Overview

• Anatomy
• History
• Preoperative axillary assesment
• ALND(Axillary Lymph Node Dissection)
• SLNB (Sentinel Lymph Node Biopsy)
• Important Trials
• SLNB IN SPECIAL SITUATION
• Future Perspectives in SLN
• Axillary Sampling
• Conclusion
Lymphatic of Breast
i. Superficial lymphatics
Cutaneous Plexus(Dermis)
Subcutaneous Plexus(Subcutaneous space)
Drain in axillary L.N
ii Deep Lymphatic plexus
Glandular plexus (lobes and ducts)
Fascial Plexus(over pectoralis fascia)
Drain in axillary and internal mammary group of L.N.
The superficial injection techniques are based on that
both gland and skin have a common embryonic origin
and therefore share the same lymphatic drainage
(Tanis et al.; Quadros & Gebrim).
• Lymphatic Drainage of the Breast from Theory to Surgical Practice Int. J.
Morphol.,27(3):873-878, 2009.
 Pre-Operative Assessment of Axilla
Technique Sensitivity Specificity
Clinical Examination 31.6%
Hr-USG Axilla 69.4% 81.8%
Hr-USG Axilla + FNAC 78.9% 100%
Mammography 14% 84%
CT Scan 93% 57%
Dynamic Contrast 93% 62%
Enhanced MRI
Zhang YN1 et al Sensitivity, Specificity and Accuracy of Ultrasound in Diagnosis of Breast Cancer Metastasis to the
Axillary Lymph Nodes in Chinese Patients.. Ultrasound Med Biol. 2015 Jul;41(7):1835-41. doi:
10.1016/j.ultrasmedbio.2015.03.024. Epub 2015 Apr 29.

2Nan Fang Yi etal [Value of mamography, CT and DCE-MRI in detecting axillary lymph node
metastasis of breast cancer 2016 Apr;36(4):493-9
 USG Metastatic nodes

Normal Lymph node

• Smooth
• cortex < 3 mm
• Echogenic central
hilum
 USG Metastatic nodes

Metastatic Lymph
node
• cortex > 3 mm
• Absence/Eccentric
of echogenic
central hilum
• Abnormal/
Hyperemic blood
flow
 Mammography
Normal Lymphnode
• Elongated
• Central
hypointense
hilum
 Mammography
Abnormal Lymphnode
• Round
• Eccentric hila/loss of
hila
• Microcalcification
 Tumour Size and axillary Metastasis

De-escalation of axillary surgery in early breast cancer Kyoto Breast Cancer Consensus
Conference 2016
 Importance of axilla Management
• Staging

• Prognosis: Most powerful predictor of recurrence and

survival

• Determines therapeutic decision making- extent of

axillary surgery, systemic therapy, radiation)

De-escalation of axillary surgery in early breast cancer Kyoto Breast Cancer Consensus
Conference 2016
Axillary Lymph node Dissection(ALND)

Removal of level I and II lymph nodes in carcinoma breast

patients with clinically positive nodes

Current indications for ALND

• Clinically node-positive axilla
• Occult breast cancer: axillary node metastasis
• Inflammatory/T4/T3 breast cancer
• SLN positive patients
• Facility of SLNB not available
• Failed SLN mapping
• Inadequate prior ALND
• After neo adjuvant chemotherapy
• Axillary recurrence following previous breast cancer
treatment
• Axillary lymph node dissection
– Standard: Level 1 and 2 dissection

– Level 3 dissection if
• Enlarged level 3 nodes
• Bulky levels 1 and 2 nodes

Adequate ALND: >10 lymph nodes removed

Sabiston 20th edition

Morbidity of ALND

50% to 70% of patients undergoing ALND will have some

complaints
Early
• Skin erythema
• Prolonged drainage or Seroma
• Wound infection

Delayed
• Arm edema (16%)
• Shoulder dysfunction (17%)
• Pain (25%)
• Chest wall and arm numbness (78%)
Complications of Level I and II Axillary Dissection in the Treatment of Carcinoma of the Breast Ann
Surg. 1999 Aug
SENTINEL LYMPHNODE BIOPSY
(SLNB)
Sentinel Lymph node

• “Node on Watch”.

