SentinelL lLymphAMY D’AMOURS, ST Node AND LYMPHOSCINTIGRAPHY

adical dis- problematic, such as large scars, section has been the , hematoma, pain, numb- surgery of choice to ness, and most significantly, regio- stage breast and nal swelling called lymphede- R , as well as ma.1,2,3,4 The practice of a much less other carcinomas for many years. invasive procedure is rapidly be-

It has been used to determine the coming a standard of care for extent, if any, of metastasis and these patients. This procedure, regional lymph node involvement called biopsy,

in order to stage the disease. This has emerged as the procedure to major procedure carries with it assess lymph node status, replacing many side effects that can become radical lymph node dissection.

JANUARY 2003 The Surgical Technologist 7 225 JANUARY 2003 CATEGORY 1

The tinel node in 59% of patients, two sentinel nodes The lymphatic system consists of a network of in 37%, and three sentinel nodes in 3% of lymphatic vessels, lymph nodes, lymph fluid patients.9 The sentinel node has also been called a (transparent fluid containing white blood cells, “gatekeeper”or a “node on watch”(as a sentinel mostly ) and a number of other would be at a gate) over the years.5,6 lymphoid organs, such as the , and Some lymph drainage follows a fairly reliable . As arteries and veins circulate the blood lymphatic flow path, such as in the breast, which to nourish the body’s tissues, some fluid escapes may cause metastasis to the regional basin in the and surrounds the cells. Lymphatic capillaries axilla (Figure 2). However, in the case of found throughout the body collect the clear, melanoma, the drainage is similar, but can vary, intercellular (interstitial) fluid, called lymph. depending on the location. For example, (The Greek word lymph means “pure, clear of the leg usually travel to the groin stream.”) The lymphatic capillaries carry the area (inguinal nodes) and melanomas on the fluid to lymphatic collecting vessels, then to lym- arm usually travel to the axillary basin (axillary phatic trunks, and finally back into the vascular nodes). If the melanoma is on the patient’s back, tsystem through one of two large ducts in the tho- however, the lymphatic channel can vary. The racic region. Through these ducts, the lymph is metastasis may travel to the axillary or the groin carried to heart (Figure 1). area. In all of these cases the tumor cells become Lymph carrying vessels have valves, similar to trapped in these nodes as a “large particle” and those found in our veins, which carry the fluid in can begin to multiply.7 one direction towards the heart, so that all this The use of a lymphatic mapping procedure, fluid ends back in our circulatory system. As the called lymphoscintigraphy, has become vital in lymph enters the lymph vessels, it is pumped highlighting the lymphatic drainage from the pri- along by our contracting muscles.8 As lymph mary tumor. This procedure is carried out in the fluid travels through the system, it is filtered by nuclear medicine department of the hospital. lymph nodes. Lymph nodes are oval shaped masses of lymph tissue covered by a fibrous cap- Cancer and lymphatic dissection sule of connective tissue.8 The size of the nodes Because lymph nodes play such a vital role in varies from the size of a pinhead to the size of a removing foreign matter (eg tumor cells) from lima bean, or 2 mm to 20 mm in length with a our bodies, surgeons have used lymphatic dis- longitudinal diameter up to 15 mm.2 section for years to stage cancer and to determine Lymph nodes are arranged in specific clusters the extent or spread, if any, of the cancer. Stag- in our body, called basins. The major basins in ing of the cancer via evaluation of the lymph the human body are in the axillary, the inguinal, node(s) is a way of predicting the prognosis and and the cervical regions.8 In these nodes, large determining further treatment for the patient. particles of foreign matter are filtered from the These radical dissections are a considerable sur- traveling lymph, hopefully before re-entry into gical procedure and carry with them numerous the bloodstream. Tumor cells are one example of side effects as well as a longer recovery period. these “foreign bodies.”When a primary tumor Lymph node dissections are done following spreads, or metastasizes, these tumor cells move a positive diagnosis of cancer, either by a through the to the regional basin lumpectomy, a biopsy, a wide incision, or an X- and become trapped in a lymph node or nodes.By ray-guided needle biopsy. The size of the definition, a sentinel node is the first node, or tumor and its histology aid in the process of nodes in some cases, that receives the primary staging the disease.1 Staging procedures lymphatic flow from the tumor site. Studies have include studies such as blood work and diag- shown any specific basin may contain more than nostic imaging studies to assess the organ(s) one sentinel node. One study found a single sen- that the cancer is known to target. For example,

The Surgical Technologist JANUARY 2003 8 Lymphatic capillaries FIGURE 1 The lymphatic and cardiovascular systems.

