1. ISOTOPE GUIDED SURGERY FOR NON PALPABLE BREAST CANCER
Dr. MP Chow
Department of Surgery
Kwong Wah Hospital
ISOTOPE GUIDED SURGERY FOR NON PALPABLE BREAST CANCER

2. Breast cancer Commonest cancer for female in Hong Kong (2004)
>2000 new cases / year
Commonest malignancy in women worldwide
> 1 million new cases diagnosed in 2000

3. Opportunistic Screening
Breast screening program
No population screening
Target group:
All woman > 40 years old (<70 years old)
35-40 if +ve family history of a first degree relative at premenopausal age
Detect early stage breast cancer
Reported to reduce mortality in up to 30% in western country
Lui et al Hong Kong Med J 2007

4. Management of non-palpable breast cancer
Topic

5. Management Triple assessment History/Physical examination Imaging
Breast complaints
Risk factors e.g. Family history, OC pills, Previous breast disease, Date of menarche,
Imaging
Ultrasound
Mammogram
Cytology / Histology
Fine Needle Aspiration
Core Biopsy

6. Treatment options for occult breast cancer
Surgery
Mastectomy + Sentinel lymph node biopsy +/- Axillary dissection
Breast conservative therapy + Sentinel lymph node biopsy + Post-operative radiotherapy +/- Axillary dissection
Extent of disease
Multifocality
Previous radiation
Patient’s wish

7. How Can we localize occult brest lesion? What choices?

8. How to localize the lesion?
Hookwire localization
Wire is deployed under stereotactic / ultrasound guidance within rigid over-shealth cannula preoperatively
Potential disadvantages
Uncomfortable for patient
Displacement in fatty breast
Wire transection
Technical difficulty in dense breast
Interference with surgical approach
Required post-procedure mammogram to confirm position

9. Problems with HWL
And sometimes…
Hookwire tip
retained after
surgery

10. New advances Potential advantages Potential disadvantage
Radio-guided surgery
Introduced by European Institute of Oncology in Milan
Luini et el, European Journal of Cancer 1998 Vol 34 No. 1
ROLL/SNOLL
Radiologically Occult Lesion Localization
Sentinel Lymph Node Occult Lesion Localization
Method
Intratumoural injection of radioactive isotope (e.g. Technetium labelled colloid) under radiological guidance
Pre-operative lymphoscintigraphy (Lymph node mapping)
Lesion excision and lymph node localization guided by radioactivity
Potential advantages
Simple and less invasive procedure
“Killing Two Birds with One Stone”.
Shorter localization time
Potential disadvantage
Radiation exposure

11. SNOLL <100 µm 100-200 µm Filtered Sulphur Colloid Sulphur Colloid
The technique of injecting the isotope is identical to ROLL
Use correct particle size
ROLL
The radiotracer used is immobile
and remains at the site of injection
SNOLL
The radiotracer used can remain at
injection site and move within the
lymph ducts to accumulate in SN + + + + + + + + + + + + + µm
Sulphur Colloid
<100 µm
Filtered Sulphur Colloid

12. SNOLL

13. SNOLL

14. SNOLL Video

15. Radiation Issue
Is it a problem?

16. Radiation Issue SNOLL is safe to patients and medical staff SNOLL MMG
Short half life of Tc99m of only 6 hours
Low dose gamma radiation used
SNOLL
MMG
CXR
Effective Dose
9.25 µSv or mSv
1-2 mSv
0.02 mSv
SNOLL <<< MMG or CXR
Clinical Radiology (2005) 60, 681–686
Nucl Med Commun 1999; 20: 919–924

17. Radiation Issue Finger Dose Surgeon 9.3+/-3.3 µSv Radiologist
If a surgeon performs 100 procedures per annum, a Finger Dose of approximately 1 mSv is received, well within the annual dose limit of 150 mSv.
Breast Apr;12(2):150-2

18. Literatrue REview

19. Monti et al Italy March 1997 to April 2004 N = 959 Methodology
Injection and scintigraphic procedures for ROLL and SNB were performed separately on the day of surgery
For ROLL
Human serum albumin macroaggregate, particle size µm and labeled with Technetium was injected into the lesion. Scintigraphy was performed after injection of isotope. Procedure was repeated in cases of failure
For SNB
Human serum albumin macroaggregate, particle size µm and labeled with Technetium was injected peritumorally or subdermally. Lymphoscintigraphy was performed mins and 3 hours. Procedure was repeated in cases of failure
Monti et al Ann. Surg. Oncol Vol 14 No

20. Result Margins status Number Percentage Positive 11 1.3%
Close margins < 1cm 65
6.7%
Negative margins >= 1cm
883
92%
Total
959
100%
Monti et al Ann. Surg. Oncol Vol 14 No

