Delayed Sentinel Lymph Node Dissection in Patients with a Preoperative Diagnosis of Ductal Cancer In Situ by Preoperative Injection with Superparamagnetic Iron Oxide (SPIO) Nanoparticles: The SentiNot Study

Ann Surg Oncol. 2023 Jul;30(7):4064-4072. doi: 10.1245/s10434-022-13064-0. Epub 2023 Jan 31.


Background: Difficulty in preoperatively assessing the risk for occult invasion or surgery that precludes future accurate axillary mapping in patients with ductal cancer in situ (DCIS) account for overutilization of SLND.

Methods: Prospective, multicenter, cohort study, including women with any DCIS planned for mastectomy or DCIS grade 2 and > 20 mm, any DCIS grade 3, any mass-forming DCIS and any planned surgery. Patients received an interstitial SPIO injection during breast surgery, but no upfront SLND was performed. If invasion was identified on final pathology, delayed SLND (d-SLND) was performed separately with the coadministration of isotope ± blue dye (BD). Study outcomes were proportion of upfront SLNDs that were avoided, detection rates during d-SLND, and impact on healthcare costs.

Results: In total, 78.7% of study participants (N = 254, mean age 60 years, mean DCIS size 37.8 mm) avoided upfront SLND. On d-SLND (median 28 days, range 9-46), SPIO outperformed Tc99 with (98.2% vs. 63.6%, p < 0.001) or without BD (92.7% vs. 50.9%, p < 0.001) and had higher nodal detection rate (86.9% vs. 32.3%, p < 0.001) and with BD (93.9% vs. 41.4%, p < 0.001). Only 27.9% of all SLNs retrieved were concordant for Tc99 and SPIO. Type of breast procedure (WLE vs. oncoplastic BCT vs. mastectomy) affected these outcomes and accounted for the low performance of Tc99 (p < 0.001). d-SLND resulted in a 28.1% total cost containment for women with pure DCIS on final pathology (4190 vs. 5828 USD, p < 0.001).

Conclusions: Marking the SLN with SPIO may avoid overtreatment and allow for accurate d-SLND in patients with DCIS.

Publication types

  • Multicenter Study

MeSH terms

  • Axilla / pathology
  • Breast Neoplasms* / surgery
  • Carcinoma, Ductal, Breast* / pathology
  • Carcinoma, Ductal, Breast* / surgery
  • Carcinoma, Intraductal, Noninfiltrating* / pathology
  • Carcinoma, Intraductal, Noninfiltrating* / surgery
  • Cohort Studies
  • Female
  • Humans
  • Lymph Node Excision
  • Lymphatic Metastasis
  • Mastectomy
  • Middle Aged
  • Prospective Studies
  • Sentinel Lymph Node Biopsy / methods
  • Sentinel Lymph Node* / pathology
  • Sentinel Lymph Node* / surgery


  • ferric oxide