ANZ J. Surg.

2002;

72

: 542–546

ORIGINAL ARTICLE

Original Article

SAME-DAY LYMPHOSCINTIGRAPHY AND SENTINEL NODE BIOPSY FOR EARLY BREAST CANCER

R

ICHARD

S

UTTON

,* J

AMES

K

OLLIAS

,*

†

V

ARNI

P

RASAD

,*

†

B

ARRY

C

HATTERTON

‡

AND

P. G

RANTLEY

G

ILL

*

†

*Breast Unit and Women’s Health Centre, Royal Adelaide Hospital Cancer Centre,

†

Adelaide University Department of Surgery,

‡

Department of Nuclear Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia

Background

:

Lymphoscintigraphy and sentinel node biopsy are currently being assessed as an alternative to axillary dissectionfor staging in early breast cancer. However, little is known about the optimum timing of surgery following injection of the radio-isotope into the breast. The aim of the present study was to establish whether lymphoscintigraphy on the morning of surgery allowedefficacious and accurate sentinel node identification and biopsy.

Methods

:

We reviewed our experience of 216 consecutive cases of lymphoscintigraphy in early breast cancer using peritumouralinjections of technetium

99m

antimony sulphide colloid and subsequent sentinel node biopsy using a hand-held gamma probe and bluedye. The time interval between radioisotope injection and successful intraoperative identification of the sentinel node was assessedand whether this was associated with certain clinical and histological variables.

Results

:

The sentinel node was identified by lymphoscintigraphy in 160 cases (74%) at a median time duration of 40 min postinjection. The median time duration between isotope injection and surgery was 5 h. Of the 160 cases where the sentinel node wasvisualized at lymphoscintigraphy, sentinel node biopsy was successfully performed in 155 cases (97%). This compares with 25/56(45%) cases where lymphoscintigraphy failed to localize the sentinel node (

P

< 0.0001). There was no association found between theinjection of the radioisotope greater or less than 5 h before surgery and the successful intraoperative identification of the sentinelnode. Failure to identify the sentinel node at lymphoscintigraphy beyond 3 h was associated with a low intraoperative identificationrate. There was no correlation found between intraoperative identification of the sentinel node according to the duration of isotopeinjection in relation to surgery and the various clinical and histological factors assessed.

Conclusions

:

In our experience, the chance of identifying the sentinel node at the time of surgery does not increase with longerisotope injection duration using technetium

99m

antimony sulphide colloid. As soon as a sentinel node is identified at lymphoscintig-raphy, one can proceed to surgery. Scanning beyond 3 h does not appear to be effective in sentinel node localization. Given that themedian time for successful lymphoscintigraphic mapping was only 40 min, lymphoscintigraphy can easily be completed during themorning to allow surgery to take place the same day.

Key words: breast cancer, sentinel node biopsy, lymphoscintigraphy.

Abbreviations

: SN, sentinel node; SNB, sentinel node biopsy.

INTRODUCTION

Sentinel Node Biopsy (SNB) has shown great promise in itsability to assess the nodal status of patients with early breastcancer. The results of recent studies have demonstrated that SNBis accurate in assessing the histological status of axillary nodes

1,2

and that the sentinel node (SN) can be found in most patients.

3–5

By limiting the extent of axillary surgery, while providing accu-rate staging information, SNB is likely to benefit women under-going breast cancer surgery in terms of inconvenience, risks andcomplications. Its efficacy compared with conventional axillarysurgery is currently being assessed in large multicentre trials suchas ALMANAC (United Kingdom), NSABP-B32 (North Amer-ica) and SNAC (Australia and New Zealand) although in certaincentres it has already been incorporated into the routine clinicalmanagement of early breast cancer.

