BREAST SENTINEL NODE LOCALISATION

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BREAST SENTINELNODE LOCALISATION BIOPSY

• Kirsten Worthington
• Senior Nuclear Medicine Technologist/MRT

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What is a Sentinel lymph node (SLN)?

• The very first lymph node to receive drainage
  from a cancer containing area of the breast
• Typically located in
• - Axilla (armpit)
• but can also be in
• - Internal Mammary
• - Clavicular groups

1. Axillary lymph nodes
2. Internal mammary lymph nodes
3. Supra infra clavicular lymph nodes

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Axillary Clearance (A.C)

• All axillary lymph nodes removed in patients with
  breast cancer
• Pathological lymph node analysis important in
  staging disease
• Typically 10?15 nodes removed (Diehl, Chang)
• A.C reduces chance of cancer returning to axilla.
  Gold Standard Procedure

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Side Effects from Axillary Clearance

• Lymphedema /-
• - Stiff shoulder
• - Numbness (nerve damage)
• - Fluid collection
• 10-15 cm surgical wound
• Long recovery period
• 70 of DCIS breast cancer cases have not
  metastasized to the lymphatic system (Journal of
  Nuclear Medicine, Vol. 42 No.8, 2001)

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What is Sentinel Lymph Node Biopsy (SLNB)?

• Recent technique checking for lymphatic mets
  without performing an A.C
• 1?3 sentinel node/s removed only
• Sentinel node/s identified at surgery by
• - 99mTc Senti-scint/Geiger probe
• - Isosulfan Blue Dye Test
• Preliminary pathological analysis of nodes during
  surgery
• Negative biopsy result ? operation completed
• Positive biopsy result ? Patient will require A.C

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Who can have Sentinel Lymph Node Biopsy?

• Patients with in-situ breast carcinoma
• - small tumours (DCIS)
• SDHB Procedure done in conjunction with
  lumpectomy or mastectomy

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Who Shouldnt have a SLNB?

• Women with large carcinomas
• - gt5 cm
• Had R/T or surgery to breast/axilla area
• Present with enlarged axillary lymph glands
• Multifocal tumour
• Occult Malignancy

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Possible Side Effects from SLNB

• Blue urine ? 24 hrs
• Breast stained blue ? 2 weeks
• - Mild reaction to dye 1-2 risk (NSW Breast
  Cancer Institute)
• - Severe reaction rare
• Wounds in breast, armpit sternum
• Lymphedema 1-2 risk (NSW Breast Cancer
  Institute)
• Numbness
• False negative result possible

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Advantages of SLNB(over Axillary Clearance)

• Reduced hospital stay
• Smaller axillary scar
• Quicker recovery time
• Reduced risk of lymphedema, pain numbness

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How is the breast SN mapped inNuclear Medicine?
Technique 1

• Affected breast ? 4 x injections 99mTc
  Senti-scint
• Radioactive injections are placed tumour quadrant
  around areolar (about oclock position)

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How is the breast SN mapped inNuclear Medicine?
Technique 2

• 2 x injections 99mTc Senti-scint placed either
  side of breast tumour
• Require Radiologist ultrasound machine

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Senti-scint Localisation in Lymph Node

• Radioactivity travels freely in lymph vessels but
  trapped in lymph nodes
• Isotope travels from tumour location to Sentinel
  Node
• Breast massage encourages flow of radio-tracer
• Scanning occurs lymph node is identified

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Nuclear Medicine SLN Images Peri-areolar
Technique

• Node/s marked on patients skin
• Patient ready to proceed to surgery

• Node/s identified
• - Anterior 57Co Flood Field
• - Lateral 57Co Flood Field

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Nuclear Medicine SLN Images Peri-tumoral
Technique

• Axillary nodes
• - Multiple
• IM node positive

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SPECT / CT Images

• 3D volume rendered SPECT/CT

• CT (top line)
• SPECT data (middle line)
• Fused data (bottom line)

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Surgery/Biopsy of SN

• Blue dye injected at commencement of surgery ?
  turns SN blue
• Geiger probe detects radioactivity in SN
• Success of biopsy depends greatly on experience
  of breast Surgeon
• Incision at SN position and blue node removed
• SN analysed for metastatic spread

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SLNB Results

• Pathological analysis categorizes nodes in
  groups
• Negative (no cancer cells) ? axilla treatment
  finished
• Positive (contains cancer) or Indeterminate
  (uncertain of cancer cells)? A.C required
• Pathologist report authorised

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False-negative Result

• Occurs when SN has no cancer cells, but another
  node in axilla does
• Metastatic spread will go undetected
• 8 risk of this result with SLNB (NSW Breast
  Cancer Institute)
• Patient is undertreated as they wont receive
  chemotherapy at time of biopsy
• ? Significance to progress of disease
• ? Further lumps of cancer in axilla

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Clinical Trials

• Global research on SLNB has been under way for
  quite some time and is still on-going
• 18 years research for SLN Biopsy

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Conclusion

• Results show that SLNB is a safe reliable
  technique in appropriately selected patients
• Determines who should or should not require A.C

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Thanks
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References

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

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QUESTIONS?