buxant f. (md) breast unit erasme hospital free university of brussels (ulb) belgium sln procedure :...
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Buxant F. (MD)Breast Unit
Erasme Hospital
Free University of Brussels (ULB)Belgium
SLN Procedure : unanswered questions
INJECTION TECHNIQUE
SLN Procedure : unanswered questions
INJECTION TECHNIQUE
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Injection TechniqueInjection Technique
• SLN technology is evolving rapidly, however,difference in techniques are widespread and a standard procedure has not yet become accepted
• I sended a questionnaire …
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What is the belgian practice ?What is the belgian practice ?
• Or …is there a belgian practice ?for the tracer agent : 99m Tc-labeled sulfur colloid(and rarely blue dye)for the dose : 8mCi (0.6mCi, 2mCi)for the injection site : PeriTumoral PT (and subdermal PT or subareolar)for the timing : the day of surgery or the day before
…and in the litterature ?
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Injection techniqueInjection technique
• Tracer Agent
• Massage Technique
• Injection Site
• Timing
• Preoperative Lymphoscintigraphy
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Injection techniqueInjection technique
• Tracer AgentTracer Agent
• Massage Technique
• Injection Site
• Timing
• Preoperative Lymphoscintigraphy
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Injection Technique :Tracer Agent
Injection Technique :Tracer Agent
• A lot of studies indicate that dual agent injection is superior.Identification SLN 92 to 99% FN rates 0 to 15%
• With blue dye alone additional axillary SLNs are difficult to identify after the first SLN is removed and it ‘s difficult to identify IM SLN
• In the early developpement of SLN biopsy for BC, Krag (1993) used radiocolloid alone, whereas Giuliano (1994) used 1% isosulfan blue dye alone.
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Witch blue dye ?Witch blue dye ?• Isosulfan blue (lymphazurin)
has been the traditional dye of choice but hypersensitivity reactions to isosulfan blue have been reported in 1 to 2%
• Isosulfan blue dye reactions during SLN mapping for BC carcinoma.Montgomery. Anaesth Analg 20011.6% of 2392 patients with urticaria, generalized rash, pruritus
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Witch blue dye ?Witch blue dye ?• Methylen blue has
been studied as an alternativeIt’s as effective as isosulfan blue in SLN identificationSimmons Ann Surg Oncol 2003Blessing Am J Surg 2002
No hypersensitivity is known and the cost is lower.
• Nevertheless intradermal injection of methylene blue can cause significant skin reactions including necrosis, erythema and ulceration
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Tracer Agent : Isotope techniqueTracer Agent : Isotope technique
• Variety of isotopes (sulfur colloid, colloid albumin, dextran).
• Tc 99m sulfur colloid has been used most often in the United States and Tc 99m colloidal albumin in European countries
• No study between different isotope tracers
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Tracer Agent : Isotope techniqueTracer Agent : Isotope technique
• Size of particle (40< and 80>nm)If particles too large >100nm :no migrationIf too small < 20-40nm :blood vessels migration
• Unfiltered or filtered radioisotope (0.22m) ?Linehan J Am Coll Surg 1999
Unfiltered (20 to 200nm) is superiorMore « Hot Axilla » with filteredBut why this difference ?
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Tracer Agent : Isotope techniqueTracer Agent : Isotope technique
• Which Radio toxicity for the surgeon ?Guidelines for the safe use of radioactive materials during localization..Miner Ann Surg Oncol 1999Exposure to surgeon’s during SLNB procedure 1mSv/hMax skin annual dose 500mSv
• Body absorbed dose 0,7m Sv/h (50cm)Natural annual irradiation 1,4 -2,4mSv
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Injection techniqueInjection technique
• Tracer Agent
• Massage TechniqueMassage Technique
• Injection Site
• Timing
• Preoperative Lymphoscintigraphy
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Massage TechniqueMassage Technique• Very rare article !• Haynes
Am Surg 2003compared 3 differing
massage techniques :
ressucitative !
Surgeon utilized a pulsatile maneuver similar to a ressucitative chest compression
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Massage TechniqueMassage Technique
Surgeon utilized a diffuse and firm double handed massage with the heel of the hand mimicking
an agressive bread
kneadind technique
• Haynes compared 3 differing massage techniques : ressucitative buffer !
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Massage TechniqueMassage Technique• Haynes compared 3 differing
massage techniques : ressucitative buffer knead like !
Surgeon utilized a circular rotating motion alternating between a clockwise and a counterclockwise direction with emphasized contact with the palm of the hand
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Massage TechniqueMassage Technique
No breast masssage technique was demonstrated to be superior !
And the winner is ?
• Haynes compared 3 differing massage techniques :
ressucitative buffer knead like !
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Injection techniqueInjection technique
• Tracer Agent
• Massage Tehnique
• Injection SiteInjection Site
• Timing
• Preoperative Lymphoscintigraphy
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Injection Site : PeritumoralInjection Site : Peritumoral
• Earlier studies used PERITUMORAL Injection because « It stands to reason that Injection into the breast tissue around the tumor should accurately reflect the L. drainage »
• However, …for upper outer quadrant BC, the high degree of background radiation from the primary tumor site renders discrimination of midly radioactive axillary nodes with the probe difficult
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Injection Site : Skin InjectionInjection Site : Skin Injection
• Subdermal or intradermalThe skin overlying the breast parenchyma has the same embryological origin as the underlying tissu (Ectoderm) and should share the same lymphatic drainage pattern
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Injection Site : SubareolarInjection Site : Subareolar
• Based on studies indicating that this area provides a central access route to the peripheral lymphatic pathway
• The lymphatics channels are much richer at the subcutaneous level than the PT site
Subdermal or Subareolar enhance the SLN identification rate
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Injection Site : Subdermal But ?Injection Site : Subdermal But ?
