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.

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.

SN Concept

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

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

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

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

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

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

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

Imaging Technique Dynamic images Static images Anterior Lateral

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.

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

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

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

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

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

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

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

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

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

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)

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

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

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:??

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

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)

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

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

Immunohistochemistry (IHC; n= 209)

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

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

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

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

SN Biopsy As Surgical Rx of Axilla