Sentinel Node Biopsy IRCH - AIIMS Experience

1. Sentinel Node Biopsy IRCH - AIIMS Experience Dr. S.V.S. Deo MS, FACS, FAIS Associate professor, Surgical Oncology All India Institute of Medical Sciences New Delhi These PowerPoint presentations are free to download only for academic purposes, with due acknowledgements to authors and this website.

2. Sentinel Lymph Node Biopsy (SLNB) • Introduction • SLNB - Concept , Rationale & Technique • SLNB - AIIMS Experience • Evidence based future strategies for Indian BC Patients

3. Sentinel Lymph Node Biopsy (SLNB) Two Most Significant Advances in the field of Surgery during the last decade • Minimally Invasive Surgery (MIS) • Sentinel Lymph Node biopsy(SLNB)

4. Lymph Nodes - Solid Tumors • Solid tumors - Spread to lymph nodes • Lymphadenectomy - Part of many curative Cancer operations • Lymphadenectomy – Staging, Prognostication & Therapeutic • Changing Concepts - Lymphadenectomy

5. Why – SLNB ? • ALND - Gold standard of Managing Axilla • ALND - Standard technique , Rigorous clinical scrutiny, excellent therapeutic efficacy • Recently – ALND - Less Popular Morbidity more than therapeutic benefit in node negative patients

6. Why – SLNB ? • Changing Treatment Philosophy • Changing patient profile • Technology driven therapeutic interventions

7. Why – SLNB ? Changing Treatment Philosophy • Better Understanding of Breast Cancer Biology • Paradigm shift - Surgical Approach • Ultra Radical – Radical – Conservative

8. Why – SLNB ? • Old Times - Big Surgeons - Big Incisions- Big Resections - ? Big Results - Big Egos • Judicious Conservatism - Current trend • Functional out come & QOL issues are important end points • Add life to years - Years to life • Critical re evaluation of ALND Morbidity

9. Morbidity- ALND Incidence - 30 to 60 % • Seroma & Lymphedema - 30% • Shoulder syndrome - 25% • Neuropathies - 50 to75% • Increased Hospital stay • Morbidity more than - Sx for Primary Roses et al ,Ann Surg, 1999 Baum M et al, W J surg, 2001

10. Morbidity- ALND

11. Why – SLNB ? Changing Patient Profile • Breast Cancer - Western world 70 % Screen detected Non Palpable lesions • Majority - DCIS / T1 • 70 % Node Negative • Majority receive Adj. Systemic therapy Irrespective of Axillary status

12. Why – SLNB ? Technology driven therapeutic interventions • Decade of medical technology • Pharmaceutical MNCs, Media playing a major role - Influencing Therapeutic options • Myth – “Technology = Cure” • Treatment modalities are forced – Fast tracking & Short circuiting rigorous scientific scrutiny

13. Sentinel Lymph Node Biopsy (SLNB) • Sentinel - “ Sentry / Guard” • Definition - Identification of first draining lymph node most likely to contain metastatic disease if metastases exists in the axilla”

14. Evolution- Sentinel Lymph Node Biopsy (SLNB) • Cabanas -1979 - SLN in Penile cancer • Wong et al- 1991- Anatomic specificity of LN • 1992 - Guliano et al - Blue dye method -Breast cancer • 1993- Alex & Krag - Gamma probe detection using radio colloid in Breast cancer

15. Sentinel Lymph Node Biopsy (SLNB) Visual detection method using dyes • Patent blue, Isosulfan blue (Lymphozurin) • Agents - LN seeking - Not - Tumor seeking • Peri tumoral/ sub dermal injection (2- 4 ml) • Exploration of lymphatic basin through small incision after 5 -15 mts • Identify the blue lymphatic going from primary to Blue LN

16. Sentinel Lymph Node Biopsy (SLNB) Radio tracer detection using Gamma probe • Injection of radiotracer tagged to pharmaceuticals • Technitium –99m most commonly used tagged to sulfur colloid / albumin • Peri tumoral / Intradermal injection of 0.450 to 1.0 m Ci – volume - 5-10 ml • Exploration of lymphatic basin after 8 hrs using a gamma detection probe

17. Sentinel Lymph Node Biopsy (SLNB) • Probe -Radiation detector • (scintillation detector) • Electronic box –solid state • detector • Converts photo signals to audio signals • Audio signal & Count • SLN- HOT NODE

