Radioactive Imaging in Sentinel Lymph Node

Biopsy for Cancer Detection

Aguilar, Ariane A. Chaduangto, Don. Palomares, Xavier B.

Introduction

The Sentinel Lymph node detection further

called Sentinel Lymph node Biopsy is a
revolutionary methods for detecting early
stage of cancer [1]. The spreading of cancer
cell inside the body was vulnerable in the
Lymph circulatory path. Each lymph node
within the body is connected and generally
accumulates at the upper part of the body.[2]
The tumors and other early stage of cancer
were located near the lymph nodes, so the
occurrence of cancer is possible at the upper
part of the body where the greater percent of
lymph nodes are located. At this time, the
SLNB (Sentinel Lymph Node Biopsy) is
generally the test being taken by the breast
cancer patients. The Sentinel Lymph Node
Biopsy detects the early stage of cancer that
is progressively became the test for early
detection of breast cancer [3]. Is it possible
for the Sentinel Lymph Node Biopsy to
detect other type of cancer inside the body?
2 Sentinel lymph nodes

Fig. 2.1 Lymph Circulatory System

Lymph nodes are part of the

lymphatic system inside the body, they are
scattered inside the body and connected to
one another by lymph vessel. Like blood
vessel instead of blood the lymph vessel has
Lymph that flows throughout the lymph
circulatory system. Lymph delivers the
primary needs of the cell in order to grow
[3]. It is also part of the bodys immune
system that collects the foreign substances
inside the body. Sentinel lymph node is the
first node near the cancer formation in the
lymph circulatory system. The sentinel
lymph nodes will be the first one to show
the evidence of cancer formation [4].
3

Sentinel lymph node biopsy

The sentinel lymph node biopsy is

the procedure to examine the closest lymph
node from the tumor or early stage of
cancer[4].
3.1. Lymphoscintigraphy
Lymphoscintigraphy is an imaging
technique used to identify the lymph
drainage basin, using a radioactive substance
that being injected near the target tumor site,
the substance then accumulates at the region
of the cancer that travels to the lymph vessel
[5]. The accumulation process of the
radioactive substance then becomes the
target location where the surgeon needs to
operate [3]. Radioactive elements are used
to become the detectors of the cancer cell an

example of radioactive element is Tc-99m

sulfur colloid. Using a Gamma probe, the
area where the cancer cells are located can
now be seen [6].
3.2. Gamma Probe Criteria [7,8]
Gamma probe detectors are imaging
detectors. A wide range of probe systems are
available with different detector materials,
detector sizes, and collimation. They are
used for pre-operative and intraoperative
detection of Sentinel Lymph Nodes.

3.2.1. Sensitivity
The sensitivity of the probe was
determined directly at the tip of the probe. In
general, the necessary sensitivity depends on
radionuclide uptake, measurement geometry
and time between injection and Sentinel
lymph node excision (SLNE). The
sensitivity can be computed by the equation.
eq. (1)
Where:
E = sensitivity

The quality of gamma probe is important

base on their:

sensitivity
spatial resolution (radial sensitivity
at defined distance)
spatial selectivity (lateral
sensitivity distribution)
quality of shielding (maximum
penetration outside the
measurement field)
energy resolution
spectral discrimination according
to 99mTc
Display of signal.

S = counts per second of

radionuclide (cps)
A = radioactive decay, MBq
(Megabecquerel) or Ci
(Microcurie)
The maximum radionuclide uptake of
the sentinel lymph node typically varies
between 0.01% and 1% with a median at
around 0.1%. The SLNE is mostly
performed at the day after 99mTc Nanocolloid injection. Then about 0.05% to
0.005% of the administered activity can be
found in the lymph node intraoperatively.
Assuming a typical activity application of 80
MBq a spot of activity between 4 and 40
kBq has to be localized. The sensitivity of
the measurement system therefore should be
better than 5 cps/kBq.

3.2.2.
Fig. 3.1

Arrangement
of
quality
control measurements

Spatial resolution

The spatial resolution can be determined

if a surgical gamma probe is scanned
laterally above a point source.

full width at half maximum (FWHM) of the

distribution function is a good quality
criterion for the detectability of lymph nodes
in presence of non-target radiation.
With a broad measurement cone the
background signal can exceed the target
signal of the lymph node, which then cannot
be detected. A small cone mainly reduces
background maintaining a constant target
signal. Therefore with increased background
in the target area a smaller FWHM of radial
sensitivity distribution is desired.

Fig 3.2

Resolution and Separation of two

lymph nodes

Spatial resolution depends on the

distance between source and probe detector.
To separate neighboring lymph nodes and
perform an adequate exact localization the
FWHM of the lateral sensitivity distribution
should be better than the typical distance
between neighboring lymph nodes or a
typical node diameter in the preparation
region. Therefore a spatial resolution better
than 25 mm for lymph nodes in the axilla,
inguinal and illiacal region is ideal.
Increased requirements have to be set up for
lymph nodes that are close together. Probes
for these applications should have a FWHM
of less than 15mm.

3.2.3.

Spatial selectivity

The sensitivity distribution is evaluated

equidistant to the frontal radiation entrance
window dependent on the polar angle. The

Fig 3.3 Radial sensitivity distribution and

detectability of a lymph node

3.2.4.