Lymph node Pulmonary circuit

Lymphatic vessel Dave Ludwig Dave

Systemic circuit ILLUSTRATION

Lymph node

JANUARY 2003 The Surgical Technologist 9 in breast cancer the target organs are bone, the History other breast, the liver, lungs, and the brain. The Sentinel lymph node have been used patient will have tests to determine distant since the late 1970s, beginning with melanoma metastasis; whereas, the sentinel node assesses studies.3 Over the next 20 years, many studies regional metastasis, if any. were done using lymphoscintigraphy and blue In complete (radical) lymph node dissec- dye. The procedure became quite popular by tions, there may be removal of 15-25 lymph the 1980s. In the 1990s, Donald Morton, MD, nodes.1 These nodes and surrounding tissue previously professor of surgery at UCLA and will go to the department for analy- now medical director and surgeon at John sis. In removing the many nodes and the sur- Wayne Cancer Institute in Santa Monica, Cali- rounding tissue, the patient is left with a fornia, presented the concept of using lymphat- significant scar, possible , or wound ic mapping and sentinel node biopsy to stage breakdown. She/he may also be left with a breast cancer at an seminar.11 He was decreased range of motion near the surgical the first to describe the “sentinel node” as the site. But most importantly, this extensive first node in the basin that receives lymphatic removal of lymph tissue can significantly flow from the primary tumor. Morton also stat- reduce the lymphatic drainage in the region, ed that if the first lymph node is negative for resulting in a painful and lifelong condition metastasis, then the rest should also be nega- known as lymphedema.1,3 tive.1 Numerous studies since have validated his Lymphedema is an accumulation of fluid theory. Since the 1990s, sentinel lymph node (lymph) in soft tissue, and regional swelling biopsy has become increasingly popular for that may cause severe swelling in the regional breast cancer staging, as well as for melanoma limb and continue for the patient’s lifetime.6 and other .11 Lymphedema can be permanent in 7-37% of Sentinel lymph node biopsy is contraindi- breast cancer patients that undergo a standard cated in some patients. Examples of this are axillary node dissection.2 Patients must use those who had previous axillary dissection, extreme care to prevent infections due to the regional trauma or an infection that might have decreased removal of lymph in a specific changed the lymphatic drainage from the region. Some preventive measures include tumor site, allergies to the dyes used, palpable wearing gloves when gardening, having no nodes, and extensive breast cancer. Also it blood drawn from the arm that has had surgery, should not be used in pregnant or nursing and to avoid blood pressure readings taken on mothers until further studies are performed on the affected arm. this population.2,3 Radical node dissections are also more expen- sive. For example, in 1998 the cost of an axillary Procedural overview lymph node dissection was approximately The sentinel lymph node procedure begins fol- $11,000. In comparison, lymphatic mapping lowing a diagnosis of cancer. This diagnosis may along with sentinel node biopsy done on an out- follow a routine mammography, a needle biopsy patient basis costs only $1,200.10 It is also impor- performed by a radiologist, or during a routine tant to remember that many patients may have visit to the patient’s primary physician. The no metastasis or lymph node involvement at all. patient may be sent to a surgeon for further eval- Studies show that approximately 55% of those uation, followed by a needle biopsy (if one has who have had an axillary node dissection had not been done) or by an excisional biopsy for negative nodes, making the practice of automat- breast cancer. A biopsy from the melanoma or ic lymph node dissection economically imprac- other tumor may be performed in order to diag- tical, especially if other diagnostic procedures nose the tumor as either benign or malignant.1,3 can be effective.4 At this time, the surgeon will need to determine

The Surgical Technologist JANUARY 2003 10 FIGURE 2 Axillary basin.