18. Current Status SLNB in BC • Positive SLN localization – 92 to100% • False negative – 0 to10 % • Best results - Combination of Dye & GPD • Accuracy in predicting ALN status > 90% • Rapidly evolving as a staging & Therapeutic procedure in N0 Axilla • SLNB - N+ Axilla – JACS, 2005,10. • Therapeutic role - Mature Data awaited

19. SLNB – AIIMS -_IRCH Experience To evaluate the applicability of SLNB among Indian BC patients • Assessment of BC Patient profile • Out come analysis - ALND • Validation study - SLNB

20. AIIMS - IRCH SLNB - Validation Study SLNB - Protocol • Validation Study – 2000 to 2003 • Total number of patients – 140 ( stage I & II) • Method – Blue dye ( Isosulfan 1%) 4 ml Peritumoral injection • All pts had post SLNB - Completion ALND

21. AIIMS - IRCH SLNB - Validation Study • LN Assessment – Intra operative Imprint cytology • Two cuts – 4 sections of LN • Jenner Geimsa / H & E staining • Average time to reporting 20 mts • Final HPE – gold standard • No - IHC / RT PCR

22. AIIMS - IRCH SLNB - Validation Study

23. AIIMS - IRCH SLNB - Validation Study Out Come • SLN identification rate - 95% • False negative SLN - 8 % • Accuracy in predicting Ax LN status - 92% • Accuracy of ICC – 98 %

24. AIIMS - IRCH SLNB - Validation Study Publications

25. Video

26. AIIMS - IRCH SLNB - Validation Study • Post NAC- SLNB Assessment using IIC “Paresh , Deo SVS, Mona et al “J Diagnostic Cytopathology, 2003” • Comparison of three Stains- JJ/H&E/ Pap Mona , Paresh , Deo SVS et al “Cancer - Cytopath – 2004”

27. AIIMS – IRCHBreast Cancer Profile & ALND Analysis Study Period - Jan 1993 to June 2000 Total number of BC patients - 742 Age : <35 yrs = 116, > 35 yrs = 626 Menopausal Status – Pre - 48 %, Post- 52% EBC (Stage I & II): 363 (48.9%) LABC (Stage III) : 379 (51.1%)

28. AIIMS – IRCHBreast Cancer Profile & ALND Analysis Types of Surgery : RM : 39 (5.3%) MRM : 582 (80.4%) BCT : 110 (12.8%) ALND : 11 (1.5%) Breast Reconstruction - 50 Treatment policy- Axilla - Complete ALND Axillary RT - LABC, >3 nodes, ENS

29. AIIMS – IRCHBreast Cancer Profile & ALND Analysis • Median Nodal Yield - 14 + 5.91 • Total number of Node + ve patients : 479 (64.6%) • Stage vs Node positivity EBC : 181/363 (49.8%) LABC : 298/379 (78.6%)

30. AIIMS – IRCHBreast Cancer Profile & ALND Analysis • Regional Relapse (N=16) EBC : 2 ( 0.5%) LABC : 14 (3.7%) • Node positivity profile < 3 node + ve - 45%, 3 to10 + ve - 32%, > 10 nodes - 22% , ENS - 18% • Lymphedema & Neuropathy – 35 %

31. Evidence Based guide lines for SLNB in India • Indian BC Scenario - LABC > EBC • Self detected BC more than Screen detected BC • Node positive more than Node Negative • Currently ALND – Excellent Results for Indian BC patients

32. India- Country in Transition

33. India- Country in Transition

34. Evidence Based guide lines for SLNB in India • Indian BC Scenario – Changing • Based on Current ALND Data 50 % EBC & 25 % LABC - Suitable SLNB • Dye method with II Cytology - Suitable for India

35. Evidence Based guide lines for SLNB in India • Who should perform SLNB Surgical Oncologist General surgeon Rx more than 25 BC / year • Learning curve - Short • Validation study - Minimum of 20 cases (Supervision) • Blind extrapolation of Western data avoided • Try and generate more Indian data

36. Evidence Based guide lines for SLNB in India • Current Era of transition Surgeons India should be familiar with ALND & SLNB • Choose a Middle path • Key to success – Customized treatment

37. Thank You