Sentinel Node Biopsy : the way forward Hemant Singhal MS FRCSEd FRCS(Gen) FRCSC Consultant Surgeon Northwick Park & St Marks Hospital Senior Lecturer,

Sentinel Node Biopsy : the way forward

Hemant SinghalMS FRCSEd FRCS(Gen) FRCSC

Consultant SurgeonNorthwick Park & St Marks Hospital

Senior Lecturer, Imperial College School Of Medicine

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MARCH 2005HEMANT SINGHAL

Introduction

Who should have it WhenHowWho will do itWhat can we hope to achieve


Background

95% of patients who present with breast cancer have apparently local disease.

Indirect features to suggest systemic involvement axillary lymph node metastasis tumour size, grade vascular or lymphatic invasion Her2neu status or p53 etc


Preoperative evaluation of axilla

Clinical examination inaccurate, false negative rate of 39-45%

Mammography/ultrasound sensitivity of 70%

CT MRI PET Ultrasound guided FNAC


Rationale for axillary surgery

Status Local controlSurvival impact (B04) study

10 years 5-6% worse

There is no tumour size so small that one can ignore the axilla upto 20% for T1a


Issues with axillary clearance

Maybe of limited therapeutic value80% of patients maybe LN

negativeShort term drains, seromaLymphoedemaSensory loss in area of ICBaffects the lifestyle of a third


Sentinel node concept

Ramon Cabanascoined the termlymphatic drainage in ca penisDonald Morton: malignant

melanoma


Sentinel node concept

First draining lymph nodereflects the status of the axillacan be identified and sampled


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


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.


Collective experience

ACS study ~ 5000 patientsALMANAC ~UK study18 other sizeable studies88% LN detection98% accuracy7 series with 100% results


Nuclear medicine aspects

Amount of radioactivitydose of 0.1 mCi for same-day and 0.4

mCi for day-before injectionPreop scintigram

useful initially know that there is a localised SNB abnormal pattern - Rotters, IM, breast


Site of injection

SLN identified by intraparenchymal subdermal intradermal subareolar injections



Surgical aspects

Identify blue lymphaticstrack hot nodeintraop palpation for involved nodegross disease can block

localisation






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


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


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.


Tips & Tricks

Map with probe3D mental mapAllow adequate time after blue dye

injLN is invariably lower than you

thinkPersevere


Can we stop after negative SNB

Axillary relapse, most studies have median FU that is too short

melanoma about 3-4%expect 1% for breast0.4% at median fu of 84 months

Singhal 1996, MSKCC


Should you go back after SNB+

39% have further involved nodesthis may be obvious at first opintraoperative analysis

cytology 10% false negative frozen section


A xi lla ry ev a lua tion

N orm a l lym p h n od es

B en ign ce lls

A xi lla ry c le ara nce

M alig na n t ce lls

F ine ne ed le a sp ira te

A b no rm a l lym n od es

U ltra sou nd o f ax i lla

B rea st lum p con sid ered m a lig na n t


S E N T IN E L N O D E B IO P S Y

Norm al scan

No further intervention

Benign

Axillary clearance

M alignant

Intraoperative cytology

SENT INEL NO DE BIO PSY

Benign cells


The important question

"HOW MANY lymph nodes are positive?"

not just "ARE lymph nodes positive?"

Documents

Sentinel Node Biopsy : the way forward Hemant Singhal MS FRCSEd FRCS(Gen) FRCSC Consultant Surgeon Northwick Park & St Marks Hospital Senior Lecturer,