Intraclavicular nodes

Lower deep cervical lymph nodes drain into venous system Lateral axillary nodes

Central axillary nodes Interpectoral nodes

Posterior axillary nodes Internal mammary lymph nodes drain into medial part of breast Apical axillary nodes

Subareolar plexus

Anterior (pectoral) axillary nodes Dave Ludwig Dave ILLUSTRATION if the cancer has spread or metastasized, and fur- medicine department for mapping of his/her ther tests are prescribed. This staging process will lymphatic system. This mapping is done to help determine the patient’s prognosis, as well highlight the drainage of the patient’s lymph as further treatment options. from the tumor site. The procedure is explained Sentinel lymph node procedures are per- to the patient and their questions are answered. formed today in an ambulatory surgery setting A radioactive isotope (tracer), technetium-99, is to determine the extent of the cancer. Within a injected at or around the tumor site.1,2,5 This is few hours of the scheduled surgery, the patient a very important step, since not everyone’s goes to the nuclear medicine department and lymph vessels are located exactly the same, and possibly to the radiology department, if a needle do not drain the same. localization is needed on a nonpalpable The tracer enters the lymphatic system and is tumor.1,3 If needed, the radiologist places a transported to the regional basin. It will settle localization wire to pinpoint the tumor, for the in the first sentinel node(s) as it travels. This nuclear medicine department as well as for the process of migration can take 10 to 30 minutes. surgeon. The patient is then taken to the nuclear The radiologist will then use a gamma camera

JANUARY 2003 The Surgical Technologist 11 Instrumentation and supplies to map the drainage of this radioactive sub- stance. A hard copy or scan (similar to an X- I. Used prior to sterile prep ray) is made for the surgeon to view before and • Gamma counter during surgery. It will guide him/her in locating • Gamma tracer probe with sterile disposable sleeve the “sentinel node”.The sentinel node location • Isosulfan 1%,5 ml single dose vial;5 cc syringe to may also be marked on the patient’s skin like a inject;21- or 25-gauge needle tattoo-type in the nuclear medicine depart- • Alcohol wipes and nonsterile gauze sponges ment.1 (used prior to injection) Studies have pointed to the importance of timing between the injection given in lym- II. Skin Prep phoscintigraphy and the time that the first surgi- • Betadine prep or Duraprep (according to surgeon’s cal incision is made to isolate the sentinel node. preference) One to four hours between these two procedures is recommended.2 III. Surgical procedure • Marking pen Intraoperative procedure • Local anesthesia;Lidocaine 2% (20 cc);Bupivacaine Within a few hours following lymphoscintigra- 0.25%-0.5% (20 cc) with or without epinephrine phy, the patient will enter the operating room. • Sodium Bicarbonate (4 cc) (surgeon’s preference) He/she will be positioned supine for breast • General anesthesia;Bupivacaine 0.5 % (surgeon’s surgery; however, the position will vary accord- preference) ing to the tumor location in melanoma or other • 10 cc syringe/25-gauge needle type of cancer. Anesthesia, which may be local • #3 knife handle/#10 and #15 blades (enough to or general, will then be administered. change skin knife and use after dissecting nodes) At this time, the surgeon injects 3-5 cc of a • Electrosurgical unit with dispersing pad blue dye, usually 1% isosulfan blue, about five • Suction tubing with Yankauer suction tip minutes before initiation of the first incision at • Small self-retaining retractors (Weitlaner,etc), or around the tumor site.2 (Since its particles are double skin hooks,Senn retractors,small rakes too small to be trapped in the nodes, methylene (see surgeon’s preference cards) blue should not be used for this procedure.) The • Sterile normal saline with bulb syringe closer the tumor is to the regional basin, the • Sterile radiopaque 4”x4”sponges shorter the interval; increased distance lengthens • Peanuts the interval. If the incision is made too soon, the • Minor Set (Crile,Kelly,Allis,toothed,and non- dye will not have had time to travel through the toothed forceps,toothed Adson forceps,needle afferent lymphatic vessel to the node. Waiting holders,US Army retractors,Mayo and Metzen- too long decreases detectability of the sentinel baum scissors) node because nearby nodes will also have • Ligating clip applicators and clips (assorted sizes) absorbed the dye.2 • 4-0 Vicryl,5-0 Vicryl,2-0 silk (tissue marking)(see Typically, the surgeon massages the area to surgeon’s preference) facilitate the flow of the dye into the draining • Skin stapler (available) lymphatic vessels. The blue dye provides a visible • Medicine cups (approximately five) for specimens marker, as well as an auditory marker from the • Gown and towel and linen pack sound made by the gamma ray (Geiger) counter • Drain:eg Jackson Pratt 7 mm flat (available for as it detects the radioactive isotope. Some sur- axillary dissection) geons then use the nonsterile gamma probe to • Dressings,skin-closure tapes,tincture of benzoin confirm the path of lymphatic drainage. (surgeon’s preference)1,3 The circulator proceeds with prepping the surgical site. While the circulator is performing

