ISOTOPE GUIDED SURGERY FOR ISOTOPE GUIDED SURGERY FOR NON PALPABLE BREAST CANCERNON PALPABLE BREAST CANCER

25-7-2009Dr. MP ChowDepartment of SurgeryKwong Wah Hospital

Breast cancer

Commonest cancer for female in Hong Kong (2004) >2000 new cases /

year Commonest

malignancy in women worldwide > 1 million new

cases diagnosed in 2000

Opportunistic Screening

Breast screening program No population screening Target group:

All woman > 40 years old (<70 years old) 35-40 if +ve family history of a first degree relative at

premenopausal age

Detect early stage breast cancer Reported to reduce mortality in up to 30% in

western country Lui et al Hong Kong Med J 2007

Management of non-Management of non-palpable breast cancerpalpable breast cancer

Management

Triple assessment History/Physical examination

Breast complaints Risk factors e.g. Family history, OC pills,

Previous breast disease, Date of menarche, Imaging

Ultrasound Mammogram

Cytology / Histology Fine Needle Aspiration Core Biopsy

Treatment options for occult breast cancer Surgery

Mastectomy + Sentinel lymph node biopsy +/- Axillary dissection

Breast conservative therapy + Sentinel lymph node biopsy + Post-operative radiotherapy +/- Axillary dissection Extent of disease Multifocality Previous radiation Patient’s wish

How to localize the lesion? Hookwire localization

Wire is deployed under stereotactic / ultrasound guidance within rigid over-shealth cannula preoperatively

Potential disadvantages Uncomfortable for patient Displacement in fatty breast Wire transection Technical difficulty in dense

breast Interference with surgical

approach Required post-procedure

mammogram to confirm position

And sometimes…

Problems with HWL

Hookwire tipretained after

surgery

New advances

Radio-guided surgery Introduced by European Institute of Oncology in Milan

Luini et el, European Journal of Cancer 1998 Vol 34 No. 1 ROLL/SNOLL Radiologically Occult Lesion Localization Sentinel Lymph Node Occult Lesion Localization Method

Intratumoural injection of radioactive isotope (e.g. Technetium labelled colloid) under radiological guidance

Pre-operative lymphoscintigraphy (Lymph node mapping) Lesion excision and lymph node localization guided by

radioactivity Potential advantages

Simple and less invasive procedure “Killing Two Birds with One Stone”. Shorter localization time

Potential disadvantage Radiation exposure

SNOLL The technique of injecting the isotope is identical to ROLL Use correct particle size

<100 µmFiltered Sulphur Colloid

100-200 µmSulphur Colloid

ROLLThe radiotracer used is immobile and remains at the site of injection

SNOLLThe radiotracer used can remain at injection site and move within the lymph ducts to accumulate in SN

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SNOLL

SNOLL

SNOLL Video

Radiation Issue

Is it a problem?

SNOLL is safe to patients and medical staff Short half life of Tc99m of only 6 hours Low dose gamma radiation used

Radiation Issue

Nucl Med Commun 1999; 20: 919–924

Clinical Radiology (2005) 60, 681–686

SNOLL <<< MMG or CXR

SNOLL MMG CXR

Effective Dose

9.25 µSv or 0.009

mSv1-2 mSv

0.02 mSv

Radiation Issue

Finger Dose

Surgeon 9.3+/-3.3 µSv

Radiologist 0.5+/-0.13 µSv

If a surgeon performs 100 procedures per annum, a Finger Dose of approximately 1 mSv is received, well within the annual dose limit of 150 mSv.

Breast. 2003 Apr;12(2):150-2

Monti et al

Italy March 1997 to April 2004 N = 959 Methodology

Injection and scintigraphic procedures for ROLL and SNB were performed separately on the day of surgery

For ROLL Human serum albumin macroaggregate, particle size 100-

150µm and labeled with Technetium was injected into the lesion. Scintigraphy was performed after injection of isotope. Procedure was repeated in cases of failure

For SNB Human serum albumin macroaggregate, particle size 0.1-

0.8µm and labeled with Technetium was injected peritumorally or subdermally. Lymphoscintigraphy was performed 15-30 mins and 3 hours. Procedure was repeated in cases of failure

Monti et al Ann. Surg. Oncol Vol 14 No. 10. 2007

Result

Margins status Number Percentage

Positive 11 1.3%

Close margins < 1cm

65 6.7%

Negative margins >= 1cm

883 92%

Total 959 100%

Monti et al Ann. Surg. Oncol Vol 14 No. 10. 2007

Result

Axillary SNs were identified in 958 of 959 (99.6%)

Axillary dissection was performed for the case which the sentinel LN is not visualized in lymphscintigraphySN Location Number Percentage