21. Result Axillary SNs were identified in 958 of 959 (99.6%)
Axillary dissection was performed for the case which the sentinel LN is not visualized in lymphscintigraphy
SN Location
Number
Percentage
Axilla
926
96.6%
Axilla plus internal mammary chain 32
3.3%
SN not visualized 1
0.1%
Total
959
100%
Monti et al Ann. Surg. Oncol Vol 14 No

22. Other literatures Patel et al 20 90% 100% Yes Feggi et al 73 95% 97%
Authors
No. of patient
Complete excision (%)
Identification sentinel node (%)
Supplementary Blue dye
Confirmation specimen
Patel et al 20
90%
100%
Yes
Radiography
Feggi et al 73
95%
97%
Scintigraphy + Mammography
De Cicco et al
227 No
Barros et al
112
98%
I.M.C. van der Ploeg et al, EJSO 34 (2008)

23. EXPERIENCE IN KWONG WAH SURGERY

24. Kwong Wah Hospital
SNOLL has been introduced since 2004 as operative technique for BCT of non-palpable breast cancer
Interval 2004 – 2008
Total number of patient: 57
Inclusion criteria
Clinically occult lesion
Suitable for BCT
Biopsy proven breast cancer

25. Methodology
Stereotactic or ultrasonic guided intratumoral injection of 99mTc-labeled (<100 µm) filtered Sulphur Colloid will be performed by radiologist on the same day of surgery
Lymphscintigraphy was performed after radioisotope injection
(Navigator GPS) Gamma probe was used for localization of index lesion and sentinel lymph node
Supplementary blue dye injection if failed localization of sentinel lymph node by gamma probe
End points
Complete excision was defined as tumour free margins >=1mm
Successful breast lesion localization and sentinel lymph node localization

26. Result 21 (37%) patients had DCIS
36 (63%) patient had invasive carcinoma
Index lesion localization rate = 100%
Complete excision rate = 84% (48/57)
7 (12%) patient required 2nd operation

27. Sentinel Lymph Node Localization
Sentinel LN localization by Lymphoscintigraphy
72%
Sentinel LN localization by Gamma Probe
82%
Overall sentinel LN localization (Both isotope and blue dye):
95%

28. Current Evidences Monti et al 959 92% 99.6% No Patel et al 20 90% 100%
Authors
No. of patient
Complete excision (%)
Identification sentinel node (%)
Supplementary Blue dye
Confirmation specimen
Monti et al
959
92%
99.6% No
Radiography
Patel et al 20
90%
100%
Yes
Feggi et al 73
95%
97%
Scintigraphy + Mammography
De Cicco et al
227
Barros et al
112
98%
Kwong Wah Hospital 57
84%

29. Conclusion
Isotope surgery is a promising technique with good results in terms of sentinel lymph node and tumour localization.
SNOLL provides an additional benefit of sentinel lymph node identification in one procedure.

30. The End. Thank you !

31. HWL vs ROLL (KWH) HWL (n=76) ROLL (n=89) P value Age 51.2 52.0 0.508
Success
75/76 (98.7%)
86/89 (96.6%)
0.6251
Mean localisation time 31 18
0.0000
Mean OT time 52 48
0.188
Need for further excision intraop.
22/75 (29.3%)
25/86 (29.1%)
1.0000
(due to unsatisfactory specimen mammogram)
12/75 (16%)
11/86 (12.8%)
0.6536
Involved or close margin in first specimen for
malignant lesions
12/38 (31.6%)
9/55 (16.4%)
0.1290
0.0711
(1-tailed)
Need for 2nd OT for malignant lesions
Either intraop re-excision or 2nd OT
29/75 (38.7%)
31/86 (36.0%)
0.7466
Size of specimen
48.2
66.0
0.005
Therapeutic intention
23/76 (30.3%)
44/89 (49.4%)
0.0169
Size of DCIS
17.7mm (n=30)
8.8mm (n=25)
0.003
Size of invasive cancer
13.2mm (n=5)
12.7mm (n=28)

32. Cost Issue (in KWH, HK) HWL: Slightly lower cost Dose of Technetium
SNOLL
Hookwire
Dose of Technetium
62 USD
Spinal Needle
1 USD
Gamma Probe (OT)
(Capital Cost)
USD
Hookwire
BLN 20G(Promex)
13 USD
Additional
Mammograms
2 USD
HWL: Slightly lower cost

33. Cost Issue (in Prescot, UK)
SNOLL
Hookwire
Dose of Technetium
£ 28
Spinal Needle
£ 0.6
Gamma Probe (OT)
(Capital Cost)
£10,000 to £15,000
Hookwire
Reedy Wire(Cook)
£ 35
Additional
Mammograms
£ 7
ROLL: Slightly lower cost
Clinical Radiology (2005) 60, 681–686