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Sentinel Nodes J.R.BuscombeRFH. Uses the Morton principle of logical lymph drainage from a tumour Uses the Morton principle of logical lymph drainage.

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Presentation on theme: "Sentinel Nodes J.R.BuscombeRFH. Uses the Morton principle of logical lymph drainage from a tumour Uses the Morton principle of logical lymph drainage."— Presentation transcript:

1 Sentinel Nodes J.R.BuscombeRFH

2 Uses the Morton principle of logical lymph drainage from a tumour Uses the Morton principle of logical lymph drainage from a tumour Methods use include blue dye and radiotracers Methods use include blue dye and radiotracers Combination of 2 may be best Combination of 2 may be best Pioneers in breast Pioneers in breast Morton/Krag/Guilianno USA Morton/Krag/Guilianno USA (EIO, Italy and AMC, Netherlands) (EIO, Italy and AMC, Netherlands) In Melanoma-Morton/Guilianno In Melanoma-Morton/Guilianno May replace high morbidity axillary clearance May replace high morbidity axillary clearance

3 Sentinel nodes Tumour Sentinel (1 st node) 2 nd and 3 rd order nodes

4 Morbidity of Axillary Surgery Lymphoedema rates: RT alone : 10% Sampling: 10% Level III clearance30% Surgery + RT: 70% Seroma 50% Seroma 50% Lymphoedema 10-30% Lymphoedema 10-30% Severe ICBN neuralgia 5% Severe ICBN neuralgia 5% Shoulder-girdle dysfunction 20% Shoulder-girdle dysfunction 20% Numbness 80% Numbness 80%

5 Sentinel nodes

6 Methods all similar Methods all similar Depends on injecting radiotracer in or near cancer Depends on injecting radiotracer in or near cancer Using gamma camera and probing to track tracer through lymphatics Using gamma camera and probing to track tracer through lymphatics Intra-operative probe to remove the sentinel node Intra-operative probe to remove the sentinel node

7 Sentinel node Controversies Controversies Who to inject Who to inject Where to inject Where to inject How much to inject How much to inject How much activity to inject How much activity to inject What colloid to use What colloid to use When to operate When to operate Training Training

8 Injection technique is standardised: Intradermal Periareolar,tumour quadrant Different injection sites (intradermal, subareolar and peritumoural) have advantages and disadvantages depending on the desired effect on the pattern and kinetics of lymphatic drainage. NEWSTART is designed to minimise visualisation of IMN Activity injected will depend on the time from injection to surgery Activity injected will depend on the time from injection to surgery Massage post injection Massage post injection

9 Size matters The size of a colloid may have an effect on its transit The size of a colloid may have an effect on its transit However not simple as charge and flexibility of the colloid may change transit However not simple as charge and flexibility of the colloid may change transit Remember the lymph system is a complex transit system and may be affected by many factors Remember the lymph system is a complex transit system and may be affected by many factors

10 What size then? No perfect colloid for sentinel node scintigraphy No perfect colloid for sentinel node scintigraphy All colloids designed for another job All colloids designed for another job Nanocol – infection imaging Nanocol – infection imaging Albures – lymphoscintigraphy Albures – lymphoscintigraphy MAA – lung scanning MAA – lung scanning

11 How colloids made? Normally made from albumin Normally made from albumin Man Man Cow Cow Pig Pig Often heated to form clusters Often heated to form clusters May be spun May be spun Can vary in size by factor of 10 Can vary in size by factor of 10

12 Types of colloids used Tc-99m antimony colloid Tc-99m antimony colloid 3-30 nm 3-30 nm Tc-99m sulphur colloid-filtered Tc-99m sulphur colloid-filtered nm nm Tc-99m HSA-nanocoll Tc-99m HSA-nanocoll nm nm Tc-99m HAS Albures Tc-99m HAS Albures nm nm Tc-99m MAA Tc-99m MAA >5000nm >5000nm

