sentinel node biopsy : the way forward hemant singhal ms frcsed frcs(gen) frcsc consultant surgeon...
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Sentinel Node Biopsy : the way forward
Hemant SinghalMS FRCSEd FRCS(Gen) FRCSC
Consultant SurgeonNorthwick Park & St Marks Hospital
Senior Lecturer, Imperial College School Of Medicine
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MARCH 2005HEMANT SINGHAL
Introduction
Who should have it WhenHowWho will do itWhat can we hope to achieve
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Background
95% of patients who present with breast cancer have apparently local disease.
Indirect features to suggest systemic involvement axillary lymph node metastasis tumour size, grade vascular or lymphatic invasion Her2neu status or p53 etc
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Preoperative evaluation of axilla
Clinical examination inaccurate, false negative rate of 39-45%
Mammography/ultrasound sensitivity of 70%
CT MRI PET Ultrasound guided FNAC
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Rationale for axillary surgery
Status Local controlSurvival impact (B04) study
10 years 5-6% worse
There is no tumour size so small that one can ignore the axilla upto 20% for T1a
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Issues with axillary clearance
Maybe of limited therapeutic value80% of patients maybe LN
negativeShort term drains, seromaLymphoedemaSensory loss in area of ICBaffects the lifestyle of a third
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Sentinel node concept
Ramon Cabanascoined the termlymphatic drainage in ca penisDonald Morton: malignant
melanoma
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Sentinel node concept
First draining lymph nodereflects the status of the axillacan be identified and sampled
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SENTINEL NODE CONCEPT
sentinel node refers to the "node on watch.” this node is the first node to receive cancer
cells and that if this node is positive, there may be other positive nodes upstream.
The cancer cells don't "skip" and go to higher nodes.
If this node is negative, all the upstream nodes are negative 99 out of 100 times
MARCH 2005HEMANT SINGHAL
After a crime, you don't interrogate a bunch of people who were two blocks away; you focus on eye witnesses at the scene of the crime."
—Marisa Weiss, M.D.
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Collective experience
ACS study ~ 5000 patientsALMANAC ~UK study18 other sizeable studies88% LN detection98% accuracy7 series with 100% results
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Nuclear medicine aspects
Amount of radioactivitydose of 0.1 mCi for same-day and 0.4
mCi for day-before injectionPreop scintigram
useful initially know that there is a localised SNB abnormal pattern - Rotters, IM, breast
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Site of injection
SLN identified by intraparenchymal subdermal intradermal subareolar injections
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Surgical aspects
Identify blue lymphaticstrack hot nodeintraop palpation for involved nodegross disease can block
localisation
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Inaccurate results
The scenario of a negative (non-cancerous) sentinel node and positive (cancerous) additional nodes in a patient can occur for several reasons, including:
The timing of the dye injections
The type of dye/tracers used The presence of more than one sentinel node The way in which the initial node was sectioned or
stained in the pathology lab
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Poor candidates
palpable lymph nodes
Locally advanced breast cancer multi-focal breast cancer previous breast surgery (including
breast reduction) previous radiation therapy to the breast
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American College of Surgeons recommends
at least 30 snb followed by complete axillary node dissection,
with an 85% success rate in identifying the sentinel lymph node(s)
and a 5% or lower false positive rate.
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Tips & Tricks
Map with probe3D mental mapAllow adequate time after blue dye
injLN is invariably lower than you
thinkPersevere
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Can we stop after negative SNB
Axillary relapse, most studies have median FU that is too short
melanoma about 3-4%expect 1% for breast0.4% at median fu of 84 months
Singhal 1996, MSKCC
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Should you go back after SNB+
39% have further involved nodesthis may be obvious at first opintraoperative analysis
cytology 10% false negative frozen section
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A xi lla ry ev a lua tion
N orm a l lym p h n od es
B en ign ce lls
A xi lla ry c le ara nce
M alig na n t ce lls
F ine ne ed le a sp ira te
A b no rm a l lym n od es
U ltra sou nd o f ax i lla
B rea st lum p con sid ered m a lig na n t
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S E N T IN E L N O D E B IO P S Y
Norm al scan
No further intervention
Benign
Axillary clearance
M alignant
Intraoperative cytology
SENT INEL NO DE BIO PSY
Benign cells