Development of sentinel node biopsy, ROLL and IART in early breast cancer at the European Institute of Oncology, Milan (IEO).

Giovanni Paganelli

doi:10.3332/ecancer.2017.744

Abstract

The problem of unnecessary axillary clearance in many patients with early breast cancer was certainly a major issue at IEO when we started working with Prof. Umberto Veronesi in 1994. At that time, axillary dissection in EBC was offered to all patients and this procedure was often hotly debated during our multidisciplinary breast cancer meetings. The question as to whether we could avoid axillary dissection by using PET scans or other nuclear medicine methods was frequently asked by Veronesi. This eventually prompted us to investigate whether, as for melanoma patients, the sentinel node biopsy (SNB) approach could reliably be applied to breast cancer. In December 1995, we proposed a new lymphoscintigraphy protocol to detect the SN in early breast cancer patients to our Ethic Committee, and it was approved. The pilot study was published in 1997 and after only 6 years, the first randomised trial comparing SNB and axillary clearance in breast cancer patients was published. During the pilot study, we optimised the lymphoscintigraphy technique by comparing different radiotracers and different injection modalities. Following the observation that the majority of the radiocolloids injected into the tumour did not migrate to lymph nodes, a new method called ROLL or Radio-guided Occult Lesion Localisation was developed for the localisation of non-palpable breast lesions. This technique was introduced into clinical practice at the European Institute of Oncology in 1996. Several studies showed that the ROLL procedure enabled the surgeon to remove non-palpable breast lesions easily and accurately, overcoming some disadvantages of other methods such as wire-guided localisation (WGL). In addition to SNB and ROLL, other protocols such as the IART (intraoperative avidination for radionuclide therapy)-ARTHE (avidinated radiotherapy) procedure were developed at the IEO Nuclear Medicine Division during the period 1994–2013. I remember that time as the most professionally productive of my career and it would not have been possible without the help, suggestions and encouragement given to me by Umberto Veronesi.

Highlights

The most important goal of modern surgical oncology is to utilise the least aggressive methods while maintaining radicalism
Sentinel lymph node biopsy (SNB) and radioguided occult lesion localisation (ROLL) of non-palpable tumours are the logical consequence of this lesson
SNB and ROLL represent an important contribution of nuclear medicine to the management of early breast cancer

Summary

Introduction

The most important goal of modern surgical oncology is to utilise the least aggressive methods while maintaining radicalism. Sentinel lymph node biopsy (SNB) and radioguided occult lesion localisation (ROLL) of non-palpable tumours are the logical consequence of this lesson. In 2000, SNB became the standard technique at IEO to stage lymph nodes in patients with early breast cancer and clinically negative axilla. In 1996, in addition to the SN study for the optimisation of the lymphoscintigraphy technique, a new method for the localisation of nonpalpable breast lesion known as ROLL, indicating ‘radioguided occult lesion localisation’ was developed. The idea for ROLL came about almost by accident during a coffee break with my friend Alberto Luini (breast surgeon) who asked me if we could find a method similar to that of SN for non-palpable tumours. A few days later we began to use this new technique and have since never used any other methods to localise non-palpable lesions in breast cancer [8]. The present article reports some of the more important aspects of nuclear medicine relating to the development of SN, ROLL and avidin– biotin pre-targeting techniques

Methodological aspects of lymphoscintigraphy

Intraoperative gamma probe counting

The IART approach

Findings

Conclusions