Extremely indirect dermal lymphatic channels: value of areolar-cutaneous junction injection technique for breast lymphoscintigraphy.

This case describes a patient who initially had peri-excisional injections of radiocolloid around a lumpectomy site that failed to visualize sentinel nodes during lymphoscintigraphy. After additional areolar-cutaneous junction injections, extremely indirect dermal lymphatic pathways were evident with resultant drainage to two sentinel nodes, both of which contained disease. Hybrid combination injections of radiotracer during sentinel lymph node biopsy is gaining in popularity. This case illustrates the validity of the hybrid injection techniques and the demonstrated accuracy despite seemingly disconnected and extremely tortuous pathways as demonstrated in the figure.