complications of axillary node sentinel lymph node history
TRANSCRIPT
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Sentinel Node Mapping for Breast Cancer:
Progress to date and Progress for the
Future
Dr. Shikha Dhal
Associate Prof.
Dept. Of Radiation Oncology
The axillary nodal status is accepted universally as the most powerful prognostic tool for early stage breast cancer
also guides
treatment options
and adjuvant
therapies.
Axillary Node Status as Prognostic Tool Axillary Node Status as Prognostic Tool
The removal of level I
and level II lymph
nodes at axillary node
dissection (ALND)
most accurate
method for nodal
status
Complications of Axillary Node
Dissection
Lymphedema
Disruption of nerves
in the axilla
Chronic shoulder pain
Weakness
Joint dysfunction
➢Survival advantage of ALND???
➢Less morbid methods of evaluating the axillary
nodal basin?
➢Sentinel node biopsy?
Sentinel Lymph Node
sentinel lymph node:
– The first lymph node to
which cancer is likely
to spread from the
primary tumor.
– These nodes can be
identified and excised
for histological analysis
History of Sentinel Node Concept
Not new
Virchow’s node
– left supraclavicular node which corresponds to the
thoracic duct to which met. Gastric ca spreads
Sister Mary Joseph’s node
– an umbilical node that represents metastatic intra-
abdominal cancer
Delphian node
– of the thyroid
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Comparison of Side Effects Between Sentinel Lymph Node
and Axillary Lymph Node Dissection for Breast Cancer
SLND has fewer side effects Annals of Surgical Oncology, 9(8):745–753
Lymphatic Mapping Techniques
and Sentinel Lymph Node BiopsyChoice of Mapping Label– Radioisotope alone
– Blue dye
– Combination of blue dye and radioisotope
– Filtered vs. Unfiltered radioisotope
Injection Site for Mapping Agents– Peri-tumoral injection
– Subareolar and dermal injection
Preoperative Lymphoscintigraphy
Timing of radioisotope injection
The Future and Controversies
Some interesting studies
Choice of Mapping Label
Radioisotope alone
Technetium-99m sulfur colloid (albumin) and hand held gamma probe
Sentinel node identificaiton rate of 98%
False negative 11%
Krag DN, et. al. Surg Oncol, 1993
Choice of Mapping Label
Radioisotope aloneChoice of Mapping Label:
Isosulfan blue dye
Extensively studied in melanoma
SN identification rate of 98%– Without false-negative nodes.
Life threatening allergic and anaphylactic reactions (1-3%)– Commonly urticarid, rash, blue
hives, and pruritus.
Most commonly used dye
Choice of Mapping Label:
Methylene blueNode identified 93%
Preferred by some due to lower cost and lower
risk of allergic reaction
MB dye has to be injected into subcutaneous
tissues-inadvertent injection into the dermis
– severe skin reactions
Necrosis
Dermolysis
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Choice of Mapping Label:
Combination of blue dye and
radioisotope
Dual agent mapping improves SLN
identification
Some hesitant to use dual agent due to
allergic reactions from the dye.
Choice of Mapping Label
Filtered vs. Unfiltered radioisotope
Adequate uptake of isotope from the breast parencyma by intramammary lymphatics
Must travel to sentinel nodes in a timely fashion
Travel time
Size of carrier and amount of fluid used
Large particles(>400nm) too slow
Small too quick and migrate to entire nodal basin, difficult to ID single sentinel nodes.
Can alter the techn-99 size filters with specific pore size (100-220nm)
Choice of Mapping Label
Filtered vs. Unfiltered radioisotope
Were a
significantly
more SN in
unfiltered
No consensus
on the use of
filtered vs
unfiltered
J Am Coll Surg 1999; 188(4):377-81
Injection Site for Mapping Agents
Peri-tumoral injection
to replicate the
intramammary
lymphatic pathways
– Difficult and time
consuming in non-
palpable lesions
– Higher potential for
shinethrough
Artifact background from
residual radiactivity
Injection Site for Mapping Agents
Subareolar and dermal injection
Mammary lymphatics develop as radial extensions from the nipple breast bud
Nearly all lymphatic drainage passes through the subareolar plexus of Sappey and then in to axillary nodal basin– Subareolar and dermal
injection effective
Especially in multicentric tumors.
Eliminate shinethrough effect
Injection Site for Mapping Agents
Subareolar and dermal injection
Disadvantage:
– Upto 10% of breast
cancers demonstrate non-
axillary drainage
– Internal mammary or
supraclavicular nodal
basin
– May cause “blue breast”
for several months.
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Preoperative Lymphoscintigraphy
Consists of anterior and lateral views and specific patient positioning to optimize transit time and radioisotope drainage.
