Sentinel Node:Practical Experience at Frimley Park
Hospital
RJ Morton, A Fullbrook, L Wright, JRW Hall, J Ward
History
• 1951 Parotid (Gould)• 1977 Penile (Cabanas)• 1966 Testicular• 1992 Melanoma
• 1970 Breast (Blue Dye)• 1990’s Breast (Radionuclide)
What is Sentinel Lymph Node (SLN)?
• The Sentinel Node is any node which receives drainage directly from the primary tumour
SLN SLN SLN
Secondary nodeSLN
Why SLN?• Morbidity of traditional
axillary surgery (e.g. lymphoedema, seroma, numbness, stiff shoulder)
• Diagnosing more early node negative breast cancer
• Development of a minimally invasive, safe, reproducible and accurate technique to predict nodal status
SLN:The first node to receive lymph drainage directly from tumour
Other nodes will be clearSN-
Tumour
SN+ Other nodes may contain cancer
the node that predicts lymph node status
Diagnosis: who is eligible?
Eligibility: Virtually any cancer patient who requires lymph node staging.
Exclusions: Gross nodal disease and/or signs oflymphatic obstruction. Distant metastases
NEW STARTSLN training programme 2004-2006
Joint Project• Department of Education: Royal College of
Surgeons of England• Cardiff University Wales
Supported by• DoH, National Assembly in Wales • GE Healthcare
What is New Start?National Training Programme
• Standardised methodology and training materials
• Focus on multidiscipline team – Surgery, Nuclear medicine/physics, Radiology, BCN, Theatre nurses, Pathology, etc
• Experienced validated training teams• Unique workplace training and mentorship• Quality assured• Centrally audited and validated (anonymised
data collection)
NEW STARTSLN training programme: Overview
Theory Day
In House Training
Mentoring&
Validation
12-18 months
Stand alone
SLNBSkills SLNB + standard procedureTheory
Ongoing Audit
5 cases per surgeon 25 cases per surgeon
Theory
FPH - SLN
• Started 1999 (breast and melanoma)– Research ARSAC
• Full ARSAC (Dec 2003)
• 229 (1999-April 2005)
Patient Journey
Diagnosis Nuclear Medicine Surgery Pathology
99Tcm Nanocolloid Blue Dye
SLN
10 mins
Imaging
2 – 3 hours
Request Form
• Next Day– Good image statistics– Lower radiation dose/protection issues– Surgeon finds node easier to locate (less shine
through from injection site)
• Same Day– Convenient
Injection Technique
Periareolar/Sub dermal(<5% negative node)
Peritumour
Ultrasonic control (15% negative node)
SLN Injection Technique – Suggested Protocol for NEW START
Palpable Impalpable
No prior excision biopsy
15–40 MBq in 0.2ml 99mTc-Nanocoll
injected intradermally overlying tumour
15–40 MBq in 0.2ml 99mTc-Nanocoll
periareolar intradermal injection in index quadrant
Prior excision biopsy
2 x 10-25 MBq in 0.2ml 99mTc-Nanocoll
injected intradermally
either side of excision scar
2 x 10-25 MBq in 0.2ml 99mTc-Nanocoll
injected intradermally
either side of excision scar
Injection Technique (Breast) at FPH
• Cloth/inco pad around injection site
• Site – periareolar• Tc-99m Nanocolloid• 4 injections (0.5 ml each)
– 1 ml in each syringe– 25 gauge needle
• Activity– 20 MBq (same day)
– 40 MBq (next day)
Injection technique continued
• Massage injection site• Tape gauze over injection site• Disease side only
Melanoma– 4 injections around the scar
Imaging - Breast• 2 – 3 hours post injection• Supine• Arms raised• LEHR• 256 matrix• 300s static• Full field (pixel size:
2.35mm)• Ant, lateral, oblique• Cobalt source –body
outline
Mark Nodes
• Mark nodes using Co-57 pen source
• Oblique view (Ant for internal)
• Indelible pen
Imaging - Melanoma
• Dynamic– 45 * 20s frames– 128 matrix– LEHR– Area above injection site
• Static– 2 – 3 hours– 256 matrix– LEHR– 300 s– Ant, Lateral, oblique– Axilla/groin
Single Node
Multiple Nodes
Negative Image
• <5 % -Negative node rate
Importance of Oblique Image
Internal Mammary
Unexpected Results
Surgery
1.Blue dye injection 2mls in 4-5 mls saline
(allergic reaction 1.8%, hypotension 0.2%)
2. Identify SLN : Colour and Counts
Gamma Probes
Surgery
• Frozen Section – Takes up to 45 mins– Immediate axillary dissection
• SLN biopsy – second operation for reconstruction and axillary
clearance if necessary
• Reconstruction with SLN – Only return to theatre if SLN positive.– Greater risk of damage to reconstruction
77
82
96
3.4
0 10 20 30 40 50 60 70 80 90 100
Blue node
Hot node
Hot or bluenode
Failedlocalisation
SLN identification
ALMANAC TRIAL AUDIT PHASE
% Success in finding sentinel node
Results from FPH
• 96 consecutive cases• Located nodes 96.5 % (Standard >95%)• Failed localisation 1%• 2.6 nodes average• 28.4 % node positive (Standard 20-
30%)
SLNB:Safety
• Extensive clinical experience/follow up in USA/Europe (individual series of 2-3000 cases)
• Early data demonstrates very low local recurrence rates
Legislation
• Environment Agency
• ARSAC – Nuclear Medicine Specialist– Surgeon undertaking SLN biopsy as an operator– Provide proof that surgeon is undergoing
training (NEW START)
Radiation Protection
• Patient: 20MBq ED 0.42 mSv• Surgeon:
– Whole body dose 1.9 Sv/case
– Finger dose 13 Sv/case500 cases before annual limit is reached
Morton et al: BJR 2003, (76) 117-122
Local Radiation Protection Department
Theatre
– May need to store for 48 hours
• Contamination– Normal precautions for biohazards
• Training/Instruction sheet for staff
Same day 0.2 - 1.9 MBq
Next day 0.001 - 0.1 MBq
• Waste
Pathology
• Pathologist
• Fix immediately but leave for 24 hours before section
• Label samples as radioactive and store away from the main area
UK Probe Working Group
To produce guidance on issues relating to the Gamma Probe in SNB
– Purchase
– Evaluation
– Quality Assurance
Output
• BNMS web site (October 2004)– Gamma Probe Purchase Specification– Guide to User Evaluation
• In draft– Quality Assurance guidelines– Performance Evaluation– (Guidelines on use for surgeons)
Probe QC