Sentinel nodes
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Sentinel Nodes. J.R.Buscombe RFH. Sentinel Nodes. Uses the Morton principle of logical lymph drainage from a tumour Methods use include blue dye and radiotracers Combination of 2 may be best Pioneers in breast Morton/Krag/Guilianno USA (EIO, Italy and AMC, Netherlands)

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Sentinel nodes

Sentinel Nodes

J.R.Buscombe

RFH


Sentinel nodes1

Sentinel Nodes

  • Uses the Morton principle of logical lymph drainage from a tumour

  • Methods use include blue dye and radiotracers

  • Combination of 2 may be best

  • Pioneers in breast

    • Morton/Krag/Guilianno USA

    • (EIO, Italy and AMC, Netherlands)

  • In Melanoma-Morton/Guilianno

  • May replace high morbidity axillary clearance


Sentinel nodes2

Sentinel nodes

Tumour

2nd and 3rd order nodes

Sentinel (1st node)


Sentinel nodes

  • Morbidity of Axillary Surgery

  • Seroma 50%

  • Lymphoedema 10-30%

  • Severe ICBN neuralgia 5%

  • Shoulder-girdle dysfunction 20%

  • Numbness 80%

Lymphoedema rates:

RT alone : 10%

Sampling: 10%

Level III clearance30%

Surgery + RT: 70%


Sentinel nodes3

Sentinel nodes


Sentinel nodes4

Sentinel nodes

  • Methods all similar

  • Depends on injecting radiotracer in or near cancer

  • Using gamma camera and probing to track tracer through lymphatics

  • Intra-operative probe to remove the sentinel node


Sentinel node

Sentinel node

  • Controversies

    • Who to inject

    • Where to inject

    • How much to inject

    • How much activity to inject

    • What colloid to use

    • When to operate

    • Training


Injection technique is standardised intradermal periareolar tumour quadrant

Injection technique isstandardised: IntradermalPeriareolar,tumour quadrant

Different injection sites (intradermal, subareolar and peritumoural) have advantages and disadvantages depending on the desired effect on the pattern and kinetics of lymphatic drainage. NEWSTART is designed to minimise visualisation of IMN

  • Activity injected will depend on the time from injection to surgery

  • Massage post injection


Size matters

Size matters

  • The size of a colloid may have an effect on its transit

  • However not simple as charge and flexibility of the colloid may change transit

  • Remember the lymph system is a complex transit system and may be affected by many factors


What size then

What size then?

  • No perfect colloid for sentinel node scintigraphy

  • All colloids designed for another job

    • Nanocol – infection imaging

    • Albures – lymphoscintigraphy

    • MAA – lung scanning


How colloids made

How colloids made?

  • Normally made from albumin

    • Man

    • Cow

    • Pig

  • Often heated to form clusters

  • May be spun

  • Can vary in size by factor of 10


Types of colloids used

Types of colloids used

  • Tc-99m antimony colloid

    • 3-30 nm

  • Tc-99m sulphur colloid-filtered

    • 50-100 nm

  • Tc-99m HSA-nanocoll

    • 4-100 nm

  • Tc-99m HAS Albures

    • 200-2000 nm

  • Tc-99m MAA

    • >5000nm


Optimal colloids

Optimal colloids

  • Will pass to sentinel node and stay there

  • Smaller colloid will pass through so multiple nodes seen

  • May clear form sentinel node totally so no counts if >4 hours post injection

  • Frequent imaging helps


What to inject

What to inject?


Intra operative probing

Intra-operative probing

  • If using small colloids should be done within 4 hours post injection

  • Larger colloids can be done at 24 hours

  • During imaging mark site of sentinel nodes on the skin in two planes

  • External probing can help pre-op


Intra operative probing1

Intra-operative probing

  • About 20 different probe types available

  • Different crystals have different sensitivities

  • Most use CdTe, CsI, NaI BiGeO crystals

  • Needs good collimation to prevent activity passing through the side of the probe


Probing the node

Probing the node


Intra operative probing2

Intra-operative probing

  • Inject blue dye at site of tumour just before operation

  • Use blue dye to help find lymphatics

  • Probe along blue dye tract until signal high

  • Remove node send to histology


Sentinel nodes

Use of blue dye and radio-tracer


Probe box

Probe box


Sentinel nodes5

Sentinel nodes

  • Results

  • Pagenelii’s group from Milan

  • Over 400 patients 98% successful identification of sentinel node

  • Caution from USA (Krag et al) High variability in results surgeon to surgeon (64-100% PPV)