Scanning initiated 20mins after radioisotope injection and images repeated until the primary SLN basin is identified.– Then the patient is taken to the operating room.
Controversial whether preoperative scanning is of diagnostic value.
Found no significant difference identification rate, false-negative rate, or number of SLNs betweens the pre-op SLNs and intraoperative.
Preoperative
Lymphoscintigraphy
Preoperative
Lymphoscintigraphy
Preoperative
LymphoscintigraphyTiming of radioisotope injection
Done as a 1 or 2 day procedure
Single day procedure
– Breast injection on the morning of surgery
– Imaging 1 to several after until SLN is identified.
– Can delay operation significantly
2 day procedure to reduce delay
– Need higher dose of radioisotope
Tc99 half-life 6hrs.
– Greater background effect.
Sentinel lymph node biopsy in breast cancer
patients after overnight migration of radiolabelled
sulphur colloid
technically feasible for detecting sentinel lymph nodes in most breast cancer patients
accurately predicting the axillary lymph node status
and appears more accurate for T1 lesions than for larger lesions.
Postgrad. Med. J. 2004;80;546-550
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Micrometastasis in the Sentinel Lymph Node of Breast
Cancer Does Not Mandate Completion Axillary
Dissection
SLN was the only positive axillary node in 64% in this study patients
only SLN metastases 2 mm was an independent predictor of additional disease in the axilla.
completion axillary dissection may not be necessary in women who have micrometastatic disease in the SLN.
Annals of Surgery, 239 (6), 2004
The Future and Controversies
Prognostic value of axillary nodal
micrometastases identified by
immunohistochemistry?
– Not proven to affect treatment, recurrences or
survival
Those who have positive SLNs, survival
advantage in ALND?
ALND remains the standard.
General Review of Literature
Some interesting studies.
Sentinel Node Biopsy Indications
J Clin Oncol 2005; 23(30):7703-20
American Society of Clinical Oncology Guideline
Recommendations
Sentinel node biopsy and
randomized trialsOnly one prospective, randomized trial comparing SNB with ALND
Randomized 516 patients who had T1 tumors to either SNB followed by ALND or SNB alone.
Incidence of positive sentinel nodes same in both groups.– SNB alone could predict
axillary nodal metastasis
N Engl J Med 2003; 349:546-53.
Overall Survival SNB vs. ALND
No significant difference in overall survival.
Median f/u time <4 years.
Lacked power to detect small differences
False negative rate SNB 8.8%
N Engl J Med 2003; 349:546-53.
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Axillary Recurrence After Sentinel
Node Biopsy
Ann Surg 2004; 240(3): 462-71
Axillary recurrence is rare among patients with negative
sentinel nodes.
Sentinel Node Biopsy for
Prophylactic Mastectomy
163 women high risk for breast cancer or with
contra lateral breast cancer
– Underwent PM, 8% (13/163) had occult carcinoma
– 2/13 sentinel node positive
SNB also critical in patients having immediate
reconstruction.
Flap vascular supply compromise if AND.
SNB in PM may help avoid these complications.
Surg Oncol Clin N Am 16 (2007) 55-70
Multicentric Breast Cancer: A New Indication
for Sentinel Node Biopsy
Multicentric breast cancer has been considered to be a contraindication for SNB.
In this prospective multi-institutional trial, SNB-feasibility and accuracy was evaluated in 142 patients with multicentric cancer
Compared unicentric vs multicentric nodes
J. Clin. Oncol. 24(21), 2006
Multicentric breast
cancer is a new
indication for SNB
without routine
ALND in controlled
trials.
J. Clin. Oncol. 24(21), 2006
Multicentric Breast Cancer: A New
Indication for Sentinel Node Biopsy
Sentinel Node Skills Verification and
Surgeon Performance
SNB learning curves of 700 cases by 5 surgeons
– After 23 cases, 90% success rate
– After 53 cases, 95% success rate. J Am Coll Surg 2001; 193(6): 593-600
Adequate residency
experience,
fellowship training,
or mentor
supervision with
“backup” ALND and
self monitoring of
results are prudent.
Sentinel Node Skills Verification and
Surgeon Performance
J Am Coll Surg 2001; 193(6): 593-600
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Conclusion
➢SNB allows accurate axillary staging of patients
with invasive breast cancer and a clinically
negative axilla
➢SNB has fewer complications than ALND.
➢SNB has been proven to be safe and effective
for patients with relatively small brest cancers
(T1 and T2) and clinically negative axillae.
➢SNB is the preferred method for axillary staging.
➢Training programmes relevant to
multidisciplinary teams need to be developed for
this methodology.