• First node to receive

cancer cells.

• If negative, the upstream

nodes are negative
99 /100 times
Amit Goyal Management of the axilla in
Patients with breast cancer Indian J Surg
(November 2009) 71:328–334
History of Sentinel Lymph node

• Seaman&Powers 1955 first echelon node, nodal basin

with radioactive colloid gold
• Gould in 1960 labeled first-echelon node the “sentinel
node”
• Cabanas in 1977 identified specific groin node in penile
cancer
• Morton 1992 demonstrated intraoperative mapping in
melanoma using dye

Cabanas : AN approach to the treatment of penile carcinoma

Morton et al: Technical details of intraop lymphatic mapping for melanomaGould:
observations on a sentinel node in parotid cancer
Benefits of SLND

• Reduces the morbidity of axilla dissection: lymphedema ,

shoulder dysfunction, numbness, seroma and chronic pain

• Can identify patients with proven node positive disease

who may benefit from ALND
• Outpatient procedure

• Cost and time effective

• Provides reliable pathologic staging of axilla with

Identification rate 95% False Negative rate 5-10%
Amit Goyal Management of the axilla in Patients with breast cancer Indian J Surg
(November 2009) 71:328–334
 Contraindications
Absolute
Clinically positive nodes
Inflammatory breast cancer

Relative
Locally advanced and inflammatory breast cancer
Neoadjuvant chemotherapy
Previous breast and axillary procedures for benign conditions
Recurrent breast cancer and previous axillary procedures
Pregnancy
Surgeons experience and learning curve
George M Filippakis et al Contraindications of sentinel lymph node biopsy: Áre there any really?
alWorld J Surg Oncol. 2007; 5: 10.
Technique

Four steps

1 : SLN identification
2 : SLN Removal
3: Intra-op pathology of SLN
4: Management
Identification

Reagent Used Sensitivity Specificity Accuracy

Blue Dye 82% 60% 68%
Patent violent (Lymphazurin ®)
– Methylene blue
• Radio-pharmaceutical 91%
– 99mTc Sulfur colloid
– 99mTc antimony colloid
• Combination 95% 73% 83%

Blue dye versus combined blue dye radioactive tracer technique in detection of sentinel L.N. in breast
cancer Eur J Surj Oncology 2004
• Radiotracer element combined with Organic or inorganic
carrier
• Smaller the size more the speed of flow
• Optimal size 10-100 nm

Volume Used
Radiotracer- Day before 2.5 miC
Preop 0.5 miC
Blue dye 4-5 ml

• FREGNANI, J. H. T. G. & MACÉA, J. R. Lymphatic drainage of the breast: from theory

.
to surgical practice. Int. J.Morphol., 27(3):873-878, 2009
Site of Injection
IR FNR
Peritumoral 72% 8.3

Subdermal 92% 7.8

Intradermal 95.3 6.5

Peritumoral+Subdermal 93.2

Periareolar+Intradermal 98%

Comprasion of different injection sites of radionuclide for sentinel lymphnode detection in

breast cancer Mudun A Clin Nucl Med 2008
Procedure
HOW MANY NODES?

Number of Dissected False Negative Accuracy %

SLN rate %
1 10.8 96.3
2 5 98.3
3 3.5 98.7
4 0 100

How Many Sentinel Lymph Nodes Are Enough for Accurate Axillary Staging in T1-2 Breast
Cancer? Eun Jeong Ban Journal of Breast Cancer 2011 December
Non Visualisation of Sentinel Lymphnode