6

Lymphatic mapping and SNB involves a series of steps thatinclude injection of radioactive isotope into the breast, lympho-scintigraphy, transferring the patient to the operating theatre suite,injection of Patent Blue V dye into the breast and subsequentbiopsy of the node(s). Little is known about the optimum timing ofbiopsy following injection of the radioisotope. To some extent thiswill depend upon the particle size of the colloid, the rate of decayof the isotope, the location of the tumour, prior surgical biopsy,the volume of isotope injected and the site of injection; be it in thedermis directly over the tumour, in the breast tissue around thetumour or in the peri-areolar lymphatic plexus. Studies have con-cluded that SNB can be satisfactorily contemplated 2–24 h afterinjecting the breast with technetium [

99

Tc] rhenium colloid

7

or6–8 h after injection of

99

Tc colloidal albumin.

8

However, theexperience of 180 consecutive cases, using

99

Tc-sulphur colloidinjected in a peritumoural distribution, led Winchester

et al

. torecommend injection the day prior to surgery.

6

Sentinel node biopsy and lymphatic mapping techniquesemployed for breast cancer in Australia and New Zealanddiffer somewhat from other areas around the world in severalrespects. One difference is that the colloid most commonlyused is

99m

Tc-labelled antimony trisulphide colloid. Antimonyis freely available for lymphatic mapping, and its particle sizemakes it an ideal agent for lymphoscintigraphy and intra-

R. Sutton

MB BS;

J. Kollias

MB BS, FRACS;

V. Prasad

MB BS;

B. Chatterton

MB BS, FRACP;

P. Grantley Gill

FRACS, MD.

Correspondence: James Kollias, Breast Endocrine Surgical Unit, RoyalAdelaide Hospital, North Terrace, Adelaide, South Australia 5000.Email: jkollias@mail.rah.sa.gov.au

Accepted for publication 22 April 2002.

SAME-DAY LYMPHOSCINTIGRAPHY AND SENTINEL NODE BIOPSY FOR EARLY BREAST CANCER 543

operative lymphatic mapping.

9

Few studies have addressed theoptimum timing of SNB following the injection of the anti-mony colloid into the breast. In view of this uncertainty, wereviewed the results of 216 consecutive cases of SNB for earlybreast cancer using

99

Tc-labelled antimony trisulphide injectedperitumourally, in an attempt to establish whether lympho-scintigraphy on the day of surgery allowed efficacious andaccurate SN identification and removal.

METHODS

Between August 1995 and September 2000, a consecutive seriesof 216 women treated for primary operable breast cancer at theRoyal Adelaide Hospital Breast Unit participated in a prospectiveevaluation of the technique of sentinel node biopsy. Writteninformed consent was given for the study. The median age of thepatients was 59 years (range: 31–82 years). Inclusion criteriahave previously been described

2

principally involving those withoperable primary breast cancers of

≤

5 cm in diameter using clin-ical and imaging criteria and having clinically impalpable axillarylymph nodes at the time of presentation.

Isotope injection and lymphoscintigraphy

On the morning of surgery, all but two women were injected with40 MBq

99m

Tc-labelled antimony sulphide colloid into four sitessurrounding the palpable margin of the breast lesion or usingultrasound guidance if the lesion was impalpable. Two womenunderwent lymphoscintigraphy during the afternoon prior toplanned surgery the following morning. The details of isotopeinjection technique and lymphoscintigraphy have been previouslydescribed.

2

Following injection, serial anterior and appropriateoblique or lateral images using a large field of view gammacamera (GE XRT) were obtained at approximately 15-min inter-vals until the initial draining node(s) was visualized. The surfaceprojection of the SN was then marked on the skin. Scanning timeranged from 2 min to 16 h with a median of 60 min. In 160 caseswhere the sentinel node was identified on lymphoscintigraphy,the median time taken to visualize the SN was 40 min (range:5–210 min). There were 56 cases where the SN was not visual-ized at preoperative lymphoscintigraphy. Scanning time rangedfrom 10 min to 16 h (median: 120 min). Of these, 49 cases (88%)were scanned for

≤

3 h because of the need to proceed withplanned surgery.

