Converging Issues Converging Issues Demographics Demographics - - PDF document

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Converging Issues Converging Issues Demographics Demographics - - PDF document

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Review of Practice Guidelines for Review of Practice Guidelines for Sentinel Lymph Node Biopsy Sentinel Lymph Node Biopsy Allen Hayashi MD FRCS(C Allen Hayashi MD FRCS(C ) ) Symposium on Breast Cancer Symposium on Breast Cancer SON, BCCA,

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Review of Practice Guidelines for Review of Practice Guidelines for Sentinel Lymph Node Biopsy Sentinel Lymph Node Biopsy

Allen Hayashi MD FRCS(C Allen Hayashi MD FRCS(C)

) Symposium on Breast Cancer Symposium on Breast Cancer SON, BCCA, VIHA SON, BCCA, VIHA Hotel Grand Pacific, Victoria, BC Hotel Grand Pacific, Victoria, BC 24 April 2004 24 April 2004

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Converging Issues Converging Issues

  • Demographics

Demographics

  • Screening Mammography

Screening Mammography Program of British Columbia Program of British Columbia (SMPBC) (SMPBC)

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Converging Issues Converging Issues

  • Axillary nodal status

Axillary nodal status-

  • prognosticates, guides therapy

prognosticates, guides therapy

  • Axillary Node dissection

Axillary Node dissection-

  • morbidity

morbidity

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Converging Issues Converging Issues

  • Breast Cancer surgery

Breast Cancer surgery-

  • BC

BC community general surgeons community general surgeons

  • 20% performed SLNB 1996

20% performed SLNB 1996-

  • 2001

2001

  • SLNB Staging accuracy is promising

SLNB Staging accuracy is promising but incomplete but incomplete

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Practice patterns of lymph Practice patterns of lymph-

  • node mapping

node mapping and sentinel and sentinel-

  • node biopsy for breast cancer in

node biopsy for breast cancer in British Columbia (2001) British Columbia (2001)

Chua et al Can J Surg 46 (2003) 273-278

Considerable variation in: Considerable variation in:

  • Defn of SLN, indications, surgical

Defn of SLN, indications, surgical technique technique

  • Nuclear medicine mapping technique

Nuclear medicine mapping technique

  • Pathologic assessment

Pathologic assessment

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Practice patterns of lymph Practice patterns of lymph-

  • node mapping

node mapping and sentinel and sentinel-

  • node biopsy for breast cancer in

node biopsy for breast cancer in British Columbia (2001) British Columbia (2001)

Chua et al Can J Surg 46 (2003) 273-278

  • Surgeons performing SLNB

Surgeons performing SLNB 19% 19%

  • Implemented with validation study

Implemented with validation study 48% 48%

  • Mentoring plus Training Course

Mentoring plus Training Course 24% 24%

  • Self Taught

Self Taught 8% 8%

  • Fewer than 10 SLNB

Fewer than 10 SLNB 33% 33%

  • Performing SLNB alone

Performing SLNB alone 20% 20%

  • Data Management

Data Management 60% 60%

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Outcomes of sentinel node biopsy for breast Outcomes of sentinel node biopsy for breast cancer in British Columbia, 1996 to 2001 cancer in British Columbia, 1996 to 2001

Chua et al Am J Surg 185 (2003) 118-126

  • 547 SLNB

547 SLNB

  • Success rate

Success rate 88% 88%

  • False negative rate

False negative rate 22% 22%

  • Surgeon experience

Surgeon experience-

  • irrelevant

irrelevant

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Purpose of SLNB Guidelines Purpose of SLNB Guidelines

  • Define Standard of Care for SLNB

Define Standard of Care for SLNB

  • Harmonize technique

Harmonize technique

  • Improve consistency and precision for

Improve consistency and precision for SN identification and false negative rate SN identification and false negative rate

  • Quality assurance

Quality assurance-

  • Data reporting,

Data reporting, Outcomes assessment Outcomes assessment

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Provincial SLN Guidelines Provincial SLN Guidelines

2 Components 2 Components

  • Guideline #1

Guideline #1-

  • Technical document

Technical document

  • Guideline #2

Guideline #2-

  • Defining the Implementation

Defining the Implementation

  • f SLNB as a Stand alone procedure
  • f SLNB as a Stand alone procedure

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Provincial Guidelines for Lymphatic Mapping and Provincial Guidelines for Lymphatic Mapping and Sentinel Node Biopsy for Breast Cancer Sentinel Node Biopsy for Breast Cancer (part 1) (part 1)

  • http://www.bccancer.bc.ca/HPI/SON/CPG/def

ault.htm

  • TStrack@bccancer.bc.ca
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Provincial Guidelines for Lymphatic Mapping and Provincial Guidelines for Lymphatic Mapping and Sentinel Node Biopsy for Breast Cancer Sentinel Node Biopsy for Breast Cancer (part 1) (part 1)

