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Techniques of Sentinel Node Biopsy
V. Seenu
Associate Professor
Department of Surgical Disciplines,
All India Institute of Medical Sciences
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Sentinel Node & Breast Cancer
Sentinel node concept
• Sentinel = a guard, one who keeps
watch or a sentry
• The first node in the regional lymph
node basin that drains the primary
tumor.
Most often, it is a cluster of LNs.
SN Concept
Techniques
• Dye directed ( Blue dye)
• Radiotracer directed (Hot node)
• Combination
Dye directed technique
• Blue Dye Used
Iso sulphan blue; patent blue V
• Route of administration
Intra parenchymal
Intra dermal
Sub dermal
Peri areolar
Sub areolar
Blue dye technique
• Advantages
Simple, inexpensive, easy to identify
a blue stained tract against yellow fatty
background
• Disadvantages
Strong learning curve (Giuliano)
BLUE DYE
Reference
year
No of ID % False
pts
-ve rate
CR
Guiliano et al 1994
174
66
12
96
36
Nieweg et al
1996
27
89
0
100
42
Folscher et al 1997
79
40
12
85
51
Flett et al
Horgan et al
68
38
92
82
17
16
95
84
31
50
1998
1998
Node +
Pts %
Radiopharmaceutical
•
•
•
•
•
•
•
Tc99m Sulfur colloid
Filtered Tc99m labeled colloidal albumin
Tc99m Antimony trisulphide colloid*
Au-198 Gold Colloid*
Tc99m Stannous phytate*
Tc99m Dextran*
Tc99m Human serum albumin
Site of Injection
•
•
•
•
Subdermal/Intradermal
Peritumoral in deep seated lesions
specially in medial quadrant
Peri areolar
Sub areolar
Dose and Volume
•
•
•
•
0.1-0.4 ml to 4-8 ml
300 - 400 Ci
500 uCi-1mCi
Filtered or unfiltered
Imaging Technique
•
•
•
•
Dynamic images
Static images
Anterior
Lateral
Static images
Dynamic
images
Case (3): 2 positive axillary LNs in both early
and delayed images.
Static images
Dynamic
images
Case (5): 1 positive axillary LNs in early images
and 2 positive axillary LNs in delayed images
Advantages of Radiotracer
guided technique
• ‘Road map’ to the SN
• Detects SNs at unusual sites
- Level III, sub pectoral, int. mammary
Disadvantages of radiotracer
guided technique
•Radioactive shine through
• Non-sentinel nodes
• Equipment expensive
γ Probe
No of
Pts
ID (%) False – CR
ve (%)
Ref
Year
Krag et al
1993 22
82
0
100
39
Offodile et
al
1998 41
98
0
100
45
Veronesi et
al
1997 163
98
5
98
53
Pijpers et al 1997 37
92
0
100
34
Borgstein et 1998 130
al
94
2
98
42
Roumen et
al
69
4
96
40
1997 83
Node
+ve
Combination Technique
• Blue dye can help to differentiate
between SN and 2nd echelon LNs
• If accidental transection of blue
tract occurs gamma probe guides to
the SN
• All blue nodes are not hot and not
all blue nodes are blue
BLUE DYE + γ Probe
Ref
Yr
Pts ID
(%)
False
–ve
rate
CR
Node
+ve
Albertini
1996
62
92
0
100
32
Cox etal
1998
46
6
94
1
100
23
O Hea
1998
59
93
15
95
36
Gil et al
1997
36
83
8
93
-
Devries et 1997
al
10
100
0
100
60
Borgstein 1997
et al
33
100
0
100
56
Injection techniques for SLN biopsy in breast cancer
Source
Patient
no
Blue Dye
Radioac
tive
colloid
Concordance
rate %
SLN
ID %
False –
ve Rate
%
Klimberg et al 1999
69
PT
SA
95.4
94.2
NA
Bauler et al 2002
249
SA
PT
90.0
96.8
NA
Beitsch et al 2001
85
PT
SA
95.2
97.6
NA
Donahue
42
SA
PT
95.2
100
8.3
Tuttle et al
159
PT
PT
95.0
100
NA
Smith et al 2000
19
PT
SA
84.2
100
NA
D Eredita et al 2003
115
SA
PT
NA
94.8
9.1
Kern 1999
40
SA
NA
NA
97.5
0
Zavagno et al 2002
50
SA
PT
93
94
NA
Pelosi et al 200
50
PA
PT
91.8
98.0
NA
Chagpar et al
1431
Varied
PT
NA
91.1
8.6
148
Varied
SA
99.3
8.3
183
Varied
PA
95.6
8.9
Steps of Procedure
3 - 5 Ml of Blue Dye Injected Into peritumoral Breast Parenchyma
3 - 7 Min. Interval
Axillary Incision
20 Min. Of Dissection
SN Identified
SN Not Identified
WLE / TM With Conventional ALND
SN & ALND Specimen Sent for HPE
Results
•
•
•
•
•
•
Study Period: May 1999-June 2004
No of Pts: 312
Age range: 31-82 yrs (mean: 41.4 yrs)
Menopausal Status : Pre: 145 Post: 167
Side : R:L:: 160: 152
T status
T1: 68; T2: 212; Tx: 31
Results (n=312)
• Identification Rate: 92% (287/312)
• Concordance Rate: 98% (283/287)
• False –ve Rate:
5% (4/84)
SN not identified: 8% (n=25)
SN V/S ALN status (n=312)
Both SLND & ALND -ve
:
205
Only SLND +ve
:
31
Both SLND & ALND +ve
:
47
SLND -ve & ALND +ve
:
No sentinel node identified :
4
25
Tumor Location V/S failure to identify SN
7/38
3/171
4/42
10/26
1/35
False –ve SN (n=4)
• Tx with large excision bx cavity (n=2)
• T2 tumor in subareolar location blue dye –
ve hot node +ve (? non-SN)
• T2 tumor in LOQ cause:??
Location of SN (n=287)
Level I: 265
Level II: 22
Blue dye V/S Combination
IR
Blue
88% (133/149)
Combination
94% (97/104)
CR
97% (130/133)
98% (96/97)
-ve rate 7% (3/41)
No. of SNs 1-4 (1.8)
4% (1/28)
1-6 (2.6)
Lymphazurin V/S Custom made
blue dye (Lymphophil)
Lymphazurin
IR
90% (53/58)
Custom made dye
87% (80/91)
Frozen Section of SN (n=232)
PS
FS
+
-
+
70
11
8
198
False -ve:11%; False +ve: 5%
Immunohistochemistry (IHC; n= 209)
Establishing SN
Program
SURGEON
NUCLEAR MED
PATHOLOGIST
Feasibility; Validation; On going SN program
Why should our SN program be
different?
• Commercial blue dye: expensive & not
marketed in India
Custom made blue dye
• Hand held gamma probe very expensive
Indigenous probe
• Large sized tumor and  incidence of nodal mets
FS, Imprint Cytology may be mandatory
Conclusions
• Combination technique is superior to blue
dye or probe directed technique alone.
• No one site of injection has superior SN
identification rates
• Intraparenchymal peritumoral blue dye and
sub areolar/ periareolar tracer injection may
give the best results
SN Biopsy As Surgical Rx of Axilla
• SN identified: 33/ 37 pts
• SN – ve for mets on FS & IC: 27 pts.
SNB alone
• ALND: SN +ve: 5 pts
SN – ve : 1 pt
• Follow-up: 11 months (3-18 mths)
No recuurence
SN Biopsy As Surgical Rx of
Axilla