Lymphatic mapping technique

Patients underwent SNB in conjunction with a level I and II axil-lary lymph node dissection. In 163 cases, 1–2 mL of 2.5% PatentBlue V dye (Guerbet Laboratories-France, distributed by Fauld-ings-Australia, Adelaide, South Australia) was also injected intothe breast parenchyma around or overlying the tumour uponinduction of anaesthesia to facilitate intraoperative identificationof the SN. The SN was identified by its blue colour (if PatentBlue V dye was used) and/or by using the hand held gammaprobe (RMD CTC 4 with audible guidance system, Gammason-ics, Melbourne, Victoria, Australia) positioned in a sterile sheathwhich enabled the detection of individual nodes with radioactiv-ity levels significantly greater than those of the axillary fat. Theradioactivity of the SN was reassessed ex-vivo and the node(s)was sent for histological examination separate from the main

axillary nodal specimen. In general, the radioactivity of the senti-nel node(s) was at least 10 times that of the background activityfrom the axillary fat.

Timing of isotope injection in relation to surgery: Factors assessed

The time of intraoperative lymphatic mapping was noted and theduration between isotope injection and surgery documented. Clini-cal factors were assessed to determine the optimal duration ofisotope injection in relation to surgery. These included age at diag-nosis (< 50,

≥

50 years), method of presentation (symptomatic,screening), tumour site (superolateral or central/inferomedial), pre-vious core biopsy, previous open biopsy and lymphoscintigraphyidentification. The method of sentinel node identification (blue dyealone, isotope alone, both blue dye and isotope) was ascertained.Histological factors including invasive tumour size (< 2 cm

vs

2–5 cm), grade (

Ι

-

ΙΙΙ

), vascular invasion (present or absent, whereprobable vascular invasion was classified as absent) and histologicalnodal status (node positive

vs

node negative) were also assessed.

Statistics

Most afternoon theatre sessions occur at or around 2.00

PM

. Thiswould allow for at least 5 h duration between isotope injectionand theatre assuming a 9.00

AM

injection. For this logisticalreason, the duration between isotope injection and intraoperativelymphatic mapping (h) was categorized according to the follow-ing time intervals –

≤

5 h and > 5 h. Two-tailed Fisher’s exacttests were used to compare the rate of successful intraoperativeidentification of the SN according to the clinical and histologicalcriteria described in relation to the duration between isotopeinjection and intraoperative lymphatic mapping.

P

-values of

≤

0.05 were deemed significant.

RESULTS

The median time duration between isotope injection and intra-operative lymphatic mapping was 5 h (range: 115 min – 29 h).The SN was identified in 180 of 216 cases (84%) at operation. Astrong association was demonstrated between successful lympho-scintigraphic localization of the SN and intraoperative identifica-tion (Table 1;

χ

2

= 81.1;

P

< 0.0001). In 160 cases of successfullymphoscintigraphic localization, the SN was identified intra-operatively in 155 cases (97%). This compares with only 25 of 56(45%) cases where lymphoscintigraphy failed to localize the SN.In five cases where the SN was localized on lymphoscintigraphybut was not identified at surgery, the median time delay betweenvisualization of the SN on scan and surgery was 215 min (range:110–340 min). In 155 cases where the SN was localized on lym-phoscintigraphy and identified at surgery, the median time delaybetween visualization of the node on scan and surgery was300 min (range 115–470 min).

The median scanning time for lymphoscintigraphy was 60 min(range 2–1000 min). The median time to identify a SN duringscanning was 40 min Early identification of the SN during lym-phoscintigraphy was associated with a high rate of success atintraoperative SN identification (Table 2). Only one of eightcases that were scanned beyond 3 h was associated with sub-sequent success at SN identification at lymphoscintigraphy and atsurgery.

544 SUTTON

ET AL

.

