Sentinel Node Biopsy IRCH - AIIMS Experience
Dr. S.V.S. Deo MS, FACS, FAIS
Associate professor, Surgical Oncology
All India Institute of Medical Sciences
New Delhi
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Dr SVS Deo, AIIMS, SLNB
Sentinel Lymph Node Biopsy (SLNB)
Introduction SLNB - Concept , Rationale & Technique SLNB - AIIMS Experience Evidence based future strategies for Indian BC
Patients
Dr SVS Deo, AIIMS, SLNB
Sentinel Lymph Node Biopsy (SLNB)
Two Most Significant Advances in the field of Surgery during the last decade
Minimally Invasive Surgery (MIS) Sentinel Lymph Node biopsy(SLNB)
Dr SVS Deo, AIIMS, SLNB
Lymph Nodes - Solid Tumors
Solid tumors - Spread to lymph nodes Lymphadenectomy - Part of many curative Cancer
operations Lymphadenectomy –
Staging, Prognostication & Therapeutic Changing Concepts - Lymphadenectomy
Dr SVS Deo, AIIMS, SLNB
Why – SLNB ?
ALND - Gold standard of Managing Axilla
ALND - Standard technique , Rigorous clinical
scrutiny, excellent therapeutic efficacy
Recently – ALND - Less Popular
Morbidity more than therapeutic benefit in node negative patients
Dr SVS Deo, AIIMS, SLNB
Why – SLNB ?
Changing Treatment Philosophy Changing patient profile Technology driven therapeutic interventions
Dr SVS Deo, AIIMS, SLNB
Why – SLNB ?
Changing Treatment Philosophy
Better Understanding of Breast Cancer Biology
Paradigm shift - Surgical Approach Ultra Radical – Radical – Conservative
Dr SVS Deo, AIIMS, SLNB
Why – SLNB ? Old Times - Big Surgeons - Big Incisions- Big
Resections - ? Big Results - Big Egos Judicious Conservatism - Current trend Functional out come & QOL issues are
important end points Add life to years - Years to life Critical re evaluation of ALND Morbidity
Dr SVS Deo, AIIMS, SLNB
Morbidity- ALNDIncidence - 30 to 60 % Seroma & Lymphedema - 30% Shoulder syndrome - 25% Neuropathies - 50 to75% Increased Hospital stay Morbidity more than - Sx for Primary
Roses et al ,Ann Surg, 1999
Baum M et al, W J surg, 2001
Dr SVS Deo, AIIMS, SLNB
Morbidity- ALND
Dr SVS Deo, AIIMS, SLNB
Why – SLNB ?Changing Patient Profile Breast Cancer - Western world
70 % Screen detected Non Palpable lesions Majority - DCIS / T1 70 % Node Negative Majority receive Adj. Systemic therapy
Irrespective of Axillary status
Dr SVS Deo, AIIMS, SLNB
Why – SLNB ?Technology driven therapeutic interventions Decade of medical technology Pharmaceutical MNCs, Media playing a
major role - Influencing Therapeutic options Myth – “Technology = Cure” Treatment modalities are forced – Fast
tracking & Short circuiting rigorous scientific scrutiny
Dr SVS Deo, AIIMS, SLNB
Sentinel - “ Sentry / Guard”
Definition - Identification of first draining lymph node most likely to contain metastatic disease if metastases exists in the axilla”
Sentinel Lymph Node Biopsy (SLNB)
Dr SVS Deo, AIIMS, SLNB
Evolution- Sentinel Lymph Node Biopsy (SLNB)
Cabanas -1979 - SLN in Penile cancer Wong et al- 1991- Anatomic specificity of LN 1992 - Guliano et al - Blue dye method -Breast cancer 1993- Alex & Krag - Gamma probe detection using
radio colloid in Breast cancer
Dr SVS Deo, AIIMS, SLNB
Sentinel Lymph Node Biopsy (SLNB)
Visual detection method using dyes Patent blue, Isosulfan blue (Lymphozurin) Agents - LN seeking - Not - Tumor seeking Peri tumoral/ sub dermal injection (2- 4 ml) Exploration of lymphatic basin through small
incision after 5 -15 mts Identify the blue lymphatic going from primary
to Blue LN
Dr SVS Deo, AIIMS, SLNB
Sentinel Lymph Node Biopsy (SLNB)
Radio tracer detection using Gamma probe Injection of radiotracer tagged to pharmaceuticals Technitium –99m most commonly used tagged to
sulfur colloid / albumin Peri tumoral / Intradermal injection of 0.450 to 1.0 m
Ci – volume - 5-10 ml Exploration of lymphatic basin after 8 hrs using a
gamma detection probe
Dr SVS Deo, AIIMS, SLNB
Sentinel Lymph Node Biopsy (SLNB)
• Probe -Radiation detector
(scintillation detector)
• Electronic box –solid state
