Sentinel Node Biopsy : the way forward Hemant Singhal MS FRCSEd FRCS(Gen) FRCSC Consultant Surgeon Northwick Park & St Marks Hospital Senior Lecturer, Imperial College School Of Medicine These PowerPoint presentations are free to download only for academic purposes, with due acknowledgements to authors and this website.

MARCH 2005 HEMANT SINGHAL Introduction  Who should have it  When  How  Who will do it  What can we hope to achieve

MARCH 2005 HEMANT SINGHAL 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

MARCH 2005 HEMANT SINGHAL Preoperative evaluation of axilla  Clinical examination inaccurate, false negative rate of 39-45%  Mammography/ultrasound sensitivity of 70%  CT  MRI  PET  Ultrasound guided FNAC

MARCH 2005 HEMANT SINGHAL Rationale for axillary surgery  Status  Local control  Survival 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

MARCH 2005 HEMANT SINGHAL Issues with axillary clearance  Maybe of limited therapeutic value  80% of patients maybe LN negative  Short term drains, seroma  Lymphoedema  Sensory loss in area of ICB  affects the lifestyle of a third

MARCH 2005 HEMANT SINGHAL Sentinel node concept  Ramon Cabanas  coined the term  lymphatic drainage in ca penis  Donald Morton: malignant melanoma

MARCH 2005 HEMANT SINGHAL Sentinel node concept  First draining lymph node  reflects the status of the axilla  can be identified and sampled

MARCH 2005 HEMANT SINGHAL 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 2005 HEMANT 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.

MARCH 2005 HEMANT SINGHAL Collective experience  ACS study ~ 5000 patients  ALMANAC ~UK study  18 other sizeable studies  88% LN detection  98% accuracy  7 series with 100% results

MARCH 2005 HEMANT SINGHAL Nuclear medicine aspects  Amount of radioactivity  dose of 0.1 mCi for same-day and 0.4 mCi for day-before injection  Preop scintigram useful initially know that there is a localised SNB abnormal pattern - Rotters, IM, breast

MARCH 2005 HEMANT SINGHAL Site of injection  SLN identified by intraparenchymal subdermal intradermal subareolar injections

MARCH 2005 HEMANT SINGHAL

MARCH 2005 HEMANT SINGHAL Surgical aspects  Identify blue lymphatics  track hot node  intraop palpation for involved node  gross disease can block localisation

MARCH 2005 HEMANT SINGHAL

MARCH 2005 HEMANT SINGHAL

MARCH 2005 HEMANT SINGHAL

MARCH 2005 HEMANT SINGHAL

MARCH 2005 HEMANT SINGHAL 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

MARCH 2005 HEMANT SINGHAL 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

MARCH 2005 HEMANT SINGHAL 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.

MARCH 2005 HEMANT SINGHAL Tips & Tricks  Map with probe  3D mental map  Allow adequate time after blue dye inj  LN is invariably lower than you think  Persevere

MARCH 2005 HEMANT SINGHAL Can we stop after negative SNB  Axillary relapse, most studies have median FU that is too short  melanoma about 3-4%  expect 1% for breast  0.4% at median fu of 84 months Singhal 1996, MSKCC

MARCH 2005 HEMANT SINGHAL Should you go back after SNB+  39% have further involved nodes  this may be obvious at first op  intraoperative analysis cytology 10% false negative frozen section

MARCH 2005 HEMANT SINGHAL

MARCH 2005 HEMANT SINGHAL

MARCH 2005 HEMANT SINGHAL The important question  "HOW MANY lymph nodes are positive?"  not just "ARE lymph nodes positive?"