As part of our ‘Save Our Nodes’ campaign, we recently spoke with Dr Manpreet Kohli, MD – Director of Breast Surgery at Monmouth Medical Center, part of the RWJ Barnabas Health group – about this revolutionary new technique that is enabling up to 80% of mastectomy patients with high-risk DCIS to avoid unnecessary axilla surgery.
Dr Kohli had long been concerned about the disruption to the lymphatic system that patients can experience with axillary surgery and was keen to find out about the solutions available to solve this problem.
During our conversation we spoke about the limitations of the current treatment methods for high-risk DCIS, the signs to look out for with secondary lymphedema and how the long-term retention of Magtrace® in the lymph nodes is helping to reduce the risk to patients.
Dr Kohli began by sharing her experiences of treating patients at Monmouth, explaining how treatment for mastectomy had previously been more complicated than for lumpectomy, finding that often her mastectomy patients would have a larger span of the DCIS.
This naturally involves removing a larger amount of breast tissue, which can disrupt the lymphatic system and render it difficult to return for a sentinel lymph node biopsy procedure if an invasive component is found. That, Dr Kohli said, is why sentinel lymph node biopsy (SLNB) was introduced to replace a complete axillary dissection (ALND).
“For many years now, all of these women have been offered – or the vast majority of these women have been offered – a sentinel lymph node biopsy at the time of their mastectomy for treatment of DCIS.”
"However, even though with a sentinel lymph node biopsy you're removing fewer lymph nodes, you still do have the risk of the lymphedema."
Secondary lymphedema is a condition that occurs when the patients lymphatic system is compromised, often during breast surgery, causing long-term swelling and pain. Recent figures suggest that the rate of lymphedema can vary from 3.7% to 17% in patients undergoing sentinel lymph node biopsy procedures.
It’s a major concern to those already going through treatment and Dr Kohli told us how it’s something that patients are often not made aware of until it’s too late.
“When we survey patients who are survivors, it is one of the issues in their list of top five concerns. That they feel like it was an unaddressed issue and it’s an issue that they continue to have to face over and over again.”
"It can happen any time after you're treated for breast cancer. So it's not something that is just a perioperative issue - it's a long-term issue."
Fortunately, recent studies have proven that there is an alternative way to treat the axilla and reduce that risk of lymphedema.
Studies from Uppsala University in Sweden and University Hospitals Cleveland in the US have demonstrated that using Magtrace® – a lymphatic tracer which provides signal for a significantly longer amount of time than any other tracer alternative – breast care teams now have the flexibility to:
If after all of that a SLNB is still required, the Magtrace® will have remained in the nodes, making them easy to identify and remove for analysis of cancer spread to the underarm.
“Having Magtrace available is a really wonderful, wonderful thing,” Dr Kohli told us. “I inject it intraoperatively, right after they go to sleep, in the subareolar plexus. I do a few moments of massage. The mastectomy is performed and after it is completed, I confirm that there is still the Magtrace in the lymph nodes with the Sentimag probe. Then we simply await the results from pathology.”
So far, Dr Kohli hasn’t had to return to perform the sentinel lymph node biopsy on many patients – but for the first patient who did require it, the process of going back was straightforward.
“It was so easy. It was so focused on one lymph node that was brown and it had the tracer in it and it [the magnetic signal] maxed out. The best part is that the lymph node was negative, so that patient was extremely happy that we hadn’t made a cavalier decision.”
For many years, the gold standard treatment for performing SLNB has been to use technetium-99 and a blue dye together to help identify the lymph nodes most likely to contain cancer if it has spread. While the technetium provides a radioactive signal to help surgeons to the node, the blue dye offers visual confirmation once you’re close to the target nodes.
We asked Dr Kohli for her thoughts on how Magtrace® compared with it’s ability to provide dual-identification in the form of magnetic signal and visual brown staining of the nodes.
“It was extremely easy because you don’t have to worry about one tracer going to one lymph node and another tracer going to another lymph node. It was one tracer that went to the same lymph node. It was brown and it had some auditory feedback to help identify it.”
Providing innovative treatments such as ‘delayed’ SLNB is a major reason that Monmouth attract patients from across the state of New Jersey – and even out of state, from Pennsylvania, Michigan and further afield.
"I'm very, very proud that we were the first hospital in New Jersey to offer Magseed and Magtrace - and that's because I have a very, very supportive hospital administration."
Note: ‘Delayed’ SLNB is currently only indicated for use in patients undergoing a mastectomy in the US.