sentinel nodes

Sentinel NodesSentinel Nodes

J.R.BuscombeJ.R.Buscombe

RFHRFH

Sentinel NodesSentinel Nodes Uses the Morton principle of logical Uses the Morton principle of logical

lymph drainage from a tumourlymph drainage from a tumour Methods use include blue dye and Methods use include blue dye and

radiotracersradiotracers Combination of 2 may be bestCombination of 2 may be best Pioneers in breast Pioneers in breast

Morton/Krag/Guilianno USAMorton/Krag/Guilianno USA (EIO, Italy and AMC, Netherlands) (EIO, Italy and AMC, Netherlands)

In Melanoma-Morton/GuiliannoIn Melanoma-Morton/Guilianno May replace high morbidity axillary May replace high morbidity axillary

clearanceclearance

Sentinel nodesSentinel nodes

Tumour Sentinel (1st node)

2nd and 3rd order nodes

•Morbidity of Axillary Surgery

Lymphoedema rates:

RT alone : 10%Sampling: 10% Level III clearance 30%Surgery + RT: 70%

Seroma 50%Seroma 50% Lymphoedema 10-30%Lymphoedema 10-30% Severe ICBN neuralgia 5%Severe ICBN neuralgia 5% Shoulder-girdle Shoulder-girdle

dysfunction 20%dysfunction 20% Numbness 80%Numbness 80%

Sentinel nodesSentinel nodes

Sentinel nodesSentinel nodes

Methods all similarMethods all similar Depends on injecting radiotracer in Depends on injecting radiotracer in

or near canceror near cancer Using gamma camera and probing Using gamma camera and probing

to track tracer through lymphaticsto track tracer through lymphatics Intra-operative probe to remove Intra-operative probe to remove

the sentinel nodethe sentinel node

Sentinel nodeSentinel node

ControversiesControversies Who to injectWho to inject Where to injectWhere to inject How much to injectHow much to inject How much activity to injectHow much activity to inject What colloid to useWhat colloid to use When to operateWhen to operate TrainingTraining

Injection technique isInjection technique isstandardised: Intradermalstandardised: IntradermalPeriareolar,tumour quadrantPeriareolar,tumour quadrant

Different injection sites (intradermal, Different injection sites (intradermal, subareolar and peritumoural) subareolar and peritumoural) have advantages and have advantages and disadvantages depending on the disadvantages depending on the desired effect on the pattern and desired effect on the pattern and kinetics of lymphatic drainage. kinetics of lymphatic drainage. NEWSTART is designed to NEWSTART is designed to minimise visualisation of IMNminimise visualisation of IMN

Activity injected will depend on Activity injected will depend on the time from injection to surgerythe time from injection to surgery

Massage post injectionMassage post injection

Size mattersSize matters

The size of a colloid may have an The size of a colloid may have an effect on its transiteffect on its transit

However not simple as charge and However not simple as charge and flexibility of the colloid may flexibility of the colloid may change transitchange transit

Remember the lymph system is a Remember the lymph system is a complex transit system and may complex transit system and may be affected by many factorsbe affected by many factors

What size then?What size then?

No perfect colloid for sentinel node No perfect colloid for sentinel node scintigraphyscintigraphy

All colloids designed for another All colloids designed for another jobjob Nanocol – infection imagingNanocol – infection imaging Albures – lymphoscintigraphyAlbures – lymphoscintigraphy MAA – lung scanningMAA – lung scanning

How colloids made?How colloids made?

Normally made from albuminNormally made from albumin ManMan CowCow PigPig

Often heated to form clustersOften heated to form clusters May be spunMay be spun Can vary in size by factor of 10Can vary in size by factor of 10

Types of colloids usedTypes of colloids used

Tc-99m antimony colloidTc-99m antimony colloid 3-30 nm3-30 nm

Tc-99m sulphur colloid-filteredTc-99m sulphur colloid-filtered 50-100 nm50-100 nm

Tc-99m HSA-nanocollTc-99m HSA-nanocoll 4-100 nm4-100 nm

Tc-99m HAS AlburesTc-99m HAS Albures 200-2000 nm200-2000 nm

Tc-99m MAATc-99m MAA >5000nm>5000nm

Optimal colloidsOptimal colloids

Will pass to sentinel node and stay Will pass to sentinel node and stay therethere

Smaller colloid will pass through so Smaller colloid will pass through so multiple nodes seenmultiple nodes seen

May clear form sentinel node totally May clear form sentinel node totally so no counts if >4 hours post so no counts if >4 hours post injectioninjection

Frequent imaging helps Frequent imaging helps

What to inject?What to inject?

