buxant f. (md) breast unit erasme hospital free university of brussels (ulb) belgium sln procedure :...

Buxant F. (MD)Breast Unit

Erasme Hospital

Free University of Brussels (ULB)Belgium

SLN Procedure : unanswered questions

INJECTION TECHNIQUE

SLN Procedure : unanswered questions

INJECTION TECHNIQUE

Injection TechniqueInjection Technique

• SLN technology is evolving rapidly, however,difference in techniques are widespread and a standard procedure has not yet become accepted

• I sended a questionnaire …

What is the belgian practice ?What is the belgian practice ?

• Or …is there a belgian practice ?for the tracer agent : 99m Tc-labeled sulfur colloid(and rarely blue dye)for the dose : 8mCi (0.6mCi, 2mCi)for the injection site : PeriTumoral PT (and subdermal PT or subareolar)for the timing : the day of surgery or the day before

…and in the litterature ?

Injection techniqueInjection technique

• Tracer Agent

• Massage Technique

• Injection Site

• Timing

• Preoperative Lymphoscintigraphy


• Tracer AgentTracer Agent


• Injection Site

• Timing


Injection Technique :Tracer Agent

Injection Technique :Tracer Agent

• A lot of studies indicate that dual agent injection is superior.Identification SLN 92 to 99% FN rates 0 to 15%

• With blue dye alone additional axillary SLNs are difficult to identify after the first SLN is removed and it ‘s difficult to identify IM SLN

• In the early developpement of SLN biopsy for BC, Krag (1993) used radiocolloid alone, whereas Giuliano (1994) used 1% isosulfan blue dye alone.

Witch blue dye ?Witch blue dye ?• Isosulfan blue (lymphazurin)

has been the traditional dye of choice but hypersensitivity reactions to isosulfan blue have been reported in 1 to 2%

• Isosulfan blue dye reactions during SLN mapping for BC carcinoma.Montgomery. Anaesth Analg 20011.6% of 2392 patients with urticaria, generalized rash, pruritus

Witch blue dye ?Witch blue dye ?• Methylen blue has

been studied as an alternativeIt’s as effective as isosulfan blue in SLN identificationSimmons Ann Surg Oncol 2003Blessing Am J Surg 2002

No hypersensitivity is known and the cost is lower.

• Nevertheless intradermal injection of methylene blue can cause significant skin reactions including necrosis, erythema and ulceration

Tracer Agent : Isotope techniqueTracer Agent : Isotope technique

• Variety of isotopes (sulfur colloid, colloid albumin, dextran).

• Tc 99m sulfur colloid has been used most often in the United States and Tc 99m colloidal albumin in European countries

• No study between different isotope tracers


• Size of particle (40< and 80>nm)If particles too large >100nm :no migrationIf too small < 20-40nm :blood vessels migration

• Unfiltered or filtered radioisotope (0.22m) ?Linehan J Am Coll Surg 1999

Unfiltered (20 to 200nm) is superiorMore « Hot Axilla » with filteredBut why this difference ?


• Which Radio toxicity for the surgeon ?Guidelines for the safe use of radioactive materials during localization..Miner Ann Surg Oncol 1999Exposure to surgeon’s during SLNB procedure 1mSv/hMax skin annual dose 500mSv

• Body absorbed dose 0,7m Sv/h (50cm)Natural annual irradiation 1,4 -2,4mSv


• Tracer Agent

• Massage TechniqueMassage Technique

• Injection Site

• Timing


Massage TechniqueMassage Technique• Very rare article !• Haynes

Am Surg 2003compared 3 differing

massage techniques :

ressucitative !

Surgeon utilized a pulsatile maneuver similar to a ressucitative chest compression

Massage TechniqueMassage Technique

Surgeon utilized a diffuse and firm double handed massage with the heel of the hand mimicking

an agressive bread

kneadind technique

• Haynes compared 3 differing massage techniques : ressucitative buffer !

Massage TechniqueMassage Technique• Haynes compared 3 differing

massage techniques : ressucitative buffer knead like !

Surgeon utilized a circular rotating motion alternating between a clockwise and a counterclockwise direction with emphasized contact with the palm of the hand

Massage TechniqueMassage Technique

No breast masssage technique was demonstrated to be superior !

And the winner is ?

• Haynes compared 3 differing massage techniques :

ressucitative buffer knead like !


• Tracer Agent

• Massage Tehnique

• Injection SiteInjection Site

• Timing


Injection Site : PeritumoralInjection Site : Peritumoral

• Earlier studies used PERITUMORAL Injection because « It stands to reason that Injection into the breast tissue around the tumor should accurately reflect the L. drainage »

• However, …for upper outer quadrant BC, the high degree of background radiation from the primary tumor site renders discrimination of midly radioactive axillary nodes with the probe difficult

Injection Site : Skin InjectionInjection Site : Skin Injection

• Subdermal or intradermalThe skin overlying the breast parenchyma has the same embryological origin as the underlying tissu (Ectoderm) and should share the same lymphatic drainage pattern

Injection Site : SubareolarInjection Site : Subareolar

• Based on studies indicating that this area provides a central access route to the peripheral lymphatic pathway

• The lymphatics channels are much richer at the subcutaneous level than the PT site

Subdermal or Subareolar enhance the SLN identification rate

Injection Site : Subdermal But ?Injection Site : Subdermal But ?

