SLN Procedure : unanswered questions INJECTION TECHNIQUE Buxant F. (MD) Breast Unit Erasme Hospital Free University of Brussels (ULB) Belgium

Injection 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 … SLN technology is evolving rapidly, however,difference in techniques are widespread and a standard procedure has not yet become accepted. The objectives of this communication are to focus on exciting controversies regarding technical consideration for SLN biopsy for breast cancer (BC). I sended a questionnaire to some belgian breast unit I m sorry but i can’t send to all unit because I was a little late for this meeting…

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 Or …are there a belgian practice ? for the tracer agent : 99m Tc-labeled sulfur colloid (and rarely blue dye, usually blue dye is injected if the preoperative lymphoscintigraphy is negative) for the dose : 8mCi (0.6mCi, 2mCi) for the injection technique : PeriTumoral PT (and subdermal PT or subdermal subareolar) for the timing : the day of surgery or the day before …and in the litterature ?

Injection technique Tracer Agent Massage Technique Injection Site Timing Preoperative Lymphoscintigraphy So What can we find in the litterature ? About

Injection technique Tracer Agent Massage Technique Injection Site Timing Preoperative Lymphoscintigraphy So What can we find in the litterature ? About

Injection Technique : Tracer Agent In the early developpement of SLN biopsy for BC, Krag (1993) used radiocolloid alone, whereas Giuliano (1994) used 1% isosulfan blue dye alone. 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 used radiocolloid alone, whereas Giuliano (1994) used 1% isosulfan blue dye alone. A lot of studies indicate that dual agent injection is superior. Identification SLN 92 to 99% FN rates 0 to 15% The single agent use is associated with a significantly higher false negative rate With blue dye alone additional axillary SLNs are difficult to identify after the first SLN is removed

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 2001 1.6% of 2392 patients with urticaria, generalized rash, pruritus Isosulfan blue (lymphazurin) has been the traditional dye of choice but hypersensitivity reactions to isosulfan blue have been reported in 1 to 2% (urticaria,generalized rash, Methylen blue has been studied as an alternative because 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

Witch blue dye ? Methylen blue has been studied as an alternative It’s as effective as isosulfan blue in SLN identification Simmons Ann Surg Oncol 2003 Blessing 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 Isosulfan blue (lymphazurin) has been the traditional dye of choice but hypersensitivity reactions to isosulfan blue have been reported in 1 to 2% (urticaria,generalized rash, Methylen blue has been studied as an alternative because 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

Tracer 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 The literature on SLN radiolocalization reports on a variety of isotopes (sulfur coloid, coloid albumin, dextran). Tc 99m sulfur colloid has been used most often in the United States and TC 99m colloidal albumin in European countries

Tracer Agent : Isotope technique Size of particle (40< and 80>nm) If particles too large >100nm :no migration If too small < 20-40nm :blood vessels migration Unfiltered or filtered radioisotope (0.22m) ? Linehan J Am Coll Surg 1999 Unfiltered (20 to 200nm) is superior More  « Hot Axilla » with filtered But why this difference ?

Tracer Agent : Isotope technique Which Radio toxicity for the surgeon ? Guidelines for the safe use of radioactive materials during localization.. Miner Ann Surg Oncol 1999 Exposure to surgeon’s during SLNB procedure 1mSv/h Max skin annual dose 500mSv Body absorbed dose 0,7m Sv/h (50cm) Natural annual irradiation 1,4 -2,4mSv

Injection technique Tracer Agent Massage Technique Injection Site Timing Preoperative Lymphoscintigraphy So What can we find in the litterature ? About

Massage Technique Very rare article ! Haynes Am Surg 2003 compared 3 differing massage techniques : ressucitative ! Surgeon utilized a pulsatile maneuver similar to a ressucitative chest compression 5min massage 25 patients in each arm First technique : surgeon A utilized a pulsatile maneuver similar to a ressucitative chest compression surgeon B utilized a diffuse and firm double handed massage with the heel of the hand mimicking an agressive bread kneadind technique Surgeon C utilized a circular rotating motion altenating between a clockwise and a counterclockwise direction

Massage Technique Haynes compared 3 differing massage techniques : ressucitative buffer ! Surgeon utilized a diffuse and firm double handed massage with the heel of the hand mimicking an agressive bread kneadind technique First technique : surgeon A utilized a pulsatile maneuver similar to a ressucitative chest compression surgeon B utilized a diffuse and firm double handed massage with the heel of the hand mimicking an agressive bread kneadind technique Surgeon C utilized a circular rotating motion altenating between a clockwise and a counterclockwise direction

Massage 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 First technique : surgeon A utilized a pulsatile maneuver similar to a ressucitative chest compression surgeon B utilized a diffuse and firm double handed massage with the heel of the hand mimicking an agressive bread kneadind technique Surgeon C utilized a circular rotating motion altenating between a clockwise and a counterclockwise direction with emphasized contact with the palm of the hand

Massage Technique And the winner is ? Haynes compared 3 differing massage techniques : ressucitative buffer knead like ! And the winner is ? First technique : surgeon A utilized a pulsatile maneuver similar to a ressucitative chest compression surgeon B utilized a diffuse and firm double handed massage with the heel of the hand mimicking an agressive bread kneadind technique Surgeon C utilized a circular rotating motion altenating between a clockwise and a counterclockwise direction with emphasized contact with the palm of the hand No breast masssage technique was demonstrated to be superior !