There were 65 cases where the axillary nodes were found tocontain metastatic tumour deposits. Five cases had a normal SNin the presence of involved nodes in the remainder of the axillaryfat. The false negative rate was 7.1% (5/70). In comparing thestatus of the SN with that of the non-sentinel axillary nodes, theoverall accuracy of SNB in assessing axillary nodal status was175 of 180 (97.2%) and the predictive value of a negative SNin determining negative axillary node status was 115 of 120(95.8%).

Successful identification of the SN at surgery according toisotope injection duration is shown in Table 3. No significant dif-ference in intraoperative SN identification was demonstrated forcases where the injection time duration was

≤

5 h or > 5 h (87%

vs

80%;

P

= 0.15; Fisher’s exact test). No significant findingswere demonstrated for the various clinical and histological vari-ables for intraoperative SN identification according to isotopeinjection time duration (Tables 4 and 5).

Table 3.

Successful identification of the sentinel node at surgeryaccording to isotope injection duration

Isotope InjectionDuration (h)

No. cases Successful SN Identification (%)

< 3 19 17 (89)3–4 34 28 (82)4.01–5 50 45 (90)5.01–6 52 43 (83)> 6 61 47 (77)

Total 216 180 (83)

SN, sentinel node.

Table 5.

Intraoperative sentinel node identification according toisotope injection duration for histological variables

Histological variable Isotope injection duration

SN intraoperative identification

P

-value

No Yes

Size

≤

2 cm

≤

5 h 10 53 0.52> 5 h 16 63 –

Size > 2 cm

≤

5 h 3 33 0.17> 5 h 7 24 –

Grade I

≤

5 h 4 20 0.36> 5 h 9 23 –

Grade II

≤

5 h 4 37 0.37> 5 h 9 40 –

Grade III

≤

5 h 5 29 1.0> 5 h 5 25 –

VI negative

≤

5 h 12 71 0.33> 5 h 20 75 –

VI positive

≤

5 h 1 10 0.3> 5 h 3 13 –

LN negative

≤

5 h 10 55 0.29> 5 h 18 60 –

LN positive

≤

5 h 3 35 0.47> 5 h 5 30 –

LN, lymph node; SN, sentinel node; VI, lymphatic/vascular invasion.

Table 2.

Identification of the sentinel node during lymphoscintigraphyand intraoperative sentinel node identification – the effect of scanningduration

Scanning duration

No. cases SN identified on scan (%)

SN identified at surgery (%)

< 30 75 73 (97.3) 72 (96)30–60 47 39 (83) 42 (89.4)61–90 26 17 (65.4) 20 (77)91–120 30 16 (53.3) 26 (87)120–180 30 14 (46.7) 21 (70)> 180 8 1 (12.5) 1 (12.5)Total 216 160 (74.1) 182 (84.5)

SN, sentinel node.

Table 4.

Intraoperative sentinel node identification according toisotope injection duration for clinical variables

Clinical variable Isotope injection duration

SN intraoperative identification

P

-value

No Yes

Lateral lesions

≤

5 h 11 70 0.47> 5 h 15 70 –

Medial lesions

≤

5 h 2 19 0.16> 5 h 8 20 –

Age < 50

≤

5 h 3 32 0.64> 5 h 1 23 –

Age

≥

50

≤

5 h 10 58 0.16> 5 h 22 67 –

Screen-detected

≤

5 h 10 37 0.50> 5 h 15 40 –

Symptomatic

≤

5 h 3 53 0.2> 5 h 8 50 –

Negative scan

≤

5 h 10 12 0.28> 5 h 21 13 –

Positive scan

≤

5 h 3 78 1.0> 5 h 2 77 –

Previous core biopsy

≤

5 h 1 15 0.17> 5 h 5 11 –

No previous core biopsy

≤

5 h 12 75 0.38> 5 h 18 79 –

Previous open biopsy

≤

5 h 2 9 0.59> 5 h 1 11 –

No previous open biopsy

≤

5 h 11 81 0.09> 5 h 22 79 –

Scan time

≤

60 min

≤

5 h 6 61 0.51> 5 h 3 52 –

Scan time 61–120 min

≤

5 h 5 23 0.75> 5 h 7 21 –

Scan time > 120 min

≤

5 h 2 6 0.44> 5 h 13 17 –

SN, sentinel node.

