SENTINEL LYMPH NODE CONCEPT IN OESOPHAGEAL CANCER
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1 SENTINEL LYMPH NODE CONCEPT IN OESOPHAGEAL CANCER Sarah K Thompson, M.D. Queenstown ANZGOSA Mtg, 2010
2 Sentinel Lymph Node (SLN)
3 Sentinel Lymph Node (SLN) Not always on a direct drainage pathway Not always the nearest node Not always hot or blue May be more than one
4 SLN Concept Well-established in: Melanoma; Breast cancer Less well-established in: Colorectal cancer; gastric cancer Controversial in oesophageal cancer: anatomy + lymphatic flow
5 2 Reasons 1. Minimally invasive surgery 2. Focused analysis of specific lymph nodes
6
7
8 Aims 1. To determine the feasibility of SLN biopsy in oesophagectomy with conservative lymphadenectomy 2. To evaluate the accuracy of SLN biopsy in predicting the status of non-slns 3. To identify potential technical problems in performing SLN biopsy
9 Study Design consecutive patients
10 Oesophageal Cancer <pt2 pt2 Surgery Neoadj Tx + Surgery 9 35% 17 65%
11 Study Design consecutive patients 2. Radioactive tracer injection
12 Injection of Radioactive Tracer Endoscopic injection 99m Tc-antimony sulfide 4 mls = 40MBq Submucosal injection Proximal/Distal margins
13 Study Design consecutive patients 2. Radioactive tracer injection 3. Oesophagectomy with conservative lymphadenectomy
14 Radical Lymphadenectomy Mediastinal Nodes 1 Paratracheal 2 Carinal 3 Left bronchial 4 Right bronchial 5 Para-aortic 6 Middle para-oesophageal 7 Lower para-oesophageal Abdominal Nodes 8 Right paracardial 9 Left paracardial 10 Left gastric 11 Lesser curve 12 Common hepatic 13 Splenic artery 14 Coeliac axis
15 Conservative Lymphadenectomy Mediastinal Nodes Middle para-oesophageal 7 Lower para-oesophageal Abdominal Nodes 8 Right paracardial 9 Left paracardial 10 Left gastric 11 Lesser curve
16 Study Design consecutive patients 2. Radioactive tracer injection 3. Oesophagectomy with conservative lymphadenectomy 4. In vivo lymphatic mapping
17 Lymphatic Mapping Sentinel Lymph Node Activity 2:1 to adjacent tissue with Navigator TM Gamma Probe
18 Study Design consecutive patients 2. Radioactive tracer injection 3. Oesophagectomy with conservative lymphadenectomy 4. In vivo lymphatic mapping 5. Ex vivo lymphatic mapping
19 Ex vivo lymphatic mapping Sentinel Lymph Node Background ratio of 10:1 Any node with 10% activity of hottest node
20 Study Design consecutive patients 2. Radioactive tracer injection 3. Oesophagectomy with conservative lymphadenectomy 4. In vivo lymphatic mapping 5. Ex vivo lymphatic mapping 6. Analysis of SLN
21 Analysis of SLN Isolated tumor cell: 0.2mm Micrometastasis: >0.2mm and 2mm
22 Results Age: Sex: Tumour type: 64 yrs (range = yrs) 92% male 81% adenocarcinoma Resection rate: 96%
23 Sentinel Nodes Total number of SLNs: 66 Median # of SLNs: 3 (range 0-5) Median # of LNs: 12 (range 4-30)
24 Sentinel Node Identification >
25 Sentinel Node Distribution Lower oesophagus GOJ 60% 18% 40% 82%
26 Sentinel Node Characteristics Success rate = 92%
27 Accuracy of the Sentinel Lymph Node Sentinel Node Overall Nodal Status H&E +ve Immuno +ve -ve H&E +ve 4 1 Immuno +ve 3 Negative 1 14 False negative rate = 11% (1/9) Overall accuracy = 96% (22/23)
28 Discussion No. pts Detection Sensitivity Kitigawa, /27 (93%) 14/16 (88%) Kato, /25 (92%) 13/15 (87%) Lamb, /57 (100%) 35/37 (96%) Current study 25 22/23 (92%) 8/9 (89%)
29 Choice of Radioactive Tracer North America: Europe: Japan: Australia: 99m Tc-sulphur colloid 99m Tc-albumin nanocolloid 99m Tc-tin fluoride colloid 99m Tc-antimony trisulfide colloid
30 Choice of Radioactive Tracer North America: Europe: Japan: Australia: 99m Tc-sulphur colloid 99m Tc-albumin nanocolloid 99m Tc-tin fluoride colloid 99m Tc-antimony trisulfide colloid
31 Technical Problems
32 Summary 1. SLN concept in oesophageal cancer does work 2. It seems accurate 3. Technical problems exist and the technique needs to be refined
33 Acknowledgements SAGES project grant 2008 Mr Peter Lamb, University of Edinburgh, U.K. Dr Dylan Bartholomeusz, Dr Andrew Ruszkiewicz, A/Prof Peter Devitt, Prof Glyn Jamieson, Mr Philip Game, Dr Andrew Lord
34
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