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The Role of Intra-Operative Mobile Gamma Camera and Gamma Probe in Detection of Sentinel Lymph Node in Early Stage Breast Cancer

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The Role of Intra-Operative Mobile Gamma Camera and Gamma Probe in Detection of Sentinel Lymph Node in Early Stage Breast Cancer J Cancer Sci Clin Ther 2019; 3 (4): 229-239 DOI: 10.26502/jcsct.5079037 Research Article The Role of Intra-Operative Mobile Gamma Camera and Gamma Probe in Detection of Sentinel Lymph Node in Early Stage Breast Cancer Maher H Ibraheem1*, Mohamed Gamil2, Ahmed Tantawy3, Omnia Talaat4, Rimoun Boutrrus5, Mohammed Mohammed Mohammed Gomaa6 1Lecturer of Surgical Oncology, National Cancer Institute, Cairo University, Egypt 2Professor of Surgical Oncology, National Cancer Institute, Cairo University, Egypt 3Associate Lecturer of Surgical Oncology, National Cancer Institute, Cairo University, Egypt 4Lecturer of Nuclear Medicine, National Cancer Institute, Cairo University, Egypt 5Lecturer of Radiotherapy, National Cancer Institute, Cairo University, Egypt 6Lecturer of Radiodiagnosis, National Cancer Institute, Cairo University, Egypt *Corresponding Author Maher H Ibraheem, Lecturer of Surgical Abstract Oncology, National Cancer Institute, Cairo Background: The use of intraoperative mobile gamma camera that provide University, Egypt, E-mail: real-time intraoperative images of the sentinel lymph node (SLN), in [email protected] combination with hand held gamma probe, is assumed to increase the accuracy of yielding the SLN, in early breast cancer patients, with more Received: 22 August 2019 proper site localization. Accepted: 30 September 2019 Published: 07 October 2019 Purpose: To assess the added value of intraoperative mobile gamma camera in combination with hand held gamma probe in detection of SLN(s) in early Citation: Maher H Ibraheem, Mohamed stage breast cancer patients. Gamil, Ahmed Tantawy, Omnia Talaat, Rimoun Boutrrus, Mohammed Mohammed Methods: It was a prospective study on 30 patients, with breast cancer Mohammed Gomaa. The Role of Intra- scheduled SLN. biopsy in the National Cancer Institute, Cairo University, Operative Mobile Gamma Camera and Egypt. From January 2015 till December 2015. A new device Gamma Probe in Detection of Sentinel (intraoperative mobile gamma camera) was used in conjunction with a Lymph Node in Early Stage Breast Cancer. gamma probe in early stage breast cancer patients Journal of Cancer Science and Clinical Therapeutics 3 (2019): 229-239. Journal of Cancer Science and Clinical Therapeutics 229 J Cancer Sci Clin Ther 2019; 3 (4): 229-239 DOI: 10.26502/jcsct.5079037 Results: The hand held gamma probe detected SLNs in 28 Conclusion: The use of intraoperative mobile gamma out of 30 (93.4%) patients, while the intraoperative mobile camera in conjunction with the handheld gamma probe gamma camera detected SLN(s) in 29 patients out of 30 resulted in a higher SLN detection rate, made the SLNB (96.7%) patients. In total, 59 SLNs were found using the more accurate with proper site localization, either axillary gamma probe, and 62 SLNs were found using the mobile or extra axillary sites and with less complications. gamma camera. For patients whom underwent a SLNB, the pain in axilla ranged from 1 to 3, while the severity reached Keywords: SLN; Intraoperative mobile gamma camera; 6 and 7 in the two patients who underwent axillary Gamma probe; Breast cancer dissection. 1. Introduction 2. Purpose Breast cancer is the most common cancer in women. In The aim of the study is to assess the added value of 2012, it comprised 25.2% of cancers diagnosed in women intraoperative mobile gamma camera in combination with [1]. Axillary staging is one of the most important prognostic hand held gamma probe in detection of sentinel lymph node factors in all invasive breast cancer, and imperative for SLN(s) in early stage breast cancer patients prognosis, regional treatment and local control according to NCCN guidelines [2]. Axillary lymph node dissection was 3. Patients and Methods considered the key step for evaluating axillary lymph node This a prospective study on 30 breast cancer patients whom status, and it was routine for any patient with invasive breast were operated upon, in the National Cancer Institute (NCI) cancer [3]. After wide implementation early detection Cairo University, (Egypt). From January 2015 till December protocols for breast cancer, the probability of nodal 2015, these patients were operated with the following metastasis has markedly been decreased. Lymphatic inclusion criteria: Pathologically proven early stage breast mapping with sentinel lymph node biopsy (SLNB) has cancer with clinically and radiologically negative axillary markedly replaced axillary lymph node dissection in those nodes (T1, T2, N0, M0). Exclusion criteria were: Patients with clinically and radiologically negative axillae [4]. So, who underwent previous axillary surgery or radiation, the use of SLNB, added the advantages of limiting the excision of the tumor without axillary staging for more than associated morbidities with axillary dissection, including, three months or patients who received neoadjuvant arm pain, sensory