  • Patient Selection

Patient Selection

  • Radiologic Procedures

Radiologic Procedures

  • Surgery

Surgery

  • Pathology

Pathology

  • Data Reporting

Data Reporting

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Provincial Guidelines for Lymphatic Mapping and Provincial Guidelines for Lymphatic Mapping and Sentinel Node Biopsy for Breast Cancer Sentinel Node Biopsy for Breast Cancer (part 1) (part 1)

Patient Selection Patient Selection

  • Indications

Indications

  • T1/T2 N0 Invasive Breast Cancers

T1/T2 N0 Invasive Breast Cancers

  • Contraindications

Contraindications

  • Advanced Local Cancer Conditions

Advanced Local Cancer Conditions

  • Previous surgery or breast

Previous surgery or breast “ “disruption disruption” ”

  • Allergy to blue dye

Allergy to blue dye

  • Pregnancy or Breast feeding

Pregnancy or Breast feeding

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Provincial Guidelines for Lymphatic Mapping and Provincial Guidelines for Lymphatic Mapping and Sentinel Node Biopsy for Breast Cancer Sentinel Node Biopsy for Breast Cancer (part 1) (part 1)

Radiology Radiology

  • Peritumoural injection 99mTc sulphur colloid

Peritumoural injection 99mTc sulphur colloid

  • Optional

Optional-

  • Intradermal injection

Intradermal injection

  • Preoperative Lymphoscintigram

Preoperative Lymphoscintigram

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Provincial Guidelines for Lymphatic Mapping and Provincial Guidelines for Lymphatic Mapping and Sentinel Node Biopsy for Breast Cancer Sentinel Node Biopsy for Breast Cancer (part 1) (part 1)

Preoperative Lymphoscintigram Preoperative Lymphoscintigram

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Provincial Guidelines for Lymphatic Mapping and Provincial Guidelines for Lymphatic Mapping and Sentinel Node Biopsy for Breast Cancer Sentinel Node Biopsy for Breast Cancer (part 1) (part 1)

Surgery Surgery

  • Combination technique of 99mTc sulphur colloid

Combination technique of 99mTc sulphur colloid and Lymphazurin and Lymphazurin

  • Technique for SLN identification

Technique for SLN identification

  • Definition of a completed SLN study

Definition of a completed SLN study

  • Protocol for finding SLN if no Hot spot

Protocol for finding SLN if no Hot spot

  • Data Documentation

Data Documentation

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Provincial Guidelines for Lymphatic Mapping and Provincial Guidelines for Lymphatic Mapping and Sentinel Node Biopsy for Breast Cancer Sentinel Node Biopsy for Breast Cancer (part 1) (part 1)

Pathology Pathology-

  • Protocol

Protocol

  • Fixation in 10% buffered formalin

Fixation in 10% buffered formalin

  • 10 Sections cut at 50 microns

10 Sections cut at 50 microns

  • Slide Levels 1,5&10 stained with H&E

Slide Levels 1,5&10 stained with H&E

  • Slide Level 2 Negative control for IHC

Slide Level 2 Negative control for IHC

  • Slide Level 6 IHC (cytokeratin)

Slide Level 6 IHC (cytokeratin)

  • Remainder of levels kept for future use

Remainder of levels kept for future use

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Provincial Guidelines for Lymphatic Mapping and Provincial Guidelines for Lymphatic Mapping and Sentinel Node Biopsy for Breast Cancer Sentinel Node Biopsy for Breast Cancer (part 1) (part 1)

Pathology Pathology-

  • Optional

Optional

  • Intraoperative SLN Consultation/assessment

Intraoperative SLN Consultation/assessment

  • Touch imprint H&E rapid section

Touch imprint H&E rapid section

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Data Management Data Management

Operative Documentation Operative Documentation

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Provincial Guidelines for Lymphatic Mapping and Provincial Guidelines for Lymphatic Mapping and Sentinel Node Biopsy for Breast Cancer Sentinel Node Biopsy for Breast Cancer (part 1) (part 1)

  • Validation

Validation

  • Identification (success) rate

Identification (success) rate

[# [# successful ID of SLN / # surgical attempts successful ID of SLN / # surgical attempts] ]

  • False negative rate

False negative rate [ [FN / (FN + TP) FN / (FN + TP)] ]

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Provincial SLN Guidelines Provincial SLN Guidelines

2 Components 2 Components

  • Guideline #1

Guideline #1-

  • Technical document

Technical document

  • Guideline #2

Guideline #2-

  • Defining the Implementation

Defining the Implementation

  • f SLNB as a Stand alone procedure
  • f SLNB as a Stand alone procedure
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SLN Provincial Guideline #2 SLN Provincial Guideline #2

Implementation of SLNB as a Stand alone procedure Implementation of SLNB as a Stand alone procedure

  • Define:

Define:

  • Patient Cohort

Patient Cohort

  • Surgeon Cohort

Surgeon Cohort

  • Institutional Requirements

Institutional Requirements

  • Data set and Outcome measurements

Data set and Outcome measurements

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Guidelines Guidelines

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