The Surgical Technologist JANUARY 2003 12 Staging options for cutaneous melanoma

Since the late 1980s,there has been debate within versy by providing a minimally invasive solution by the medical community regarding the staging for identifying metastatic disease in clinically node cutaneous melanoma that centers on the different negative patients. approaches for thin,intermediate or thick lesions. Therapy is determined by analyzing the character- Lymphatic mapping istics and depth of the tumor. Thin lesions are SLNB provides the same histopathological informa- defined as less than 0.75 mm in Breslow thickness, tion as a radical lymph node dissection with mini- thick cancers,greater than 4 mm,and intermediate, mal morbidity and far less complications;a far bet- everything in between.The greatest prospects for ter surgical outcome. Generally, the surgeon complete curative treatment remains with patients removes only one or two lymph nodes that are inter- with the intermediate and thin range lesions. rogated rigorously and subjected to specialized his- Since the mid-1990s the gold standard for accu- tochemical staining techniques in addition to rou- rate staging of melanoma patients has become the tine H&E sections.If these sentinel nodes are free of sentinel lymph node biopsy (SLNB).SLNB is most disease (80% of the time),the rest of that lymph suitable for malignant melanoma patients with node basin is likely to be free of metastases with lesions greater than 0.76 mm Breslow thickness and confidence limits to 98%.Many multi-site trials have breast cancer patients with invasive disease up to 5 validated these findings with a false negative rate of cm in dimension. less than 2.6% nationally.

Melanoma patients Minimally invasive SLNB is designed for staging of patients who have a solid tumor lesion with a high risk of metastases.Malignant Melanoma is one of the most aggressive cancers.There are two schools of thought regarding lymphatic evaluation in patients with clinically node negative disease.One group (elective lymph node dissection) believe all patients with intermediate thickness melanomas and clinically negative lymph node basins should undergo complete to identify occult disease and prevent spread of disease to other organs.The second group (therapeutic lymph node dissection) would argue lymphadenectomy to prevent metastases could create greater complica- tions than improve survival rates.These complica- tions include lymphedema, injury,wound complications,such a seroma and infection.The sur- gical intervention (elective lymph node dissection) group has taken a much more aggressive position on staging these patients. Their approach was to Source:“Sentinel Lymph Node Biopsy:The Standard of remove all or most of the draining lymph nodes, Care for Staging Malignant Melanoma.”[press release] most often many more than necessary.The Sentinel Boca Raton,Florida:Gamma Surgery;2002. Lymph Node Biopsy (SLNB) eliminates this contro- www.gammasurgery.com

