Dr Miranda Chan Consultant Surgeon

Breast Centre, Kwong Wah Hospital

Radioguided surgery � Use of radioactive isotope �  Localisation of clinically occult lesion �  Localisation of sentinel lymph node � Close collaboration between radiologist,

NM physician and surgeons �  Facility of scintigraphy within hospital � Handheld gamma camera in operation

room

•  Run by Tung Wah Group of Hospitals •  Oldest charity organisation in Hong Kong •  2 clinics ( at Mongkok and Causeway Bay) •  located within HA hospital •  General health check •  Pap smear •  Screening Mammogram •  Osteoporosis Service •  Menopause Service

Screening mammogram in Hong Kong � Not advocated by Department of Health � No public funding � No public health insurance �  Individual NGO advocate and provide

service as a non profit making item (e.g. Hong Kong Breast Cancer Foundation, Well Women Clinic)

� Private sector � Variable insurance plans coverage

Screening Mammogram � Women >40yrs � Women >35yrs if family history positive �  2 standard view: MLO &CC �  Tomosynthesis if indicated � Additional view if indicated � Ultrasound if indicated

Stereotactic biopsy n  Atypical hyperplasia n  Radial scar n  DCIS n  Invasive cancer n  Intraduct papilloma n  Lobular neoplasm (especially

pleomorphic LCIS)

Radioguided occult lesion localization (ROLL) �  Clinically occult breast lesion �  Localised by imaging (mammogram,

ultrasound, MRI) �  Injection of liquid radioactive tracer (Tc99) �  Insertion of radio opapue titanium seed

containing I125

�  Scintigraphy after localization �  Use of hand held gamma camera in

Operating room

Radioguided occult lesion localization � Hottest spot identified �  10 sec count measured � Skin incision: over the hottest spot vs

circumareolar � Specimen mammogram/ ultrasound to

confirm complete removal of index lesion

ROLL � Removal of the index lesion � Clear margin in cases of malignancy � Re-operation rate � Radiation protection

Trouble shooting �  Activity not identified

�  Leakage from puncture site �  Delay of operation for too long

�  Activity at the unexpected site �  Isotope travels to nipple along lactiferous duct

�  Index lesion not identified in the specimen mammogram �  Previous bx has removed all microcal

�  Inadequate margins �  Further excision for margin

Trouble shooting

l  No residual microcal left for localization � Routinely put in gelmark after sBx � Use hematoma , if present, for target � Abandon procedure �  Localise using previous measurement

(according to previous biopsy)

Trouble shooting

l No activity detected after injection of isotope

� Associated with usg guided injection � Short tract �  Leakage through the track on the skin/

dressing �  Intraoperative USG by surgeon or

radiologist

Practical Tips �  Joint decision making with radiologist �  Interpretation of breast pathology in the

clinical context �  Use of scintigraphy �  Use of gamma probe by radiologist �  Intraoperative breast ultrasound �  Minor adjustment of surgical techniques �  Rapid access of image in OT �  Real time reporting by radiologist

Radioguided Occult Lesion Localization

Intraop ultrasound for mass localization Specimen mammogram for microcalcification

Intraop ultrasound for localization

Skin mark Primary tumour Isotope for sln

Radioguided Intraoperative Margin Evaluation (RIME) � Preoperative MRI with injection of

gadonilium �  99Tc-Sestamibi scintimammography � Calibrate the optimal time for incision �  Intraoperative use of gamma probe to

remove the tumour

RIME � Not used in clinical practice � No good evidence in clear margins and

lower re-operation rate � High cost � Additional imaging procedure needed

Sentinel lymph node biopsy �  Standard practice in early invasive breast

cancer �  Cancer staging has been modified with the

widespread practice of sln bx �  Pathology result affect the subsequent

management �  Axillary dissection will be done in positive

sln with macrometastasis �  Chemotherapy will be administered in

positive sln (macrometasis and micrometastasis)

Scintigraphy for SLN localization

*.

pNX Regional lymph nodes cannot be assessed (e.g., previously removed, or not removed for pathologic study)

pN0 No regional lymph node metastasis identified histologically

Note: Isolated tumor cell clusters (ITC) are defined as small clusters of cells not greater than 0.2 mm, or single tumor cells, or a cluster of fewer than 200 cells in a single histologic cross-section. ITCs may be detected by routine histology or by immunohistochemical (IHC) methods. Nodes containing only ITCs are excluded from the total positive node count for purposes of N classification but should be included in the total number of nodes evaluated.

pN0(i-) No regional lymph node metastases histologically, negative IHC

pN0(i+) Malignant cells in regional lymph node(s) no greater than 0.2 mm (detected by H&E or IHC including ITC)

pN0(mol-) No regional lymph node metastases histologically, negative molecular findings (RT-PCR)

pN0(mol+) Positive molecular findings (RT-PCR),** but no regional lymph node metastases detected by histology or IHC

pN1 Micrometastases; or metastases in 1-3 axillary lymph nodes; and/or in internal mammary nodes with metastases detected by sentinel lymph node biopsy but not clinically detected***

pN1mi Micrometastases (greater than 0.2 mm and/or more than 200 cells, but none greater than 2.0 mm)

pN1a Metastases in 1-3 axillary lymph nodes, at least one metastasis greater than 2.0 mm

pN1b Metastases in internal mammary nodes with micrometastases or macrometastases detected by sentinel lymph node biopsy but not clinically detected***

pN1c Metastases in 1-3 axillary lymph nodes and in internal mammary lymph nodes with micrometastases or macrometastases detected by sentinel lymph node biopsy but not clinically detected

AJCC Cancer Staging Handbook 7th Edition (2010)

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Isotope vs dye n Technique Identification FN

Krag 443 Tc 91 11 Borgstein 130 Tc 94 1.7 Giuliano 107 Dye 93 0 Giuliano 174 Dye 65.5 11.9 McMasters 1074 Tc+ Dye 90 8.3 Guenther 145 Dye 71 9.7 Krag 157 Tc 75.8 4.9 Tafra 535 Tc+ Dye 87 13 Fraile 132 Tc 96 4 Noguchi 674 Tc + Dye 94 10.2 Bass 186 Tc + Dye 93 1.9 Kollias 117 Tc + Dye 81 6.5

Technique of SLN bx �  Injection before OT or evening prior to

operation � Peritumoral injection, intratumoral,

intradermal, subareolar injection � Combined with ROLL (SNOLL) � Scintigraphy � Combined with blue dye

Technique of SLN �  Use of handheld gamma probe �  Separate incision at axilla �  Hot lymph node identified �  10 sec count of the hottest LN registered �  10% of the hottest LN or >100 count �  Check the residual activity

Technique of SLN biopsy �  Use of handheld gamma

probe �  Separate incision at axilla �  Hot lymph node identified �  10 sec count of the hottest

LN registered �  10% of the hottest LN or

>100 �  Check the residual activity

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Intraoperative processing �  Touch cytology �  Frozen section

� H&E staining �  IHC staining

� One step nucleic acid amplification(OSNA) � Molecular assay � Quantitative analysis � No tissue left for histology

Management of SLN positive patients �  Full axillary dissection

� On table decision vs 2nd operation � No further axillary surgery

� Micrometasis �  Isolated tumour cells � Macrometastasis (ASCOG Z0011)

� Adjuvant therapy including chemotherapy and herceptin in HER overexpressed tumour

Radiation protection � Maximal dose at injection site � Maximal exposure: surgeons hand � No specific protective gear � Avoid manipulation of specimen with

hands � Specimen labelled to avoid inadverdent

exposure