Sentinel Lymph Node Biopsy (SLNB) for Breast Cancer

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Hey guys, it's Metacosis Perfectionitis, where medicine makes perfect sense and today we'll continue our play that's called labs.

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It's Sentinel lymph node biopsy time, so let's get started.

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Before we get started, we use this for what? We use the Sentinel lymph node biopsy for breast cancer.

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Where does breast cancer drain usually into auxiliary lymph nodes?

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Alright, my friend, what are the clinical uses of the Sentinel lymph node biopsy?

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Oh, breast cancer!

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Yes, that's true, but if you stop here, you are a mediocre student.

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Everyone knows that Sentinel lymph node biopsy is used for breast cancer.

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What else?

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And the answer is, it's melanoma, baby.

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What is cancer?

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Cancer is here, it's a new plate.

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We have many types of cellular growth hypertrophy, which means increase size of the tissue or the cell.

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Hyperplasia increased number of cells.

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Metoplage when you change one tissue type into another tissue type in the same category.

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From epithelium to epithelium or from connective tissue to connective tissue,

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you cannot jump from epithelium to connective tissue.

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One example of Metoplasia is Barrett's esophagus.

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Next, you have dysplasia.

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This means defective or difficulty or something like this.

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Pleasure means growth, so defective growth.

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That's bad, because you are that close from having a neoplasia.

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Neoplasia is a tumor.

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Neoplasia is anything that ends in omen.

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Neoplages are divided into benign, no big deal, and malignant tumors.

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This is a big deal, and of course every cancer is different.

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Some of them are not so dangerous.

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Case in point, basal cell carcinoma of the skin.

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You go to the dermatologist twice.

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One to diagnose it, and one to remove it.

01:43

Boom, that's it.

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But pancreatic cancer, however, your life has been turned upside down.

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Most patients only have about six months to live.

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That's horrible.

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Tumor is the same as Neoplasia, is the same as anything that ends in omen.

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And then we divide those into benign tumors and malignant tumors.

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Malignant tumors, you have carcinomas, and sarcomas.

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What's the difference?

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carcinoma is a malignant tumor arising from epithelium.

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sarcomas, malignant tumors arising from connective tissue.

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All of these are cancers, but benign is not cancer.

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Where do they metastasize?

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A carcinoma has a predeliction to go to lymph nodes.

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Sarcomas have predeliction to go to the blood.

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The word sarcomines flesh, so you can remember it.

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It's flesh and blood.

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Okay, breast, do you think?

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Most of the cancers are rising from the breast

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are going to be carcinoma or sarcoma.

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Let's think about it.

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What do you call the breast?

02:39

Memory glands.

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Say it one more time, please.

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Memory glands.

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Glands.

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So they have a glandular epithelium that secreeds.

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Yeah, you said epithelium.

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Yep, that's why most breast cancers are carcinomas.

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Connective tissue does not secrete.

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So most breast cancers are carcinoma.

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That's why they metastasize to lymph nodes.

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And since the breast is in the thorax,

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and since the breast is superficial,

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it's going to drain to exolary lymph nodes.

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On my glorious website,

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medicosisperfectionaries.com,

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I have a video on lymphatic drainage.

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If you are here, upper extremity and breast,

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you will go to the exolary lymph node.

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If you are skin in the anterior abdominal wall,

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above the umbilicus,

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you will also end up in the exolary lymph nodes.

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But if you happen to be skin at the anterior abdominal wall below the umbilicus,

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you'll go to the superficial epi gastric lymph nodes,

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and these will drain into the superficial anguina lymph nodes.

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This slide alone is going to save you a lot of time.

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So sentinel lymph node biopsy, what does sentinel mean?

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It means a guard.

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Well, I don't understand.

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Let me tell you the story.

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Here's the breast.

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The breast has cancer.

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Cancer will metastasize with the exolary lymph nodes.

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Here are your exolary lymph nodes,

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and they are arranged like this.

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Some lymph nodes are closer to the cancer.

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Some are distant from the cancer.

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Which one is the guard?

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The one closest.

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The guard is the lymph node that has cancer

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and is closest to the primary tumor.

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That's why we call it the guard.

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I still don't get it.

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Let's imagine that this guard is negative.

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It does not have cancer.

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Do you think the others will have the cancer?

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No, because the first one did not have the cancer.

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How come those will have cancer

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if the first one is free?

