BREAST SENTINEL NODE LOCALISATION & BIOPSY

1. BREAST SENTINELNODE LOCALISATION& BIOPSY Kirsten Worthington Senior Nuclear Medicine Technologist/MRT

2. 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 • Axillary lymph nodes • Internal mammary lymph nodes • Supra & infra clavicular lymph nodes

3. 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

4. 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)

6. 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

7. 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

8. Who Shouldn’t have a SLNB? • Women with large carcinomas - >5 cm • Had R/T or surgery to breast/axilla area • Present with enlarged axillary lymph glands • Multifocal tumour • Occult Malignancy

9. 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

10. Advantages of SLNB(over Axillary Clearance) • Reduced hospital stay • Smaller axillary scar • Quicker recovery time • Reduced risk of lymphedema, pain & numbness

12. How is the breast SN mapped inNuclear Medicine? • Affected breast  4 x injections 99mTc Senti-scint • Radioactive injections are placed tumour quadrant around areolar (about o’clock position) Technique 1

13. How is the breast SN mapped inNuclear Medicine? • 2 x injections 99mTc Senti-scint placed either side of breast tumour • Require Radiologist + ultrasound machine Technique 2

14. 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

15. Nuclear Medicine SLN Images Peri-areolar Technique Node/s identified - Anterior + 57Co Flood Field - Lateral + 57Co Flood Field Node/s marked on patient’s skin Patient ready to proceed to surgery

16. Nuclear Medicine SLN Images Peri-tumoral Technique Axillary nodes - Multiple IM node positive

17. SPECT / CT Images • 3D volume rendered SPECT/CT CT (top line) SPECT data (middle line) Fused data (bottom line)

19. 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

20. 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

21. 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 won’t receive chemotherapy at time of biopsy • ? Significance to progress of disease • ? Further lumps of cancer in axilla

22. 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

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

24. Thanks

25. 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

26. QUESTIONS?