Techniques of Sentinel Node Biopsy

V. Seenu

Associate Professor

Department of Surgical Disciplines,

All India Institute of Medical Sciences

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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

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 0 100 42

Folscher et al 1997 79 40 12 85 51

Flett et al

Horgan et al

1998

1998

68

38

92

82

17

16

95

84

31

50

RadiopharmaceuticalRadiopharmaceutical

• 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 InjectionSite of Injection

• Subdermal/Intradermal

• Peritumoral in deep seated lesions specially in medial quadrant

• Peri areolar

• Sub areolar

Dose and VolumeDose and Volume

• 0.1-0.4 ml to 4-8 ml

• 300 - 400 Ci

• 500 uCi-1mCi

• Filtered or unfiltered

Imaging TechniqueImaging Technique

• Dynamic images

• Static images

• Anterior

• Lateral

Dynamic images

Static images

Case (3): 2 positive axillary LNs in both early and delayed images.

Dynamic images

Static 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 ProbeRef

Krag et al

Year

1993

No of Pts

22

ID (%)

82

False –ve (%)

0

CR

100

Node +ve

39

Offodile et al

1998 41 98 0 100 45

Veronesi et al

1997 163 98 5 98 53

Pijpers et al 1997 37 92 0 100 34

Borgstein et al

1998 130 94 2 98 42

Roumen et al

1997 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 ProbeRef Yr Pts ID

(%)False –ve rate

CR Node +ve

Albertini 1996 62 92 0 100 32

Cox etal 1998 466

94 1 100 23

O Hea 1998 59 93 15 95 36

Gil et al 1997 36 83 8 93 -

Devries et al

1997 10 100 0 100 60

Borgstein et al

1997 33 100 0 100 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 SA PT 90.0 96.8 NA

Beitsch et al 2001 85 PT SA 95.2 97.6 NA

Donahue 42 SA PT 95.2 100 8.3

Tuttle et al 159 PT PT 95.0 100 NA

Smith et al 2000 19 PT SA 84.2 100 NA

D Eredita et al 2003 115 SA PT NA 94.8 9.1

Kern 1999 40 SA NA NA 97.5 0

Zavagno et al 2002 50 SA PT 93 94 NA

Pelosi et al 200 50 PA PT 91.8 98.0 NA

Chagpar et al 1431 Varied PT NA 91.1 8.6

148 Varied SA 99.3 8.3

183 Varied PA 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

10/26

3/171

1/35

4/42

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)

70 11

8 198FS

-+

-

+

PS

False -ve:11%; False +ve: 5%

Immunohistochemistry (IHC; n= 209)

Establishing SN Program

Feasibility; Validation; On going SN program

NUCLEAR MED

SURGEON

PATHOLOGIST

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