• Shine through” from primary tumor can obscure

identification

• Tumor filling a node, distorting architecture, could

redirect lymphatic flow

• Tumor size can directly compress draining lymphatics

• Technical Incompetence

Isabelle Brenot-Rossi etal 2009Nonvisualization of Axillary Sentinel Node During Lymphoscintigraphy: Is There a
Pathologic Significance in Breast Cancer?, m jnm.snmjournals.org
Pathological Examination of SLN
Rapid/ intra-op pathology to aid one-stage operation
Technique Sensitivity(%) Specificity(%)
Touch Imprint Cytology 71.4 100
Frozen Section(FS) 87 98.5
Rapid Cytokeratin Immune 80 97.5
Staining(RCI)
FS+RCI 87 100
OSNA(One step nucleic acid 99-100 90-100
amplification )

• The value of touch imprint cytology and frozen section for intra-operative evaluation of axillary sentinel lymph
nodes. Pol J Pathol. 2010;61(3):161-5
• Cytokeratin on Frozen Sections of Sentinel Node May Spare Breast Cancer Patients Secondary Axillary Surgery
Pathology Research InternationalVolume 2012 (2012), Article ID 802184,
• Intraoperative diagnosis of sentinel lymph node metastases in breast cancer treatment with one-step nucleic acid
amplification assay (OSNA) Arch Med Sci. 2016
 Interpretation result of SLND

Isolated Tumour Cell Micrometastasis Macrometastasis

(pN0(i+))
Clusters of tumor cells
< 0.2 mm or
nonconfluent or nearly
confluent clusters of
cells <200 cells in a
single histologic lymph
node cross section
(pN1mi )
Nodal involvement Nodal involvement
with metastatic (classically designated
deposit >0.2 mm but as "node-positive") by
<2.0 mm. any tumor cell deposit
>2.0 mm.

Recent consideration :-
Occult metastatic disease (pN0) Nodal metastases detected only by
immunohistochemical staining or reverse transcriptase polymerase
chain reaction
("Z-0011-eligible" criteria and NCCN 2017 Guidelines)
MANAGEMENT AFTER SENTINEL LYMPH NODE BIOPSY
Completion ALND
• >2 metastatic sentinel lymph nodes on SLNB.
• 1-2 metastatic sentinel lymph nodes on SLNB but who do
not desire whole-breast irradiation.

No ALND
• A T1 or T2 (≤5 cm) primary breast cancer
• <3 metastatic sentinel lymph nodes on SLNB.
• Breast conserving surgery
• whole-breast irradiation

("Z-0011-eligible" criteria and NCCN 2017 Guidelines)

IMPORTANT TRIALS
NSABP B-32
AIM-Whether SLN resection achieves same survival and
regional control as ALND

Time Period 96 months

Inclusion Criteria
• Clinically node negative
• Age <70
• Tumour size <4 cm
• Surgery planned waslumpectomy/mastectomy
MILAN TRIAL (UMBERTO VERONESI, M.D. et al 1986)
• AIM Comparison of Radical Mastectomy with Quadrantectomy
• Inclusion criteria Clinically negative nodes
Age < 70 yrs
Breast Cancer < 2 cm
• Time Period 8 YEARS

ALND NO ALND
Over all Survival 83+2.2 85+2.1
Disease Free Survival 77+2.4 80+2.4
ACOSOG Z0011 TRIAL (Guliano et al)
• AIM: impact of completion ALND on survival of patients
with SLN metastasis in breast cancer.
• Time Period 5 Years (1999-2004)
• Sample 891
Inclusion Criteria
• T1 or T2 breast cancer;
• no palpable adenopathy;

Patients with sentinel lymph node-positive disease were

randomly assigned to ALND or no further axillary surgery
AMAROS61
AIM: Comparison of ALND with SLNB+RT
Year -2001
Sample 1425
Inclusion Criteria T1 or T2 breast cancer;
no palpable adenopathy;
primary tumour treated with breast-
conserving therapy or mastectomy
SLNB IN SPECIAL SITUATION
 Post NACT SLN
Still under study
Studies carried out
Study Type Prechemo node Identification False Negative
identification rate (IR) rate (FNR)
In Study conducted in SGPGI 2015 concludes

SLNB in post-NACT N0 patients was not found robust in

staging the axilla
• Minimum acceptable quality standards for staging axilla,
SLN-IR of 90% and SLN-FNR of 10%

• Patients with index stage T3,N0-1 are

exception to this.

