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Transcript of Techniques of Sentinel Node Biopsy V. Seenu Associate Professor Department of Surgical Disciplines,...
Techniques of Sentinel Node Biopsy
V. Seenu
Associate Professor
Department of Surgical Disciplines,
All India Institute of Medical Sciences
These PowerPoint presentations are free to download only for academic purposes, with due acknowledgements to authors and this website.
Sentinel Node & Breast Cancer
Sentinel node concept
• Sentinel = a guard, one who keeps watch or a sentry
• The first node in the regional lymph node basin that drains the primary tumor.
Most often, it is a cluster of LNs.
SN Concept
Techniques
• Dye directed ( Blue dye)
• Radiotracer directed (Hot node)
• Combination
Dye directed technique
• Blue Dye Used Iso sulphan blue; patent blue V• Route of administration Intra parenchymal Intra dermal Sub dermal Peri areolar Sub areolar
Blue dye technique
• Advantages Simple, inexpensive, easy to identify a blue stained tract against yellow fatty background
• Disadvantages Strong learning curve (Giuliano)
BLUE DYE
Reference year No of pts
ID % False
-ve rate
CR Node +
Pts %
Guiliano et al 1994 174 66 12 96 36
Nieweg et al 1996 27 89 0 100 42
Folscher et al 1997 79 40 12 85 51
Flett et al
Horgan et al
1998
1998
68
38
92
82
17
16
95
84
31
50
RadiopharmaceuticalRadiopharmaceutical
• Tc99m Sulfur colloid
• Filtered Tc99m labeled colloidal albumin
• Tc99m Antimony trisulphide colloid*
• Au-198 Gold Colloid*
• Tc99m Stannous phytate*
• Tc99m Dextran*
• Tc99m Human serum albumin
Site of InjectionSite of Injection
• Subdermal/Intradermal
• Peritumoral in deep seated lesions specially in medial quadrant
• Peri areolar
• Sub areolar
Dose and VolumeDose and Volume
• 0.1-0.4 ml to 4-8 ml
• 300 - 400 Ci
• 500 uCi-1mCi
• Filtered or unfiltered
Imaging TechniqueImaging Technique
• Dynamic images
• Static images
• Anterior
• Lateral
Dynamic images
Static images
Case (3): 2 positive axillary LNs in both early and delayed images.
Dynamic images
Static images
Case (5): 1 positive axillary LNs in early images and 2 positive axillary LNs in delayed images
Advantages of Radiotracer guided technique
• ‘Road map’ to the SN
• Detects SNs at unusual sites
- Level III, sub pectoral, int. mammary
Disadvantages of radiotracer guided technique
•Radioactive shine through
• Non-sentinel nodes
• Equipment expensive
γ ProbeRef
Krag et al
Year
1993
No of Pts
22
ID (%)
82
False –ve (%)
0
CR
100
Node +ve
39
Offodile et al
1998 41 98 0 100 45
Veronesi et al
1997 163 98 5 98 53
Pijpers et al 1997 37 92 0 100 34
Borgstein et al
1998 130 94 2 98 42
Roumen et al
1997 83 69 4 96 40
Combination Technique
• Blue dye can help to differentiate between SN and 2nd echelon LNs• If accidental transection of blue tract occurs gamma probe guides to the SN• All blue nodes are not hot and not all blue nodes are blue
BLUE DYE + γ ProbeRef Yr Pts ID
(%)False –ve rate
CR Node +ve
Albertini 1996 62 92 0 100 32
Cox etal 1998 466
94 1 100 23
O Hea 1998 59 93 15 95 36
Gil et al 1997 36 83 8 93 -
Devries et al
1997 10 100 0 100 60
Borgstein et al
1997 33 100 0 100 56
Injection techniques for SLN biopsy in breast cancer
Source Patient no
Blue Dye Radioactive colloid
Concordance rate %
SLN
ID %
False –ve Rate %
Klimberg et al 1999 69 PT SA 95.4 94.2 NA
Bauler et al 2002 249 SA PT 90.0 96.8 NA
Beitsch et al 2001 85 PT SA 95.2 97.6 NA
Donahue 42 SA PT 95.2 100 8.3
Tuttle et al 159 PT PT 95.0 100 NA
Smith et al 2000 19 PT SA 84.2 100 NA
D Eredita et al 2003 115 SA PT NA 94.8 9.1
Kern 1999 40 SA NA NA 97.5 0
Zavagno et al 2002 50 SA PT 93 94 NA
Pelosi et al 200 50 PA PT 91.8 98.0 NA
Chagpar et al 1431 Varied PT NA 91.1 8.6
148 Varied SA 99.3 8.3
183 Varied PA 95.6 8.9
Steps of Procedure
3 - 5 Ml of Blue Dye Injected Into peritumoral Breast Parenchyma
3 - 7 Min. Interval
Axillary Incision
20 Min. Of Dissection
SN Identified SN Not Identified
WLE / TM With Conventional ALND
SN & ALND Specimen Sent for HPE
Results• Study Period: May 1999-June 2004
• No of Pts: 312
• Age range: 31-82 yrs (mean: 41.4 yrs)
• Menopausal Status : Pre: 145 Post: 167
• Side : R:L:: 160: 152
• T status
T1: 68; T2: 212; Tx: 31
Results (n=312)
• Identification Rate: 92% (287/312)
• Concordance Rate: 98% (283/287)
• False –ve Rate: 5% (4/84)
SN not identified: 8% (n=25)
SN V/S ALN status (n=312)
Both SLND & ALND -ve : 205
Only SLND +ve : 31
Both SLND & ALND +ve : 47
SLND -ve & ALND +ve : 4
No sentinel node identified : 25
Tumor Location V/S failure to identify SN
7/38
10/26
3/171
1/35
4/42
False –ve SN (n=4)
• Tx with large excision bx cavity (n=2)
• T2 tumor in subareolar location blue dye –ve hot node +ve (? non-SN)
• T2 tumor in LOQ cause:??
Location of SN (n=287)
Level I: 265
Level II: 22
Blue dye V/S Combination
Blue Combination
IR 88% (133/149) 94% (97/104)
CR 97% (130/133) 98% (96/97)
-ve rate 7% (3/41) 4% (1/28)
No. of SNs 1-4 (1.8) 1-6 (2.6)
Lymphazurin V/S Custom made blue dye (Lymphophil)
Lymphazurin Custom made dye
IR 90% (53/58) 87% (80/91)
Frozen Section of SN (n=232)
70 11
8 198FS
-+
-
+
PS
False -ve:11%; False +ve: 5%
Immunohistochemistry (IHC; n= 209)
Establishing SN Program
Feasibility; Validation; On going SN program
NUCLEAR MED
SURGEON
PATHOLOGIST
Why should our SN program be different?
• Commercial blue dye: expensive & not marketed in India
Custom made blue dye
• Hand held gamma probe very expensive
Indigenous probe
• Large sized tumor and incidence of nodal mets
FS, Imprint Cytology may be mandatory
Conclusions
• Combination technique is superior to blue dye or probe directed technique alone.
• No one site of injection has superior SN identification rates
• Intraparenchymal peritumoral blue dye and sub areolar/ periareolar tracer injection may give the best results
SN Biopsy As Surgical Rx of Axilla
• SN identified: 33/ 37 pts
• SN – ve for mets on FS & IC: 27 pts.
SNB alone
• ALND: SN +ve: 5 pts
SN – ve : 1 pt
• Follow-up: 11 months (3-18 mths)
No recuurence
SN Biopsy As Surgical Rx of Axilla