1. 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.

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

3. 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)

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

5. 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

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

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

8. 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

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

10. Morbidity- ALND

11. 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

12. 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

13. 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”

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

15. 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 mts
Identify the blue lymphatic going from primary to Blue LN

16. 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 to 1.0 m Ci – volume ml
Exploration of lymphatic basin after 8 hrs using a gamma detection probe

17. 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

18. 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

19. 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

20. 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

21. 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

22. AIIMS - IRCH SLNB - Validation Study

23. 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 %

24. AIIMS - IRCH SLNB - Validation Study
Publications

25. Video

26. 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”

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

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

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

30. 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 % , ENS - 18%
Lymphedema & Neuropathy – 35 %

31. 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

32. India- Country in Transition

33. India- Country in Transition

34. 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

35. 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

36. 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

37. Thank You