Intra-operative probingIntra-operative probing

If using small colloids should be If using small colloids should be done within 4 hours post injectiondone within 4 hours post injection

Larger colloids can be done at 24 Larger colloids can be done at 24 hourshours

During imaging mark site of During imaging mark site of sentinel nodes on the skin in two sentinel nodes on the skin in two planesplanes

External probing can help pre-opExternal probing can help pre-op

Intra-operative probingIntra-operative probing

About 20 different probe types About 20 different probe types availableavailable

Different crystals have different Different crystals have different sensitivitiessensitivities

Most use CdTe, CsI, NaI BiGeO crystalsMost use CdTe, CsI, NaI BiGeO crystals Needs good collimation to prevent Needs good collimation to prevent

activity passing through the side of the activity passing through the side of the probe probe

Probing the nodeProbing the node

Intra-operative probingIntra-operative probing

Inject blue dye at site of tumour Inject blue dye at site of tumour just before operationjust before operation

Use blue dye to help find Use blue dye to help find lymphaticslymphatics

Probe along blue dye tract until Probe along blue dye tract until signal highsignal high

Remove node send to histologyRemove node send to histology

Use of blue dye and radio-tracer

Probe boxProbe box

Sentinel nodesSentinel nodes

ResultsResults Pagenelii’s group from MilanPagenelii’s group from Milan Over 400 patients 98% successful Over 400 patients 98% successful

identification of sentinel nodeidentification of sentinel node Caution from USA (Krag et al) High Caution from USA (Krag et al) High

variability in results surgeon to variability in results surgeon to surgeon (64-100% PPV) surgeon (64-100% PPV)

Issues of training/audit ALMANACIssues of training/audit ALMANAC

Potential problemsPotential problems

Injection incorrect (intradermal)Injection incorrect (intradermal) Breast not massagedBreast not massaged Colloid too small/big (manafcturer’s QC)Colloid too small/big (manafcturer’s QC) Probing performed badly so node missedProbing performed badly so node missed Poor collimation means signal swampedPoor collimation means signal swamped Problems with histology etcProblems with histology etc

Areas where problems Areas where problems seen in breast cancerseen in breast cancer

Multifocal/centric tumours (maybe Multifocal/centric tumours (maybe helped by nipple injection) helped by nipple injection)

Find this disease with Tc-99m MIBI Find this disease with Tc-99m MIBI or MRIor MRI

Previous surgery around primaryPrevious surgery around primary Breast irradiationBreast irradiation Neo-adjuvant chemotherapyNeo-adjuvant chemotherapy Vascular invasion of tumourVascular invasion of tumour

MRI and Tc-99m MIBIMRI and Tc-99m MIBI

Sentinel nodesSentinel nodes

Can it replace axillary clearance as Can it replace axillary clearance as a staging procedurea staging procedure

Need to await phase III trialsNeed to await phase III trials Patients with T1N0 randomised to Patients with T1N0 randomised to

ax clearance or sent nodeax clearance or sent node Who has better morbidityWho has better morbidity Any difference in survivalAny difference in survival Need 5 year follow-upNeed 5 year follow-up

Results in MelanomaResults in Melanoma

Published by Morton’s groupPublished by Morton’s group Reviewed results of 1900 patients Reviewed results of 1900 patients

having sentinel node for melanomahaving sentinel node for melanoma All had blue dye and colloidAll had blue dye and colloid All had Breslow thickness greater All had Breslow thickness greater

than 5mmthan 5mm Recurrence rate measured at a Recurrence rate measured at a

mean of 7 yearsmean of 7 years

Does sentinel node effect Does sentinel node effect outcomes?outcomes?

Morton’s reviewMorton’s review Ann Sur Onocol Ann Sur Onocol

20002000 1900 patients1900 patients Sentinel node vs Sentinel node vs

blind wide local blind wide local excisionexcision

0%

10%

20%

30%

40%

50%

60%

SNWLE

How is melanoma sentinel How is melanoma sentinel node different?node different?

