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Role of sln biopsy 12-12-12

Image guided surgery - sentinel lymph node biopsy

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Role of sln biopsy 12-12-12

  1. 1. Image Guided Oncological Surgery Julio M. Mayol Servicio de Cirugia , Hospital Clinico San Carlos Madrid, Spain
  2. 2. Goals• SLN Biopsy: the concept – Current status in GI surgical oncology • Colon cancer • Gastric cancer• Research – Image-Guided SLN Biopsy
  3. 3. Principles of Oncologic SurgeryEn-bloc excision – Primary tumor – Vascular pedicle • Lymphatic nodes and vessels included
  4. 4. Principles of Oncologic SurgeryLymphadenectomy – Therapeutic – Staging • Prognosis • Selection for adjuvant treatment
  5. 5. The Halstedian Principlelarger incisions, more aggresive approach, unnecessary procedures
  6. 6. SLN Biopsy: the concept Riveros M, et al. Cancer. 1967;20:2026–2031.
  7. 7. Sentinel lymph node:The first lymph node to receive lymphatic drainage from a tumor Cabañas RM. Cancer 1977;39:456-66
  8. 8. Intraoperative lymphatic mapping with sentinel node biopsy Morton D et al. Arch Surg 1992;127:392
  9. 9. SLN Biopsy: the concept• To modify the surgical approach• To minimize morbidity• To improve accuracy and survival
  10. 10. SLN Biopsy: the conceptMorton - 1990 Giuliano - 1994
  11. 11. Image-Guided SLN Bx
  12. 12. Image-Guided SLN Bx Post AntLateral derecha
  13. 13. Image-Guided SLN BxPreoperative planning
  14. 14. Gamma camera
  15. 15. Portable gamma camera Sentinella FDA approval pending
  16. 16. Image-Guided SLN BxIntraoperative identification
  17. 17. Image-Guided SLNBxIntraoperative monitoring
  18. 18. Does it work for GI malignacies?
  19. 19. • SLN Biopsy: the concept• Current status in GI surgical oncology• Research – Image-guided surgery
  20. 20. SLNBx Goals in GI malignancy
  21. 21. SLNBx Goals in GI malignancy
  22. 22. SLNBx Goals in GI malignancy
  23. 23. SLNBx Goals in GI malignancy• To modify the surgical approach• To minimize morbidity ?• To improve accuracy and survival
  24. 24. Current applications• Colon cancer• Gastric cancer• Other: rectum, esophagus, pancreas
  25. 25. SLNBx in Colon Cancer– Stage II – recurrence 20-30% • Understaging? • Hematogenous route?– Stage III • Chemotherapy increases survival
  26. 26. SLNBx in Colon CancerThe larger number of LNs, the better • Better staging • Improved survival in LN - patients – More LN + patients receive chemotherapy – Less false-negative LN - patients
  27. 27. SLNBx in Colon CancerNumber of lymph nodes assesseddepends on: “Overall, the quantitative requirement forThe patient the nodal staging of colorectal carcinomas is to recover as many lymph nodes asThe surgeon possible”The pathologist Cserin G. Nodal staging of colorectal carcinomas and sentinel nodes. J Clin Pathol 2003;56:327
  28. 28. Lymphadenectomy – same morbidity Why SLNBx in colon cancer?
  29. 29. SLNBx in Colon CancerLength of specimen – Perioperative transfusions – Diarrhea – Dehydration – Meteorism Tartter PI et al. World J Surg 2005;10:516-520
  30. 30. SLNBx in Colon CancerUnderstaging 15%-20% of CRC patients • Insufficient number of nodes • About 70% of positive nodes <5 mm S. Saha et al. The American Journal of Surgery 2006;191: 305–310
  31. 31. UltrastagingSentinel lymph node biopsy“.. was developed in part to identify the first few nodes most likely to harbormetastatic disease when present in order to reduce such pathologicalunderstaging and thereby increase the accuracy of nodal staging” S. Saha et al. The American Journal of Surgery 2006;191: 305–310
  32. 32. SLNBx in Colon CancerSaha et al in 1997Indications • Patients without metastatic disease • Open or laparoscopic approach
  33. 33. SLNBx in Colon CancerTechnique – In vivo • Injection of dye and/or radiotracer – Submucosal - via colonoscopy – Subserosal - laparotomy • Identification – Visually – Gamma probe
  34. 34. SLNBx in Colon CancerTechnique – Ex vivo • Injection of dye – After removal of the specimen – Subserosal injection • Visual identification Wong JH, et al. Ann Surg Oncol 2004;11:772–777
  35. 35. SLNBx in Colon CancerTechnique – Histophathology • Hematoxilin-eosin • Immunohistochemistry • RT-PCR Micrometastases • Frozen section
  36. 36. SLNBx in Colon CancerResults Saha S. et al. The American Journal of Surgery 2006;191: 305–310
  37. 37. SLNBx in Colon CancerResults Cancer & Leukemia Group B • False negative rate: 54% (13/24) • False positive rate: 20% • Sensitivity: 40% SNs did not accurately predict the presence of either conventionally defined nodal metastases or MMD Redston M et al. JCO 2006;24:878-883
  38. 38. SLNBx in Colon CancerResults – Meta-analysis; 33 CRC papers – Patients: n = 1794 ( colon 1201; rectum 332) • Sensitivity 70% • Specificity 81% “...for future studies of CRC, it • False negative 9% will be necessary to stratify • Failure rate 10% patients according to their T stage.” • DOR 10.7 Des Guetz D et al. World J Surg (2007) 31:1304–1312
