procedure takes less than 10 min and can be com-
pleted during surgery [2].
Intra-operative Imprint Cytology
Intra-operative imprint cytology is an area which
requires more investigation. The preliminary data
are very encouraging and we are presently evaluat-
ing the role of this method at our institution. The
study performed by Fisher et al. [3] revealed that
out of 50 patients who underwent axillary clearance,
21 had histologically confirmed metastatic disease;
intra-operative imprint cytology detected 18/21 posi-
tive sentinel nodes. It was established that, had the
technique of imprint cytology been used intra-
operatively, 29 out of 50 patients may have avoided
the operation, one would have had to have under-
gone extended axillary surgery and two would not
have received further axillary surgery. The technical
details and the pitfalls of this technique have been
described in Chapter 10 of this book.
Clinical Applications
The utility of detection of the sentinel node in the
management of patients with malignant mela-
noma is slowly becoming established, accompa-
nied by the recognition that the technique re-
presents a clear advance over past procedures. The
jury is still out for patients with carcinoma of the
breast, and data are only now beginning to accrue
in other pathologies, such as colorectal and head
and neck cancer. Only a few additional comments
are pertinent at this stage.
An interesting area under investigation is the
evaluation of breast cancer patients undergoing
pre-operative neoadjuvant chemotherapy [1]. As
the micrometastatic foci can be destroyed by
chemotherapy,sentinel node biopsy can be per-
formed prior to commencement of chemotherapy
to appropriately stage the patient; if the sentinel
node is negative, it may be possible to avoid axil-
lary lymph node dissection, although the patient
will need to be kept under close review for any
recurrence in the axilla.
The implications which result from the detec-
tion of internal mammary nodes will need to be
clarified. Marked variation in the detection of
these nodes is reported by the different groups
involved with this work, and at present there is no
consensus on a management strategy for this
group of patients.
As far as the sensitivity of the technique in
breast cancer patients is concerned, have we
already achieved an acceptable false-negative rate?
Since the reported false-negative rate for the as-
sumed gold standard management of axillary
node dissection is of the order of 3 % [4], it does
seem that the minimum required target has nearly
been achieved.
Clinical protocols will require rapid standardi-
sation, but this will necessitate a major consensus
conference.
There is a need for continuing education and
training for this methodology to remain success-
ful and reproducible. There is a definite learn-
ing curve associated with the technique, and a
multidisciplinary team needs to be identified and
supported.
There is a need for a cost-benefit study to inves-
tigate the implications of the technique in terms
of resources and to assess its benefits and risks.
The Future
189
Fig. 2.
J-Tip Needle Free Injector applied to
a
melanoma of
the upper arm and
b
a male breast volunteer. (Provided by
Mr. SGE Barker)
a
b
