sentinel node: practical experience at frimley park hospital
DESCRIPTION
Sentinel Node: Practical Experience at Frimley Park Hospital. RJ Morton, A Fullbrook, L Wright, JRW Hall, J Ward. History. 1951Parotid (Gould) 1977Penile (Cabanas) 1966Testicular 1992Melanoma 1970Breast (Blue Dye) 1990’sBreast (Radionuclide). SLN. SLN. SLN. - PowerPoint PPT PresentationTRANSCRIPT
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Sentinel Node:Practical Experience at Frimley Park
Hospital
RJ Morton, A Fullbrook, L Wright, JRW Hall, J Ward
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History
• 1951 Parotid (Gould)• 1977 Penile (Cabanas)• 1966 Testicular• 1992 Melanoma
• 1970 Breast (Blue Dye)• 1990’s Breast (Radionuclide)
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What is Sentinel Lymph Node (SLN)?
• The Sentinel Node is any node which receives drainage directly from the primary tumour
SLN SLN SLN
Secondary nodeSLN
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Why SLN?• Morbidity of traditional
axillary surgery (e.g. lymphoedema, seroma, numbness, stiff shoulder)
• Diagnosing more early node negative breast cancer
• Development of a minimally invasive, safe, reproducible and accurate technique to predict nodal status
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SLN:The first node to receive lymph drainage directly from tumour
Other nodes will be clearSN-
Tumour
SN+ Other nodes may contain cancer
the node that predicts lymph node status
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Diagnosis: who is eligible?
Eligibility: Virtually any cancer patient who requires lymph node staging.
Exclusions: Gross nodal disease and/or signs oflymphatic obstruction. Distant metastases
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NEW STARTSLN training programme 2004-2006
Joint Project• Department of Education: Royal College of
Surgeons of England• Cardiff University Wales
Supported by• DoH, National Assembly in Wales • GE Healthcare
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What is New Start?National Training Programme
• Standardised methodology and training materials
• Focus on multidiscipline team – Surgery, Nuclear medicine/physics, Radiology, BCN, Theatre nurses, Pathology, etc
• Experienced validated training teams• Unique workplace training and mentorship• Quality assured• Centrally audited and validated (anonymised
data collection)
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NEW STARTSLN training programme: Overview
Theory Day
In House Training
Mentoring&
Validation
12-18 months
Stand alone
SLNBSkills SLNB + standard procedureTheory
Ongoing Audit
5 cases per surgeon 25 cases per surgeon
Theory
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FPH - SLN
• Started 1999 (breast and melanoma)– Research ARSAC
• Full ARSAC (Dec 2003)
• 229 (1999-April 2005)
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Patient Journey
Diagnosis Nuclear Medicine Surgery Pathology
99Tcm Nanocolloid Blue Dye
SLN
10 mins
Imaging
2 – 3 hours
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Request Form
• Next Day– Good image statistics– Lower radiation dose/protection issues– Surgeon finds node easier to locate (less shine
through from injection site)
• Same Day– Convenient
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Injection Technique
Periareolar/Sub dermal(<5% negative node)
Peritumour
Ultrasonic control (15% negative node)
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SLN Injection Technique – Suggested Protocol for NEW START
Palpable Impalpable
No prior excision biopsy
15–40 MBq in 0.2ml 99mTc-Nanocoll
injected intradermally overlying tumour
15–40 MBq in 0.2ml 99mTc-Nanocoll
periareolar intradermal injection in index quadrant
Prior excision biopsy
2 x 10-25 MBq in 0.2ml 99mTc-Nanocoll
injected intradermally
either side of excision scar
2 x 10-25 MBq in 0.2ml 99mTc-Nanocoll
injected intradermally
either side of excision scar
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Injection Technique (Breast) at FPH
• Cloth/inco pad around injection site
• Site – periareolar• Tc-99m Nanocolloid• 4 injections (0.5 ml each)
– 1 ml in each syringe– 25 gauge needle
• Activity– 20 MBq (same day)
– 40 MBq (next day)
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Injection technique continued
• Massage injection site• Tape gauze over injection site• Disease side only
Melanoma– 4 injections around the scar
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Imaging - Breast• 2 – 3 hours post injection• Supine• Arms raised• LEHR• 256 matrix• 300s static• Full field (pixel size:
2.35mm)• Ant, lateral, oblique• Cobalt source –body
outline
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Mark Nodes
• Mark nodes using Co-57 pen source
• Oblique view (Ant for internal)
• Indelible pen
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Imaging - Melanoma
• Dynamic– 45 * 20s frames– 128 matrix– LEHR– Area above injection site
• Static– 2 – 3 hours– 256 matrix– LEHR– 300 s– Ant, Lateral, oblique– Axilla/groin
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Single Node
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Multiple Nodes
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Negative Image
• <5 % -Negative node rate
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Importance of Oblique Image
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Internal Mammary
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Unexpected Results
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Surgery
1.Blue dye injection 2mls in 4-5 mls saline
(allergic reaction 1.8%, hypotension 0.2%)
2. Identify SLN : Colour and Counts
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Gamma Probes
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Surgery
• Frozen Section – Takes up to 45 mins– Immediate axillary dissection
• SLN biopsy – second operation for reconstruction and axillary
clearance if necessary
• Reconstruction with SLN – Only return to theatre if SLN positive.– Greater risk of damage to reconstruction
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77
82
96
3.4
0 10 20 30 40 50 60 70 80 90 100
Blue node
Hot node
Hot or bluenode
Failedlocalisation
SLN identification
ALMANAC TRIAL AUDIT PHASE
% Success in finding sentinel node
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Results from FPH
• 96 consecutive cases• Located nodes 96.5 % (Standard >95%)• Failed localisation 1%• 2.6 nodes average• 28.4 % node positive (Standard 20-
30%)
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SLNB:Safety
• Extensive clinical experience/follow up in USA/Europe (individual series of 2-3000 cases)
• Early data demonstrates very low local recurrence rates
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Legislation
• Environment Agency
• ARSAC – Nuclear Medicine Specialist– Surgeon undertaking SLN biopsy as an operator– Provide proof that surgeon is undergoing
training (NEW START)
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Radiation Protection
• Patient: 20MBq ED 0.42 mSv• Surgeon:
– Whole body dose 1.9 Sv/case
– Finger dose 13 Sv/case500 cases before annual limit is reached
Morton et al: BJR 2003, (76) 117-122
Local Radiation Protection Department
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Theatre
– May need to store for 48 hours
• Contamination– Normal precautions for biohazards
• Training/Instruction sheet for staff
Same day 0.2 - 1.9 MBq
Next day 0.001 - 0.1 MBq
• Waste
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Pathology
• Pathologist
• Fix immediately but leave for 24 hours before section
• Label samples as radioactive and store away from the main area
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UK Probe Working Group
To produce guidance on issues relating to the Gamma Probe in SNB
– Purchase
– Evaluation
– Quality Assurance
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Output
• BNMS web site (October 2004)– Gamma Probe Purchase Specification– Guide to User Evaluation
• In draft– Quality Assurance guidelines– Performance Evaluation– (Guidelines on use for surgeons)
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Probe QC