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P252 Clinical implication of the internal mammary lymph node detected by lymphoscintigraphy
S60
Poster Session II. Surgery/Sentinels/DCIS
that are missed due to inadequate visualisation. It will be an extremely useful tool in Hospitals who do not have a full fledged Nuclear medicine department and Conventional gamma camera. Disclosure of Interest: None Declared
P250
Sentinel lymph node biopsy in large node negative breast cancers: results of a validation study using low-cost blue dye & 99mTc-antimony colloid
G. Agarwal1 , S. Gambhir2 , P. Lal3 , N. Krishnani4 , S. Kheruka2 , S. Mishra1 . 1 Endocrine & Breast Surgery, 2 Nuclear Medicine, 3 Radiation Oncology, 4 Pathology, SGPGIMS, Lucknow, India Goals: Sentinel lymph node biopsy (SLNB) has established role in primary management of node-negative small breast cancers. Its utility is questionable in developing countries as most patients present at large & locally advanced cancers, and cost is a major concern. Commercially marketed blue-dye and radio-pharmaceutical increase cost of breast cancer surgery in Indian public-hospital setting by two-third. We evaluated, in a prospective study SLNB in large (>4 cm) breast cancers, using methylene-blue & 99m Tc-Antimony-colloid produced in-house, which cost 7% of commercial products. Methods: 75 large (mean tumor size 4.4 cm, range 4−8 cm) nodenegative breast cancer (T2−3,N0) patients were subjected to validation SLNB using in-house prepared methylene-blue & 99m Tc-Antimony-colloid. 40MBq 99m Tc-Antimony-colloid (prepared by radio-pharmacy of Dept of Nuclear Medicine) was injected 12−24h before operation. 2ml sterile 1%w/v methylene-blue (medical grade, filtered, sterilized in-house) was injected 15mins before incision. With minimal axillary dissection, any blue and/or hot nodes were excised with help of hand-held gamma probe & subjected to frozen section histology. Levels 1 & 2 validation axillary dissection was done in all irrespective of SLN histology. Paraffin section histology of all axillary nodes was compared with the SLN histology. Results: SLN identification rate was 94.6% with combination, 88% with blue-dye & 93.3% with radio-pharmaceutical. 41 (54.6%) pts had non-metastatic SLN, of whom 3 had metastases in other nodes (4.2% false negative). All 34 metastatic SLN on frozen-section were indeed metastatic (no false positive), and were the only metastatic nodes in 22. Negative-predictive-value of SLNB in ruling out axillary metastases was 95.8%, positive-predictive-value 100% and overall accuracy 94.6%. Blue discoloration of urine occurred in 43% patients, none had major reactions. No patients had axillary recurrence in follow up (12−54 months). Conclusion: In patients with large node negative breast cancers, SLNB using low-cost indigenous blue-dye and radio-pharmaceutical can predict axillary metastases with comparable accuracy and safety as SLNB in small cancers using commercially available dyes, at fraction of the cost. Disclosure of Interest: None Declared
P251
3D navigated sentinel lymph node biopsy in 29 breast cancer patients with use of freehand SPECT for intraoperative navigation and quality assurance
A. Schnelzer1 , A. Ehlerding1 , K. Scheidhauer2 , S. Paepke1 , M. Kiechle1 . 1 Gynecology, 2 Nuclear Medicine, TU Munchen, ¨ Munich, Germany Goals: The sentinel lymph node (SLN) concept in breast cancer is an integral standard of care. However, several practical issues have been raised preventing proper identification of the sentinel node in certain clinical scenarios. Moreover, the criteria for definition of sentinel node have recently been questioned, including the value of dynamic information or the value of preoperative lymphoscintigraphy. The problems behind some of these questions rely on the lack of intraoperative 3D information for localization of the sentinel lymph nodes. Methods: For the freehand SPECT (fhSPECT, SurgicEye GmbH, Germany) a gamma probe system and an infrared optical tracking system were combined in one system. To date, 29 patients with invasive breast cancer undergoing SLNB were recruited and scanned using fhSPECT before excision of SLNs. The localization of SLNs with fhSPECT was compared to the position of SLNs detected using gamma probe and blue dye. fhSPECT was further used to prove the excision of the SLN postoperatively. Preoperative planar scintigraphy was used as a reference. Results: Preoperatively 58 SLNs were mapped with conventional scintigraphy. In the pre-excision scan fhSPECT had a sensitivity of 91%