Table 1.

Association between successful lymphoscintigraphiclocalization of the sentinel node and intraoperative sentinel nodeidentification

Localization of SN on lymphoscintigraphy

Intraoperative SN identification TotalYes No

Yes 155 5 160No 25 31 56Total 180 36 216

SN, sentinel node.

SAME-DAY LYMPHOSCINTIGRAPHY AND SENTINEL NODE BIOPSY FOR EARLY BREAST CANCER 545

DISCUSSION

The rate of migration of a radioisotope from injection site to SNis directly related to particle size,

9

the volume injected

10

andlymphatic flow. Within the lymphatic channels the average rateof flow of

99

Tc-antimony trisulphide is 4.4 cm/min, although thisis highly dependent on the anatomical location. The fastest lym-phatic flow area is the lower limb at 10.2 cm/min.

11

Movement ofthe limb or massage of the breast after injection will also greatlyincrease the rate of lymph flow and radioisotope. The subdermallymphatic plexus is more developed than that in the parenchymaof the breast such that the migration rate of a radioisotopeinjected in the subdermal plexus is likely to be faster than inbreast parenchyma. In this study the radioisotope was injectedinto the parenchyma of the breast in a peritumoural location. Thevolume injected will affect uptake into lymphatic capillaries withlarger volumes likely to increase the interstitial pressure, thusincreasing tracer movement into the lymph vessels. The initialsuccess of preoperative identification of the SN by lympho-scintigraphy, and of subsequent intraoperative SNB, was lower inour series than that in published reports. This was overcome byincreasing the volume of the isotope injection.

2

The importanceof isotope volume in achieving successful identification of theSN at lymphoscintigraphy has also been suggested by others

10

although Uren

et al.

have argued that injected volumes in excessof 0.2 mL may place pressures that are not physiological on thelymphatic pathway, leading to the identification of ‘false’ sen-tinel nodes.

12

This has not been our experience, having demon-strated a high degree of histological accuracy with the technique.

Particle size of the radioactive colloid suspension is likely toaffect the lymphatic migration. The particle size of a radioisotopeshould be as small as possible to allow rapid migration into thelymphatic channels to reach the SN, though particles less than5 nm in size tend to enter the venous blood system directly.

12

Par-ticles between 5 and 25 nm enter the lymphatic channels directlyvia the gaps between cell junctions and the intercellular clefts,which even when closed measure 10–25 nm across.

12

Above thissize direct movement into the lymphatic capillary lumen is moredifficult. Particles up to 75 nm may gain entry into the lymphaticlumen by pinocytosis.

13

The matrix of connective tissue sur-rounding the lymphatic capillaries begins to pose a physicalbarrier to particles in the 70–100 nm range. Above this diameterparticles will find this connective tissue lattice increasingly dif-ficult to penetrate. Larger particles (100–1000 nm) will remaintrapped in the interstitial space for a period of time and rely onmechanical factors to open up gaps in the intercellular junc-tions.

12

99

Technetium antimony trisulphide has a particulate sizeof 9.3

±

3.6 nm14 Other agents commonly used elsewhere include99Tc colloidal albumin (Nanocoll, Sorin Biomedica Diagnosics,Vericelli, Italy), 99Tc rhenium colloid (CIS Biointernational, GifSur Yvette Cedex, France) and either filtered or unfiltered 99Tcsulphur colloid. Their respective sizes are < 80 nm, 4–12 nm,< 50 nm and 100–200 nm. Theoretically, 99Tc-AC has an idealmolecular size for lymphoscintigraphy. It is of interest to notethat many other studies have suggested injection of the radioiso-tope many hours before surgery7,8 or even the day before.6 Thesedifferences can be explained, at least in part, by the use a radio-isotope with a larger particulate size.

