This document summarizes the concept and technique of sentinel lymph node biopsy for breast cancer. It defines the sentinel lymph node as the first lymph node to receive lymphatic drainage from a tumor site. The summary describes how sentinel lymph node biopsy gained acceptance as a less invasive alternative to axillary lymph node dissection, with studies finding it to be a reliable indicator of axillary node status. The document also reviews factors such as tumor size, sentinel node status, and the number of positive lymph nodes that help determine the need for further axillary treatment.

1. GANGLIO CENTINELA DR.ULISES SANTOS AGUILAR R5 CIRUGÍA ONCOLÓGICA SEPTIEMBRE 2011

2. DEFINICIÓN Ganglio localizado directamente en la vía de drenaje, Y EL primero en recibir la linfa proveniente de la zona del tumor. Mabry H, Giuliano AE. Sentinel node mapping for breast cancer: progress to date and prospects for the future. Surg Oncol Clin N Am 2007; 16:55. Krag D, Weaver D, Ashikaga T, et al. Thesentinelnode in breastcancer--a multicentervalidationstudy. N Engl J Med 1998; 339:941. KragD, Ashikaga T. The design of trials comparing sentinel-node surgery and axillary resection. N Engl J Med 2003; 349:603.

3. DEFINICIÓN DISEMINA TUMOR Concepto gc Cáncer mama ORDEN MECANICO ESTACIÓN GANGLIONAR Mabry H, Giuliano AE. Sentinel node mapping for breast cancer: progress to date and prospects for the future. Surg Oncol Clin N Am 2007; 16:55. Krag D, Weaver D, Ashikaga T, et al. Thesentinelnode in breastcancer--a multicentervalidationstudy. N Engl J Med 1998; 339:941. KragD, Ashikaga T. The design of trials comparing sentinel-node surgery and axillary resection. N Engl J Med 2003; 349:603.

4. PRINCIPIOS Y LEYES DEL GANGLIO CENTINELA PRINCIPIOS TEORÍA DE HALSTED SIGUIENDO FLUJO LINFÁTICO PREVISIBLE DINÁMICO ORDENADO PRIMER RELEVO GANGLIONAR DEL SISTEMA LINFÁTICO SIRVE DE FILTRO PARA LA DISEMINACIÓN TUMORAL

5. SE CONSIDERA GANGLIO CENTINELATODO AQUEL VIA DIRECTA COLORANTE NO ES EL MÁS CERCANO AL TUMOR TUMOR DRENA J E RADIO ACTIVIDAD ELEVADA PUEDE EXISTIR MÁS DE UN GANGLIO CENTINELA

6. HISTORIA Cabanas RM. An approach for the treatment of penile carcinoma. Cancer.1977;39(2):456-466.

7. Cabanas RM. An approach for the treatment of penile carcinoma. Cancer.1977;39(2):456-466.

8. EL TRATAMIENTO QUE COMPRENDIA LA RESECCION INGUINAL BILATERAL

9. CASI SIEMPRE SE REGISTRABA UNA ALTA TASA DE MORTALIDAD

10. Sentinel node localization in patients with breast cancer , FLETT M.M. British Journal of Surgery, Volume 85, Number 7, July 1998 , pp. 991-993(4) Lymphatic drainage of skin to a sentinel lymph node in a feline model.JH Wong, L A Cagle, and D L Morton Division of Surgical Oncology, John Wayne Cancer Clinic, UCLA School of Medicine 90024

13. EN LA ACTUALIDAD

15. RECOMENDACIÓN GENERALEN CÁNCER DE MAMA Turner RR, Ollila DW, Krasne DL, Giuliano AE. Histopathologicvalidation of thesentinellymphnodehypothesisforbreast carcinoma. Ann Surg. 1997;226(3):271-6; discussion 276-278.

16. METODO DE INVESTIGACION DEL GANGLIO CENTINELA Krag DN, et al. Surgical resection and radiolocalization of the sentinel lymph node in breast cancerusing a gamma probe. Surg Oncol 1993;2(6):335–9. Linehan DC, Hill AD, Akhurst T, Yeung H, Yeh SD, Tran KN, Borgen PI, Cody HS 3rd. Intradermalradiocolloid and intraparenchymalbluedyeinjectionoptimizesentinelnodeidentification in breastcancerpatients. Ann Surg Oncol. 1999;6(5):450-454 Mabry H, Giuliano AE. Sentinel node mapping for breast cancer: progress to date and prospects for the future. Surg Oncol Clin N Am 2007; 16:55.

17. LA EXPERIENCIA DE DIVERSOS AUTORES DEMUESTRAN VALORES DE CONFIABILIDAD VARIABLE 94-95% COMBINADO 65-90% AZUL PATENTE

18. MÉTODO COMBINADO ENTRENAMIENTO PARA IDENTIFICAR COLECTORES LINFÁTICOS EDUCACIÓN VISUAL REDUCE LOS TIEMPOS OPERATORIOS Zakaria S, Hoskin TL, Degnim AC. Safety and technical success of methylene blue dye for lymphatic mapping in breast cancer. Am J Surg 2008; 196:228 Motomura K, Komoike Y, Hasegawa Y, et al. Intradermalradioisotopeinjectionis superior tosubdermalinjectionfortheidentification of thesentinelnode in breastcancerpatients. J Surg Oncol 2003; 82:91.