Friday, 18 March 2011 (conventional gamma probe only 72%). fhSPECT detected 17 SLNs in 15 patients after primary SLN excision which had not been detected by the gamma probe during the control scan. In the remaining 13 patients no residual radioactivity was found in the axilla. fhSPECT acquisitions took approx. 2.1 min (SD, 1.0 min). Conclusion: Intraoperative 3D imaging with fhSPECT is a very sensitive tool to guide complete and precise resection of the sentinel node(s). For quality assurance the system can digitally document that all SLNs have been successfully removed. The freehand SPECT provides new options concerning the controversies in the sentinel lymph node concept. Controlled studies using 3D intraoperative imaging could help to clarify many of the discussed issues, including the role of lymphatic uptake on selecting the nodes for surgical resection. Also, the option to transfer information from preoperative imaging into the operating room or the possibility to skip preoperative imaging bears additional advantages over the standard procedure. Disclosure of Interest: None Declared
P252
Clinical implication of the internal mammary lymph node detected by lymphoscintigraphy
S.Y. Bae1 , J. Jang1 , S. Nam1 , J. Lee1 , J.-H. Yang1 , S.K. Lee1 . 1 General Surgery, Samsung Medical Center, Seoul, Korea, Republic of Goals: The purpose of this study is to investigate the characteristics of IMLN drainage breast tumors and to determine the clinical implication of the IMSLN in early breast tumors and to analyze the long term significance of IMLN detected in lymphoscintigraphy. To determine the necessity of the IMSLN biopsy or lymphoscintigraphic identification of nodal basins outside axilla. Methods: From January 2001 until December 2006, clinically early female breast cancer patients underwent radical surgery at Samsung Medical Center, Sungkyunkwan University School of Medicine. The clinical characteristics, follow up results, recurrences, deaths were analyzed, retrospectively. Results: Among the 470 patients, 15 patients (3.2%) died of the breast cancer during the median follow up period of 119.2 (range 7–124) months, and breast cancer related relapse occurred in 46 (9.8%) patients, during the median follow up period of 109.8 (range 7–122) months. Locoregional recurrence was found in 25 patients (5.3%). Recurrence in IM lymphatic chain was found in 3 cases (0.6%). During the median follow up period of 118.8 (range 7–122) months in axilla only group, and 107.7 (range 14–108) months in IMLN group, breast cancer related death rate in axilla only group was 3.6% without statistically significant difference from IMLN group (1.3%) (p = 0.484). Conclusion: Long term follow up results showed that there was no significant difference in both overall and disease free survival between the two groups. Especially, the recurrence in locoregional area and IM lymphatic chain did not differ between the two groups. Because the recurrence in IMLN is very low, lymphoscintigraphic identification of nodal basins outside axilla, the necessity of IMLN sentinel biopsy should be reconsidered. Disclosure of Interest: None Declared
P253
The consequences of shoulder mobility in early breast cancer patients with sentinel lymph node biopsy or axillary lymph node dissection
T. Utsumi1 , C. Yoneda2 , N. Kobayashi1 , S. Miyajima1 , M. Hikichi1 , E. Saittoh2 . 1 Department of breast surgery, 2 Department of rehabilitation Medicine, Fujita Health University, Toyoake, Japan Goals: The aim of this study was to evaluate the relationship between the type of breast cancer surgery and postoperative shoulder mobility. Methods: The study group consisted of 362 consecutive patients, aged 28 to 86 years with breast cancer, operated between February 2005 and November 2009. Out of the 362 patients, 174 (group 1) underwent breast conserving therapy with SLNB, 67 (group 2) simple mastectomy with SLNB, 68 (group 3) breast conserving therapy with ALND and 53 (group 4) modified radical mastectomy. Upper limb function was evaluated one day before surgery (baseline), at discharge, and 1 month and 3 months after surgery. In this study assessment consisted of shoulder flexion and shoulder abduction. The frequency of recovery of shoulder mobility was