Axilla 926 96.6%

Axilla plus internal mammary chain

32 3.3%

SN not visualized

1 0.1%

Total 959 100%

Monti et al Ann. Surg. Oncol Vol 14 No. 10. 2007

Other literatures

Authors No. of patient Complete excision (%)

Identification sentinel node (%)

Supplementary Blue dye

Confirmation specimen

Patel et al 20 90% 100% Yes Radiography

Feggi et al 73 95% 97% Yes Scintigraphy + Mammography

De Cicco et al

227 95% 90% No Radiography

Barros et al 112 90% 98% No Radiography

I.M.C. van der Ploeg et al, EJSO 34 (2008)

EXPERIENCE EXPERIENCE IN IN

KWONG WAH KWONG WAH SURGERYSURGERY

Kwong Wah Hospital

SNOLL has been introduced since 2004 as operative technique for BCT of non-palpable breast cancer

Interval 2004 – 2008 Total number of patient: 57 Inclusion criteria

Clinically occult lesion Suitable for BCT Biopsy proven breast cancer

Methodology

Stereotactic or ultrasonic guided intratumoral injection of 99mTc-labeled (<100 µm) filtered Sulphur Colloid will be performed by radiologist on the same day of surgery

Lymphscintigraphy was performed after radioisotope injection

(Navigator GPS) Gamma probe was used for localization of index lesion and sentinel lymph node

Supplementary blue dye injection if failed localization of sentinel lymph node by gamma probe

End points1. Complete excision was defined as tumour free

margins >=1mm2. Successful breast lesion localization and sentinel

lymph node localization

Result

21 (37%) patients had DCIS 36 (63%) patient had invasive carcinoma

Index lesion localization rate = 100% Complete excision rate = 84% (48/57) 7 (12%) patient required 2nd operation

Sentinel Lymph Node Localization Sentinel LN localization by

Lymphoscintigraphy 72%

Sentinel LN localization by Gamma Probe 82%

Overall sentinel LN localization (Both isotope and blue dye): 95%

Current EvidencesAuthors No. of patient Complete

excision (%)Identification sentinel node (%)

Supplementary Blue dye

Confirmation specimen

Monti et al 959 92% 99.6% No Radiography

Patel et al 20 90% 100% Yes Radiography

Feggi et al 73 95% 97% Yes Scintigraphy + Mammography

De Cicco et al

227 95% 90% No Radiography

Barros et al 112 90% 98% No Radiography

Kwong Wah Hospital

57 84% 95% Yes Radiography

Conclusion

Isotope surgery is a promising technique with good results in terms of sentinel lymph node and tumour localization.

SNOLL provides an additional benefit of sentinel lymph node identification in one procedure.

The End.The End.Thank you !Thank you !

HWL (n=76)

ROLL (n=89)

P valu

e

Age 51.2 52.0 0.508

Success 75/76 (98.7%) 86/89 (96.6%) 0.6251

Mean localisation time 31 18 0.0000

Mean OT time 52 48 0.188

Need for further excision intraop. 22/75 (29.3%) 25/86 (29.1%) 1.0000

Need for further excision intraop. (due to unsatisfactory specimen mammogram)

12/75 (16%) 11/86 (12.8%) 0.6536

Involved or close margin in first specimen for malignant lesions

12/38 (31.6%) 9/55 (16.4%)0.12900.0711

(1-tailed) Need for 2nd OT for malignant lesions 12/38 (31.6%) 9/55 (16.4%)

Either intraop re-excision or 2nd OT 29/75 (38.7%) 31/86 (36.0%) 0.7466

Size of specimen 48.2 66.0 0.005

Therapeutic intention 23/76 (30.3%) 44/89 (49.4%) 0.0169

Size of DCIS17.7mm (n=30)

8.8mm (n=25)

0.003

Size of invasive cancer13.2mm

(n=5)12.7mm (n=28)

HWL vs ROLL (KWH)

Cost Issue (in KWH, HK)

HWL: Slightly lower cost

SNOLL Hookwire

Dose of Technetium62 USD

Spinal Needle1 USD

Gamma Probe (OT)(Capital Cost)

18000-20000 USD

HookwireBLN 20G(Promex)

13 USD

Additional Mammograms

2 USD

Cost Issue (in Prescot, UK)

ROLL: Slightly lower cost

SNOLL Hookwire

Dose of Technetium£ 28

Spinal Needle£ 0.6

Gamma Probe (OT)(Capital Cost)

£10,000 to £15,000

Clinical Radiology (2005) 60, 681–686

HookwireReedy Wire(Cook)

£ 35

Additional Mammograms

£ 7