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%

Lymphatic drainage of the breast

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 ????