13 Optimal colloids Will pass to sentinel node and stay there Will pass to sentinel node and stay there Smaller colloid will pass through so multiple nodes seen Smaller colloid will pass through so multiple nodes seen May clear form sentinel node totally so no counts if >4 hours post injection May clear form sentinel node totally so no counts if >4 hours post injection Frequent imaging helps Frequent imaging helps

14 What to inject?

15 Intra-operative probing If using small colloids should be done within 4 hours post injection If using small colloids should be done within 4 hours post injection Larger colloids can be done at 24 hours Larger colloids can be done at 24 hours During imaging mark site of sentinel nodes on the skin in two planes During imaging mark site of sentinel nodes on the skin in two planes External probing can help pre-op External probing can help pre-op

16 Intra-operative probing About 20 different probe types available About 20 different probe types available Different crystals have different sensitivities Different crystals have different sensitivities Most use CdTe, CsI, NaI BiGeO crystals Most use CdTe, CsI, NaI BiGeO crystals Needs good collimation to prevent activity passing through the side of the probe Needs good collimation to prevent activity passing through the side of the probe

17 Probing the node

18 Intra-operative probing Inject blue dye at site of tumour just before operation Inject blue dye at site of tumour just before operation Use blue dye to help find lymphatics Use blue dye to help find lymphatics Probe along blue dye tract until signal high Probe along blue dye tract until signal high Remove node send to histology Remove node send to histology

19 Use of blue dye and radio-tracer

20 Probe box

21 Sentinel nodes Results Results Pagenelii’s group from Milan Pagenelii’s group from Milan Over 400 patients 98% successful identification of sentinel node Over 400 patients 98% successful identification of sentinel node Caution from USA (Krag et al) High variability in results surgeon to surgeon (64-100% PPV) Caution from USA (Krag et al) High variability in results surgeon to surgeon (64-100% PPV) Issues of training/audit ALMANAC Issues of training/audit ALMANAC

22 Potential problems Injection incorrect (intradermal) Injection incorrect (intradermal) Breast not massaged Breast not massaged Colloid too small/big (manafcturer’s QC) Colloid too small/big (manafcturer’s QC) Probing performed badly so node missed Probing performed badly so node missed Poor collimation means signal swamped Poor collimation means signal swamped Problems with histology etc Problems with histology etc

23 Areas where problems seen in breast cancer Multifocal/centric tumours (maybe helped by nipple injection) Multifocal/centric tumours (maybe helped by nipple injection) Find this disease with Tc-99m MIBI or MRI Find this disease with Tc-99m MIBI or MRI Previous surgery around primary Previous surgery around primary Breast irradiation Breast irradiation Neo-adjuvant chemotherapy Neo-adjuvant chemotherapy Vascular invasion of tumour Vascular invasion of tumour

24 MRI and Tc-99m MIBI

25 Sentinel nodes Can it replace axillary clearance as a staging procedure Can it replace axillary clearance as a staging procedure Need to await phase III trials Need to await phase III trials Patients with T1N0 randomised to ax clearance or sent node Patients with T1N0 randomised to ax clearance or sent node Who has better morbidity Who has better morbidity Any difference in survival Any difference in survival Need 5 year follow-up Need 5 year follow-up

26 Results in Melanoma Published by Morton’s group Published by Morton’s group Reviewed results of 1900 patients having sentinel node for melanoma Reviewed results of 1900 patients having sentinel node for melanoma All had blue dye and colloid All had blue dye and colloid All had Breslow thickness greater than 5mm All had Breslow thickness greater than 5mm Recurrence rate measured at a mean of 7 years Recurrence rate measured at a mean of 7 years

27 Does sentinel node effect outcomes? Morton’s review Morton’s review Ann Sur Onocol 2000 Ann Sur Onocol patients 1900 patients Sentinel node vs blind wide local excision Sentinel node vs blind wide local excision

