Post on 14-Jul-2015
Sentinel Lymph node concept in Early breast cancer
BY: PROF. R.W.WASIKE MB CHB, MMED(UoN) FRCS(C)
Associate ProfessorConsultant General /Breast Surgeon
Department of SurgeryAga Khan University Hospital, Nairobi
Case OneA 50 years old female patientA 2cm lump – core biopsy invasive ductal carcinoma
of the breast grade I (ROUQSegmentectomy with sentinel lymph node biopsy –
negativeER/PR – negativeRadiotherapy givenHas recovered well
Case Two
A 40-year-old female presented with 2.5cm lump in LLOQ.
•No axillary lymphadenopathy
•Core biopsy invasive ductal
carcinoma
•Done BCT/sentinel negative
lymph biopsy
Given
•Radiotherapy
•Chemotherapy due to age and
grade of tumour
Case ThreeA 45-year old female presented with 1cm lump in the ROUQ
•No lymphadenopathy
•Core biopsy
•Grade I invasive ductal carcinoma
•Done BCT/SLNB (-ve)
Given
•Radiotherapy and Tamoxifen – ER/PR positive
B C T / S L N B..105 MASTECTOMY/S L N B..68
STAGE O 30
STAGE 1 60
T2 TUMOURS 83
KEY:
BCT:- Breast Conservation Therapy
SLNB:- Sentinel Lymph Node Biopsy
False negative rate 6%
Positive Predictive value 96%
Management of Axillary Lymph Nodes
•Infitrating ductal cell carcinoma (IDCA)•Invasion of tumor cells beyond the basement Membrane•Nodal basin needs evaluation• Gold Standard•Complete ALND•Sentinel Node Biopsy (SLNB)•Early breast cancer
Axillary Node Dissection
•Staging:•Single best predictor for risk of systemic disease and cancer recurrence•Therapeutic decisions• Systemic therapy• Radiation therapy
•May improve survival and cure
Sentinel Lymph Node Biopsy (SLNB)•Definition
•“gate-keeper” or first echelon node to drain a tumor,i.e. primary breast cancer
•Focuses on• Identify node-negative patients
•avoid unnecessary node dissection•Identify node-positive patients
•Complete node dissection•Systemic therapy• XRT
The navigator sentinel probeSmart.Simple.Precise.
Mapping the sentinel nodeSurgical procedure performed to locate, excise and
pathologically evaluate the Sentinel Lymph Node.Used for breast tumors or melanoma Sentinel Lymph Node (SLN) is the first lymph node
receiving lymphatic drainage from the tumorNavigator used in conjunction with a
radiocolloid(Tc99) and Lymphazurin blue dye to locate the SLN
SLN biopsied to determine metastases
Identifying the sentinel node
Node basin re-examined for secondary, tertiary SLN’s – 10% Rule
SLN(‘s) sent to pathology to see if positive for metastases
Incision closed after pathology report
Identifying the Sentinel Node•Injection material
•Technetium-99m sulfur colloid• Isosulfan blue
•Site of injection•Intra-tumoral•Intra-parenchymal•Intra-dermal/peri-areolar
•Embryological: axilla•May miss internal mammary nodes
European Insti tute of Oncology 1998 – 1999 (516 patients)
Axillary Dissection Sentinel lymph-nodeBiopsyDissection if the sentinel node is positive
Overall Survival
IEO 2001SN with Micrometastases <2mm
931 cases
Axil lary Dissecti
on
NO Axil lary
Dissection
IEO 2001
Galimberti V, et a l. 2013
New IEO Trial( in progress)
T1 NOWithout clinical and ultrasound evidence of suspicious axillary nodes
Sentinel Node Biopsy
No Axillary treatment
Interpretive SummarySLNB for early breast cancer is relatively a new procedure.
SLNB is acceptably accurate assessment of the axillary status.
The role of routine IHC and/or molecular biological analysis of SLNB remains unclear.
Appropriately identified patients, successfully mapped, with a negative SLNB do not require a level I or II ALND.
Gary H. Lyman et al Journal of Clinical Oncology 2005
Questions ????