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It's not going to happen.

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If this one is free,

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all of the rest will be free.

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And that's why it's called the guard,

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because it's the sentinel.

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It's the first lymph node in the chain of exolary lymph nodes.

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The guard or the sentinel is the hot lymph node

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closest to the primary tumor.

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Okay, what do you mean by hot?

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I remember Will Smith in the YouTube Rewind video

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when he said,

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oh, that's hot.

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That's hot.

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What people did not understand

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that he was talking about sentinel lymph node biopsy.

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A hot lymph node is a lymph node that has cancer.

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And how do you know this?

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You need three things.

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Number one, you need to see it

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as a blue colored lymph node.

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Like, how do I see it as a blue?

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Because he used a tracer, such as

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isosulfon blue or technician.

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When I be a tracer,

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I'm a ready tracer.

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What kind of tracer isosulfon blue or technician?

05:18

Oh, we'll see this blue color,

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the freaking surgeon.

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Together with the surgeon,

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a surgical pathologist is going to enter into the operating room.

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Whenever the surgeon finds a blue node,

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the surgeon is going to take the lymph node out

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and throw it into the pathologist's face.

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The pathologist will give you the result

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within about 10 to 20 minutes.

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The surgical pathologist will say to the surgeon,

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hey, surgeon, it's cancer.

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Please remove it.

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Or, hey, surgeon,

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it's not cancer.

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You do not need to remove it.

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And if it's not cancer,

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it means the rest of the chain is cancer-free.

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How does the pathologist determine this

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based on histopathology?

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This is the slide under the microscope

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and amino histochemistry.

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And this is very important

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because some nodes will appear

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normal under the microscope.

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But when you do the amino histochemistry,

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you'll find cancer in those lymph nodes.

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So histopathology alone is not enough.

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When all of these are positive,

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it's time to remove the node.

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And here is the most common misconception among students.

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They think that just because the lymph node is blue,

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that this means it has cancer.

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No, no, no, no, no.

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A lymph node that is blue means

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it's in the same pathway as the cancer.

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The purpose of the tracer is not to decide

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which node is free and which node is cancerous.

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The purpose of the tracer is to identify the path

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that chain of the lymph nodes where this cancer will drain.

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And now the surgeon will take the,

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okay, I identify the path.

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Let me take this lymph node

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and throw it to the pathologist.

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It's the pathologist job to tell you

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which one is free and which one has cancer.

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That's it.

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The tracer only locates

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the lymph node that is most likely to contain

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the cancer metastasis.

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Something your professor will never tell you.

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Okay, metacosis, are there any contraindication

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to the sentinel lymph node biopsy?

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Sure.

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Let's not forget what was in the tracer.

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Some radioactive components.

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This is nuclear medicine, baby.

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Such like the bones can.

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The technicians can.

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All of these are nuclear medicine.

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And therefore, they could be teratogenics.

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So they are contraindicate and early pregnancy.

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Like, is this like all or none?

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No, no, there are no solutions in life.

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There are incremental trade-offs.

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If the benefits of this procedure outweigh the risk,

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it's time to do it.

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Example, if mommy has a 90% chance of dying

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in case this is cancer, you're going to do it.

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If there is just 1% chance that this is a malignant tumor,

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you probably are gonna postpone it or do something else.

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For example, you can remove the lymph nodes

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without using a tracer.

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Another contraindication, if the cancer is so large

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and you already know that there is like 95% chance

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of metastas to the exotherium node.

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So if you are sure, you're gonna remove the lymph nodes anyway.

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So just go ahead and remove them.

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Do not expose the patient to unnecessary tests

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and unnecessary radiation.

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Because according to Hippocrates,

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what was rule number one in medicine?

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Do no harm.

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What was rule number two?

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Do not forget rule number one.

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Are there any complications?

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Yes, this is nuclear medicine.

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This is tracer.

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Any chemical, there is risk of allergy

08:32

and anaphylaxis.

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And it does not matter if it's penicillin or a freakin tracer.

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Are there any complications of lymph node excisions?

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Of course, there are complications to everything in life.

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Example, swelling can happen after the procedure.

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Cellulitis, postoperative pain,

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and maybe decreased range of motion of the upper extremity.

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After any surgery or body can heal through a regeneration,

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or it can heal through fibrosis.