Melanoma can occur anywhereMelanoma can occur anywhere Drainage much more variableDrainage much more variable May drain to more than one set of May drain to more than one set of

nodesnodes Head and neckHead and neck TrunkTrunk

Different speeds of flowDifferent speeds of flow Leg 20-30 minutesLeg 20-30 minutes Head 60-120 minutesHead 60-120 minutes

Method-melanomaMethod-melanoma

Normally done after removal of primaryNormally done after removal of primary Aim to identify correct block of lymph Aim to identify correct block of lymph

nodes to disectnodes to disect Inject at 4 pints around scar of excisionInject at 4 pints around scar of excision Inject at least 5mm away from the scarInject at least 5mm away from the scar Massage gentlyMassage gently Image draining nodesImage draining nodes

Calf-groinCalf-groin Back Both inguinals and both upper thoraxBack Both inguinals and both upper thorax

Injection for melanoma

Melanoma-methodsMelanoma-methods

Mark any node foundMark any node found Use shadow gram and laterals and Use shadow gram and laterals and

obliques help surgeon identify nodeobliques help surgeon identify node In op use blue dye to find lymphatics In op use blue dye to find lymphatics

and direct surgeon to nodeand direct surgeon to node Surgeon the removes sentinel and Surgeon the removes sentinel and

associated nodesassociated nodes

Melanoma in the leg

In leg passage fast up into groin, as the groin nodes are the draining nodes the sentinel node is in the groin

The popliteal nodes are ignored

Melanoma on crest of head covered by lead; note bilateral sentinel nodes

Other sites in which Other sites in which sentinel node can be usedsentinel node can be used

Melanoma – all patients as variable Melanoma – all patients as variable drainagedrainage

PenisPenis TongueTongue Head and neckHead and neck VulvaVulva Colon!Colon!

NEW STARTNEW STARTSentinel Lymph Sentinel Lymph NodeNode(SLN) training (SLN) training programmeprogramme

NEW STARTNEW STARTSLN training programme 2004-SLN training programme 2004-20062006

Joint ProjectJoint Project Department of Education: Royal College of Department of Education: Royal College of

Surgeons of EnglandSurgeons of England Cardiff University WalesCardiff University Wales

Supported bySupported by DoH, National Assembly in Wales DoH, National Assembly in Wales GE HealthcareGE Healthcare BNMSBNMS

NEW STARTNEW STARTSLN training programmeSLN training programme

National Training ProgrammeNational Training Programme

Standardised methodology and training materialsStandardised methodology and training materials Focus on multidiscipline Focus on multidiscipline team – team – Surgery,Surgery, Nuclear Nuclear

medicine/physics, Radiology, Theatre nurses, Pathology, etcmedicine/physics, Radiology, Theatre nurses, Pathology, etc Experienced validated training teamsExperienced validated training teams Unique workplace training and mentorshipUnique workplace training and mentorship Quality assuredQuality assured Centrally audited and validated Centrally audited and validated (anonymised data collection)(anonymised data collection)

NEW START SLN training NEW START SLN training programme: programme: Standardized National TrainingStandardized National Training

World wide trials* have shown World wide trials* have shown ad-hoc adoption ad-hoc adoption of SLNBof SLNB, with little formal training, reduces the , with little formal training, reduces the accuracy of SLN identification for the first accuracy of SLN identification for the first 50 50 proceduresprocedures..

Evidence from the UK ALMANAC trial Evidence from the UK ALMANAC trial demonstrates that demonstrates that structured trainingstructured training shortens shortens the learning curve to less than the learning curve to less than 10 procedures.10 procedures.

* Cox et al: Annals Surg. Oncol.1999, vol l6, page 6

NEW START SLN training NEW START SLN training programme programme OverviewOverview

1.Theory Day

In House Training Validation

Projected Time frame:18-24 months

Stand alone

SLNBSkills SLNB + standard procedureTheory

3 training phases

ConclusionConclusion

Sentinel node study established in Sentinel node study established in melanoma and breastmelanoma and breast

Useful in reducing mutilating surgeryUseful in reducing mutilating surgery Simple to learn technique but needs Simple to learn technique but needs

good colloid and good probegood colloid and good probe Can be combined with other NM test Can be combined with other NM test

such as PET and scintimammographysuch as PET and scintimammography All members of the team importantAll members of the team important