Transcript Document

Sentinel Node Biopsy : the
way forward
Hemant Singhal
MS FRCSEd FRCS(Gen) FRCSC
Consultant Surgeon
Northwick Park & St Marks Hospital
Senior Lecturer, Imperial College School Of Medicine
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Introduction
Who should have it
When
How
Who will do it
What can we hope to achieve
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Background
 95% of patients who present with breast
cancer have apparently local disease.
 Indirect features to suggest systemic
involvement
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axillary lymph node metastasis
tumour size, grade
vascular or lymphatic invasion
Her2neu status or p53 etc
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Preoperative evaluation of axilla
 Clinical examination inaccurate, false negative rate of
39-45%
 Mammography/ultrasound
 sensitivity of 70%
 CT
 MRI
 PET
 Ultrasound guided FNAC
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Rationale for axillary surgery
 Status
 Local control
 Survival impact (B04) study
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10 years 5-6% worse
 There is no tumour size so small that one can
ignore the axilla
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upto 20% for T1a
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Issues with axillary clearance
Maybe of limited therapeutic value
80% of patients maybe LN negative
Short term drains, seroma
Lymphoedema
Sensory loss in area of ICB
affects the lifestyle of a third
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Sentinel node concept
Ramon Cabanas
coined the term
lymphatic drainage in ca penis
Donald Morton: malignant melanoma
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Sentinel node concept
First draining lymph node
reflects the status of the axilla
can be identified and sampled
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SENTINEL NODE CONCEPT
 sentinel node refers to the "node on watch.”
 this node is the first node to receive cancer cells and
that if this node is positive, there may be other
positive nodes upstream.
 The cancer cells don't "skip" and go to higher nodes.
 If this node is negative, all the upstream nodes are
negative 99 out of 100 times
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After a crime, you don't interrogate a
bunch of people who were two blocks
away; you focus on eye witnesses at
the scene of the crime."
—Marisa Weiss, M.D.
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Collective experience
ACS study ~ 5000 patients
ALMANAC ~UK study
18 other sizeable studies
88% LN detection
98% accuracy
7 series with 100% results
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Nuclear medicine aspects
 Amount of radioactivity
 dose of 0.1 mCi for same-day and 0.4
mCi for day-before injection
 Preop scintigram
 useful initially
 know that there is a localised SNB
 abnormal pattern - Rotters, IM,
breast
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Site of injection
SLN identified by
 intraparenchymal
 subdermal
 intradermal
 subareolar
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injections
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Surgical aspects
Identify blue lymphatics
track hot node
intraop palpation for involved node
gross disease can block localisation
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Inaccurate results
 The scenario of a negative (non-cancerous) sentinel
node and positive (cancerous) additional nodes in a
patient can occur for several reasons, including:
 The timing of the dye injections
 The type of dye/tracers used
 The presence of more than one sentinel node
 The way in which the initial node was sectioned or
stained in the pathology lab
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Poor candidates
palpable lymph nodes
Locally advanced breast cancer
multi-focal breast cancer
previous breast surgery (including
breast reduction)
previous radiation therapy to the breast
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American College of Surgeons
recommends
at least 30 snb followed by complete
axillary node dissection,
with an 85% success rate in identifying
the sentinel lymph node(s)
and a 5% or lower false positive rate.
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Tips & Tricks
Map with probe
3D mental map
Allow adequate time after blue dye inj
LN is invariably lower than you think
Persevere
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Can we stop after negative SNB
Axillary relapse, most studies have
median FU that is too short
melanoma about 3-4%
expect 1% for breast
0.4% at median fu of 84 months
Singhal 1996, MSKCC
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Should you go back after SNB+
39% have further involved nodes
this may be obvious at first op
intraoperative analysis
 cytology
10% false negative
 frozen section
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Axillary evaluation
Breast lump considered malignant
Ultrasound of axilla
Normal lymph nodes
Abnormal lym nodes
Fine needle aspirate
Benign cells
Malignant cells
Axillary clearance
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SENTINEL NODE BIOPSY
Benign cells
Normal scan
SENTINEL NODE BIOPSY
Intraoperative cytology
Benign
Malignant
No further intervention
Axillary clearance
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The important question
"HOW MANY lymph nodes are
positive?"
not just "ARE lymph nodes positive?"
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