  • Issues of training/audit ALMANAC


Potential problems

Potential problems

  • Injection incorrect (intradermal)

  • Breast not massaged

  • Colloid too small/big (manafcturer’s QC)

  • Probing performed badly so node missed

  • Poor collimation means signal swamped

  • Problems with histology etc


Areas where problems seen in breast cancer

Areas where problems seen in breast cancer

  • Multifocal/centric tumours (maybe helped by nipple injection)

  • Find this disease with Tc-99m MIBI or MRI

  • Previous surgery around primary

  • Breast irradiation

  • Neo-adjuvant chemotherapy

  • Vascular invasion of tumour


Mri and tc 99m mibi

MRI and Tc-99m MIBI


Sentinel nodes6

Sentinel nodes

  • Can it replace axillary clearance as a staging procedure

  • Need to await phase III trials

  • Patients with T1N0 randomised to ax clearance or sent node

  • Who has better morbidity

  • Any difference in survival

  • Need 5 year follow-up


Results in melanoma

Results in Melanoma

  • Published by Morton’s group

  • Reviewed results of 1900 patients having sentinel node for melanoma

  • All had blue dye and colloid

  • All had Breslow thickness greater than 5mm

  • Recurrence rate measured at a mean of 7 years


Does sentinel node effect outcomes

Does sentinel node effect outcomes?

  • Morton’s review

  • Ann Sur Onocol 2000

  • 1900 patients

  • Sentinel node vs blind wide local excision


How is melanoma sentinel node different

How is melanoma sentinel node different?

  • Melanoma can occur anywhere

  • Drainage much more variable

  • May drain to more than one set of nodes

    • Head and neck

    • Trunk

  • Different speeds of flow

    • Leg 20-30 minutes

    • Head 60-120 minutes


Method melanoma

Method-melanoma

  • Normally done after removal of primary

  • Aim to identify correct block of lymph nodes to disect

  • Inject at 4 pints around scar of excision

  • Inject at least 5mm away from the scar

  • Massage gently

  • Image draining nodes

    • Calf-groin

    • Back Both inguinals and both upper thorax


Sentinel nodes

Injection for melanoma


Melanoma methods

Melanoma-methods

  • Mark any node found

  • Use shadow gram and laterals and obliques help surgeon identify node

  • In op use blue dye to find lymphatics and direct surgeon to node

  • Surgeon the removes sentinel and associated nodes


Sentinel 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


Sentinel nodes

Melanoma on crest of head covered by lead; note bilateral sentinel nodes


Other sites in which sentinel node can be used

Other sites in which sentinel node can be used

  • Melanoma – all patients as variable drainage

  • Penis

  • Tongue

  • Head and neck

  • Vulva

  • Colon!


New start sentinel lymph node sln training programme

NEW STARTSentinel Lymph Node(SLN) training programme


New start sln training programme 2004 2006

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

  • BNMS


New start sln training programme

NEW STARTSLN training programme

National Training Programme

  • Standardised methodology and training materials

  • Focus on multidiscipline team – Surgery,Nuclear medicine/physics, Radiology, Theatre nurses, Pathology, etc

  • Experienced validated training teams

  • Unique workplace training and mentorship

  • Quality assured

  • Centrally audited and validated (anonymised data collection)


New start sln training programme standardized national training

NEW START SLN training programme: Standardized National Training

  • World wide trials* have shown ad-hoc adoption of SLNB, with little formal training, reduces the accuracy of SLN identification for the first 50 procedures.

  • Evidence from the UK ALMANAC trial demonstrates that structured training shortens the learning curve to less than 10 procedures.

* Cox et al: Annals Surg. Oncol.1999, vol l6, page 6


New start sln training programme overview

NEW START SLN training programme Overview

3 training phases

1.Theory Day

In House Training

Validation

Stand alone

SLNB

Theory

Skills

SLNB + standard procedure

Projected Time frame:18-24 months


Conclusion

Conclusion

  • Sentinel node study established in melanoma and breast

  • Useful in reducing mutilating surgery

  • Simple to learn technique but needs good colloid and good probe

  • Can be combined with other NM test such as PET and scintimammography

  • All members of the team important


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