We were able to locate the SN at surgery in 180 of the 216 cases(83.3%) which compares favourably with other studies.1,4 Theseresults include the early cases studied, incorporating the ‘learningphase’. We have previously demonstrated that the strongest associa-

tion with successful identification of a SN at operation is pre-operative localization of the SN on lymphoscintigraphy.3 Of the160 cases where the SN was identified at lymphoscintigraphy,the median time taken to visualize the SN was 40 min (range:5–210 min). Of these, a SN was successfully identified intraopera-tively in 155 cases (97%), after a median time from isotope injectionto surgery of 5 h. There was no association between longer orshorter time intervals from lymphoscintigraphy to surgery with thechance of locating the SN at operation. The need to scan beyond 3 hafter isotope injection was associated with low success in preopera-tive localization of the SN and a similar low success at intraopera-tive SN identification when isotope injection was performed on thesame day of surgery. Because of the prospective nature of thisstudy, cases where the SN was not identified after 3 h of scanningwere not scanned again at a later time or the following day. It is notclear whether the 49 cases scanned for ≤ 3 h without localizationof the SN would have benefited from a longer scanning duration.The results of a recent study suggest very little differencebetween a one-day and two-day isotope injection protocol, suchthat an improvement in lymphoscintigraphic and intraoperative SNidentification would not be expected following prolonged scanningin the current study.15 Nevertheless, 25 of 56 cases without preoper-ative SN localization successfully underwent SNB; one case of SNidentification with blue dye; 14 cases with hot SN using the intraop-erative gamma probe; and 10 cases where the SN was hot and blue.

Despite the supposition that some clinical variables might beassociated with longer isotope migration times (i.e. previous openbiopsy, medial tumours, older age group), there were no clinicalor histological variables that were associated with successfulSNB and the interval from lymphoscintigraphy to surgery. Highbody mass index and large breast size may affect lymphaticmigration and have been associated with failure to identify thesentinel node.16 Unfortunately, these variables were not prospec-tively evaluated in this study.

This study demonstrates that when using 99Tc antimony trisul-phide as a radioisotope in early breast cancer, the chance of iden-tifying the SN intraoperatively did not increase with a longerisotope injection duration. Surgery can proceed as soon as a senti-nel node is identified at lymphoscintigraphy. The chance of suc-cessful SNB was highest in cases where early lymphatic flow wasdemonstrated to visualize a SN at lymphoscintigraphy. Scanningbeyond 3 h with failure to identify a SN at lymphoscintigraphywas associated with low success at SNB. It is unlikely that longerscanning times are likely to offer improvements in SN identifica-tion. Given that the median time for successful lymphoscinti-graphic mapping was only 40 min, lymphoscintigraphy can beeasily completed in the morning to allow for SNB to be under-taken the same day with a high degree of efficacy and accuracy.

REFERENCES

1. Veronesi U, Paganelli G, Viale G et al. Sentinel lymph nodebiopsy and axillary dissection in breast cancer: Results in a largeseries. J. Natl Cancer Inst. 1999; 91: 368–73.

2. Kollias J, Gill PG, Chatterton BA et al. The reliability of sentinelnode status in predicting axillary lymph node involvement inbreast cancer. Med. J. Aust. 1999; 171: 461–5.

3. Kollias J, Gill PG, Coventry BJ et al. Clinical and histologicalfactors associated with sentinel node identification in breastcancer. ANZ J. Surg. 2000; 70: 132–6.

4. Guilliano AE. Lymphatic mapping and sentinel node biopsy inbreast cancer [letter]. JAMA 1997; 277: 791.

546 SUTTON ET AL.

5. Veronesi U, Paganelli G, Galimberti V et al. Sentinel nodebiopsy to avoid axillary dissection in breast cancer with clini-cally negative nodes. Lancet 1997; 348: 1864–7.

