1. Image Guided Oncological
Surgery
Julio M. Mayol
Servicio de Cirugia , Hospital Clinico San Carlos
Madrid, Spain
2. Goals
โข SLN Biopsy: the concept
โ Current status in GI surgical oncology
โข Colon cancer
โข Gastric cancer
โข Research
โ Image-Guided SLN Biopsy
3. Principles of Oncologic Surgery
En-bloc excision
โ Primary tumor
โ Vascular pedicle
โข Lymphatic nodes and vessels included
4. Principles of Oncologic Surgery
Lymphadenectomy
โ Therapeutic
โ Staging
โข Prognosis
โข Selection for adjuvant treatment
25. SLNBx in Colon Cancer
โ Stage II โ recurrence 20-30%
โข Understaging?
โข Hematogenous route?
โ Stage III
โข Chemotherapy increases survival
26. SLNBx in Colon Cancer
The larger number of LNs, the better
โข Better staging
โข Improved survival in LN - patients
โ More LN + patients receive chemotherapy
โ Less false-negative LN - patients
27. SLNBx in Colon Cancer
Number of lymph nodes assessed
depends on:
โOverall, the quantitative requirement for
The patient the nodal staging of colorectal carcinomas
is to recover as many lymph nodes as
The surgeon possibleโ
The pathologist
Cserin G. Nodal staging of colorectal carcinomas and sentinel nodes. J Clin Pathol
2003;56:327
29. SLNBx in Colon Cancer
Length of specimen
โ Perioperative transfusions
โ Diarrhea
โ Dehydration
โ Meteorism
Tartter PI et al. World J Surg 2005;10:516-520
30. SLNBx in Colon Cancer
Understaging
15%-20% of CRC patients
โข Insufficient number of nodes
โข About 70% of positive nodes <5 mm
S. Saha et al. The American Journal of Surgery 2006;191: 305โ310
31. Ultrastaging
Sentinel lymph node biopsy
โ.. was developed in part to identify the first few nodes most likely to harbor
metastatic disease when present in order to reduce such pathological
understaging and thereby increase the accuracy of nodal stagingโ
S. Saha et al. The American Journal of Surgery 2006;191: 305โ310
32. SLNBx in Colon Cancer
Saha et al in 1997
Indications
โข Patients without metastatic disease
โข Open or laparoscopic approach
33. SLNBx in Colon Cancer
Technique
โ In vivo
โข Injection of dye and/or radiotracer
โ Submucosal - via colonoscopy
โ Subserosal - laparotomy
โข Identification
โ Visually
โ Gamma probe
34. SLNBx in Colon Cancer
Technique
โ Ex vivo
โข Injection of dye
โ After removal of the specimen
โ Subserosal injection
โข Visual identification
Wong JH, et al. Ann Surg Oncol 2004;11:772โ777
35. SLNBx in Colon Cancer
Technique
โ Histophathology
โข Hematoxilin-eosin
โข Immunohistochemistry
โข RT-PCR Micrometastases
โข Frozen section
36. SLNBx in Colon Cancer
Results
Saha S. et al. The American Journal of Surgery 2006;191: 305โ310
37. SLNBx in Colon Cancer
Results
Cancer & Leukemia Group B
โข False negative rate: 54% (13/24)
โข False positive rate: 20%
โข Sensitivity: 40%
SNs did not accurately predict the presence of either conventionally
defined nodal metastases or MMD
Redston M et al. JCO 2006;24:878-883
38. SLNBx in Colon Cancer
Results
โ Meta-analysis; 33 CRC papers
โ Patients: n = 1794 ( colon 1201; rectum 332)
โข Sensitivity 70%
โข Specificity 81%
โ...for future studies of CRC, it
โข False negative 9% will be necessary to stratify
โข Failure rate 10% patients according to their T
stage.โ
โข DOR 10.7
Des Guetz D et al. World J Surg (2007) 31:1304โ1312
39. SLNBx in Colon Cancer
Results
Technique
โ Dyes = radioactive tracer
โ In vivo = ex vivo
Des Guetz D et al. World J Surg (2007) 31:1304โ1312
40. SLNBx in Colon Cancer
Results
Histopathology
Upstaging
0-38%
โ H&E
โ ICH (Cytokeratin +/- CEA)
Des Guetz D et al. World J Surg (2007) 31:1304โ1312
41. SLNBx in Colon Cancer
โข Micrometastases in N0 - Meta-analysis
โ Eleven studies
โ ICH: 566 patients
โ RT-PCR: 173 patients
โ Disease free and overall survival
โ Upstaging
โ ICH: 32%
โ RT-PCR: 37%
โ 3 year-OS: RT-PCR positive < RT-PCR negative
Iddigins D et al. Ann Surg Oncol 2006; 13:1386โ1392
42. SLNBx in Colon Cancer
โBased on the results of our meta-analysis, future studies on the use
of SLNM in CRC patients should:
