Original articleSurgical resection and radiolocalization of the sentinel lymph node in breast cancer using a gamma probe
Abstract
We have recently reported on a technique of gamma probe localization of radiolabelled lymph nodes to identify the sentinel node in malignant melanoma. In order to determine whether this technique is applicable to assist in staging breast cancer, a pilot study was begun to address two questions: (i) can the sentinel lymph node draining a breast cancer be identified for selective resection; and (ii) is the sentinel lymph node predictive of the status of the entire axillary lymph nodes? One to four hours prior to axillary lymph node dissection, 22 consecutive patients had approximately 0.4 mCi of technetium sulfur colloid in 0.5 ml saline injected around the perimeter of the breast lesion. A hand-held gamma counter was used at surgery to locate the lymph node(s) receiving drainage from the breast. A sentinel lymph node was identified in 18 of 22 patients. Of these 18 patients, the sentinel lymph node was positive in seven of seven patients, with pathologically verified metastatic breast cancer to at least one lymph node. In three out of seven patients, the sentinel lymph node was the only lymph node with metastatic cancer. In this pilot study of breast cancer patients, we conclude that: (i) radiolocalization and selective resection of sentinel lymph nodes is possible; and (ii) the sentinel lymph node appears to predict correctly the status of the remaining axilla. These data justify a larger clinical trial to verify the value of this technique.
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Cited by (1512)
Is my patient an appropriate candidate for sentinel node biopsy? Less axillary surgery, for the right patients. Critical review and grades of recommendation
2024, Surgical OncologyWhile general conclusions of historical trials are widely recognized, the nuances regarding precise indications of Sentinel Node Biopsy (SNB) in breast cancer in complex clinical scenarios often remain a source of debate and require further elucidation.
Two reviewers (JFB and GNM) independently searched electronic databases for studies including SNB as the main intervention. Filters were applied to retrieve only clinical trials (randomized or experimental non-randomized); non-oncological outcomes were excluded. The selected studies were considered to construct a narrative review focused on inclusion criteria and survival outcomes, followed by recommendations.
Fourteen (n = 14) trials were selected, including eleven (n = 11) randomized trials for upfront surgery, and three (n = 3) single-group clinical trials for surgery following neoadjuvant therapy. All trials for upfront surgery provided long-term survival data for SNB, that was equivalent or non-inferior to axillary dissection, in tumors without palpable adenopathy (caution for larger T3 and T4 tumors) - Grade of recommendation: A. In tumors up to 5 cm, complete axillary dissection is not necessary if up to two sentinel nodes are positive for macrometastasis, and radiation therapy is planned - Grade of recommendation: A. If there are more than two sentinel nodes positive for macrometastasis, or a positive node other than the sentinel one, complete axillary dissection is recommended - Grade of recommendation: A. Following neoadjuvant chemotherapy, considering 10% as an acceptable false negative rate, SNB might be offered for cN0 patients who have remained negative, and for cN1 (caution for cN2) patients become clinically negative; complete axillary dissection might not be necessary if at least two sentinel lymph nodes are retrieved, and there is no residual disease - Grade of recommendation: B.
SNB can be performed in most cases of clinically negative nodes. After neoadjuvant chemotherapy, SNB is feasible and may have acceptable performance for cN0 and cN1 tumors, although prospective survival data is still awaited.
Can we avoid axillary lymph node dissection in patients with node positive invasive breast carcinoma?
2024, Gynecologie Obstetrique Fertilite et SenologieLes indications et les modalités de la chirurgie mammaire et axillaire font l’objet de profondes évolutions, visant à personnaliser la prise en charge chirurgicale tout en évitant le surtraitement. Pour actualiser les bonnes pratiques de chirurgie axillaire, quatre questions ont été choisies par la Commission de Sénologie (CS) du Collège national des gynécologues et obstétriciens français (CNGOF) et ont porté sur, premièrement, la définition et l’évaluation des techniques de dissection axillaire ciblée (DAC), deuxièmement, la possibilité de désescalade chirurgicale en cas d’atteinte ganglionnaire lors d’une chirurgie initiale, troisièmement, après une thérapie systémique néoadjuvante (TSNA), et quatrièmement, les contre-indications à la désescalade de la chirurgie axillaire pour permettre l’accès à certaines thérapies systémiques adjuvantes.
La CS a essentiellement basé ses réponses sur l’analyse de la littérature internationale, les recommandations de l’Institut national du cancer et les référentiels internationaux.