6. Winchester DJ, Sener S, Winchester DP et al. Sentinel lymph-adenectomy for breast cancer: Experience with 180 consecutivepatients: Efficacy of filtered technetium 99m sulphur colloid withovernight migration time. J. Am. Coll. Surg. 1999; 188: 597–603.

7. Schneebaum S, Stadler J, Cohen M et al. Gamma probe-guidedsentinel node biopsy – optimal timing for injection. Eur. J. Surg.Oncol. 1999; 24: 515–19.

8. Roumen R, Geuskens L, Valkenberg J. In search of the true sen-tinel node by different injection techniques in breast cancerpatients. Eur. J. Surg. Oncol. 1999; 25: 347–51.

9. Henze E, Schelbert H, Collins J et al. Lymphoscintigraphy with99mTC-labeled Dextran. J. Nucl. Med. 1982; 23: 923–9.

10. Krag D, Ashikaga T, Harlow S, Weaver DL. Development ofsentinel node targeting technique in breast cancer patients.Breast J. 1998; 4: 67–74.

11. Uren R, Howman-Giles R, Thompson J et al. Variability of cuta-neous lymphatic flow rates. Melanoma Res. 1998; 8: 279.

12. Uren R, Thompson J, Howman-Giles R. Lymphatic Drainage ofthe Skin and Breast – Lymphatic Mapping Using Lymphoscintig-raphy. Singapore: Harwood Academic Publishers, 1999.

13. Yoffrey J, Coutice F. Lymphatics, Lymph and the Lympho-myeloid Complex. London: Academic Press, 1970.

14. Tsopelas C. Particle size analysis of (99m) Tc-labeled and unla-beled antimony trisulfide and rhenium sulfide colloids intendedfor lymphoscintigraphic application. J. Nucl. Med. 2001; 42:460–6.

15. Yueng HWD, Cody HS, Turlakow A et al. Lymphoscintigraphyand sentinel node localization in breast cancer patients: A com-parison between 1-day and 2-day protocols. J. Nucl. Med. 2001;42: 420–3.

16. Morrow M, Rademaker AW, Bethke KP et al. Learning sentinelnode biopsy: Results of a prospective randomized trial of twotechniques. Surgery 1999; 126: 714–20.

ANZ J. Surg. 2002; 72: 546

BOOK REVIEW

Surgery, Ethics and the Law. Edited by B. DOOLEY, M. FEARN-

SIDE and M. GORTON. Melbourne: Blackwell Science Asia,2000. 23 chapters + 235 pages. No illustrations, no index. ISBN0-8679-3021-7. Price: A$43.95.

This book is a timely and appropriate contribution to the rapidlyexpanding field of medical ethics and the law. It is essentialreading (and a prescribed text) for surgical trainees. I think that itis necessary reading and a necessary reference book for all prac-tising surgeons. Each chapter is written by an acknowledgedauthority in that field. The chapters cover a broad spectrum ofproblem areas in ethics and the law. The chapters contain usefulreferences for further study. State and territory legislative differ-ences are appropriately acknowledged.

The difficulties associated with this book, and indeed by anybook written about these areas, is that the rate of change of legis-lation covering these areas is rapid and it is therefore not possiblefor a book such as this to cover all areas in an up to date manner.

For instance, recent privacy legislation is likely to have a dra-matic effect on surgical practice and surgical record-keeping.

However, this book provides an excellent starting point for thenecessary study of ethics and the law.

The book contains glowing forewords by Sir Gustav Nossal,Professor Louis Waller and Dr Michael Wooldridge.

Surgery, Ethics and the Law is relatively inexpensive. It isacknowledged that part of the proceeds from the sale of the bookwill benefit the Royal Australasian College of Surgeons Founda-tion. I think that the College should encourage all surgeons –trainee and otherwise – to purchase the book. I have enjoyedreading it and learned much by doing so. I am grateful to havebeen privileged to review it.

TONY BUZZARD, FRACSMonash University Department of Surgery

Alfred HospitalMelbourne, Victoria, Australia