Injection technique Tracer Agent Massage Tehnique Injection Site Timing Preoperative Lymphoscintigraphy So What can we find in the litterature ? About

Injection 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 Ealier 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 gamma probe difficult

Injection Site : Skin Injection Subdermal or intradermal The skin overlying the breast parenchyma has the same embryological origin as the underlying tissu (Ectoderm) and should share the same lymphatic drainage pattern

Injection 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

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

Injection Site Subdermal vs Peritumoral Mateos, Nuclear medicine 2001 80 women- similar blue dye injection 100% subdermal lympho + vs 89% PT lympho + similar results for sensitivity with lympho+blue+gamma probe (92% vs 91% identification SLN) Intradermal vs Intramammary Martin Surgery 2001 200 women- IP blue dye 98% vs 89% identification SLN dye-isotope concordance (92% vs 93%)comparable

Injection Site Intradermal isotope is superior to PT blue dye and isotope Lin J Am Coll Surg 2004 180 women Intradermal (97%) was found to be superior to PT isotope (78%) and PT blue dye in identifying SLNs

Injection Site Comparison of subdermal and peritumoral Inj. Eroglu Clin Nucl Med 2004 36 patients – PT and SD on each patient SD higher sucess rate of axillary SLN detection PT more effective in imaging IM and extraaxillary SLNs (30% vs 26%)

Injection Site Intraoperative Subdermal Radioisotope Injection Layeeque Annals of Surgery 2004 96 patients – Intraoperative inj. Blue dye and 99mTc on each patient beause of the rapid drainage…

Injection technique Tracer Agent Massage Tehnique Injection Site Timing Preoperative Lymphoscintigraphy So What can we find in the litterature ? About

Timing : blue dye Surgeons who use blue dye inject it in the operating room, usually 5 to 15 minutes before making an axillary skin incision Surgeons who use blue dye inject it in the operating room, usually 5 to 15 minutes before making an axillary skin incision

Timing : isotope Identical results with same-day vs day-before isotope injection McCarter Ann Surg Oncol 2001 933 patients 1-day (0.1mCi) protocol vs 387 patients 2-day (0.5mCi) protocol isotope intradermal injection intraparenchymal blue dye 2 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) Surgeons who use blue dye inject it in the operating room, usually 5 to 15 minutes before making an axillary skin incision

Timing : isotope Is 1-day better than 2-day protocol ? Chok Am Surg 2003 60 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) Surgeons who use blue dye inject it in the operating room, usually 5 to 15 minutes before making an axillary skin incision SIMILAR RESULTS !

Injection technique Tracer Agent Massage Tehnique Injection Site Timing Preoperative Lymphoscintigraphy So What can we find in the litterature ? About

Preoperative 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 probe An axillary SLN could be identified with the gamma probe in 50% of the scan-negative patients Routine preoperative lymphoscintigraphy is unnecessary ?

Preoperative Lymphoscintigraphy The SLN node in Breast Cancer A multicenter validation study Krag 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%

Conclusions Tracer Agent 99mTc colloidal albumin Blue dye ? If isotope technique negative 1 – 10 mCi

Conclusions Massage Technique No enough study !

Conclusions Injection Site Subdermal or Subareolar easier ideal for upper outer quadrant but for Internal Node ? PT and if lymphoscintigraphy neg, SD

Conclusions Timing one-day or two-day protocol? Choose what’s more confortable for your unit !

Conclusions Preoperative Lymphoscintigraphy Yes because IM? because to know if you have to inject blue dye ?

Conclusions Tracer Agent Massage Technique Injection Site Timing Preoperative Lymphoscintigraphy Thank you for your attention ! F Buxant

Conclusions Tracer Agent Massage Technique Injection Site Timing Preoperative Lymphoscintigraphy Thank you for your attention !

Conclusions Tracer Agent Massage Technique Injection Site Timing Preoperative Lymphoscintigraphy Thank you for your attention !

Conclusions Tracer Agent Massage Tehnique Injection Site Timing Preoperative Lymphoscintigraphy Thank you for your attention !

Conclusions