Premièrement, la DAC est une technique couplant l’exérèse de ganglion(s) axillaire(s) métastatique(s) clippé(s) et de ganglions axillaires sentinelles (GAS). Elle permet un taux de détection et une sensibilité augmentés en comparaison avec la seule identification du ganglion clippé, mais nécessite encore une homogénéisation et une meilleure évaluation des pratiques. Deuxièmement, la DAC représente une alternative au curage axillaire (CA) en cas d’atteinte métastatique d’un seul ganglion pouvant être réséqué. Troisièmement, cette technique de DAC n’est pas recommandée en France après TSNA en dehors des essais cliniques, alors qu’elle peut être utilisée dans différents pays en cas de réponse histologique complète au niveau ganglionnaire et de prélèvement d’au moins trois ganglions. Quatrièmement, certaines thérapies ciblées adjuvantes étant indiquées en cas d’envahissement ganglionnaire de plus de trois ganglions, la place de la DAC dans ce contexte reste à définir.
La désescalade chirurgicale axillaire permet de limiter la morbidité des CA. Ayant prouvé que la DAC ne diminue pas la survie des patientes, elle va donc très probablement remplacer les CA dans des indications bien définies. Cela nécessitera au préalable une standardisation de la méthode et de ses indications et contre-indications notamment pour permettre l’utilisation de nouvelles thérapies ciblées.
The indications and modalities of breast and axillary surgery are undergoing profound change, with the aim of personalizing surgical management while avoiding over-treatment. To update best practices for axillary surgery, four questions were selected by the Senology Commission of the Collège National des Gynécologues et Obstétriciens Français (CNGOF), focusing on, firstly, the definition and evaluation of targeted axillary dissection (TAD) techniques; secondly, the possibility of surgical de-escalation in case of initial lymph node involvement while performing initial surgery; thirdly, in case of surgery following neo-adjuvant systemic therapy (NAST), and fourthly, contra-indications to de-escalation of axillary surgery to allow access to particular adjuvant systemic therapies.
The Senology Commission based its responses primarily on an analysis of the international literature, clinical practice recommendations and national and international guidelines.
Firstly, TAD is a technique that combines excision of clipped metastatic axillary node(s) and the axillary sentinel lymph nodes (ASLNs). The detection rate and sensitivity are increased but it still needs to be standardized and practices better evaluated. Secondly, TAD represents an alternative to axillary clearance in cases of metastatic involvement of a single node that can be resected. Thirdly, neither TAD nor ASLN alone is recommended in France after NAST outside of clinical trials, although it is used in several countries in cases of complete pathological response in the lymph nodes, and when at least three lymph nodes have been removed. Fourthly, as some adjuvant targeted therapies are indicated in cases of lymph node invasion of more than three lymph nodes, the place of TAD in this context remains to be defined.
Axillary surgical de-escalation can limit the morbidity of axillary clearance. Having proved that TAD does not reduce patient survival, it will most probably replace axillary clearance in well-defined indications. This will require prior standardization of the method and its indications and contra-indications, particularly to enable the use of new targeted therapies.
This house believes that: MARI/TAD is better than sentinel node biopsy after PST for cN+ patients
2023, BreastThe increasing use and effectiveness of primary systemic treatment (PST) enables tailored locoregional treatment. About one third of clinically node positive (cN+) breast cancer patients achieve pathologic complete response (pCR) of the axilla, with higher rates observed in Human Epidermal growth factor Receptor (HER)2-positive or triple negative (TN) breast cancer subtypes. Tailoring axillary treatment for patients with axillary pCR is necessary, as they are unlikely to benefit from axillary lymph node dissection (ALND), but may suffer complications and long-term morbidity such as lymphedema and impaired shoulder motion. By combining pre-PST and post-PST axillary staging techniques, ALND can be omitted in most cN + patients with pCR. Different post-PST staging techniques (MARI/TAD/SN) show low or ultra-low false negative rates for detection of residual disease. More importantly, trials using the MARI (Marking Axillary lymph nodes with Radioactive Iodine seeds) procedure or sentinel lymph node biopsy (SLNB) as axillary staging technique post-PST have already shown the safety of tailoring axillary treatment in patients with an excellent response. Tailored axillary treatment using the MARI procedure in stage I-III breast cancer resulted in 80% reduction of ALND and excellent five-year axillary recurrence free interval (aRFI) of 97%. Similar oncologic outcomes were seen for post-SLNB in stage I-II patients. The MARI technique requires only one invasive procedure pre-NST and a median of one node is removed post-PST, whereas for the SLNB and TAD techniques two to four nodes are removed. A disadvantage of the MARI technique is its use of radioactive iodine, which is subject to extensive regulations.
Radioguided surgery of mesenchymal tumors with <sup>125</sup>I seeds
2023, Revista Espanola de Medicina Nuclear e Imagen MolecularLa cirugía radioguiada emplea fuentes radioactivas para identificar y extirpar lesiones de difícil localización. Los tumores mesenquimales constituyen un grupo heterogéneo de neoplasias derivados del mesodermo, incluyendo lesiones benignas y sarcomas malignos. El objetivo de este estudio fue evaluar la capacidad de la semilla radioactiva de 125I para guiar la localización intraoperatoria de tumores mesenquimales, analizando sus tasas de complicación y evaluando los márgenes de las piezas quirúrgicas recuperadas.
