This document discusses radioguided surgery techniques used at the Breast Centre of Kwong Wah Hospital, including radioguided occult lesion localization (ROLL) to locate clinically occult breast lesions, and sentinel lymph node biopsy (SLN) to stage breast cancer. It describes the techniques, including injection of radioactive tracers, use of a handheld gamma probe in surgery, and specimen processing. It also covers troubleshooting, sentinel lymph node staging, and radiation protection measures.
2. Radioguided surgery
ž Use
of radioactive isotope
ž Localisation of clinically occult lesion
ž Localisation of sentinel lymph node
ž Close collaboration between radiologist,
NM physician and surgeons
ž Facility of scintigraphy within hospital
ž Handheld gamma camera in operation
room
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Run by Tung Wah Group of Hospitals
Oldest charity organisation in Hong Kong
2 clinics ( at Mongkok and Causeway Bay)
located within HA hospital
General health check
Pap smear
Screening Mammogram
Osteoporosis Service
Menopause Service
4. Screening mammogram in Hong
Kong
ž Not
advocated by Department of Health
ž No public funding
ž No public health insurance
ž Individual NGO advocate and provide
service as a non profit making item (e.g.
Hong Kong Breast Cancer Foundation,
Well Women Clinic)
ž Private sector
ž Variable insurance plans coverage
5. Screening Mammogram
ž Women
>40yrs
ž Women >35yrs if family history positive
ž 2 standard view: MLO &CC
ž Tomosynthesis if indicated
ž Additional view if indicated
ž Ultrasound if indicated
7. Radioguided occult lesion
localization (ROLL)
Clinically occult breast lesion
ž Localised by imaging (mammogram,
ultrasound, MRI)
ž Injection of liquid radioactive tracer (Tc99)
ž Insertion of radio opapue titanium seed
containing I125
ž Scintigraphy after localization
ž Use of hand held gamma camera in
Operating room
ž
8. Radioguided occult lesion
localization
ž Hottest
spot identified
ž 10 sec count measured
ž Skin incision: over the hottest spot vs
circumareolar
ž Specimen mammogram/ ultrasound to
confirm complete removal of index
lesion
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12.
13.
14. ROLL
ž Removal
of the index lesion
ž Clear margin in cases of malignancy
ž Re-operation rate
ž Radiation protection
15. Trouble shooting
ž
Activity not identified
— Leakage from puncture site
— Delay of operation for too long
ž
Activity at the unexpected site
— Isotope travels to nipple along lactiferous duct
ž
Index lesion not identified in the specimen
mammogram
— Previous bx has removed all microcal
ž
Inadequate margins
— Further excision for margin
16. Trouble shooting
No residual microcal left for localization
ž Routinely put in gelmark after sBx
ž Use hematoma , if present, for target
ž Abandon procedure
ž Localise using previous measurement
(according to previous biopsy)
l
17. Trouble shooting
l No
activity detected after injection
of isotope
ž Associated
ž Short
with usg guided injection
tract
ž Leakage through the track on the skin/
dressing
ž Intraoperative USG by surgeon or
radiologist
18. Practical Tips
Joint decision making with radiologist
Interpretation of breast pathology in the
clinical context
ž Use of scintigraphy
ž Use of gamma probe by radiologist
ž Intraoperative breast ultrasound
ž Minor adjustment of surgical techniques
ž Rapid access of image in OT
ž Real time reporting by radiologist
ž
ž
25. Radioguided Intraoperative
Margin Evaluation (RIME)
ž Preoperative
MRI with injection of
gadonilium
ž 99Tc-Sestamibi scintimammography
ž Calibrate the optimal time for incision
ž Intraoperative use of gamma probe to
remove the tumour
26. RIME
ž Not
used in clinical practice
ž No good evidence in clear margins and
lower re-operation rate
ž High cost
ž Additional imaging procedure needed
27.
28. Sentinel lymph node biopsy
Standard practice in early invasive breast
cancer
ž Cancer staging has been modified with the
widespread practice of sln bx
ž Pathology result affect the subsequent
management
ž Axillary dissection will be done in positive
sln with macrometastasis
ž Chemotherapy will be administered in
positive sln (macrometasis and
micrometastasis)
ž
30. pNX
Regional lymph nodes cannot be assessed (e.g., previously removed, or not
removed for pathologic study)
pN0
No regional lymph node metastasis identified histologically
*.
Note: Isolated tumor cell clusters (ITC) are defined as small clusters of cells not greater than 0.2 mm, or
single tumor cells, or a cluster of fewer than 200 cells in a single histologic cross-section. ITCs may be
detected by routine histology or by immunohistochemical (IHC) methods. Nodes containing only ITCs are
excluded from the total positive node count for purposes of N classification but should be included in the
total number of nodes evaluated.
pN0(i-)
pN0(i+)
pN0(mol-)
pN0(mol+)
pN1
pN1mi
pN1a
No regional lymph node metastases histologically, negative IHC
Malignant cells in regional lymph node(s) no greater than 0.2 mm (detected by
H&E or IHC including ITC)
No regional lymph node metastases histologically, negative molecular findings (RTPCR)
Positive molecular findings (RT-PCR),** but no regional lymph node metastases
detected by histology or IHC
Micrometastases; or metastases in 1-3 axillary lymph nodes; and/or in internal
mammary nodes with metastases detected by sentinel lymph node biopsy but not
clinically detected***
Micrometastases (greater than 0.2 mm and/or more than 200 cells, but none
greater than 2.0 mm)
Metastases in 1-3 axillary lymph nodes, at least one metastasis greater than 2.0
mm
pN1b
Metastases in internal mammary nodes with micrometastases or macrometastases
detected by sentinel lymph node biopsy but not clinically detected***
pN1c
Metastases in 1-3 axillary lymph nodes and in internal mammary lymph nodes with
micrometastases or macrometastases detected by sentinel lymph node biopsy but
not clinically detected
AJCC Cancer Staging Handbook 7th Edition (2010)
32. Technique of SLN bx
ž Injection
before OT or evening prior to
operation
ž Peritumoral injection, intratumoral,
intradermal, subareolar injection
ž Combined with ROLL (SNOLL)
ž Scintigraphy
ž Combined with blue dye
33. Technique of SLN
Use of handheld gamma probe
ž Separate incision at axilla
ž Hot lymph node identified
ž 10 sec count of the hottest LN registered
ž 10% of the hottest LN or >100 count
ž Check the residual activity
ž
34. Technique of SLN biopsy
ž
ž
ž
ž
ž
ž
Use of handheld gamma
probe
Separate incision at axilla
Hot lymph node identified
10 sec count of the hottest
LN registered
10% of the hottest LN or
>100
Check the residual activity
38. Intraoperative processing
ž Touch
cytology
ž Frozen section
— H&E staining
— IHC staining
ž One
step nucleic acid
amplification(OSNA)
— Molecular assay
— Quantitative analysis
— No tissue left for histology
39.
40. Management of SLN positive
patients
ž Full
axillary dissection
— On table decision vs 2nd operation
ž No
further axillary surgery
— Micrometasis
— Isolated tumour cells
— Macrometastasis (ASCOG Z0011)
ž Adjuvant
therapy including
chemotherapy and herceptin in HER
overexpressed tumour
41. Radiation protection
ž Maximal
dose at injection site
ž Maximal exposure: surgeons hand
ž No specific protective gear
ž Avoid manipulation of specimen with
hands
ž Specimen labelled to avoid inadverdent
exposure