JANUARY 2003 The Surgical Technologist 13 the prep, the surgeon(s) scrub, gown and glove. Radiation safety Having already set up the back table and Mayo Facility policies differ concerning radiation stand, the surgical technologist assists the sur- exposure safety due to the use of the radioactive geon with draping. isotope used in this procedure. The policy in the The surgeon uses the gamma probe (wand), past was to use disposable paper goods and to which has been covered with a sterile sleeve to isolate these goods with all used instruments and find the radioactive “hot spots” by listening for supplies and trash until the amount of radiation the loudest noise as well as reading the numbers decreased to a certain predetermined level.3 This displayed on the gamma counter. The higher the isolation process took up to 72 hours, but varied number shown, the more radioactivity at the according to policy from one facility to another. site. The surgeon may also refer to the lymphatic Radiation monitoring badges were worn by the map at this time, which is in the operating room surgical team to determine the amount of radia- and ready to be viewed. Marking of the skin is tion exposure. However, research has now then performed with a marking pen above the shown that the amount of radiation exposure first (sentinel) node, and the incision above the during this procedure is not high enough to sentinel node begins.3,5 necessitate this process.1 The surgeon carefully dissects down, using Many facilities today do not require the use blunt dissection, following the lymphatic of paper goods or any special disposal process. drainage from the tumor and using the blue However, facilities may specify special handling color of the Lymphazurin to direct the approach. of the sentinel node specimen when it is sent to When the node is located, the probe will again be pathology, as well as during the time it is in the used to take a reading to confirm the amount of pathology department. With the rapidly chang- radioactive isotope amount in the node. All of ing regulations and hospital policies, it is of these readings must be documented by the cir- utmost importance that the surgical technolo- culating nurse.1 gist be fully aware of their facility’s policy on this The sentinel node is excised, and placed in a subject, to evaluate the practice from time to sterile specimen cup. With the surgeon’s per- time, and to work to change practices when they mission, it is passed to the circulator to be become obsolete.As procedures evolve, the early labeled with the location of the node and sent to restrictions may no longer be theoretically or pathology for a frozen section analysis or touch clinically significant. prep analysis. Numerous specimen cups should be available for this purpose, each specifically The future labeled.3 Another reading from the gamma The American Cancer Society estimates that counter is taken, and the circulator continues to there will be 205,000 new cases of breast cancer record all results. The surgeon looks for further and 53,600 new cases of melanoma in 2002 in sentinel nodes in the same manner. the United States alone.12 As more clinical trials If the lumpectomy or wide excision has not continue to show positive results, the number of been performed previously, it would be com- new cases of these types of cancer should impact pleted while waiting for the pathology report. If on the increased use of sentinel lymph node the pathology results come back negative for biopsy. With the trend in today’s health care to metastasis in the sentinel node(s), the surgical improve diagnosis with less invasive surgery and site(s) will be irrigated and closed. If the results to keep the cost of surgery as low as possible, are positive, further lymphatic dissection will including minimizing the patient’s hospital stay, be performed and a drain may be inserted at the these minimally invasive procedures should con- surgical site. Dressings will be applied and the tinue to increase. Surgical technologists’ under- patient will be moved to the post anesthesia standing of the different phases of this procedure care unit. as well as the time involved for the patient are key

The Surgical Technologist JANUARY 2003 14 to set the standards of care and to improve the 7. Poole CM. Melanoma: Prevention, Detection care given to these patients. and Treatment. New Haven, Connecticut: Yale University Press; 1998:61-66. About the author 8. Marieb EN. Human Anatomy and Physiology Amy D’Amours graduated from Springfield Laboratory Manual. 6th ed. Menlo Park, Cal- Technical Community College in Springfield, ifornia: Benjamin Cummings; 2000:368-369. Massachusetts, with an associate’s degree in sur- 9. Davita VT Jr, Hellman S, Rosenberg SA, eds. gical technology in May 2002. She now works as Cancer: Principles and Practices of Oncology. a surgical technologist at Maple Surgery Cen- 6th ed. Philadelphia, Pennsylvania: Lippin- ter, an affiliate of Baystate Health Systems, in cott, Williams & Wilkins; 2001:2033-2037. Springfield. Amy is married and has three 10. Imaging System Pinpoints Sentinel Lymph teenage children. Nodes: Lymphoscintigraphy is inexpensive, Simple and Excellent. Medical Post [online]. Acknowledgments 6/30/1998. eLibrary. ask.elibrary.com/index.asp Special thanks to the operating room staff and Assessed 12/13/02 nuclear medicine staff at Mercy Medical Center 11. John Wayne Cancer Institute. About Us. and Baystate Medical Center in Springfield, www.jwci.org/aboutus.html Assessed 12/13/02 Massachusetts, for their cooperation in prepar- 12. Cancer Statistics 2002. CA. 2002;52:25. ing this manuscript. Additional thanks to Kath- leen Flynn, surgical technology program direc- tor at Springfield Technical Community College, as well as to the STCC library staff.

