Techniques of Sentinel Node Biopsy

1. 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.

2. 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.

3. SN Concept

4. Techniques Dye directed ( Blue dye) Radiotracer directed (Hot node) Combination

5. 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

12. Blue dye technique Advantages Simple, inexpensive, easy to identify a blue stained tract against yellow fatty background Disadvantages Strong learning curve (Giuliano)

13. BLUE DYE

14. Radiopharmaceutical • 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

15. Site of Injection • Subdermal/Intradermal • Peritumoral in deep seated lesions specially in medial quadrant • Peri areolar • Sub areolar

16. Dose and Volume • 0.1-0.4 ml to 4-8 ml • 300 - 400 Ci • 500 uCi-1mCi • Filtered or unfiltered

17. Imaging Technique • Dynamic images • Static images • Anterior • Lateral

18. Static images Dynamic images Case (3): 2 positive axillary LNs in both early and delayed images.

19. Static images Dynamic images Case (5): 1 positive axillary LNs in early images and 2 positive axillary LNs in delayed images

22. Advantages of Radiotracer guided technique ‘Road map’ to the SN Detects SNs at unusual sites - Level III, sub pectoral, int. mammary

23. Disadvantages of radiotracer guided technique Radioactive shine through Non-sentinel nodes Equipment expensive

25. γ Probe

26. 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

27. BLUE DYE + γ Probe

28. Injection techniques for SLN biopsy in breast cancer

29. 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 Steps of Procedure

30. 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

31. Identification Rate: 92% (287/312) Concordance Rate: 98% (283/287) False –ve Rate: 5% (4/84) SN not identified: 8% (n=25) Results (n=312)

32. 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

33. Tumor Location V/S failure to identify SN 7/38 3/171 4/42 10/26 1/35

34. 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:??

35. Location of SN (n=287) Level I: 265 Level II: 22

36. 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)

37. Lymphazurin V/S Custom made blue dye (Lymphophil) Lymphazurin Custom made dye IR 90% (53/58) 87% (80/91)

38. Frozen Section of SN (n=232) PS + - + FS - False -ve:11%; False +ve: 5%

39. Immunohistochemistry (IHC; n= 209)

40. SURGEON Establishing SN Program NUCLEAR MED PATHOLOGIST Feasibility; Validation; On going SN program

41. 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

42. 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

44. 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

45. SN Biopsy As Surgical Rx of Axilla