SENTINAL LYMPH NODE IN

GI TRACT CANCER
GUIDE:PROF.R.C.NAGAR
CO-GUIDE:DR.S.P.SINGH

PRESENTED BY:Dr.RAM LAL KRISHAK

INTRODUCTION:1. LYMPH NODE METASTASES

-Common route of metastases in solid
organ malignancy and G.I. tract cancer.
-It is multilevel process .
-Predictors of poor survival.
2. SENTINEL LYMPH NODE
-First lymph node (s) that receives lymphatic
drainage from a malignancy.
-Accurately predict the tumour status of entire
lymph node group.
-Locating by injection of blue dye or radio
active tracer
-Important changes in management of cancer
surgery.

3. CONCEPT OF SENTINEL LYMPH NODE

-Introduced by CABANAS in 1977 in patients of Ca
penis.
-Reapplied by Dr. DONALD MORTON in early stage melanoma in 1992.
-In breast carcinoma also by Dr. DONALD
MORTON.
-In G.I. tract malignancy.
-Still unclear and controversial.
-Due to random involvement of nodes and
skip
metastases have delayed the use of this
technique for G.I.T. cancer.
-Recent studies reports SN Mapping in GI
cancer is feasible
and has diagnostic
reliability.
-For SN Biopsy there should be an element of
erratic behavior in
biology of tumour and
direction of lymphatic spread.

RATIONALE FOR SENTINEL

LYMPH NODE BIOPSY:1.Accurately determined nodal micrometastases.
2.To obtain lymph node with high possibility of
being positive for metastases.
3.Find the extent of spread in regional nodes.
4.Less chance of missing the tumour.
5.Use in management protocol for cancer surgery.

METHOD OF SN NAVIGATION IN GI
CANCER:1.Indication
-Tumour limited to submucosa or
muscularis propria(T1 and T2) with no
regional nodal metastases(N0).
-Useless in lymph node with massive tumour
load.

2. Markers for sentinal lymph

node:(a) Isosulphane blue (lymphazurin) and
patent blue violet (CI42045)
(b) Radioactive tracer :-- Technetium99m-radiolabelled tin colloid soln.(99m Tc Sn
colloid).

3. Procedure
ofcategorised
SN mapping:Broadly
into two methods:(a)Endoscopic Method
-Applied for luminal organs.
-Radioactive tracer is used as marker.
-Peritumoural submucosal injection given.
-Radioactivity of marker has to be adjusted
according to time of injection before procedure.
-Identification of SN lymph node according to
containing radioactivity.
-Particularly useful for small sub mucosal
lesions.

.
(b) Peroperative
Method
-It is intraoperative procedure.
-Both markers can be used .
-Peritumoural sub mucosal injection given.
-SN are the first 1-4 nodes that change colour in
1-5 minutes.

4.Validity of SN mapping in GIT cancer:Result of sentinal node navigation in GI cancers in different series
Authors

Kitagava

Organ

Oeso,
Stomach,
Colon
Kitagava Stomach
Bilchik
GI
Tsioulias
GI
Evangelista Colon
Miwa
stomach

Identifiable
Only SN
Accuracy
SN
Metastasis
%
%
%
-91
97
95
96
95
91
96

99
86
89
80
98

8
42
15
9
--

Aberrant
Nodal
Spread %
--8
8
---

Result of various series

-Identification rate of SN was very high.
-SN analysis is important for predicting
metastases.
-No significant difference between blue dye
and radio active tracer (Saha S, Wiese DA).
-Significant higher accuracy when both use
in combination.

5. Application of SN mapping in various

GI cancer :Ca oesophagus :Although the SN in oesophagus cancer is
wildly spread from cervical to abdominal area
but selective and modified lymphadenectomy
for
clinically N0 stays is likely to become
feasible
and clinically viable by SN navigation.
(Annual of surgical oncology 2004).

Execuo: Leandro Valdir

Traduccin: Fidelia Garca

CA Stomach :-Most suitable for target in GIT for SN mapping.

-Mapping of SN success was 96% and diagnostic accuracy
98%
(BJS-Feb-2004).
-In Ketagava series SN mapping success was 95% and
diagnostic accuracy was
99%.
-By SN mapping curative minimal resection is feasible in
early stage N0 Ca stomach.

In Colorectal Carcinoma :-Upstaging node negative patient to node positivity.

-Detection of small pericolonic nodes.
-Application of ultrastaging methods such as RTPCR or IHC for detection of occult metastases.
-SN mapping does not change standard surgical
procedure like total mesorectal excision (TME).
-But useful for sampling SN in unexpected area
beyond the extent of TME without extended
lymph node dissection.

Pathological examination of SN :-In depth analysis.

-serial sectioning .
-Immunohistochemistry for tumour
related antigen (Cytokeratins).
-At least three levels of 100 micron
intervals should be examined.
-Radiation safety norms should be
followed.
-