1. The sentinel lymph node concept can help detect colon cancer patients with minimal residual disease that may impact postoperative chemotherapy. 2. The reliability of sentinel lymph node biopsy in predicting nodal status depends on tumor stage and surgeon experience, and it is most reliable for early stage colon cancers. 3. Technical improvements are needed to enhance sentinel lymph node visualization for more accurate staging, particularly in rectal cancers.

2. Sentinel-Publications per year Total-SLN Colon-SLN

4. Is there any impact of SLNB on colon cancer nodal staging?

5. N? Surgeon Pathologist The nodal status (N-X) is relative!

6. Tan et al. Colorectal Dis 2010 Influence on nodal status Position of the first involved lymph node 30% 52% 18% 5 cm 5 cm

7. Hida et al. Dis Colon Rectum 2005 4% Influence on nodal status Position of the first involved lymph node

8. Le Voyer et al. J Clin Oncol 2003 Influence on nodal status Number of examined lymph nodes Stage II (N0)

9. Valsecchi et al. Clin Colorectal Cancer 2010 Influence on nodal status Number of examined lymph nodes

10. Richter et al. Pathologe 2007 „ Fat Clearance“-Technique with Acetone Influence on nodal status Preparation techniques n = 188 Influence of Fat Clearance on staging No. of examined lymph nodes 11 27 Additional Metastases +15% der Pat. Upstaging +8% der Pat.

11. involved Hermanek, Arch Chir 1996 Influence on nodal status Selection of the lymph nodes at risk Pathologist´s assessment

12. Mönig et al. Ann Surg Oncol 1999 Influence on nodal status Selection of the lymph nodes at risk

13. Influence on nodal status Technique of lymph node preparation Serial sections + IHC Step sections HE negativ Lamellation 2-3 mm (500µm) RT-PCR

14. Influence on nodal status Prognostic significance of minimal residual disease No. N0-Pat. Method Target % MM/ITC-positive patients Prognostic significance Greenson 1994 50 IHC CK,TAG-72 28% Yes Jeffers 1994 77 IHC CK 25% No Adell 1996 100 IHC CK 8,18,19 39% No Clarke 1999 134 IHC Mp53P 26% Yes Tschmelitsch 2000 50 IHC CK (AE1/AE3) 76% No Noura 2002 98 IHC CK (AE1/AE3) 46% No Fisher 2003 399 IHC CK (AE1/AE3) 18% No Rosenberg 2004 85 IHC CEA, CK20 27% Yes Kronberg 2004 90 IHC CK (AE1/AE3) 29% No Lee 2006 121 IHC CK (MNF 116) 50% No

15. Influence on nodal status Prognostic significance of minimal-residual disease No. N0-Pat. Method Target % PCR-positive patients Prognostic significance Hayashi 1995 71 PCR K-ras, p53 52% Yes Belly 2001 38 PCR K-ras 37% Yes Rosenberg 2002 85 RT-PCR CK-20 52% Yes Noura 2002 64 RT-PCR CEA 30% Yes Merrie 2003 141 RT-PCR CK-20 34% Yes Bustin 2004 42 Real-time RT-PCR CK-20,CEA,GCC Not stated No Ho 2004 33 Real-time RT-PCR CEA 18% No Bilchik 2007 99 Realt-time RT-PCR C-MET, MAGE-A3, CK20, GalNAC-T 11% Yes

19. Open technique

20. Laparoscopic technique

21. Influence on nodal status Technique of lymph node preparation Serial sections + IHC Step sections HE negativ Lamellation 2-3 mm (500µm) RT-PCR

22. n = 82 patients n = 18 nodes (median) Stojadinovic et al, Ann Surg 2007 Standard histopathology +/- SLN n.s. p<0,02 %

23. USA 2005 n= 191 Serbia 2007 n= 40 Netherlands 2007 n= 56 Norway 2008 Germany 2007 n=141 n= 122 „ Upstaging by step sections + IHC of the SLN Standard histopathology +/- SLN H&E-negative patients

24. An accidental finding? Is it more frequent in the SLN than in Non-SLN? Minimal residual disease in the SLN:

25. Non-SLN SLN Mikrometastases/ Isolated tumor cells (MM/ ITC) 14/70 (20%) 37/941 (3,9%) p < 0,001 Distribution of MM/ITC in SLN and Non-SLN Bembenek A et al. World J Surg 2005

26. Prognostic impact Minimal residual disease in the SLN H&E-neg. Pat.: n = 58 Recurr.: n = 10 (17%) qRT-pos. Recurr.: n = 6/10 (60%) Mittl. follow-up: 43 (qRT+) Mon. 57 (qRT-) Mon. Multimarker-Panel: c-MET, GalNAc-t, CK20, MAGE-3 Koyanagi et al, Clin Cancer Res 2009 N0-Patienten!