28 How is melanoma sentinel node different? Melanoma can occur anywhere Melanoma can occur anywhere Drainage much more variable Drainage much more variable May drain to more than one set of nodes May drain to more than one set of nodes Head and neck Head and neck Trunk Trunk Different speeds of flow Different speeds of flow Leg minutes Leg minutes Head minutes Head minutes

29 Method-melanoma Normally done after removal of primary Normally done after removal of primary Aim to identify correct block of lymph nodes to disect Aim to identify correct block of lymph nodes to disect Inject at 4 pints around scar of excision Inject at 4 pints around scar of excision Inject at least 5mm away from the scar Inject at least 5mm away from the scar Massage gently Massage gently Image draining nodes Image draining nodes Calf-groin Calf-groin Back Both inguinals and both upper thorax Back Both inguinals and both upper thorax

30 Injection for melanoma

31 Melanoma-methods Mark any node found Mark any node found Use shadow gram and laterals and obliques help surgeon identify node Use shadow gram and laterals and obliques help surgeon identify node In op use blue dye to find lymphatics and direct surgeon to node In op use blue dye to find lymphatics and direct surgeon to node Surgeon the removes sentinel and associated nodes Surgeon the removes sentinel and associated nodes

32 Melanoma in the leg In leg passage fast up into groin, as the groin nodes are the draining nodes the sentinel node is in the groin The popliteal nodes are ignored

33 Melanoma on crest of head covered by lead; note bilateral sentinel nodes

34 Other sites in which sentinel node can be used Melanoma – all patients as variable drainage Melanoma – all patients as variable drainage Penis Penis Tongue Tongue Head and neck Head and neck Vulva Vulva Colon! Colon!

35 NEW START Sentinel Lymph Node (SLN) training programme

36 NEW START SLN training programme Joint Project Department of Education: Royal College of Surgeons of England Department of Education: Royal College of Surgeons of England Cardiff University Wales Cardiff University Wales Supported by DoH, National Assembly in Wales DoH, National Assembly in Wales GE Healthcare GE Healthcare BNMS BNMS

37 NEW START SLN training programme National Training Programme Standardised methodology and training materials Standardised methodology and training materials Focus on multidiscipline team – Surgery, Nuclear medicine/physics, Radiology, Theatre nurses, Pathology, etc Focus on multidiscipline team – Surgery, Nuclear medicine/physics, Radiology, Theatre nurses, Pathology, etc Experienced validated training teams Experienced validated training teams Unique workplace training and mentorship Unique workplace training and mentorship Quality assured Quality assured Centrally audited and validated (anonymised data collection) Centrally audited and validated (anonymised data collection)

38 NEW START SLN training programme: Standardized National Training World wide trials* have shown ad-hoc adoption of SLNB, with little formal training, reduces the accuracy of SLN identification for the first 50 procedures. World wide trials* have shown ad-hoc adoption of SLNB, with little formal training, reduces the accuracy of SLN identification for the first 50 procedures. Evidence from the UK ALMANAC trial demonstrates that structured training shortens the learning curve to less than 10 procedures. Evidence from the UK ALMANAC trial demonstrates that structured training shortens the learning curve to less than 10 procedures. * Cox et al: Annals Surg. Oncol.1999, vol l6, page 6

39 NEW START SLN training programme Overview 1.Theory Day In House Training Validation Projected Time frame:18-24 months Stand alone SLNB SkillsSLNB + standard procedureTheory 3 training phases

40 Conclusion Sentinel node study established in melanoma and breast Sentinel node study established in melanoma and breast Useful in reducing mutilating surgery Useful in reducing mutilating surgery Simple to learn technique but needs good colloid and good probe Simple to learn technique but needs good colloid and good probe Can be combined with other NM test such as PET and scintimammography Can be combined with other NM test such as PET and scintimammography All members of the team important All members of the team important


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