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Techniques of Sentinel Node Biopsy V. Seenu Associate Professor Department of Surgical Disciplines, All India Institute of Medical Sciences These PowerPoint.

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Presentation on theme: "Techniques of Sentinel Node Biopsy V. Seenu Associate Professor Department of Surgical Disciplines, All India Institute of Medical Sciences These PowerPoint."— Presentation transcript:

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

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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 ReferenceyearNo of pts ID %False -ve rate CRNode + Pts % Guiliano et al Nieweg et al Folscher et al Flett et al Horgan et al

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 ml to 4-8 ml Ci 500 uCi-1mCi Filtered or unfiltered

17 Imaging Technique Dynamic images Static images Anterior Lateral

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

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

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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

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25 γ Probe Ref Krag et al Year 1993 No of Pts 22 ID (%) 82 False – ve (%) 0 CR 100 Node +ve 39 Offodile et al Veronesi et al Pijpers et al Borgstein et al Roumen et al

26 Combination Technique Blue dye can help to differentiate between SN and 2 nd 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 RefYrPtsID (%) False –ve rate CRNode +ve Albertini Cox etal O Hea Gil et al Devries et al Borgstein et al

28 Injection techniques for SLN biopsy in breast cancer SourcePatient no Blue DyeRadioac tive colloid Concordance rate % SLN ID % False – ve Rate % Klimberg et al PTSA NA Bauler et al SAPT NA Beitsch et al PTSA NA Donahue42SAPT Tuttle et al159PT NA Smith et al PTSA NA D Eredita et al SAPTNA Kern SANA Zavagno et al SAPT9394NA Pelosi et al 20050PAPT NA Chagpar et al1431VariedPTNA VariedSA VariedPA

29 Steps of Procedure Ml of Blue Dye Injected Into peritumoral Breast Parenchyma 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: 5% (4/84) SN not identified: 8% (n=25)

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 10/26 3/171 1/35 4/42

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) LymphazurinCustom made dye IR90% (53/58) 87% (80/91)

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

39 Immunohistochemistry (IHC; n= 209)

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

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

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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


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