Sentinel Node Biopsy IRCH - AIIMS Experience Dr. S.V.S. Deo MS, FACS, FAIS Associate professor, Surgical Oncology All India Institute of Medical Sciences New Delhi These PowerPoint presentations are free to download only for academic purposes, with due acknowledgements to authors and this website.

Sentinel Lymph Node Biopsy (SLNB) Introduction SLNB - Concept , Rationale & Technique SLNB - AIIMS Experience Evidence based future strategies for Indian BC Patients

Sentinel Lymph Node Biopsy (SLNB) Two Most Significant Advances in the field of Surgery during the last decade Minimally Invasive Surgery (MIS) Sentinel Lymph Node biopsy(SLNB)

Lymph Nodes - Solid Tumors Solid tumors - Spread to lymph nodes Lymphadenectomy - Part of many curative Cancer operations Lymphadenectomy – Staging, Prognostication & Therapeutic Changing Concepts - Lymphadenectomy

Why – SLNB ? ALND - Gold standard of Managing Axilla ALND - Standard technique , Rigorous clinical scrutiny, excellent therapeutic efficacy Recently – ALND - Less Popular Morbidity more than therapeutic benefit in node negative patients

Why – SLNB ? Changing Treatment Philosophy Changing patient profile Technology driven therapeutic interventions

Why – SLNB ? Changing Treatment Philosophy Better Understanding of Breast Cancer Biology Paradigm shift - Surgical Approach Ultra Radical – Radical – Conservative

Why – SLNB ? Old Times - Big Surgeons - Big Incisions- Big Resections - ? Big Results - Big Egos Judicious Conservatism - Current trend Functional out come & QOL issues are important end points Add life to years - Years to life Critical re evaluation of ALND Morbidity

Morbidity- ALND Incidence - 30 to 60 % Seroma & Lymphedema - 30% Shoulder syndrome - 25% Neuropathies - 50 to75% Increased Hospital stay Morbidity more than - Sx for Primary Roses et al ,Ann Surg, 1999 Baum M et al, W J surg, 2001

Morbidity- ALND

Why – SLNB ? Changing Patient Profile Breast Cancer - Western world 70 % Screen detected Non Palpable lesions Majority - DCIS / T1 70 % Node Negative Majority receive Adj. Systemic therapy Irrespective of Axillary status

Why – SLNB ? Technology driven therapeutic interventions Decade of medical technology Pharmaceutical MNCs, Media playing a major role - Influencing Therapeutic options Myth – “Technology = Cure” Treatment modalities are forced – Fast tracking & Short circuiting rigorous scientific scrutiny

Sentinel Lymph Node Biopsy (SLNB) Sentinel - “ Sentry / Guard” Definition - Identification of first draining lymph node most likely to contain metastatic disease if metastases exists in the axilla”

Evolution- Sentinel Lymph Node Biopsy (SLNB) Cabanas -1979 - SLN in Penile cancer Wong et al- 1991- Anatomic specificity of LN 1992 - Guliano et al - Blue dye method -Breast cancer 1993- Alex & Krag - Gamma probe detection using radio colloid in Breast cancer

Sentinel Lymph Node Biopsy (SLNB) Visual detection method using dyes Patent blue, Isosulfan blue (Lymphozurin) Agents - LN seeking - Not - Tumor seeking Peri tumoral/ sub dermal injection (2- 4 ml) Exploration of lymphatic basin through small incision after 5 -15 mts Identify the blue lymphatic going from primary to Blue LN

Sentinel Lymph Node Biopsy (SLNB) Radio tracer detection using Gamma probe Injection of radiotracer tagged to pharmaceuticals Technitium –99m most commonly used tagged to sulfur colloid / albumin Peri tumoral / Intradermal injection of 0.450 to 1.0 m Ci – volume - 5-10 ml Exploration of lymphatic basin after 8 hrs using a gamma detection probe

Sentinel Lymph Node Biopsy (SLNB) Probe -Radiation detector (scintillation detector) Electronic box –solid state detector Converts photo signals to audio signals Audio signal & Count SLN- HOT NODE