Shielding

Due to constructional reasons, the

shielding of a surgical gamma probe is
mostly a weak area. A high background
source in the direction of such a leakage can
lead to false orientation. The lymph node
should produce a higher signal than any
background source. Assuming an uptake of
0.1% for a lymph node the leak sensitivity
should not exceed 0.1% of the system
sensitivity.

3.2.6. Display

Fig 3.4
Apparent SLN in the
measurement cone by background
activity nearby a shielding leak
3.2.5. Energy resolution
With the presence of scatter, medium and
high background activity Compton photons
produce an additional blurring of the spatial
information. An energy discrimination that
separates Compton- and photo peak-signal is
therefore important. Good energy resolution
is one of the most important requirements to
consider. When the body is injected with
radioactivity, Cobalt 57 for example, in
order to identify the sentinel lymph node,
the probe should detect Cobalt 57 photo
peak signal only and not scatter radiation.

All kinds of display have to be

adapted to the special situation in an
operation room. An acoustic display should
enable the user to visually concentrate to the
operation field during measurement.
Therefore a clear display correlation
between the acoustic tone and the
measurement signal has to be available. For
the quantitative results either a digital or
analogue display is necessary which has to
be clearly readable from at least 6 ft
distance. To cope with the statistical
variation and to influence the inertia of the
display measurement interval respectively
time constant should be adjustable.

Fig 3.6 sample Display of the gamma probe

4

Advantages of SLNB

Examination proposes that the sentinel

node biopsy system can be helpful in
figuring out which lymph nodes to remove,
without the danger of intricacies connected
with surgically uprooting all possibly
dangerous nodes [9].
Fig 3.5 spectral graph of energy resolution

There is no need to stay overnight in the

hospital or clinics. There is no for a channel,
or non-intrusive treatment works out. Your
recovery from the method is faster. You are
ordinarily doing your normal exercises
inside a couple of days, and the entry point
is generally mended inside a couple of
weeks [10]. A sentinel lymph node biopsy
can prompt a more exact evaluation of
whether the growth has spread to the lymph
nodes [3]. In a conventional axillary
dissection, the pathologist gets no less than
10 lymph nodes or more; there is no chance
to get of telling which one is the sentinel
lymph node [11].
So the pathologist makes one cut in
every lymph node and searches for tumor.
At the point when the pathologist gets stand
out, or a couple of, lymph nodes from a
sentinel lymph node methodology, he or she
can make numerous slices through that
lymph node to search for malignancy. A
negative sentinel lymph node(s) shows a
>95% risk that the remaining lymph nodes
in the axilla are additionally malignancy
free. Therefore, there is no compelling
reason to experience a full axillary lymph
node dissection, or to hazard the long haul
confusions and symptoms from an axillary
dissection [11].
If the SLN biopsy is carried out and the
sentinel node does not contain growth cells,
whatever is left of the regional lymph nodes
doesnt have to be removed. Since less
lymph node is evacuated, there may be
fewer side effects. At the point when various
regional lymph nodes are removed, the
patient may experience reactions, for
example, lymphedema (swelling created by

abundance liquid form up), numbness, a

determined
smoldering
sensation,
contamination, and trouble moving the
influenced body zone [12].
For melanoma patients, SLN biopsy is lowrisk methodology that serves to recognize
high-hazard patients who may advantage
from more forceful treatment, for example,
particular or complete lymphadenectomy or
adjuvant interferon alfa-2b.
5

Limitations of SLNB

Sentinel lymph node biopsy SHOULD NOT

be offered under these circumstances:

the cancer is 5 cm or larger or locally

advanced (the cancer has spread
extensively in the breast or to the
nearby lymph nodes)
the cancer is inflammatory breast
cancer
the woman is pregnant

Unfortunately, the sentinel lymph node

biopsy method can't be performed on
everybody with an invasive breast cancer.
Individuals who have had radiation therapy
or surgery in their breast or axilla ought not
to experience the procedure, as changes in
the breast and axilla from the radiation
therapy or surgery may make the results
inaccurate. Individuals who have enlarged
lymph nodes underneath their arm, or
individuals who we know already have
breast cancer metastatic to their axillary
lymph nodes ought to experience a
traditional axillary lymph node analysis
[13].

6 Other Applications
Sentinel lymph node biopsy is applicable not
only to breast cancer, other cancer like colon
and colorectal cancer that is a cancer in the
intestinal part of the body [3], cutaneous
melanoma the cancer in skin, head and neck
cancer, and cervical cancer [13]. The
attainability of medication by SNLB is
limited to those cancer sites that are near to
lymph nodes which help the surgeon to
identify the speculations and characteristic
of the tumor or other early stage of cancer.

SUMMARY & CONCLUSION

Sentinel lymph node biopsy is capable in

detecting primarily formation of cancer. By
the help of radioactive materials which used
to locate the lymph nodes and determined
whether there is a cancer cell present there,
the risk of cancer intensification will be
prevented.
Radioactive imaging is not
harmful to the body, by a small amount
intake of a medical radionuclide will give no
damage to the body. The lymph nodes has a
great role as a materials to detect cancer
inside the body, the body is composed of
numerous lymph nodes that can be the
sensors of the body for cancer. For
conclusion, the lymph nodes that scattered
in different parts of the body can be the root
for cancer treatment, given by the fact that
lymph nodes can be the sentinel lymph
nodes for cancer detection which primarily
cured by SNLB, the only limitations is that
not having the tumor near a lymph node
which gives difficulties to the surgeon to
detect the cancer cell location.

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