References 1. Giuliano R. Lymphatic Mapping and Sen- tinel Node Biopsy [video and study guide] CineMed: 1-9. 2. Bland K. Lymphatic Mapping and Sentinel Lymphadenectomy for Breast Cancer. In: The Breast: Comprehensive Management of Benign and Malignant Diseases. Bland KI and Copeland III EM, eds. 2nd ed. Philadelphia, Pennsylvania: WB Saunders; 1998: 1105- 1108. 3. Kellar S. Sentinel Lymph Node Biopsy for Breast Cancer. AORN Journal. August 2001;74(2): 197-200. 4. Smeltzer SC and Bare BG, eds. Textbook of Medical-Surgical Nursing. 9th ed. Philadel- phia, Pennsylvania: Lippincott; 2000:11295- 11297. 5. Meeker MH and Rothrock JC, eds. Alexan- der’s Care of the Patient in Surgery. 11th ed. St Louis, Missouri: Mosby; 1999:626-627. 6. Anderson KN, revision ed. Mosby’s Medical, Nursing and Allied Health Directory. 5th ed. St Louis, Missouri: Mosby; 1998: 967-968.

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6. Possible complications of lymph node dissec- CECONTINUINGExam EDUCATION EXAMINATION 1. Which is not part of the lymphatic system? tion include: a. thyroid gland a. increased susceptibility to infections b. spleen b. decreased range of motion c. lymph nodes c. scarring d. tonsils d. all of the above

2. Which statement about lymph is not accurate? 7. Which is true about lymphedema? a. it contains lymphocytes a. caused by accumulation of lymph in the tissue Sentinel lymph node b. it is a clear fluid b. may follow axillary node dissection c. it is initially collected by the vascular system c. may be permanent biopsy d. it is eventually carried to the heart d. all of the above

3. Basins are clusters of 8. The time between isosulfan injection and the a. lymphatic capillaries first injection is critical because: Earn CE credit at home b. lymph vessels a. dye must have time to reach the sentinel node You will be awarded one continuing education (CE) credit for c. lymphocytes b. dye must not have time to absorb into sur- recertification after reading the designated article and com- d. lymph nodes rounding nodes pleting the exam with a score of 70% or better. c. both a and b If you are a current AST member and are certified,credit 4. What is the primary characteristic of the sen- d. none of the above earned through completion of the CE exam will automatically tinel node(s)? be recorded in your file—you do not have to submit a CE a. it is the only one that filters tumor cells 9. Radioactive dye is used to ___. reporting form.A printout of all the CE credits you have earned, b. it is the size of a lima bean a. audibly locate the sentinel node including Journal CE credits,will be mailed to you in the first c. it receives the primary lymphatic flow from the b. confirm the path of lymphatic drainage quarter following the end of the calendar year.You may check tumor site c. visually map the surgical site the status of your CE record with AST at any time. d. it is located in the sentinel basin d. all of the above If you are not an AST member or not certified,you will be notified by mail when Journal credits are submitted,but your 5. The main purpose of lymphoscintigraphy is to 10. A ___ may be performed while waiting for the credits will not be recorded in AST’s files. ___? pathology report. Detach or photocopy the answer block,include your check or a. map the lymphatic drainage a. lumpectomy money order ($6 for members or $10 for nonmembers) made b. assess lymph for tumor cells b. mastectomy payable to AST and send it to the Accounting Department,AST, c. locate the spleen c. Geiger count 7108-C South Alton Way,Centennial,CO 80112-2106. d. determine distant metastasis d. all of the above

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Sentinel lymph node biopsy abcd abcd

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Certification No ______2 ❑❑❑❑ 7 ❑❑❑❑

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Telephone ______Mark one box next to each number. Only one correct or best answer can be selected for each question.