Nuclear Medicine Mapping of Sentinel Nodes in Breast Cancer

Targeted CE per ARRT’s Discipline, Category, and Subcategory classification:
[Note: Discipline-specific Targeted CE credits may be less than the total Category A credits approved for this course.]

Breast Sonography: 0.50
Patient Care: 0.50
Patient Interactions and Management: 0.50

Mammography: 1.00
Procedures: 1.00
Mammographic Positioning, Special Needs, and Imaging Procedures: 1.00

Magnetic Resonance Imaging: 0.50
Procedures: 0.50
Body: 0.50

Nuclear Medicine Technology: 1.50
Patient Care: 0.25
Patient Interactions and Management: 0.25
Procedures: 1.25
Endocrine and Oncology Procedures: 1.25

Registered Radiologist Assistant: 2.00
Safety: 0.50
Patient Safety, Radiation Protection and Equipment Operation: 0.50
Procedures: 1.50
Thoracic Section: 1.50

Sonography: 0.50
Procedures: 0.50
Superficial Structures and Other Sonographic Procedures: 0.50

Radiation Therapy: 1.50
Patient Care: 0.75
Patient and Medical Record Management: 0.75
Procedures: 0.75
Treatment Sites and Tumors: 0.75

Outline

1. Introduction
2. SNB Strategy and Surgical Morbidity
3. Locoregional Recurrence and Survival
4. Alarming Results Concerning False-negative Rate
5. Optimization of SNM Procedure
   1. Impact of Prior Excisional Biopsy on False-Negative Rate
   2. Importance of Dual Mapping
   3. Resection of All Hot or Blue Nodes
   4. Effect of a Different Injection Site for Radiotracer and Blue Dye on False-E. Negative Rate
   5. Improvement of SNB Procedure Through Lymphoscintigraphy
6. SNB in Patients at High Risk of Nodal Involvement
   1. SNB in Various Categories of Tumor Size
   2. SNB in Patients with Multiple Simultaneous Ipsilateral Carcinomas
   3. SNB After Neoadjuvant Chemotherapy
   4. Safety Measures in Patients with High Probability of Axillary Involvement
7. Internal Mammary Drainage: Potential Impact on Decisions About Radiotherapy
   1. Probability of Internal Mammary Involvement in Patients with Internal Mammary Drainage According to Axilla Sentinel Node Status
   2. Patients with Internal Mammary Drainage and Negative Axillary Sentinel Node
8. SNB and Some Controversial Issues
   1. Prognostic Significance of Micrometastases and Isolated Tumor Cell Clusters
   2. Alternatives to Routine ALND in Patients with Positive Sentinel Node
   3. SNB After Aesthetic Breast Surgery
   4. SNB and Pregnancy
   5. SNB in Ductal Carcinoma in Situ
9. Research Areas in Lymphatic Mapping
   1. Axillary Reverse Mapping (ARM
   2. SNB and Concomitant Probe-Guided Excision of Nonpalpable Breast Cancer
   3. Intraoperative Imaging
10. Conclusion

Objectives

Upon completion of this course, students will:

1. describe the major prognostic factor in early stage breast cancer
2. know the risk of axillary lymph node dissection
3. know the advantage of sentinel node biopsy
4. be familiar with the imaging tools for SNB
5. know the reason for the use of radiopharmaceuticals for SNB
6. be familiar with the risk factors when using blue dye
7. know that SNB is associated with lower risk than ALND
8. know that SNB is associated with lower incidence of recurrence
9. know the standards of ASCO for successful SNB (without completion ALND)
10. define and understand the importance of identification rate
11. define false-negative rate and know the difference from identification rate
12. know that uninvolved lymph nodes have no impact on the false-negative rate
13. understand that previous surgery impacts the false-negative rate
14. know that different dyes are used in various countries & especially what is used in the USA
15. state the specific radiotracer used in Europe
16. define the standard of resection of lymph nodes for SNB
17. know that the site of injection affects results of SNB
18. recognize the advantage of lymphoscintigraphy
19. know that tumor size affects the rate of missed disease resulting in need for completion ALND
20. understand why SNB after chemotherapy is not advocated
21. recognize the value of ultrasonography to minimize morbidity due to ALND
22. indentify when intra-operative pathology assessment is recommended
23. state the reason for the controversy surrounding the choice of treatment of internal mammary lymph nodes
24. identify the importance of lymphoscintigraphy in imaging the internal mammary drainage
25. explain the impact of the result of positive IM involvement and how it influences treatment management
26. know the current recommendations for patients with positive SNB
27. recognize the correct risk factors associated with additional lymph node involvement
28. understand that pregnant patients need specific management when diagnosed with breast cancer
29. know the importance that the tumor pathology/histology has on offering SNB to patients
30. understand the most important challenge related to SNB is reduction of false-negatives