Current Status SLNB in BC Positive SLN localization – 92 to100% False negative – 0 to10 % Best results - Combination of Dye & GPD Accuracy in predicting ALN status > 90% Rapidly evolving as a staging & Therapeutic procedure in N0 Axilla SLNB - N+ Axilla – JACS, 2005,10. Therapeutic role - Mature Data awaited

SLNB – AIIMS -_IRCH Experience To evaluate the applicability of SLNB among Indian BC patients Assessment of BC Patient profile Out come analysis - ALND Validation study - SLNB

AIIMS - IRCH SLNB - Validation Study SLNB - Protocol Validation Study – 2000 to 2003 Total number of patients – 140 ( stage I & II) Method – Blue dye ( Isosulfan 1%) 4 ml Peritumoral injection All pts had post SLNB - Completion ALND

AIIMS - IRCH SLNB - Validation Study LN Assessment – Intra operative Imprint cytology Two cuts – 4 sections of LN Jenner Geimsa / H & E staining Average time to reporting 20 mts Final HPE – gold standard No - IHC / RT PCR

AIIMS - IRCH SLNB - Validation Study

AIIMS - IRCH SLNB - Validation Study Out Come SLN identification rate - 95% False negative SLN - 8 % Accuracy in predicting Ax LN status - 92% Accuracy of ICC – 98 %

AIIMS - IRCH SLNB - Validation Study Publications

Video

AIIMS - IRCH SLNB - Validation Study Post NAC- SLNB Assessment using IIC “Paresh , Deo SVS, Mona et al “J Diagnostic Cytopathology, 2003” Comparison of three Stains- JJ/H&E/ Pap Mona , Paresh , Deo SVS et al “Cancer - Cytopath – 2004”

AIIMS – IRCH Breast Cancer Profile & ALND Analysis Study Period - Jan 1993 to June 2000 Total number of BC patients - 742 Age : <35 yrs = 116, > 35 yrs = 626 Menopausal Status – Pre - 48 %, Post- 52% EBC (Stage I & II): 363 (48.9%) LABC (Stage III) : 379 (51.1%)

AIIMS – IRCH Breast Cancer Profile & ALND Analysis Types of Surgery : RM : 39 (5.3%) MRM : 582 (80.4%) BCT : 110 (12.8%) ALND : 11 (1.5%) Breast Reconstruction - 50 Treatment policy- Axilla - Complete ALND Axillary RT - LABC, >3 nodes, ENS

AIIMS – IRCH Breast Cancer Profile & ALND Analysis Median Nodal Yield - 14 + 5.91 Total number of Node + ve patients : 479 (64.6%) Stage vs Node positivity EBC : 181/363 (49.8%) LABC : 298/379 (78.6%)

AIIMS – IRCH Breast Cancer Profile & ALND Analysis Regional Relapse (N=16) EBC : 2 ( 0.5%) LABC : 14 (3.7%) Node positivity profile < 3 node + ve - 45%, 3 to10 + ve - 32%, > 10 nodes - 22% , ENS - 18% Lymphedema & Neuropathy – 35 %

Evidence Based guide lines for SLNB in India Indian BC Scenario - LABC > EBC Self detected BC more than Screen detected BC Node positive more than Node Negative Currently ALND – Excellent Results for Indian BC patients

India- Country in Transition

India- Country in Transition

Evidence Based guide lines for SLNB in India Indian BC Scenario – Changing Based on Current ALND Data 50 % EBC & 25 % LABC - Suitable SLNB Dye method with II Cytology - Suitable for India

Evidence Based guide lines for SLNB in India Who should perform SLNB Surgical Oncologist General surgeon Rx more than 25 BC / year Learning curve - Short Validation study - Minimum of 20 cases (Supervision) Blind extrapolation of Western data avoided Try and generate more Indian data

Evidence Based guide lines for SLNB in India Current Era of transition Surgeons India should be familiar with ALND & SLNB Choose a Middle path Key to success – Customized treatment

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