ISOTOPE GUIDED SURGERY FOR ISOTOPE GUIDED SURGERY FOR NON PALPABLE BREAST CANCERNON PALPABLE BREAST CANCER
25-7-2009Dr. MP ChowDepartment of SurgeryKwong Wah Hospital
Breast cancer
Commonest cancer for female in Hong Kong (2004) >2000 new cases /
year Commonest
malignancy in women worldwide > 1 million new
cases diagnosed in 2000
Opportunistic Screening
Breast screening program No population screening Target group:
All woman > 40 years old (<70 years old) 35-40 if +ve family history of a first degree relative at
premenopausal age
Detect early stage breast cancer Reported to reduce mortality in up to 30% in
western country Lui et al Hong Kong Med J 2007
Management of non-Management of non-palpable breast cancerpalpable breast cancer
Management
Triple assessment History/Physical examination
Breast complaints Risk factors e.g. Family history, OC pills,
Previous breast disease, Date of menarche, Imaging
Ultrasound Mammogram
Cytology / Histology Fine Needle Aspiration Core Biopsy
Treatment options for occult breast cancer Surgery
Mastectomy + Sentinel lymph node biopsy +/- Axillary dissection
Breast conservative therapy + Sentinel lymph node biopsy + Post-operative radiotherapy +/- Axillary dissection Extent of disease Multifocality Previous radiation Patient’s wish
How to localize the lesion? Hookwire localization
Wire is deployed under stereotactic / ultrasound guidance within rigid over-shealth cannula preoperatively
Potential disadvantages Uncomfortable for patient Displacement in fatty breast Wire transection Technical difficulty in dense
breast Interference with surgical
approach Required post-procedure
mammogram to confirm position
And sometimes…
Problems with HWL
Hookwire tipretained after
surgery
New advances
Radio-guided surgery Introduced by European Institute of Oncology in Milan
Luini et el, European Journal of Cancer 1998 Vol 34 No. 1 ROLL/SNOLL Radiologically Occult Lesion Localization Sentinel Lymph Node Occult Lesion Localization Method
Intratumoural injection of radioactive isotope (e.g. Technetium labelled colloid) under radiological guidance
Pre-operative lymphoscintigraphy (Lymph node mapping) Lesion excision and lymph node localization guided by
radioactivity Potential advantages
Simple and less invasive procedure “Killing Two Birds with One Stone”. Shorter localization time
Potential disadvantage Radiation exposure
SNOLL The technique of injecting the isotope is identical to ROLL Use correct particle size
<100 µmFiltered Sulphur Colloid
100-200 µmSulphur Colloid
ROLLThe radiotracer used is immobile and remains at the site of injection
SNOLLThe radiotracer used can remain at injection site and move within the lymph ducts to accumulate in SN
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SNOLL
SNOLL
SNOLL Video
Radiation Issue
Is it a problem?
SNOLL is safe to patients and medical staff Short half life of Tc99m of only 6 hours Low dose gamma radiation used
Radiation Issue
Nucl Med Commun 1999; 20: 919–924
Clinical Radiology (2005) 60, 681–686
SNOLL <<< MMG or CXR
SNOLL MMG CXR
Effective Dose
9.25 µSv or 0.009
mSv1-2 mSv
0.02 mSv
Radiation Issue
Finger Dose
Surgeon 9.3+/-3.3 µSv
Radiologist 0.5+/-0.13 µSv
If a surgeon performs 100 procedures per annum, a Finger Dose of approximately 1 mSv is received, well within the annual dose limit of 150 mSv.