Estudio observacional retrospectivo de todos los pacientes consecutivos sometidos a cirugía radioguiada de un tumor mesenquimal con semilla radioactiva de 125I desde enero de 2012 hasta enero de 2020 en un centro de referencia terciario en España. La semilla fue insertada mediante punción percutánea guiada con ecografía o tomografía computarizada de forma ambulatoria.
Se extirparon 15 lesiones en 11 cirugías a 11 pacientes, recuperando todas las lesiones marcadas (100%) con semilla de 125I. Las lesiones incluyeron áreas de fibrosis benigna (26,7%), angiofibroma celular (6,7%), tumor desmoide (20%), tumor fibroso solitario (13,3%), condrosarcoma (6,7%) y sarcoma pleomórfico (26,7%), con una tasa elevada de tumores recurrentes (60%). Solo hubo una complicación (6,7%) por caída de la semilla dentro del lecho quirúrgico. Según la clasificación de la Union for International Cancer Control de tumor residual, el 80% de las lesiones resultaron en una resección R0, el 6,7% fueron una resección R1 y el 13,3% fueron una resección R2.
La cirugía radioguiada fue una técnica precisa para la extirpación de tumores mesenquimales de difícil localización.
Radioguided surgery uses radioactive substances to identify and remove hard-to-locate lesions. Mesenchymal tumors constitute a heterogeneous group of neoplasms derived from the mesoderm, including benign lesions and malignant sarcomas. The aim of this study was to evaluate the ability of the 125I radioactive seed to guide intraoperative localization of mesenchymal tumors, analyzing its complication rates and evaluating the margins of the surgical specimens retrieved.
Retrospective observational study of all consecutive patients undergoing radioguided surgery of a mesenchymal tumor with a 125I radioactive seed from January 2012 to January 2020 at a tertiary referral center in Spain. The seed was inserted percutaneously guided by ultrasound or computed tomography on an outpatient setting.
Fifteen lesions were removed in 11 surgeries on 11 patients, recovering all marked lesions (100%) with a 125I seed. The lesions included areas of benign fibrosis (26.7%), cellular angiofibroma (6.7%), desmoid tumor (20%), solitary fibrous tumor (13.3%), chondrosarcoma (6.7%), and pleomorphic sarcoma (26.7%), with a high rate of recurrent tumors (60%). There was only one complication (6.7%) due to the seed falling within the surgical bed. According to the UICC classification of residual tumor, 80% of the lesions resulted in an R0 resection, 6.7% were an R1 resection, and 13.3% were an R2 resection.
Radioguided surgery was a precise technique for the removal of hard-to-locate mesenchymal tumors.
Continuous innovation in precision radio-guided surgery
2023, Revista Espanola de Medicina Nuclear e Imagen MolecularDesde sus inicios, la medicina nuclear se ha enfrentado a cambios tecnológicos que la han obligado a modificar sus modos operativos y a adecuar sus protocolos. En el campo de la cirugía radioguiada (CRG), la incorporación de la imagen gammagráfica preoperatoria y la detección intraoperatoria con la sonda gamma proporcionó un impulso definitivo a la biopsia del ganglio centinela (GC) para convertirse en el procedimiento estándar de aplicación en el melanoma y el cáncer de mama.
Las diversas innovaciones tecnológicas y la adaptación consiguiente de protocolos confluyen en lo disruptivo y lo gradual. Como ejemplos evidentes tenemos la introducción de la tomografía por emisión de fotón único/tomografía computarizada (SPECT/TC) en el campo preoperatorio y las sondas Drop-in (Lightpoint Medical Ltd; Crystal photonics, Eurorad) en el intraoperatorio. Otros aspectos innovadores con posible aplicación en la CRG se basan en la utilización de la inteligencia artificial (IA), navegación y teleasistencia.
Since its origins, nuclear medicine has faced technological changes that led to modifying operating modes and adapting protocols. In the field of radioguided surgery, the incorporation of preoperative scintigraphic imaging and intraoperative detection with the gamma probe provided a definitive boost to sentinel lymph node biopsy to become a standard procedure for melanoma and breast cancer.
The various technological innovations and consequent adaptation of protocols come together in the coexistence of the disruptive and the gradual. As obvious examples we have the introduction of SPECT/CT in the preoperative field and Drop-in probes in the intraoperative field. Other innovative aspects with possible application in radio-guided surgery are based on the application of artificial intelligence, navigation and telecare.