sentinel node biopsy irch - aiims experience

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.

Dr SVS Deo, AIIMS, SLNB

Sentinel Lymph Node Biopsy (SLNB)

Introduction SLNB - Concept , Rationale & Technique SLNB - AIIMS Experience Evidence based future strategies for Indian BC

Patients



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- ALNDIncidence - 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 - “ 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



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



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



• 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



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



Out Come

SLN identification rate - 95% False negative SLN - 8 % Accuracy in predicting Ax LN status - 92% Accuracy of ICC – 98 %



Publications


Video



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 – IRCHBreast 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%)



Types of Surgery : RM : 39 (5.3%)MRM : 582 (80.4%)BCT : 110 (12.8%)ALND : 11 (1.5%)Breast Reconstruction - 50Treatment policy- Axilla - Complete ALNDAxillary RT - LABC, >3 nodes, ENS



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%)



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



Indian BC Scenario – Changing Based on Current ALND Data

50 % EBC & 25 % LABC - Suitable SLNB Dye method with II Cytology - Suitable for

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



Current Era of transition Surgeons India should be familiar with ALND & SLNB

Choose a Middle path

Key to success – Customized treatment


Thank You

sentinel node biopsy irch - aiims experience

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