Sentinel Node: Practical Experience at Frimley Park Hospital

1. Sentinel Node:Practical Experience at Frimley Park Hospital RJ Morton, A Fullbrook, L Wright, JRW Hall, J Ward

2. History • 1951 Parotid (Gould) • 1977 Penile (Cabanas) • 1966 Testicular • 1992 Melanoma • 1970 Breast (Blue Dye) • 1990’s Breast (Radionuclide)

4. SLN SLN SLN What is Sentinel Lymph Node (SLN)? • The Sentinel Node is any node which receives drainage directly from the primary tumour SLN Secondary node

5. 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

6. SN+ Other nodes may contain cancer Tumour SN- Other nodes will be clear SLN:The first node to receive lymph drainage directly from tumour the node that predicts lymph node status

7. Diagnosis: who is eligible? Eligibility: Virtually any cancer patient who requires lymph node staging. Exclusions: Gross nodal disease and/or signs of lymphatic obstruction. Distant metastases

8. 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

9. 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)

10. NEW STARTSLN training programme: Overview Mentoring & Validation In House Training Theory Day Ongoing Audit 5 cases per surgeon 25 cases per surgeon Stand alone SLNB Theory Skills SLNB + standard procedure Theory 12-18 months

11. FPH - SLN • Started 1999 (breast and melanoma) • Research ARSAC • Full ARSAC (Dec 2003) • 229 (1999-April 2005)

12. Patient Journey Diagnosis Nuclear Medicine Surgery Pathology 2 – 3 hours 10 mins 99Tcm Nanocolloid Blue Dye Imaging SLN

13. 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

14. Injection Technique Periareolar/Sub dermal (<5% negative node) Peritumour Ultrasonic control (15% negative node)

15. SLN Injection Technique – Suggested Protocol for NEW START

16. 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)

17. Injection technique continued • Massage injection site • Tape gauze over injection site • Disease side only Melanoma • 4 injections around the scar

18. 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

20. Mark Nodes • Mark nodes using Co-57 pen source • Oblique view (Ant for internal) • Indelible pen

21. 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

22. Single Node

23. Multiple Nodes

24. Negative Image • <5 % -Negative node rate

25. Importance of Oblique Image

26. Internal Mammary

27. Unexpected Results

28. Surgery 2. Identify SLN : Colour and Counts 1.Blue dye injection 2mls in 4-5 mls saline (allergic reaction 1.8%, hypotension 0.2%)

29. Gamma Probes

30. 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

31. ALMANAC TRIAL AUDIT PHASE % Success in finding sentinel node

32. 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%)

33. SLNB:Safety • Extensive clinical experience/follow up in USA/Europe (individual series of 2-3000 cases) • Early data demonstrates very low local recurrence rates

34. Legislation • Environment Agency • ARSAC • Nuclear Medicine Specialist • Surgeon undertaking SLN biopsy as an operator • Provide proof that surgeon is undergoing training (NEW START)

35. Radiation Protection Local Radiation Protection Department • Patient: 20MBq ED 0.42 mSv • Surgeon: • Whole body dose 1.9 Sv/case • Finger dose 13 Sv/case 500 cases before annual limit is reached Morton et al: BJR 2003, (76) 117-122

36. Theatre • Waste • May need to store for 48 hours • Contamination • Normal precautions for biohazards • Training/Instruction sheet for staff

37. Pathology • Pathologist • Fix immediately but leave for 24 hours before section • Label samples as radioactive and store away from the main area

38. UK Probe Working Group To produce guidance on issues relating to the Gamma Probe in SNB • Purchase • Evaluation • Quality Assurance

39. 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)

40. Probe QC