  39. 39. SLNBx in Colon CancerResults Technique – Dyes = radioactive tracer – In vivo = ex vivo Des Guetz D et al. World J Surg (2007) 31:1304–1312
  40. 40. SLNBx in Colon CancerResults Histopathology Upstaging 0-38% – H&E – ICH (Cytokeratin +/- CEA) Des Guetz D et al. World J Surg (2007) 31:1304–1312
  41. 41. SLNBx in Colon Cancer• Micrometastases in N0 - Meta-analysis – Eleven studies – ICH: 566 patients – RT-PCR: 173 patients – Disease free and overall survival – Upstaging – ICH: 32% – RT-PCR: 37% – 3 year-OS: RT-PCR positive < RT-PCR negative Iddigins D et al. Ann Surg Oncol 2006; 13:1386–1392
  42. 42. SLNBx in Colon Cancer “Based on the results of our meta-analysis, future studies on the use of SLNM in CRC patients should:1. Use blue dye for reasons of simplicity,2. Be performed by experienced surgeons and pathologists,3. Be prospective,4. Include more than 40 consecutive patients. Des Guetz D et al. World J Surg (2007) 31:1304–1312
  43. 43. SLNBx in Colon CancerSummary SLN Biopsy in patients with colon cancer may improve staging Saha S. et al. The American Journal of Surgery 2006;191: 305–310
  44. 44. Current use• Colon cancer• Gastric cancer• Other: rectum, esophagus, pancreas…
  45. 45. SLN Biopsy in Gastric CancerGastrectomyD2 lymphadenectomy– T1-T2 lesions = 10-15% LN MTX
  46. 46. SLN Biopsy in Gastric CancerLymphadenectomy in LN positive patientsprolongs survivalLymphadenectomy in LN negative patients doesnot increase survivalExtended lymphadenectomy increases morbidity
  47. 47. SLN Biopsy in Gastric CancerProof-of-concept studies in 2000
  48. 48. SLN Biopsy in Gastric Cancer…the feasibility of sentinel node mapping in gastrointestinal cancers andits diagnostic reliability remains unclear because of the complicatedlymphatic drainage of the GI tract and the high frequency of skipmetastasis. Zulfikaroglu et al. Surgery 2005;138:899-904
  49. 49. SLN Biopsy in Gastric CancerTechnique – Dyes – Radioguided biopsy - Endoscopic injection - Subserosal injection
  50. 50. SLN Biopsy in Gastric CancerDetection rates – Dye: 90% – Radioguided biopsy: 90% – Dual method: 100% Hayashi H et al. J Am Coll Surg 2003;196:68-74
  51. 51. SLN Biopsy in Gastric Cancer Rabin I, et al. IMAJ. 2006;8:40-43
  52. 52. SLN Biopsy in Gastric CancerSensitivity for a positive LN – Dye: 66% – Radioguided biopsy: 92% – Dual method: 92% SLN negative patients may be selected for limited surgical procedure Gretschel S, et al. Ann Surg Oncol. 2007;14:2028-35
  53. 53. SLN Biopsy in Gastric CancerResults – Number of SLN: 2-7 – Sensitivity 85%-100% – Specificity 90-95% – Failure rate 0-6% – False negative (skip mtx): 0-20% Hayashi H et al. J Am Coll Surg 2003;196:68-74 Zulfikaroglu et al. Surgery 2005;138:899-904 Gretschel S, et al. Ann Surg Oncol. 2007;14:2028-35
  54. 54. SLNBx in Gastric CancerSummary SLN Biopsy in patients with gastric cancer may improve staging Tangoku A. J Med Invest 2007;54:1-18
  55. 55. Role of SLN Biopsy in GI malignancies?
  56. 56. SLN Bx Issues in GI malignancy• Technical issues • Complex lymphatic drainage • Intraoperative identification • Imaging methods • Histopathological study• Impact on morbidity and mortality • Distant Mtx in the absence of LN mtx • Micrometastases • Adjuvant therapy available
  57. 57. SLN Bx Issues in GI malignancyFalse negative results – Unpredictible drainage patterns – High background signal – Absence of real-time imaging
  58. 58. SLN Bx Issues in GI malignancy• Improvements in the technique• Intraoperative diagnosis
  59. 59. Role of SLN Bx in GI malignancy• Based on SLN biopsy results, the surgical approach be can NOT be modified
  60. 60. Role of SLN Bx in GI malignancy• Procedure-related morbidity is NOT reduced
  61. 61. Role of SLN Bx in GI malignancy• SLN biopsy MAY increase staging accuracy
  62. 62. • SLN Biopsy: the concept• Current applications in surgical oncology• Research
  63. 63. Does Image-Guided SLNBx improve the results of the traditional technique?
  64. 64. ResearchColorectal & gastric cancer protocols – Inclusion criteria – Exclusion criteria – Technique • In vivo • Ex vivo
  65. 65. ResearchTechnique Injection • 99mTc- colloid • Four injections – 2.0 ml – 0.5 mCi
  66. 66. ResearchTechnique Dynamic intraoperative lymphoscintigraphy
  67. 67. ResearchTechnique Identification of the SLN • Gamma camera • Gamma probe Probe SLN
  68. 68. ResearchTechnique Ex vivo • Difficult locations • Rectal tumors • Failure with in vivo tech.
  69. 69. Image-guided mapping and SLN biopsy To improve accuracy ? To increase survival To individualize the surgical technique To decrease morbidity
  70. 70. AcknowledgementsServicio de Cirugía I Nuclear Medicine Dpt.Rocio Anula Roberto Delgado-BoltonMaría J. Peña-Soria Jose L. CarrerasAna Arbeo-EscolarIris Sanchez-EgidoJesús A. Fdez-Represa

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