metcalfe K., Huzarski T., Gronwald J., Kotsopoulos J., Kim R., Moller P., Pal T., Aeilts A., Eisen A., Karlan B., Bordeleau L., Tung N., Olopade O., Zakalik D., Singer C.F., Foulkes W., Couch F., Neuhausen S.L., Eng C., Sun P., Lubinski J., Narod S.A.; Hereditary Breast Cancer Clinical Study Group. Risk-reducing mastectomy and breast cancer mortality in women with a BRCA1 or BRCA2 pathogenic variant: an international analysis. Br J Cancer. 2024; 130(2): 269–74. doi: 10.1038/s41416-023-02503-8.

18. Hunt K.K., Euhus D.M., Boughey J.C., Chagpar A.B., Feldman S.M., Hansen N.M., Kulkarni S.A., McCready D.R., Mamounas E.P., Wilke L.G., van Zee K.J., Morrow M.; Society of Surgical Oncology Breast Disease Working Group. Statement on Prophylactic (Risk-Reducing) Mastectomy. Ann Surg Oncol. 2017; 24(2): 375–97. doi: 10.1245/s10434-016-5688-z.