deficit of arm pit and medial side of the chemotherapy. All patients underwent preoperative patient arm, limited range of motion at the shoulder level, axillary assessment including full medical history, physical seroma and the most serious complication is the upper limb examination, breast imaging, preoperative pathology, routine lymphedema [5]. The use of intraoperative mobile gamma laboratory investigations, anesthesia assessment. Informed camera that provide real-time intraoperative images of the consent was taken from all patients. SLNs, which can be used in combination with hand held gamma probe, is assumed to increase the accuracy of 4. Methods yielding the SLNs, with proper site localization, either Technetium-99m albumin nano colloid (99 mTc- axillary or extra axillary sites like, internal mammary or nanocolloid) (500 μCi in a volume of 0.3-0.5 ml) was infra clavicular region [6]. injected peri-areolar sub-dermal corresponding to site of the lesion 12-24 hours prior to operative time (Figure 1). Journal of Cancer Science and Clinical Therapeutics 230 J Cancer Sci Clin Ther 2019; 3 (4): 229-239 DOI: 10.26502/jcsct.5079037 Intraoperatively, prior to sterilization, the mobile gamma of the mobile gamma camera was used to virtually shield the camera was placed at distance of 15 cm to acquire an highly radioactive injection site and improve the SLN overview image of the breast and axilla and to assess localization and visualization close to the injection site radioactive uptake by the SLN(s) either axillary or internal (Figure 5). After incision, the hand held gamma probe was mammary, or infraclavicular region location. (Figure 2). used to detect and excise the lymph nodes with high tracer Then this detector was placed nearer to the field to precisely uptake (high count), which were considered the SLNs localize the detected SLN uptake using a cross laser pointer (Figure 6). After retrieval of a lymph node, the mobile on the field that is matched to the hotspot on the camera gamma camera was used in conjunction with the gamma screen and the location was marked on the patient’s skin. probe to confirm ex vivo that the lymph node contained The gamma probe was used to confirm the proper site of the radioactivity (Figure 7). Finally, the surgical field was SLN after scanning the axilla, internal mammary region, and checked again using the mobile gamma camera and hand infraclavicular region (Figure 3). held gamma probe to confirm that all radioactive nodes have been removed (Figure 8). The retrieved SLN(s) were sent for During surgery, the arm of the mobile gamma camera was frozen section and paraffin section to assess the pathology sterile draped allowing the placement and movement above result. Early postoperative follow up of the patients the surgical field by the surgeon. Surgical incision was done regarding; axillary and arm pain, sensory changes, seroma, guided by the skin marks (Figure 4). In some cases the was recorded. Pain assessment was done using a patient breast tumor, radiotracer injection site, was located close to questionnaire according to the Numeric Rating Scale of pain the SLN. The gamma probe was in these situations not able (NRS-11), which is an 11-point scale for patient self- to locate the SLNs due to the radioactive noise from the reporting of pain (Table 1). highly radioactive injection site. The ‘masking’ functionality Rating Pain level 0 No pain 1-3 Mild pain (nagging, annoying, interfering little with daily life activities). 4-6 Moderate pain (interferes significantly with daily life activities). 7-10 Severe pain (disabling; unable to perform daily life activities). Table 1: Pain assessment scoring according to NRS-11. Figure 1: Peri areolar sub-dermal injection of radio-colloid. Journal of Cancer Science and Clinical Therapeutics 231 J Cancer Sci Clin Ther 2019; 3 (4): 229-239 DOI: 10.26502/jcsct.5079037 Figure 2: Rapid pre-operative scanning, to properly localize the site of the SlN. Figure 3: Gamma probe used in SLN detection pre operatively with corresponding high count on the screen. Journal of Cancer Science and Clinical Therapeutics 232 J Cancer Sci Clin Ther 2019; 3 (4): 229-239 DOI: 10.26502/jcsct.5079037 Figure 4: Intra-operative gamma camera and cross laser pointer image in the axilla with corresponding hot spot on the screen, for SLN localization. Figure 5: The ‘masking’ functionality of the mobile gamma camera was used to virtually shield the highly radioactive injection site. Figure 6: Gamma probe inside surgical field detecting the SLN, with high count on the screen. Journal of Cancer Science and Clinical Therapeutics 233 J Cancer Sci Clin Ther 2019; 3 (4): 229-239 DOI: 10.26502/jcsct.5079037 Figure 7: Gamma probe confirming retrieval of SLN EX. Vivo with high count. Figure 8: Intra-operative gamma camera scanning the surgical field after SLN excision without any radio activity on the screen. 5. Results in the lower outer quadrant in 6.7%, and central quadrant in 5.1 Patient characteristics 3.3% of the patients. The Pathology of these tumors were; Patients' age ranged from 27-67 years with the mean age at IDC in 24 patients (~ 80%), ILC in 3 patients (~10%), mixed 48.7 (± SD 10.9).
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