1. Use blue dye for reasons of simplicity,
2. Be performed by experienced surgeons and pathologists,
3. Be prospective,
4. Include more than 40 consecutive patients.
Des Guetz D et al. World J Surg (2007) 31:1304โ1312
43. SLNBx in Colon Cancer
Summary
SLN Biopsy in patients with colon cancer
may improve staging
Saha S. et al. The American Journal of Surgery 2006;191: 305โ310
44. Current use
โข Colon cancer
โข Gastric cancer
โข Other: rectum, esophagus, pancreasโฆ
45. SLN Biopsy in Gastric Cancer
Gastrectomy
D2 lymphadenectomy
โ T1-T2 lesions = 10-15% LN MTX
46. SLN Biopsy in Gastric Cancer
Lymphadenectomy in LN positive patients
prolongs survival
Lymphadenectomy in LN negative patients does
not increase survival
Extended lymphadenectomy increases morbidity
47. SLN Biopsy in Gastric Cancer
Proof-of-concept studies in 2000
48. SLN Biopsy in Gastric Cancer
โฆthe feasibility of sentinel node mapping in gastrointestinal cancers and
its diagnostic reliability remains unclear because of the complicated
lymphatic drainage of the GI tract and the high frequency of skip
metastasis.
Zulfikaroglu et al. Surgery 2005;138:899-904
49. SLN Biopsy in Gastric Cancer
Technique
โ Dyes
โ Radioguided biopsy
- Endoscopic injection
- Subserosal injection
50. SLN Biopsy in Gastric Cancer
Detection rates
โ Dye: 90%
โ Radioguided biopsy: 90%
โ Dual method: 100%
Hayashi H et al. J Am Coll Surg 2003;196:68-74
51. SLN Biopsy in Gastric Cancer
Rabin I, et al. IMAJ. 2006;8:40-43
52. SLN Biopsy in Gastric Cancer
Sensitivity for a positive LN
โ Dye: 66%
โ Radioguided biopsy: 92%
โ Dual method: 92%
SLN negative patients may be selected for limited surgical
procedure
Gretschel S, et al. Ann Surg Oncol. 2007;14:2028-35
53. SLN Biopsy in Gastric Cancer
Results
โ Number of SLN: 2-7
โ Sensitivity 85%-100%
โ Specificity 90-95%
โ Failure rate 0-6%
โ False negative (skip mtx): 0-20%
Hayashi H et al. J Am Coll Surg 2003;196:68-74
Zulfikaroglu et al. Surgery 2005;138:899-904
Gretschel S, et al. Ann Surg Oncol. 2007;14:2028-35
54. SLNBx in Gastric Cancer
Summary
SLN Biopsy in patients with gastric cancer
may improve staging
Tangoku A. J Med Invest 2007;54:1-18
56. SLN Bx Issues in GI malignancy
โข Technical issues
โข Complex lymphatic drainage
โข Intraoperative identification
โข Imaging methods
โข Histopathological study
โข Impact on morbidity and mortality
โข Distant Mtx in the absence of LN mtx
โข Micrometastases
โข Adjuvant therapy available
57. SLN Bx Issues in GI malignancy
False negative results
โ Unpredictible drainage patterns
โ High background signal
โ Absence of real-time imaging
58. SLN Bx Issues in GI malignancy
โข Improvements in the technique
โข Intraoperative diagnosis
59. Role of SLN Bx in GI malignancy
โข Based on SLN biopsy results, the surgical
approach be can NOT be modified
60. Role of SLN Bx in GI malignancy
โข Procedure-related morbidity is NOT
reduced
61. Role of SLN Bx in GI malignancy
โข SLN biopsy MAY increase staging
accuracy
62. โข SLN Biopsy: the concept
โข Current applications in surgical oncology
โข Research
68. Research
Technique
Ex vivo
โข Difficult locations
โข Rectal tumors
โข Failure with in vivo tech.
69. Image-guided mapping and
SLN biopsy
To improve accuracy ?
To increase survival
To individualize the surgical technique
To decrease morbidity
70. Acknowledgements
Servicio de Cirugรญa I Nuclear Medicine Dpt.
Rocio Anula Roberto Delgado-Bolton
Marรญa J. Peรฑa-Soria Jose L. Carreras
Ana Arbeo-Escolar
Iris Sanchez-Egido
Jesรบs A. Fdez-Represa