• (Pre-NACT) skin involvement (T4b),

matted axillary nodes (N2a) and LVI
predict high-risk of non-identification
and false-negative SLNB.

Gaurav Agarwal etal 2015 Sentinel Lymph Node Biopsy (SLNB) after Neo-adjuvant Chemotherapy (NACT) in Large/ Locally Advanced
Breast Cancer Patients: Results of a Validation Study San Antonio Breast Cancer Symposium - 2015
Methods to IR and FNR for post NACT SLN

• dual localization technique

• harvesting > 2 sentinel nodes
• routine imaging of the axilla after NACT
• addition of IHC to HPE
• Marking the positive node with a marker clip

Is sentinel lymph node biopsy a viable alternative to complete axillary dissection following neoadjuvant
chemotherapy in women with node-positive breast cancer at diagnosis?An updated meta-analysis involving
3,398 patients The American Journal of Surgery (2016)
SLN biopsy in patients with ductal carcinoma in
situ (DCIS)
CORE NEEDLE
BIOPSY

DCIS WITH
PURE DCIS
INVASION

WLE WLE+SLN

EXTENSIVE DCIS
REQUIRING MASTECTOMY+SNLB
MASTECTOMY Emiel J etal Current approach of axilla in EBC Lancet Aug 2017
Locoregional Recurrence following SLN
Future Perspectives in SLN
• Newer technologies for lymphatic mapping
Indocyanine green fluroscent
Super paramagnetic iron oxide nanoparticle

• Omission of SLN Biopsy in early Breast Cancer

SOUND trial(tumour size<2 cm)
INSEMA Trial(tumour size<5 cm)

(Prof E P Mamounas MD etal August 14, 2017 Current approach of the axilla in patients with
early-stage breast cancer Published Online University of Florida Health Cancer Center—
Orlando Health,and University of Central Florida, Orlando, FL, USA
Ongoing Trial
 POSNOC64
(Ongoing)
Inclusion Criteria Design

Year 2014 Invasive breast cancer Patients with sentinel lymph

(≤5 cm);no palpable
node-positive disease were
Sample adenopathy; primary
randomly assigned to axillary
1900 tumour treated with
therapy (surgery or
Planned breast-conserving
radiotherapy) or no further
surgery or mastectomy
axillary therapy
Aim
• Learn more about the side effect of
treatment of axilla node

• Effect of axillary treatment on Quality of life

AXILLARY SAMPLING
Blind technique and relies on palpation to removal
lymph nodes.
Indication Fail SLNB
No Facility of SLNB
Largest node (min 4) excised
Accuracy 95%
Sensory loss and lymphoedema worse after four
node sampling compared with SLNB
Monypenny IJ et al (2005) End of 4 node sampling?- Comparative morbidity
versus sentinel lymph node biopsy in the ALMANAC trial. Proceedings of the
Nottingham Breast Cancer Conference 2005
Sentinel node biopsy versus low axillary sampling in women
with clinically node negative operable breast cancer
(V.Parmar et al 2004-11)
• Excision of all fibrofatty tissue overlying the second
digitation of serratus anterior below the intercostobrachial
nerve
• Done before pre-operative injection of radioactive colloid
and injection of blue dye

• False Negative Rate not significant(p=0.56)

• Effective and low cost procedure that minimizes axillary

surgery and can be implemented widely
CONCLUSION
NCCN Guidelines® Insights Breast Cancer, Version 1.2017
Schematic of progressive de-escalation of axillary surgery

De-escalation of axillary surgery in early breast cancer Kyoto Breast Cancer Consensus
Conference 2016
 Switch to new paradigm

“maximum tolerable treatment”

“minimum effective treatment.”

T H A N K YO U