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