• Although Subdermal and intradermal injection can help to anatomically visualize the superficial L system running to the axilla, they cannot do this for the deep lymphatic system running to the internal mammary IM or interpectoral nodes
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Injection SiteInjection Site• Subdermal vs Peritumoral
Mateos, Nuclear medicine 2001
80 women- similar blue dye injection100% subdermal lympho + vs 89% PT lympho +similar results for sensitivity with lympho+blue+gamma probe (92% vs 91% identification SLN)
• Intradermal vs IntramammaryMartin Surgery 2001
200 women- IP blue dye98% vs 89% identification SLNdye-isotope concordance (92% vs 93%)comparable
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Injection SiteInjection Site
• Intradermal isotope is superior to PT blue dye and isotopeLin J Am Coll Surg 2004180 women Intradermal (97%) was found to be superior to PT isotope (78%) and PT blue dye in identifying SLNs
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Injection SiteInjection Site
• Comparison of subdermal and peritumoral Inj.Eroglu Clin Nucl Med 2004
36 patients – PT and SD on each patientSD higher sucess rate of axillary SLN detectionPT more effective in imaging IM and extraaxillary SLNs (30% vs 26%)
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Injection SiteInjection Site
• Intraoperative Subdermal Radioisotope InjectionLayeeque Annals of Surgery 2004
96 patients – Intraoperative inj. Blue dye and 99mTc on each patientbeause of the rapid drainage…
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Injection techniqueInjection technique
• Tracer Agent
• Massage Tehnique
• Injection Site
• TimingTiming
• Preoperative Lymphoscintigraphy
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Timing : blue dyeTiming : blue dye
• Surgeons who use blue dye inject it in the operating room, usually 5 to 15 minutes before making an axillary skin incision
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Timing : isotopeTiming : isotope• Identical results with same-day vs day-before isotope
injectionMcCarter Ann Surg Oncol 2001933 patients 1-day (0.1mCi) protocol vs 387 patients 2-day (0.5mCi) protocolisotope intradermal injectionintraparenchymal blue dye2 vs 2.7 SLN (p<0.05)no difference for mean level of counts (Inj. site and SLN)identification rate 93% vs 96%(NS)within each group, isotope succeeded more often than blue dye (S)
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Timing : isotopeTiming : isotope
• Is 1-day better than 2-day protocol ?Chok Am Surg 200360 patients 4h (0.5mCi) or 24h before surgery (2mCi)combination with Patent blue dye (2ml)mean number of SLN found : 1.46 vs 1.96 (NS)radioactivity in the resected specimen higher in 1-day protocol (S)identification SLN 98% vs 99% (combined technique)
SIMILAR RESULTS !SIMILAR RESULTS !
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Injection techniqueInjection technique
• Tracer Agent
• Massage Tehnique
• Injection Site
• Timing
• Preoperative Preoperative LymphoscintigraphyLymphoscintigraphy
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Preoperative LymphoscintigraphyPreoperative Lymphoscintigraphy
• The role of SLN biopsy in breast cancer Bass J Am Coll Surg 1999
94% of all axillary SLN are found within a 5cm perimeter in the axilla and easily detected by gamma probeAn axillary SLN could be identified with the gamma probe in 50% of the scan-negative patientsRoutine preoperative lymphoscintigraphy isunnecessary ?
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Preoperative LymphoscintigraphyPreoperative Lymphoscintigraphy
• The SLN node in Breast Cancer A multicenter validation studyKrag N Eng J Med 1998
Only 19 (4.3%) of 455 hot spots were identified in the IMN chain with intraoperative gamma probe
• In other studies, the rate of identification of BC with IMN drainage with preop lympho. was 11-35%
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ConclusionsConclusions
• Tracer Agent99mTc colloidal albuminBlue dye ? If isotope technique negative1 – 10 mCi
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ConclusionsConclusions
• Massage Technique No enough study !
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ConclusionsConclusions
• Injection SiteSubdermal or Subareolar easierideal for upper outer quadrantbut for Internal Node ?PT and if lymphoscintigraphy neg, SD
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ConclusionsConclusions
• Timingone-day or two-day protocol?Choose what’s more confortable for your unit !
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ConclusionsConclusions
• Preoperative LymphoscintigraphyYes because IM?
because to know if you have to inject blue dye ?
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ConclusionsConclusions
• Tracer Agent
• Massage Technique
• Injection Site
• Timing
• Preoperative Lymphoscintigraphy
Thank you for your attention !
F Buxant
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ConclusionsConclusions
• Tracer Agent
• Massage Technique
• Injection Site
• Timing
• Preoperative Lymphoscintigraphy
Thank you for your attention !
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ConclusionsConclusions
• Tracer Agent
• Massage Technique
• Injection Site
• Timing
• Preoperative Lymphoscintigraphy
Thank you for your attention !Thank you for your attention !
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ConclusionsConclusions
• Tracer Agent
• Massage Tehnique
• Injection Site
• Timing
• Preoperative Lymphoscintigraphy
Thank you for your attention !
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Conclusions Conclusions
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