19. AZUL PATENTE Raut CP, Hunt KK, Akins JS, et al. Incidence of anaphylactoidreactionstoisosulfanbluedyeduringbreast carcinoma lymphaticmapping in patientstreatedwithpreoperativeprophylaxis: results of a surgicalprospectiveclinicalpracticeprotocol. Cancer 2005; 104:692.

20. ANAFILAXIA

21. INDICACIONES DE LA BIOPSIA DEL GC National Comprehensive Cancer Network (NCCN) guidelines. Available at: www.nccn.org (Accessed on February 04, 2011). Lyman GH, Giuliano AE, Somerfield MR, et al. American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol 2005; 23:7703.

22. CONTRAINDICACIONES ABSOLUTAS

23. CONTRAINDICACIONES RELATIVAS Y CONTROVERSIAS Lyman GH, Giuliano AE, Somerfield MR, et al. American Society of ClinicalOncologyguidelinerecommendationsforsentinellymphnodebiopsy in early-stagebreastcancer. J Clin Oncol 2005; 23:7703. KlimbergVS, Rubio IT, Henry R, et al. Subareolar versus peritumoralinjectionforlocation of thesentinellymphnode. Ann Surg 1999; 229:860. BorgsteinPJ, Meijer S, Pijpers RJ, van Diest PJ. Functionallymphaticanatomyforsentinelnodebiopsy in breastcancer: echoesfromthepast and theperiareolarbluemethod. Ann Surg 2000; 232:81.

24. MANEJO DE METASTASIS EN GANGLIO CENTINELA Lyman GH, Giuliano AE, Somerfield MR, et al. American Society of ClinicalOncologyguidelinerecommendationsforsentinellymphnodebiopsy in early-stagebreastcancer. J Clin Oncol 2005; 23:7703.

25. CÉLULAS TUMORALES AISLADAS NO SE CONSIDERA INDICACIÓN PARA DRA, RT NI QT 7th Edition AJCC Cancer Staging Manual 2010 EDITORIAL SPRIGER

26. MICROMETÁSTASIS ? PX< 3 GLANGLIOS + Chen SL, Hoehne FM, Giuliano AE. Theprognosticsignificance of micrometastases in breastcancer: a SEER population-basedanalysis. Ann Surg Oncol 2007; 14:3378. Reed J, Rosman M, Verbanac KM, et al. Prognosticimplications of isolated tumor cells and micrometastases in sentinelnodes of patientswithinvasivebreastcancer: 10-year analysis of patientsenrolled in theprospective East Carolina University/AnneArundel Medical Center SentinelNodeMulticenterStudy. J Am CollSurg 2009; 208:333. Weaver DL, Ashikaga T, Krag DN, et al. Effect of occultmetastasesonsurvival in node-negativebreastcancer. N Engl J Med 2011; 364:412. Lyman GH, Giuliano AE, Somerfield MR, et al. American Society of ClinicalOncologyguidelinerecommendationsforsentinellymphnodebiopsy in early-stagebreastcancer. J Clin Oncol 2005; 23:7703. Straver ME, Meijnen P, van Tienhoven G, et al. Sentinelnodeidentificationrate and nodal involvement in the EORTC 10981-22023 AMAROS trial. Ann Surg Oncol 2010; 17:1854.

27. MACROMETÁSTASIS

28. CUÁNDO SE DEBE REALIZAR LA DISECCIÓN AXILAR? DEPENDE DE RESULTADO DE GC

29. 1.- KragDN, Anderson SJ, Julian TB, et al. Sentinel-lymph-noderesectioncomparedwithconventionalaxillary-lymph-nodedissection in clinicallynode-negativepatientswithbreastcancer: overallsurvivalfindingsfromtheNSABP B-32 randomisedphase 3 trial. Lancet Oncol 2010; 11:927. 2.- WeaverDL, Ashikaga T, Krag DN, et al. Effect of occultmetastasesonsurvival in node-negativebreastcancer. N Engl J Med 2011; 364:412 3.- LymanGH, Giuliano AE, Somerfield MR, et al. American Society of ClinicalOncologyguidelinerecommendationsforsentinellymphnodebiopsy in early-stagebreastcancer. J Clin Oncol 2005; 23:7703.