Poster Session II. Surgery/Sentinels/DCIS
that are missed due to inadequate visualisation. It will be an extremely useful tool in Hospitals who do not have a full fledged Nuclear medicine department and Conventional gamma camera. Disclosure of Interest: None Declared
P250
Sentinel lymph node biopsy in large node negative breast cancers: results of a validation study using low-cost blue dye & 99mTc-antimony colloid
G. Agarwal1 , S. Gambhir2 , P. Lal3 , N. Krishnani4 , S. Kheruka2 , S. Mishra1 . 1 Endocrine & Breast Surgery, 2 Nuclear Medicine, 3 Radiation Oncology, 4 Pathology, SGPGIMS, Lucknow, India Goals: Sentinel lymph node biopsy (SLNB) has established role in primary management of node-negative small breast cancers. Its utility is questionable in developing countries as most patients present at large & locally advanced cancers, and cost is a major concern. Commercially marketed blue-dye and radio-pharmaceutical increase cost of breast cancer surgery in Indian public-hospital setting by two-third. We evaluated, in a prospective study SLNB in large (>4 cm) breast cancers, using methylene-blue & 99m Tc-Antimony-colloid produced in-house, which cost 7% of commercial products. Methods: 75 large (mean tumor size 4.4 cm, range 4−8 cm) nodenegative breast cancer (T2−3,N0) patients were subjected to validation SLNB using in-house prepared methylene-blue & 99m Tc-Antimony-colloid. 40MBq 99m Tc-Antimony-colloid (prepared by radio-pharmacy of Dept of Nuclear Medicine) was injected 12−24h before operation. 2ml sterile 1%w/v methylene-blue (medical grade, filtered, sterilized in-house) was injected 15mins before incision. With minimal axillary dissection, any blue and/or hot nodes were excised with help of hand-held gamma probe & subjected to frozen section histology. Levels 1 & 2 validation axillary dissection was done in all irrespective of SLN histology. Paraffin section histology of all axillary nodes was compared with the SLN histology. Results: SLN identification rate was 94.6% with combination, 88% with blue-dye & 93.3% with radio-pharmaceutical. 41 (54.6%) pts had non-metastatic SLN, of whom 3 had metastases in other nodes (4.2% false negative). All 34 metastatic SLN on frozen-section were indeed metastatic (no false positive), and were the only metastatic nodes in 22. Negative-predictive-value of SLNB in ruling out axillary metastases was 95.8%, positive-predictive-value 100% and overall accuracy 94.6%. Blue discoloration of urine occurred in 43% patients, none had major reactions. No patients had axillary recurrence in follow up (12−54 months). Conclusion: In patients with large node negative breast cancers, SLNB using low-cost indigenous blue-dye and radio-pharmaceutical can predict axillary metastases with comparable accuracy and safety as SLNB in small cancers using commercially available dyes, at fraction of the cost. Disclosure of Interest: None Declared
P251
3D navigated sentinel lymph node biopsy in 29 breast cancer patients with use of freehand SPECT for intraoperative navigation and quality assurance
A. Schnelzer1 , A. Ehlerding1 , K. Scheidhauer2 , S. Paepke1 , M. Kiechle1 . 1 Gynecology, 2 Nuclear Medicine, TU Munchen, ¨ Munich, Germany Goals: The sentinel lymph node (SLN) concept in breast cancer is an integral standard of care. However, several practical issues have been raised preventing proper identification of the sentinel node in certain clinical scenarios. Moreover, the criteria for definition of sentinel node have recently been questioned, including the value of dynamic information or the value of preoperative lymphoscintigraphy. The problems behind some of these questions rely on the lack of intraoperative 3D information for localization of the sentinel lymph nodes. Methods: For the freehand SPECT (fhSPECT, SurgicEye GmbH, Germany) a gamma probe system and an infrared optical tracking system were combined in one system. To date, 29 patients with invasive breast cancer undergoing SLNB were recruited and scanned using fhSPECT before excision of SLNs. The localization of SLNs with fhSPECT was compared to the position of SLNs detected using gamma probe and blue dye. fhSPECT was further used to prove the excision of the SLN postoperatively. Preoperative planar scintigraphy was used as a reference. Results: Preoperatively 58 SLNs were mapped with conventional scintigraphy. In the pre-excision scan fhSPECT had a sensitivity of 91%