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If fibrosis happen, it's gonna decrease lymphatic drainage

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because all of these lymphatic vessels are fibrosed right now.

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This will lead to stagnation,

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which will increase hydrostatic pressure.

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This will end up as lymphadema.

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Can you tell me the pathophysiology of lymphadema?

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Sure, hydrostatic pressure is going up a lot,

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leading to leakage of lymphatics,

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to the interstitial space.

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What is edema again?

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Accumulation to float in the interstitial space,

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not in the intercellular space,

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in the interstitial.

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This is extracellular.

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And this is what we mean by lymphadema.

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Edema means swelling.

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Swelling that is made of lymph.

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Lymphadema is an unpetting edema.

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Generally speaking, if you want to be super sophisticated,

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it starts as petting,

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but later becomes non-pitting.

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But if you just want to describe it,

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it's an unpetting edema.

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Why non-pitting?

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Because of the increased viscosity of the freaking lymph,

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making it non-pitting.

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This is not plasma.

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This is not just some lovely fluid.

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This is a thick viscous, ugly fluid.

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Increase viscosity will make it non-pitting.

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Contrast that with the ankle edema that happens

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in congestive heart failure.

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That one was pitting.

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What the flip does pitting mean?

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Pitting mean when you poke the patient's skin with your finger.

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And remove your finger.

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It still leaves an indentation for about two or three seconds.

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This is called pitting.

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Non-pitting, however,

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it means that once you remove the finger,

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the indentation disappears.

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Lymphadema, of course, has lymph and lymph is a protein rich fluid.

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What are the causes of lymphadema?

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We have primary causes

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and secondary causes.

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Primary causes could be inherited

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or sporadic.

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Example, turn or syndrome.

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Melore disease.

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Or secondary, which means secondary to something else.

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Secondary to a surgeon.

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Lymph node is secondary to a radiologist.

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Another surgeon, or an infectious disease

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such as Usheria Bankrupti,

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which causes elephantiasis.

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And this is very important.

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The most common cause of lymphadema

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in developing countries,

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infection, developed countries,

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cancer treatment,

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especially after treatment of breast cancer.

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So you have two patients.

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First patient came from Azerabhijan.

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Second came from Japan.

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Play odds.

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The patient was around.

11:05

Probably an infection.

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Probably a Usheria Bankrupti,

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tuberculosis, fungal infection,

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etc.

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The patient from Japan,

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it's probably secondary to cancer treatment.

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If you want to be a good doctor,

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you need to be able to help all patients.

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But you will never do this

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if you do not know where to look.

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Also, it helps the patient feel

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that you are confident

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and you know what the flip you're talking about.

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For example, a patient came to you

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from Canada with lymphadema.

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You can ask one question.

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Did you have breast cancer before?

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Oh, doctor, that's amazing.

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How did you know?

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Some pearls for the pros.

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This is a very, very, very high yield case for your exam.

11:42

Here is a lady with breast cancer.

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She underwent radical mastectomy

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and radiation or dissection

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to the auxiliary lymph nodes.

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When you dissect those doozy lymph nodes,

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you might injure the long thoracic nerve.

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When you injure the long thoracic nerve,

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what do you get?

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Winged scapula and loss of shoulder abduction

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from 90 degrees to 180 degrees.

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And what was the name of the muscle

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that is suffering in this case

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is the serratus anterior muscle.

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Several months later after those surgical procedures,

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she developed secondary lymphadema

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and the upper extremities

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at the same side as the lymph node dissection.

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If this happened on the left side,

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this will happen on the left side.

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And then five to 10 years later,

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she developed lymph and geosarcoma.

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It's a sarcoma.

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When it metastasizes,

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it goes to the blood.

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You need to memorize

12:34

every single stinking word in the scenario.

12:37

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Description

The video begins by explaining the purpose of the Sentinel lymph node biopsy for breast cancer diagnosis. It then delves into the technique involved in the procedure, including the identification of the sentinel lymph node and the removal of the lymph node for further examination. The clinical uses of the Sentinel lymph node biopsy are also discussed, including its ability to detect breast cancer at an early stage and improve patient outcomes. The video also highlights the potential complications that can arise during the procedure, such as lymphedema, and provides tips on how to minimize these risks. Finally, the video concludes by emphasizing the importance of accurate sampling and the potential benefits of the Sentinel lymph node biopsy for breast cancer diagnosis.