30. -3 GANGLIOS LINFÁTICOS + CON MICRO O MACRO METS DGLA ? = Carlson GW, Wood WC. Management of axillary lymph node metastasis in breast cancer: making progress. JAMA 2011; 305:606

31. GANGLIO CENTINELA ES EL UNICO PORTADOR DE TUMOR HASTA EN EL 60% DE LOS CASOS HASTA EN EL 90% DE LOS PX QUE TIENEN SÓLO MICROMETÁSTASIS ESTO NOS LLEVA A ESPECULAR QUE LA DGLA NO ES NECESARIA EN PX CON GANGLIO CENTINELA + EN MENOS DE 3 RIESGO DE RECIDIVA ES BAJO Carlson GW, Wood WC. Management of axillary lymph node metastasis in breast cancer: making progress. JAMA 2011; 305:606 Chagpar AB. Clinical significance of minimal sentinel node involvement and management options. Surg Oncol Clin N Am 2010; 19:493.

32. ACOSOGZ-0011 PX T1 Ó T2 CLINICAMENTE GANGLIOS NEG. Y – DE 3 GC + OBJETIVO 1900 RADIACIÓN 425 GC 388 GC+DGLA Giuliano AE, McCall L, Beitsch P, et al. Locoregionalrecurrenceaftersentinellymphnodedissectionwithorwithoutaxillarydissection in patientswithsentinellymphnodemetastases: theAmerican College of SurgeonsOncologyGroup Z0011 randomized trial. Ann Surg 2010; 252:426. Giuliano AE, Hunt KK, Ballman KV, et al. Axillarydissection vs no axillarydissection in womenwithinvasivebreastcancer and sentinelnodemetastasis: a randomizedclinical trial. JAMA 2011; 305:569.

33. EL OBJETIVO DE NSABP 32 FUE ESTABLECER SI LA RESECCION DE GLC EN PACIENTES CON CÁNCER DE MAMA ALCANZAN LA MISMA SUPERVIVENCIA Y CONTROL LOCAL QUE LA DGLA PERO CON MENOS EFECTOS SECUANDARIOS ESTUDIO FASE 3 80 CENTROS ENTRE CANADA Y EU 1999-2004 SEGUIMIENTO 95.6M TUMOR -2CM, 2-4CM, +4.1CM EDAD 2 GRUPOS <49- > 50 DOS PLANES QX LUMPECTOMIA Y MASTECTOMIA

35. RESULTADOS 5611 309 3989 PATOLOGICAMENTE NEGATIVO SL.ENFERMEDAD 82.4% G1 VS 81.4% G2 S.GLOBAL 91.8% VS 90.3% SOBREVIDA GLOBAL, SOBREVIDA LIBRE DE ENFERMEDAD Y CONTROL LOCAL FUERON EQUIVALENTES EN LOS DOS GRUPOS

37. *Silva, Orlando, MD, et al, Breast Cáncer a practical guide, 3rd ed, Edit. Elsevier, *Schwartz GF, Giuliano AE, Veronesi U, ConsensusConferenceCommittee. Proceedings of theconsensusconferenceonthe role of sentinellymphnodebiopsy in carcinoma of thebreast, April 19-22, 2001, Philadelphia, Pennsylvania. Cancer 2002; 94:2542. *Giuliano AE, Jones RC, Brennan M, Statman R. Sentinellymphadenectomy in breastcancer. J Clin Oncol 1997; 15:2345. 2006, pp 171- 229

38. MATERIAL 1.-aut CP, Hunt KK, Akins JS, et al. Incidence of anaphylactoidreactionstoisosulfanbluedyeduringbreast carcinoma lymphaticmapping in patientstreatedwithpreoperativeprophylaxis: results of a surgicalprospectiveclinicalpracticeprotocol. Cancer 2005; 104:692. 2.-Julian, TB, Krag, D, Brown, A, et al. Preliminarytechnicalresults of NSABP B-32, a randomizedphase III clinical trial to compare sentinelnoderesectiontoconventionalaxillarydissection in clinicallynode-negativebreastcancerpatients (abstract). Presented at the 27th Annual San Antonio BreastCancerSymposium, San Antonio, Texas, December 9, 2004 (abstract 14). 3.- Wilke LG, McCall LM, Posther KE, et al. Surgicalcomplicationsassociatedwithsentinellymphnodebiopsy: resultsfrom a prospectiveinternationalcooperativegroup trial. Ann Surg Oncol 2006; 13:491.

39. Técnica

41. Interpretación. Martin RC 2nd, Edwards MJ, Wong SL, et al. Practicalguidelinesforoptimal gamma probedetection of sentinellymphnodes in breastcancer: results of a multi-institutionalstudy. FortheUniversity of Louisville BreastCancerStudyGroup. Surgery 2000; 128:139. LiuLC, Lang JE, Jenkins T, et al. Isitnecessarytoharvestadditionallymphnodesafterresection of themostradioactivesentinellymphnode in breastcancer? J Am CollSurg 2008; 207:853. ChungA, Yu J, Stempel M, et al. Isthe "10% rule" equallyvalidforallsubsets of sentinel-node-positive breastcancerpatients? Ann Surg Oncol 2008; 15:2728.

42. TECNICA INTRAOPERATORIA

45. Ganglio centinela.

49. GRACIASPOR SU ATENCIÓN