INDICATIONS AND

OPERATIVE
UNDERSTANDING OF
SENTINEL LYMPH
NODE BIOPSY
Dr. Murk Niaz
Resident Trainee
HISTORICAL BACKGROUND
LYMPHATICS
■ Herophilus 300 BC
■ Gasparo Aselli 1622
■ Gassendi 1628
■ Bartholin 1652
■ Anthony Nuck 1650–1692
■ Rudolf Virchow 1863
HISTORICAL BACKGROUND
SENTINEL LYMPH NODE
■ Hudack and McMaster 1933
■ Walker
■ Gould 1960
■ Cabañas
HISTORICAL BACKGROUND
SENTINEL LYMPH NODE
(BREAST)
■ William S. Halsted from Johns Hopkins Hospital in Baltimore (1852–
1922)
■ Mastectomy with en bloc axillary clearance for breast cancer in 1894
SENTINEL LYMPH NODE
DEFINITION
■ The node closest to the primary lesion
■ The node with a radioactive channel leading to it
■ The node with the highest count rate on lymphoscintigraphic imaging
and probe counting
■ The first node visible on lymphoscintigraphic imaging
■ The blue node on dye injection technique
■ The node with a blue channel leading to it
THE PATHOPHYSIOLOGY OF
SENTINEL LYMPH NODE METASTASIS
ULTRASTAGING

■ Serial sectioning
■ Immunohistochemical analysis (IHC)
■ Reverse-transcriptase polymerase chain reaction (RT-PCR)
SENTINEL LYMPH NODE
BIOPSY
ADVANTAGES
■ Decreases the morbidity related to lymph node dissection
■ Shorter duration of drain use
■ Short duration hospitalization
■ Less time to resumption of normal daily activities
LYMPHATIC DRAINAGE OF THE
BREAST
AMERICAN SOCIETY OF CLINICAL
ONCOLOGY (ASCO) INDICATIONS FOR
SENTINEL LYMPH NODE BIOPSY

■ Women with operable breast cancer (T1/T2) and multicentric tumors

■ Women with DCIS who will be undergoing mastectomy
■ Women who previously underwent breast and/or axillary surgery
■ Women who received preoperative/neoadjuvant systemic therapy
■ Older or obese patients
■ Male patients with breast cancer
AMERICAN SOCIETY OF CLINICAL
ONCOLOGY (ASCO) CONTRAINDICATIONS
FOR SENTINEL LYMPH NODE BIOPSY
■ Large or locally advanced invasive breast cancer (tumor size T3/T4)
■ Inflammatory breast cancer
■ DCIS (when breast-conserving surgery is planned)
■ Pregnancy
Technetium-99m (99mTc)

■ Most commonly used medical radioisotope

■ 99m Tc-sulfur colloid (particle size, 15-5000 nm), 99m Tc-nanocolloid
(5-100 nm), and 99m Tc-antimony trisulfide (3-30 nm)
■ Emits readily detectable gamma rays with a photon energy of 140 keV
■ Half-life for gamma emission is 6.0058 hours
■ Biological half-life of 1 day
■ Suitable only for diagnostic but never therapeutic use

 
BLUE DYES

■ Isosulfan blue
■ Patent blue
■ Methylene blue
INJECTION TECHNIQUES

■ Superficial techniques
Intradermal
Subcutaneous
Subareolar
Periareolar
■ Deep techniques
Peritumoral
Intratumoral
AXILLARY NODES APPEARANCE
CAN TAKE SEVERAL PATTERNS
■ One sentinel node, with or without a visible lymphatic duct; no second-tier
nodes
■ One sentinel and one or more second-tier nodes
■ The simultaneous appearance of two nodes with same uptake intensity (twin
sentinel nodes)
■ A node closer to the injection site that appears later than other more distant
nodes (the closer node is the sentinel node)
■ Differentiation of the sentinel node from second-tier nodes can be made by
the following:
■ The presence of a lymphatic channel leading to the sentinel node
■ The sequence of appearance (the sentinel node appears first)
■ The intensity of uptake (the sentinel node has more activity)
INTRADERMAL
INTRADERMAL
PERITUMORAL
INTRATUMORAL INJECTION TECHNIQUE

■ Concerns about tumor spread

DYE INJECTION METHOD
REFERENCES
■ Manca, G., Rubello, D., Tardelli, E., Giammarile, F., Mazzarri, S., Boni, G., … Colletti, P. M.
(2016). Sentinel Lymph Node Biopsy in Breast Cancer. Clinical Nuclear Medicine, 41(2), 126–
133. doi:10.1097/rlu.0000000000000985
■ Gary H. Lyman, Mark R. Somerfield, Linda D. Bosserman, Cheryl L. Perkins, Donald L. Weaver, and
Armando E. Giuliano. (2017). Sentinel Lymph Node Biopsy for Patients With Early-Stage Breast Cancer:
American Society of Clinical Oncology Clinical Practice Guideline Update. Journal of Clinical Oncology,
35(5), 561-564. doi: 10.1200/JCO.2016.71.0947
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be used as an alternative to patent blue dye to find the sentinel lymph node in breast cancer surgery? J
Res Med Sci. 2014 Oct;19(10):918-22.
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and Analysis of Images. RadioGraphics, 2004; 24 (1). doi: 10.1148/rg.241025713
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Anatomical and Pathophysiological Considerations and Clinical Aspects. J Oncol. 2019 Jul
29;2019:3415630. doi: 10.1155/2019/3415630.
■ Nieweg OE, Uren RF, Thompson JF. The history of sentinel lymph node biopsy. Cancer J. 2015 Jan-
Feb;21(1):3-6. doi: 10.1097/PPO.0000000000000091.
■ Tanis PJ, Nieweg OE, Valdés Olmos RA, Th Rutgers EJ, Kroon BB. History of sentinel node and validation
of the technique. Breast Cancer Res. 2001;3(2):109-12.
■ Manca G, Tardelli E, Rubello D, Gennaro M, Marzola MC, Cook GJ, Volterrani D. Sentinel lymph node
biopsy in breast cancer: a technical and clinical appraisal. Nucl Med Commun. 2016 Jun;37(6):570-6.
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THANK
YOU