detector
• Converts photo signals to audio signals
• Audio signal & Count
• SLN- HOT NODE
Dr SVS Deo, AIIMS, SLNB
Current Status SLNB in BC
Positive SLN localization – 92 to100% False negative – 0 to10 % Best results - Combination of Dye & GPD Accuracy in predicting ALN status > 90% Rapidly evolving as a staging & Therapeutic
procedure in N0 Axilla SLNB - N+ Axilla – JACS, 2005,10. Therapeutic role - Mature Data awaited
Dr SVS Deo, AIIMS, SLNB
SLNB – AIIMS -_IRCH Experience
To evaluate the applicability of SLNB among Indian BC patients
Assessment of BC Patient profile Out come analysis - ALND Validation study - SLNB
Dr SVS Deo, AIIMS, SLNB
AIIMS - IRCH SLNB - Validation Study
SLNB - Protocol Validation Study – 2000 to 2003 Total number of patients – 140 ( stage I & II) Method – Blue dye ( Isosulfan 1%)
4 ml Peritumoral injection
All pts had post SLNB - Completion ALND
Dr SVS Deo, AIIMS, SLNB
AIIMS - IRCH SLNB - Validation Study
LN Assessment – Intra operative Imprint cytology
Two cuts – 4 sections of LN Jenner Geimsa / H & E staining Average time to reporting 20 mts Final HPE – gold standard No - IHC / RT PCR
Dr SVS Deo, AIIMS, SLNB
AIIMS - IRCH SLNB - Validation Study
Dr SVS Deo, AIIMS, SLNB
AIIMS - IRCH SLNB - Validation Study
Out Come
SLN identification rate - 95% False negative SLN - 8 % Accuracy in predicting Ax LN status - 92% Accuracy of ICC – 98 %
Dr SVS Deo, AIIMS, SLNB
AIIMS - IRCH SLNB - Validation Study
Publications
Dr SVS Deo, AIIMS, SLNB
Video
Dr SVS Deo, AIIMS, SLNB
AIIMS - IRCH SLNB - Validation Study
Post NAC- SLNB Assessment using IIC
“Paresh , Deo SVS, Mona et al
“J Diagnostic Cytopathology, 2003” Comparison of three Stains- JJ/H&E/ Pap
Mona , Paresh , Deo SVS et al
“Cancer - Cytopath – 2004”
Dr SVS Deo, AIIMS, SLNB
AIIMS – IRCHBreast Cancer Profile & ALND Analysis
Study Period - Jan 1993 to June 2000
Total number of BC patients - 742
Age : <35 yrs = 116, > 35 yrs = 626
Menopausal Status – Pre - 48 %, Post- 52%
EBC (Stage I & II): 363 (48.9%)
LABC (Stage III) : 379 (51.1%)
Dr SVS Deo, AIIMS, SLNB
AIIMS – IRCHBreast Cancer Profile & ALND Analysis
Types of Surgery : RM : 39 (5.3%)MRM : 582 (80.4%)BCT : 110 (12.8%)ALND : 11 (1.5%)Breast Reconstruction - 50Treatment policy- Axilla - Complete ALNDAxillary RT - LABC, >3 nodes, ENS
Dr SVS Deo, AIIMS, SLNB
AIIMS – IRCHBreast Cancer Profile & ALND Analysis
Median Nodal Yield - 14 + 5.91 Total number of Node + ve patients :
479 (64.6%) Stage vs Node positivity
EBC : 181/363 (49.8%)
LABC : 298/379 (78.6%)
Dr SVS Deo, AIIMS, SLNB
AIIMS – IRCHBreast Cancer Profile & ALND Analysis
Regional Relapse (N=16)
EBC : 2 ( 0.5%)
LABC : 14 (3.7%) Node positivity profile
< 3 node + ve - 45%, 3 to10 + ve - 32%,
> 10 nodes - 22% , ENS - 18% Lymphedema & Neuropathy – 35 %
Dr SVS Deo, AIIMS, SLNB
Evidence Based guide lines for SLNB in India
Indian BC Scenario - LABC > EBC Self detected BC more than Screen detected
BC Node positive more than Node Negative Currently ALND – Excellent Results for Indian
BC patients
Dr SVS Deo, AIIMS, SLNB
India- Country in Transition
Dr SVS Deo, AIIMS, SLNB
India- Country in Transition
Dr SVS Deo, AIIMS, SLNB
Evidence Based guide lines for SLNB in India
Indian BC Scenario – Changing Based on Current ALND Data
50 % EBC & 25 % LABC - Suitable SLNB Dye method with II Cytology - Suitable for
India
Dr SVS Deo, AIIMS, SLNB
Evidence Based guide lines for SLNB in India
Who should perform SLNB Surgical Oncologist General surgeon Rx more than 25 BC / year Learning curve - Short Validation study - Minimum of 20 cases
(Supervision) Blind extrapolation of Western data avoided Try and generate more Indian data
Dr SVS Deo, AIIMS, SLNB
Evidence Based guide lines for SLNB in India
Current Era of transition Surgeons India should be familiar with ALND & SLNB
Choose a Middle path
Key to success – Customized treatment
Dr SVS Deo, AIIMS, SLNB
Thank You
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