BREAST SENTINELBREAST SENTINELNODE NODE

LOCALISATIONLOCALISATION& BIOPSY& BIOPSY

Kirsten WorthingtonKirsten WorthingtonSenior Nuclear Medicine Senior Nuclear Medicine

Technologist/MRTTechnologist/MRT

What is a ‘Sentinel’ lymph node What is a ‘Sentinel’ lymph node (SLN)?(SLN)?

The very The very first lymph first lymph nodenode to receive to receive drainage drainage fromfrom a a cancercancer containing containing area of the breastarea of the breast

Typically located in:Typically located in:

- Axilla (armpit)- Axilla (armpit)

but can also be in:but can also be in:

- Internal Mammary- Internal Mammary

- Clavicular groups- Clavicular groups

a)a) Axillary lymph nodesAxillary lymph nodes

b)b) Internal mammary lymph nodesInternal mammary lymph nodes

c)c) Supra & infra clavicular lymph Supra & infra clavicular lymph nodesnodes

Axillary Clearance (A.C)Axillary Clearance (A.C)

All axillary lymph nodes removed in All axillary lymph nodes removed in patients with breast cancerpatients with breast cancer

Pathological lymph node analysis Pathological lymph node analysis important in ‘staging’ diseaseimportant in ‘staging’ diseaseTypically Typically 101015 nodes15 nodes removed removed (Diehl, (Diehl, Chang)Chang)

A.C reduces chance of cancer A.C reduces chance of cancer returning to axilla. returning to axilla. Gold Standard Gold Standard ProcedureProcedure

Side Effects from Axillary Side Effects from Axillary ClearanceClearance

Lymphedema +/-Lymphedema +/-- Stiff shoulder- Stiff shoulder- Numbness (nerve damage)- Numbness (nerve damage)- Fluid collection- Fluid collection10-15 cm surgical wound10-15 cm surgical woundLong recovery periodLong recovery period

70% of DCIS breast cancer cases 70% of DCIS breast cancer cases have not metastasized to the have not metastasized to the lymphatic system lymphatic system (Journal of Nuclear Medicine, Vol. (Journal of Nuclear Medicine, Vol. 42 No.8, 2001)42 No.8, 2001)

What is ‘Sentinel Lymph Node What is ‘Sentinel Lymph Node Biopsy’ (SLNB)?Biopsy’ (SLNB)?

Recent technique checking for lymphatic Recent technique checking for lymphatic mets without performing an A.Cmets without performing an A.C113 sentinel node/s3 sentinel node/s removed only removed onlySentinel node/s identified at surgery by:Sentinel node/s identified at surgery by:- - 99m99mTc Senti-scint/Geiger probeTc Senti-scint/Geiger probe- Isosulfan Blue Dye Test- Isosulfan Blue Dye TestPreliminary pathological analysis of nodes Preliminary pathological analysis of nodes during surgeryduring surgeryNegative biopsy result Negative biopsy result operation completed operation completedPositive biopsy result Positive biopsy result Patient will require Patient will require A.CA.C

Who can have Sentinel Lymph Who can have Sentinel Lymph Node Biopsy?Node Biopsy?

Patients with ‘in-situ’ breast carcinomaPatients with ‘in-situ’ breast carcinoma

- small tumours (DCIS)- small tumours (DCIS)

SDHB: Procedure done in conjunction SDHB: Procedure done in conjunction with lumpectomy or mastectomywith lumpectomy or mastectomy

Who Shouldn’t have a Who Shouldn’t have a SLNB?SLNB?

Women with large carcinomasWomen with large carcinomas- >- >5 cm5 cmHad R/T or surgery to breast/axilla Had R/T or surgery to breast/axilla areaareaPresent with enlarged axillary lymph Present with enlarged axillary lymph glandsglandsMultifocal tumour Multifocal tumour Occult MalignancyOccult Malignancy

Possible Side Effects from Possible Side Effects from SLNBSLNB

Blue urine Blue urine 24 hrs 24 hrsBreast stained blue Breast stained blue 2 weeks 2 weeks- Mild reaction to dye: 1-2% risk - Mild reaction to dye: 1-2% risk (NSW Breast Cancer (NSW Breast Cancer Institute)Institute)

- Severe reaction: rare- Severe reaction: rare

Wounds in breast, armpit & sternumWounds in breast, armpit & sternumLymphedema: 1-2% risk Lymphedema: 1-2% risk (NSW Breast Cancer Institute)(NSW Breast Cancer Institute)

NumbnessNumbnessFalse negative result possibleFalse negative result possible

Advantages of SLNBAdvantages of SLNB(over Axillary Clearance)(over Axillary Clearance)

Reduced hospital stayReduced hospital stay

Smaller axillary scarSmaller axillary scar

Quicker recovery timeQuicker recovery time

Reduced risk of lymphedema, pain & Reduced risk of lymphedema, pain & numbnessnumbness

How is the breast SN mapped How is the breast SN mapped inin

Nuclear Medicine?Nuclear Medicine?

Affected breast Affected breast 4 x injections 4 x injections 99m99mTc Tc Senti-scintSenti-scintRadioactive injections are placed Radioactive injections are placed tumour tumour quadrantquadrant around around areolar areolar (about o’clock position)(about o’clock position)

Technique1

How is the breast SN mapped How is the breast SN mapped inin

Nuclear Medicine?Nuclear Medicine?

