BREAST SENTINEL NODE LOCALISATION & BIOPSY Kirsten Worthington Senior Nuclear Medicine Technologist/MRT 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 a) b) c) Axillary lymph nodes Internal mammary lymph nodes Supra & infra clavicular lymph nodes Axillary Clearance (A.C) All axillary lymph nodes removed in patients with breast cancer Pathological lymph node analysis important in ‘staging’ disease Typically 1015 nodes removed (Diehl, Chang) A.C reduces chance of cancer returning to axilla. Gold Standard Procedure 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) What is ‘Sentinel Lymph Node Biopsy’ (SLNB)? Recent technique checking for lymphatic mets without performing an A.C 13 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 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 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 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 Advantages of SLNB (over Axillary Clearance) Reduced hospital stay Smaller axillary scar Quicker recovery time Reduced risk of lymphedema, pain & numbness How is the breast SN mapped in Nuclear Medicine? Technique 1 Affected breast 4 x injections 99mTc Sentiscint Radioactive injections are placed tumour quadrant around areolar (about o’clock position) How is the breast SN mapped in Nuclear Medicine? Technique 2 2 x injections 99mTc Senti-scint placed either side of breast tumour Require Radiologist + ultrasound machine 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 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 Nuclear Medicine SLN Images Peri-tumoral Technique Axillary nodes - Multiple IM node positive SPECT / CT Images 3D volume rendered SPECT/CT CT (top line) SPECT data (middle line) Fused data (bottom line) 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 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 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 Clinical Trials Global research on SLNB has been under way for quite some time and is still ongoing 18 years research for SLN Biopsy Conclusion Results show that SLNB is a safe & reliable technique in appropriately selected patients Determines who should or should not require A.C Thanks 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 QUESTIONS?