1. Techniques of Sentinel Node Biopsy
V. Seenu
Associate Professor
Department of Surgical Disciplines,
All India Institute of Medical Sciences
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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. Dye directed ( Blue dye) Radiotracer directed (Hot node) Combination
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 Reference year No of pts ID % False -ve rate CR Node + Pts %
Guiliano et al
1994
174 66 12 96 36
Nieweg et al
1996 27 89
100 42
Folscher et al
1997 79 40 85 51
Flett et al
Horgan et al
1998 68 38 92 82 17 16 95 84 31 50

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. Case (3): 2 positive axillary LNs in both early and delayed images.
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 Ref Krag et al Year 1993 No of Pts 22 ID (%) 82 False –ve (%)CR
100
Node +ve 39
Offodile et al
1998 41 98 45
Veronesi et al
1997
163 5 53
Pijpers et al 37 92 34
Borgstein et al
130 94 2 42
Roumen et al 83 69 4 96 40

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 Ref Yr Pts ID (%) False –ve rate CR Node +ve
Albertini
1996 62 92
100 32
Cox etal
1998
466 94 1 23
O Hea 59 93 15 95 36
Gil et al
1997 83 8 -
Devries et al 10 60
Borgstein et al 33 56

28. Injection techniques for SLN biopsy in breast cancer
Source
Patient no
Blue Dye
Radioactive colloid
Concordance rate %
SLN
ID %
False –ve Rate %
Klimberg et al 1999 69 PT SA
95.4
94.2 NA
Bauler et al 2002
249
90.0
96.8
Beitsch et al 2001 85
95.2
97.6
Donahue 42
100
8.3
Tuttle et al
159
95.0
Smith et al 2000 19
84.2
D Eredita et al 2003
115
94.8
9.1
Kern 1999 40
97.5
Zavagno et al 2002 50 93 94
Pelosi et al 200 PA
91.8
98.0
Chagpar et al
1431
Varied
91.1
8.6
148
99.3
183
95.6
8.9

29. Steps of Procedure
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

30. Results Study Period: May 1999-June 2004 No of Pts: 312
Age range: 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. Results (n=312) Identification Rate: 92% (287/312)
Concordance Rate: 98% (283/287)
False –ve Rate: % (4/84)
SN not identified: 8% (n=25)

32. SN V/S ALN status (n=312) Both SLND & ALND -ve : 205
Only SLND +ve :
Both SLND & ALND +ve :
SLND -ve & ALND +ve :
No sentinel node identified :

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 % (133/149) % (97/104)
CR % (130/133) % (96/97)
-ve rate 7% (3/41) % (1/28)
No. of SNs 1-4 (1.8) (2.6)

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

38. Frozen Section of SN (n=232)PS + - 70 11 8
198 + FS -
False -ve:11%; False +ve: 5%

39. Immunohistochemistry (IHC; n= 209)

40. Establishing SN Program
SURGEON
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