• Although Subdermal and intradermal injection can help to anatomically visualize the superficial L system running to the axilla, they cannot do this for the deep lymphatic system running to the internal mammary IM or interpectoral nodes

Injection SiteInjection Site• Subdermal vs Peritumoral

Mateos, Nuclear medicine 2001

80 women- similar blue dye injection100% subdermal lympho + vs 89% PT lympho +similar results for sensitivity with lympho+blue+gamma probe (92% vs 91% identification SLN)

• Intradermal vs IntramammaryMartin Surgery 2001

200 women- IP blue dye98% vs 89% identification SLNdye-isotope concordance (92% vs 93%)comparable

Injection SiteInjection Site

• Intradermal isotope is superior to PT blue dye and isotopeLin J Am Coll Surg 2004180 women Intradermal (97%) was found to be superior to PT isotope (78%) and PT blue dye in identifying SLNs


• Comparison of subdermal and peritumoral Inj.Eroglu Clin Nucl Med 2004

36 patients – PT and SD on each patientSD higher sucess rate of axillary SLN detectionPT more effective in imaging IM and extraaxillary SLNs (30% vs 26%)


• Intraoperative Subdermal Radioisotope InjectionLayeeque Annals of Surgery 2004

96 patients – Intraoperative inj. Blue dye and 99mTc on each patientbeause of the rapid drainage…


• Tracer Agent


• Injection Site

• TimingTiming


Timing : blue dyeTiming : blue dye

• Surgeons who use blue dye inject it in the operating room, usually 5 to 15 minutes before making an axillary skin incision

Timing : isotopeTiming : isotope• Identical results with same-day vs day-before isotope

injectionMcCarter Ann Surg Oncol 2001933 patients 1-day (0.1mCi) protocol vs 387 patients 2-day (0.5mCi) protocolisotope intradermal injectionintraparenchymal blue dye2 vs 2.7 SLN (p<0.05)no difference for mean level of counts (Inj. site and SLN)identification rate 93% vs 96%(NS)within each group, isotope succeeded more often than blue dye (S)

Timing : isotopeTiming : isotope

• Is 1-day better than 2-day protocol ?Chok Am Surg 200360 patients 4h (0.5mCi) or 24h before surgery (2mCi)combination with Patent blue dye (2ml)mean number of SLN found : 1.46 vs 1.96 (NS)radioactivity in the resected specimen higher in 1-day protocol (S)identification SLN 98% vs 99% (combined technique)

SIMILAR RESULTS !SIMILAR RESULTS !


• Tracer Agent


• Injection Site

• Timing

• Preoperative Preoperative LymphoscintigraphyLymphoscintigraphy

Preoperative LymphoscintigraphyPreoperative Lymphoscintigraphy

• The role of SLN biopsy in breast cancer Bass J Am Coll Surg 1999

94% of all axillary SLN are found within a 5cm perimeter in the axilla and easily detected by gamma probeAn axillary SLN could be identified with the gamma probe in 50% of the scan-negative patientsRoutine preoperative lymphoscintigraphy isunnecessary ?

Preoperative LymphoscintigraphyPreoperative Lymphoscintigraphy

• The SLN node in Breast Cancer A multicenter validation studyKrag N Eng J Med 1998

Only 19 (4.3%) of 455 hot spots were identified in the IMN chain with intraoperative gamma probe

• In other studies, the rate of identification of BC with IMN drainage with preop lympho. was 11-35%

ConclusionsConclusions

• Tracer Agent99mTc colloidal albuminBlue dye ? If isotope technique negative1 – 10 mCi


• Massage Technique No enough study !


• Injection SiteSubdermal or Subareolar easierideal for upper outer quadrantbut for Internal Node ?PT and if lymphoscintigraphy neg, SD


• Timingone-day or two-day protocol?Choose what’s more confortable for your unit !


• Preoperative LymphoscintigraphyYes because IM?

because to know if you have to inject blue dye ?


• Tracer Agent


• Injection Site

• Timing


Thank you for your attention !

F Buxant


• Tracer Agent


• Injection Site

• Timing




• Tracer Agent


• Injection Site

• Timing


Thank you for your attention !Thank you for your attention !


• Tracer Agent


• Injection Site

• Timing



Conclusions Conclusions

buxant f. (md) breast unit erasme hospital free university of brussels (ulb) belgium sln procedure :...

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massage technique surgeon

massage technique haynes

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