Sentinel lymph node biopsy (slnb)

HEGAZY SURGERY

1. Sentinel lymph node biopsy (SLNB) By Dr. ABDALLAH HAMED Lecturer of General Surgery Ain Shams University

2. Diagnosing axillary disease is the most important prognostic facctor in breast cancer

3. Sentinel lymph node Definition: It is the first draining lymph node on the direct lymphatic pathway from the primary tumor site and so it is the first node to harbour cancer cells detached from the primary tumour .

4. Indications Studies validating the use of SLNB restricted its use to T1 or T2 tumors with no clinically palpable lymph nodes

5. Contraindications Large or locally advanced tumors (T3 or T4)

6. Clinical Circumstance Use of SNB Level of Evidence* T1 Or T2 tumors Acceptable Good T3 Or T4 tumors Not recommended Insufficient Multicentric tumors Acceptable Limited Inflammatory breast cancer Not recommended Insufficient DCIS with mastectomy Acceptable Limited DCIS without mastectomy Not recommended except for large DCIS (>5cm) on core biopsy or with suspected or proven microinvasion Insufficient Suspicious, palpable axillary nodes Not recommended Good Older age Acceptable Limited Obesity Acceptable Limited

7. Clinical Circumstance Use of SNB Level of Evidence* Male breast cancer Acceptable Limited Pregnancy Not recommended Insufficient Evaluation of internal mammary lymph nodes Acceptable Limited Prior diagnostic or excisional breast biopsy Acceptable Limited Prior axillary surgery Not recommended Insufficient Prior non oncologic breast surgery (reduction or augmentation mammoplasty, breast reconstruction, etc.) Not recommended Insufficient After preoperative systemic therapy Not recommended Insufficient Befor e preoperative systemic therapy Acceptable Limited

8. Technique Mapping using blue dye: 83.1per cent accuracy. Mapping using radioisotopes: 89.2 per cent accuracy. Combining both techniques: 91.9 per cent accuracy.

9. Injection: Peri-tumoral injection ( which has limited application in clinically impalpable tumors). Intra and sub-dermal. Peri or sub-areolar.

10. Prognostic value of SLNB Negative SLNB Positive SLNB

11. Prognostic value of SLNB NEGATIVE : SLNB spares many patients the potential side effects of axillary lymph node dissection (ALND) such as lymphoedema, and studies concluded that with a negative SLNB, SLN surgery alone without ALND is safe and effective

12. Prognostic value of SLNB: Positive : Isolated tumor lesions ….<0.2 mm Micrometastases ….0.2 2mm Macrometastases … >2mm

13. Prognostic value of SLNB: Positive : current guidelines recommend ALND in breast cancer patients with positive SLNB. However recent trials as ACOSOG 0011 which was published recently which provided convincing evidence that completion (ALND) was unnecessary in patients with 1 to 2 positive sentinel lymph nodes (SLNs).

14. Although the findings of ACOSOG Z0011 are impressive, in clinical practice they are applicable to limited number of cases and that was because of the limited study population, old age group, receptor status of the tumor, and length of follow up.

15. Do we ever need to perform Sentinel Node Biopsy in very small tumors ? SOUND Trial Design; Tumor<2cm,any age, negative axilla Randomized into 2 groups SN biopsy +/- ALND 780 patients Observation 780 patients

16. SOUND Trial

17. Conclusion: SLNB has lost much of it's importance, we don't do ALND when SLN is negative, micro metastasis and now even when it is positive in 2 nodes. Advancing imaging technology can identify increasingly smaller axillary involvement and may be used for axillary staging Adjuvant treatment recommendations increasingly depend on primary tumor biology and not on axilla status.

18. Thank you