Breast. 2003 Apr;12(2):150-2
Monti et al
Italy March 1997 to April 2004 N = 959 Methodology
Injection and scintigraphic procedures for ROLL and SNB were performed separately on the day of surgery
For ROLL Human serum albumin macroaggregate, particle size 100-
150µm and labeled with Technetium was injected into the lesion. Scintigraphy was performed after injection of isotope. Procedure was repeated in cases of failure
For SNB Human serum albumin macroaggregate, particle size 0.1-
0.8µm and labeled with Technetium was injected peritumorally or subdermally. Lymphoscintigraphy was performed 15-30 mins and 3 hours. Procedure was repeated in cases of failure
Monti et al Ann. Surg. Oncol Vol 14 No. 10. 2007
Result
Margins status Number Percentage
Positive 11 1.3%
Close margins < 1cm
65 6.7%
Negative margins >= 1cm
883 92%
Total 959 100%
Monti et al Ann. Surg. Oncol Vol 14 No. 10. 2007
Result
Axillary SNs were identified in 958 of 959 (99.6%)
Axillary dissection was performed for the case which the sentinel LN is not visualized in lymphscintigraphySN Location Number Percentage
Axilla 926 96.6%
Axilla plus internal mammary chain
32 3.3%
SN not visualized
1 0.1%
Total 959 100%
Monti et al Ann. Surg. Oncol Vol 14 No. 10. 2007
Other literatures
Authors No. of patient Complete excision (%)
Identification sentinel node (%)
Supplementary Blue dye
Confirmation specimen
Patel et al 20 90% 100% Yes Radiography
Feggi et al 73 95% 97% Yes Scintigraphy + Mammography
De Cicco et al
227 95% 90% No Radiography
Barros et al 112 90% 98% No Radiography
I.M.C. van der Ploeg et al, EJSO 34 (2008)
EXPERIENCE EXPERIENCE IN IN
KWONG WAH KWONG WAH SURGERYSURGERY
Kwong Wah Hospital
SNOLL has been introduced since 2004 as operative technique for BCT of non-palpable breast cancer
Interval 2004 – 2008 Total number of patient: 57 Inclusion criteria
Clinically occult lesion Suitable for BCT Biopsy proven breast cancer
Methodology
Stereotactic or ultrasonic guided intratumoral injection of 99mTc-labeled (<100 µm) filtered Sulphur Colloid will be performed by radiologist on the same day of surgery
Lymphscintigraphy was performed after radioisotope injection
(Navigator GPS) Gamma probe was used for localization of index lesion and sentinel lymph node
Supplementary blue dye injection if failed localization of sentinel lymph node by gamma probe
End points1. Complete excision was defined as tumour free
margins >=1mm2. Successful breast lesion localization and sentinel
lymph node localization
Result
21 (37%) patients had DCIS 36 (63%) patient had invasive carcinoma
Index lesion localization rate = 100% Complete excision rate = 84% (48/57) 7 (12%) patient required 2nd operation
Sentinel Lymph Node Localization Sentinel LN localization by
Lymphoscintigraphy 72%
Sentinel LN localization by Gamma Probe 82%
Overall sentinel LN localization (Both isotope and blue dye): 95%
Current EvidencesAuthors No. of patient Complete
excision (%)Identification sentinel node (%)
Supplementary Blue dye
Confirmation specimen
Monti et al 959 92% 99.6% No Radiography
Patel et al 20 90% 100% Yes Radiography
Feggi et al 73 95% 97% Yes Scintigraphy + Mammography
De Cicco et al
227 95% 90% No Radiography
Barros et al 112 90% 98% No Radiography
Kwong Wah Hospital
57 84% 95% Yes Radiography
Conclusion
Isotope surgery is a promising technique with good results in terms of sentinel lymph node and tumour localization.
SNOLL provides an additional benefit of sentinel lymph node identification in one procedure.
The End.The End.Thank you !Thank you !
HWL (n=76)
ROLL (n=89)
P valu
e
Age 51.2 52.0 0.508
Success 75/76 (98.7%) 86/89 (96.6%) 0.6251
Mean localisation time 31 18 0.0000
Mean OT time 52 48 0.188
Need for further excision intraop. 22/75 (29.3%) 25/86 (29.1%) 1.0000
Need for further excision intraop. (due to unsatisfactory specimen mammogram)
12/75 (16%) 11/86 (12.8%) 0.6536
Involved or close margin in first specimen for malignant lesions
12/38 (31.6%) 9/55 (16.4%)0.12900.0711
(1-tailed) Need for 2nd OT for malignant lesions 12/38 (31.6%) 9/55 (16.4%)
Either intraop re-excision or 2nd OT 29/75 (38.7%) 31/86 (36.0%) 0.7466
Size of specimen 48.2 66.0 0.005
Therapeutic intention 23/76 (30.3%) 44/89 (49.4%) 0.0169
Size of DCIS17.7mm (n=30)
8.8mm (n=25)
0.003
Size of invasive cancer13.2mm
(n=5)12.7mm (n=28)
HWL vs ROLL (KWH)
Cost Issue (in KWH, HK)
HWL: Slightly lower cost
SNOLL Hookwire
Dose of Technetium62 USD
Spinal Needle1 USD
Gamma Probe (OT)(Capital Cost)
18000-20000 USD
HookwireBLN 20G(Promex)
13 USD
Additional Mammograms
2 USD
Cost Issue (in Prescot, UK)
ROLL: Slightly lower cost
SNOLL Hookwire
Dose of Technetium£ 28
Spinal Needle£ 0.6
Gamma Probe (OT)(Capital Cost)
£10,000 to £15,000
Clinical Radiology (2005) 60, 681–686
HookwireReedy Wire(Cook)
£ 35
Additional Mammograms
£ 7