2 x injections 2 x injections 99m99mTc Senti-scint placed Tc Senti-scint placed either side of breast tumoureither side of breast tumour

Require Radiologist + ultrasound machineRequire Radiologist + ultrasound machine

Technique2

Senti-scint Localisation in Senti-scint Localisation in Lymph NodeLymph Node

Radioactivity travels freely in lymph Radioactivity travels freely in lymph vessels but trapped in lymph nodesvessels but trapped in lymph nodes

Isotope travels from tumour location to Isotope travels from tumour location to Sentinel NodeSentinel Node

Breast massage encourages flow of radio-Breast massage encourages flow of radio-tracertracer

Scanning occurs & lymph node is Scanning occurs & lymph node is identifiedidentified

Nuclear Medicine SLN Images Nuclear Medicine SLN Images Peri-areolar TechniquePeri-areolar Technique

Node/s identified Node/s identified

- Anterior + - Anterior + 5757Co Flood FieldCo Flood Field

- Lateral + - Lateral + 5757Co Flood FieldCo Flood Field

Node/s marked on Node/s marked on patient’s skinpatient’s skin

Patient ready to proceed Patient ready to proceed to surgeryto surgery

Nuclear Medicine SLN Nuclear Medicine SLN Images Images

Peri-tumoral TechniquePeri-tumoral Technique

Axillary nodesAxillary nodes

- Multiple- Multiple

IM node positiveIM node positive

SPECT / CT ImagesSPECT / CT Images

CT CT (top line)(top line)

SPECT data SPECT data (middle line)(middle line)

Fused data Fused data (bottom line)(bottom line)

3D volume 3D volume rendered rendered SPECT/CTSPECT/CT

Surgery/Biopsy of SNSurgery/Biopsy of SN

Blue dye injectedBlue dye injected at commencement at commencement of surgery of surgery turns SN blue turns SN blue

Geiger probe detects radioactivityGeiger probe detects radioactivity in in SNSN

Success of biopsy depends greatly on Success of biopsy depends greatly on experience of breast Surgeonexperience of breast Surgeon

Incision at SN position and blue node Incision at SN position and blue node removedremoved

SN analysedSN analysed for metastatic spread for metastatic spread

SLNB ResultsSLNB Results

Pathological analysis categorizes Pathological analysis categorizes nodes in groups:nodes in groups:NegativeNegative (no cancer cells)(no cancer cells) axilla axilla treatment finishedtreatment finishedPositivePositive (contains cancer)(contains cancer) or or IndeterminateIndeterminate (uncertain of cancer (uncertain of cancer cells)cells) A.C required A.C required

Pathologist report authorisedPathologist report authorised

False-negative ResultFalse-negative Result

Occurs when SN has no cancer cells, Occurs when SN has no cancer cells, but another node in axilla doesbut another node in axilla doesMetastatic spread will go undetectedMetastatic spread will go undetected8% risk8% risk of this result with SLNB of this result with SLNB (NSW (NSW

Breast Cancer Institute)Breast Cancer Institute) Patient is undertreated as they won’t Patient is undertreated as they won’t receive chemotherapy at time of biopsyreceive chemotherapy at time of biopsy? Significance to progress of disease? Significance to progress of disease? Further lumps of cancer in axilla? Further lumps of cancer in axilla

Clinical TrialsClinical Trials

Global research on SLNB has been Global research on SLNB has been under way for quite some time and is under way for quite some time and is still on-goingstill on-going18 years research for SLN Biopsy18 years research for SLN Biopsy

ConclusionConclusion

Results show that SLNB is a Results show that SLNB is a safe & safe & reliablereliable technique in appropriately technique in appropriately selected patientsselected patientsDetermines who should or should Determines who should or should not require A.Cnot require A.C

Thanks

ReferencesReferencesBova D, Dillehay G, Halama J, Karesh S, Wagner R, Zimmer A Bova D, Dillehay G, Halama J, Karesh S, Wagner R, Zimmer A (2006) Nuclear Medicine (2(2006) Nuclear Medicine (2ndnd Ed). China: Mosby Elsevier. Ed). China: Mosby Elsevier.Diehl KM, Chang AE. Sentinel Node Biopsy: What Breast Cancer Diehl KM, Chang AE. Sentinel Node Biopsy: What Breast Cancer Patients Need to Know. Available: Patients Need to Know. Available: [online] [online] http://www.cancernews.com/printer.asp?aid=202http://www.cancernews.com/printer.asp?aid=202Imaginis (updated Jan 31, 2008) Sentinel Lymph Node Biopsy. Imaginis (updated Jan 31, 2008) Sentinel Lymph Node Biopsy. Available: [online] Available: [online] http://www.imaginis.com/breasthealth/sentinelnode.asphttp://www.imaginis.com/breasthealth/sentinelnode.aspMariani G, Moresco L, Viale G, Vialla G, Bagnasco M, Canavese Mariani G, Moresco L, Viale G, Vialla G, Bagnasco M, Canavese G, Buscombe J, Strauss HW, Paganelli G (2001) Radioguided G, Buscombe J, Strauss HW, Paganelli G (2001) Radioguided Sentinel Lymph Node Biopsy in Breast Cancer Surgery. Sentinel Lymph Node Biopsy in Breast Cancer Surgery. Journal Journal of Nuclear Medicine. of Nuclear Medicine. Vol. 42 No. 8, P1198-1215.Vol. 42 No. 8, P1198-1215.The NSW Breast Cancer Institute, Sentinel Node Biopsy, An The NSW Breast Cancer Institute, Sentinel Node Biopsy, An Information Guide for Patients (Jan 2008). Information Guide for Patients (Jan 2008). Available: Available: [online] [online] http://www.bci.org.auhttp://www.bci.org.au

QUESTIONS?QUESTIONS?