Friday, 18 March 2011 (conventional gamma probe only 72%). fhSPECT detected 17 SLNs in 15 patients after primary SLN excision which had not been detected by the gamma probe during the control scan. In the remaining 13 patients no residual radioactivity was found in the axilla. fhSPECT acquisitions took approx. 2.1 min (SD, 1.0 min). Conclusion: Intraoperative 3D imaging with fhSPECT is a very sensitive tool to guide complete and precise resection of the sentinel node(s). For quality assurance the system can digitally document that all SLNs have been successfully removed. The freehand SPECT provides new options concerning the controversies in the sentinel lymph node concept. Controlled studies using 3D intraoperative imaging could help to clarify many of the discussed issues, including the role of lymphatic uptake on selecting the nodes for surgical resection. Also, the option to transfer information from preoperative imaging into the operating room or the possibility to skip preoperative imaging bears additional advantages over the standard procedure. Disclosure of Interest: None Declared
P252
Clinical implication of the internal mammary lymph node detected by lymphoscintigraphy
S.Y. Bae1 , J. Jang1 , S. Nam1 , J. Lee1 , J.-H. Yang1 , S.K. Lee1 . 1 General Surgery, Samsung Medical Center, Seoul, Korea, Republic of Goals: The purpose of this study is to investigate the characteristics of IMLN drainage breast tumors and to determine the clinical implication of the IMSLN in early breast tumors and to analyze the long term significance of IMLN detected in lymphoscintigraphy. To determine the necessity of the IMSLN biopsy or lymphoscintigraphic identification of nodal basins outside axilla. Methods: From January 2001 until December 2006, clinically early female breast cancer patients underwent radical surgery at Samsung Medical Center, Sungkyunkwan University School of Medicine. The clinical characteristics, follow up results, recurrences, deaths were analyzed, retrospectively. Results: Among the 470 patients, 15 patients (3.2%) died of the breast cancer during the median follow up period of 119.2 (range 7–124) months, and breast cancer related relapse occurred in 46 (9.8%) patients, during the median follow up period of 109.8 (range 7–122) months. Locoregional recurrence was found in 25 patients (5.3%). Recurrence in IM lymphatic chain was found in 3 cases (0.6%). During the median follow up period of 118.8 (range 7–122) months in axilla only group, and 107.7 (range 14–108) months in IMLN group, breast cancer related death rate in axilla only group was 3.6% without statistically significant difference from IMLN group (1.3%) (p = 0.484). Conclusion: Long term follow up results showed that there was no significant difference in both overall and disease free survival between the two groups. Especially, the recurrence in locoregional area and IM lymphatic chain did not differ between the two groups. Because the recurrence in IMLN is very low, lymphoscintigraphic identification of nodal basins outside axilla, the necessity of IMLN sentinel biopsy should be reconsidered. Disclosure of Interest: None Declared
P253
The consequences of shoulder mobility in early breast cancer patients with sentinel lymph node biopsy or axillary lymph node dissection
T. Utsumi1 , C. Yoneda2 , N. Kobayashi1 , S. Miyajima1 , M. Hikichi1 , E. Saittoh2 . 1 Department of breast surgery, 2 Department of rehabilitation Medicine, Fujita Health University, Toyoake, Japan Goals: The aim of this study was to evaluate the relationship between the type of breast cancer surgery and postoperative shoulder mobility. Methods: The study group consisted of 362 consecutive patients, aged 28 to 86 years with breast cancer, operated between February 2005 and November 2009. Out of the 362 patients, 174 (group 1) underwent breast conserving therapy with SLNB, 67 (group 2) simple mastectomy with SLNB, 68 (group 3) breast conserving therapy with ALND and 53 (group 4) modified radical mastectomy. Upper limb function was evaluated one day before surgery (baseline), at discharge, and 1 month and 3 months after surgery. In this study assessment consisted of shoulder flexion and shoulder abduction. The frequency of recovery of shoulder mobility was