27. No adjuvant th. N0 - SLN MMR+ Adjuvante th. Optimized indication for adjuvant therapy? N0-SLN MMR-

29. Is there any impact of SLNB on lymphadenectomy? Does the SLN predict/exclude the presence of N+?

30. Selective lymph node dissection in breast cancer Axillary dissection SLNB + Schnellschnitt No tumor cells in SLN No axillary therapy No SLN Tumor cells in SLN

31. Definitions Detection rate (%): Number of successful SLN-detections Number of initiated SLNB Sensitivity (%): Number of patients with macrometastases in the SLN Total number of nodal positive patients (true positive + false negative) Upstaging (%) Number of patients with micromet./ITC in the SLN Total number of nodal negative patients after routine-HE Negative predictive value (%): Number of patients with uninvolved SLN Number of (nodal negative + false-negative) patients

32. Definitions „ Accuracy“ Number of correct results (true negative and positive) All (nodal negative and positive) Sensitivity (%): Number of patients with macrometastases in the SLN Total number of nodal positive patients (true positive + false negative)

33. LA/Michigan 2006 Boston 2004 Serbia 2007 n= 408 n= 79 n= 84 Multicenter studies Netherlands 2007 n= 69 n= 203 Germany 2007

34. (Un)Reliability to predict N+ 268/315 44/82 81% 46% **p=0,0001 Combination of the Multicenter Studies USA + Germany n = 891 Pat. Cahill et al, Ann Surg Oncol 2009 % of patients N+ Sensitivität pT1 10% 5% pT2 17% 19% pT3 67% 36% pT4 6% 44%

35. 268/315 44/82 81% 46% **p=0,0001 Cahill et al, Ann Surg Oncol 2009 (Un)Reliability to predict N+ Combination of the Multicenter Studies USA + Germany n = 891 Pat. % of patients N+ Sensitivity pT1 10% 5% pT2 17% 19% pT3 67% 36% pT4 6% 44%

36. 268/315 44/82 81% 46% ** 89% Cahill et al, Ann Surg Oncol 2009 (Un)Reliability to predict N+ Combination of the Multicenter Studies USA + Germany n = 891 Pat. % of patients N+ Sensitivität Sensitivity in centers >22 P. pT1 10% 5% pT2 17% 19% pT3 67% 36% pT4 6% 44%

37. Reliable prediction of N+ Experienced centers >=22 Pat. Cahill et al, Ann Surg Oncol 2009 Bembenek et al, Ann Surg 2007

38. Comparison: Sensitivity in breast cancer Bembenek et al. WJS 2007

40. Lymph node metastases in pT1-tumors Hida et al. Dis Colon Rectum 2005

41. Wang et al, J Gastrointest Surg 2007 Optimized indication for limited surgery Endoscopic Resection SLNB pT1 SN-N0 Limited Resection ( endoscop. /laparoscopic/NOTES) after appropriate patient selection? +

42. Cahill et al. Ann Surg Oncol 2008 Optimized indication for limited surgery after appropriate patient selection? Transgastric („NOTES“) SLNB in pigs

46. Endoscopic application 17h after application Preoperative endoscopic radiocolloid injection rectal cancer

47. Rectoscopic radiocolloid injection ex-vivo-lymph node preparation TME-specimen problem: overlapping radioactivity specimen scintigraphy rectal cancer

48. meso-scintigraphy meso-separation Ex-vivo-preparation of SLN rectal cancer

49. Results rectal cancer n % LN+-Pat. Injection SLN-identification Detection rate Sensitivity Upstaging Kitagawa 2000 56 RM (preop.) In vivo 91% 81% n. s. Own Results 2004 48 33% RM (preop.) ex vivo 96% 44% 0 Saha 2004 71 32% BDM (intraop.) in vivo 92% 94% 7% Baton 2005 31 23% BDM (postop.) ex vivo 97% 57% 13% Yagci 2007 47 43% BDM (postop.) Ex vivo 98% 80% 15% Finan 2010 58 48% BDM (postop.) ex vivo 85% 53% n.s.

53. Ferumoxtrane-10 Saokar A. Abdom Imaging 2006 Lymphotrophic MR-Nanoparticles Future options for an improved SLN-visualisation

54. Talanov VS. Nan Lett 2006 Subcutanous injection of G6-(Cy5.5) 1.25 (1B4M-Gd) 145 Combination of MRI + Fluorescence Future options for an improved SLN-visualisation

55. Fluorescence-guided lymphatic mapping with optical fusion Own setting Future options for an improved SLN-visualisation

56. Fluorescence-guided lymphatic mapping with optical fusion Own setting Future options for an improved SLN-visualisation

57. Still Big Mountains to defeat! Thank you!