Contrast-enhanced ultrasonography and blue dye methods in detection of sentinel lymph nodes following neoadjuvant chemotherapy in initially node positive breast cancer

Application of Contrast-Enhanced Ultrasound Parameters of Metastatic Axillary Lymph Nodes in Breast Cancer Patients in Predicting the Efficacy of Neoadjuvant Chemotherapy in Early Stage

BACKGROUND

To investigate the performance of contrast-enhanced ultrasound(CEUS) parameters of metastatic axillary lymph nodes (ALNs) before and after two courses of neoadjuvant chemotherapy (NAC) in breast cancer patients in predicting the efficacy of NAC.

METHODS

A total of 41 postoperative breast cancer patients were selected. All patients underwent NAC, and ALN biopsy was positive before chemotherapy. Metastatic ALN was examined by CEUS before and after two courses of NAC. The CEUS parameters of metastatic ALNs before and after two courses of NAC were analyzed to determine the performance of CEUS parameters in predicting the efficacy of NAC in early stage.

RESULTS

The NAC was effective for 28 cases and ineffective for 13 cases. There were no statistically significant differences in the CEUS parameters between effective NAC and ineffective NAC individuals before and after two courses of NAC. But, there were statistically significant differences in long diameter (LD), short diameter (SD), Peak intensity (Peak%) and area under the curve (AUC) between the effective and ineffective NAC patients after two courses of NAC. Receiver operating characteristic curve (ROC) analysis suggested the drop-out value of LD, SD, Peak% and AUC after two courses of NAC can be used as important indicators to evaluate the efficacy of NAC (p < 0.05).

CONCLUSIONS

CEUS parameters of metastatic axillary lymph nodes (ALNs) before and after two courses of neoadjuvant chemotherapy (NAC) in breast cancer patients can predict the efficacy of NAC in early stage.

Combining Contrast-Enhanced Ultrasound with Methylene Blue for Detection of Sentinel Lymph Nodes in Early Breast Cancer

Aims/Background Sentinel lymph nodes (SLNs) are an important prognostic factor for breast cancer patients, but traditional axillary lymph node dissection methods have many complications, while sentinel lymph node biopsy has been developed as a better method. This study aimed to evaluate the efficiency of combining contrast-enhanced ultrasound (CEUS) with methylene blue for identifying SLNs in early-stage breast cancer patients. Methods This retrospective study included clinical data from 163 female patients with lymph node-negative and T1-2 early breast cancer admitted to China-Japan Friendship Hospital between August 2022 and November 2023. All patients received a periareolar injection of SonoVue followed by ultrasonography to identify SLNs. The methylene blue was used to detect SLNs during the surgery, and the patients underwent sentinel lymph node biopsy. We compared the methylene blue method with combined CEUS and methylene blue to identify the number of SLNs per patient. Furthermore, these two methods were compared to determine the number of SLNs and the number of SLNs positive in 34 SLNs positive patients. Results This study included 163 patients with tumor (T)1-2 node (N)0-3 metastasis (M)0. The identification rate of SLNs was 100% for CEUS. We detected 376 SLNs using a combined CEUS and methylene blue method, with a median of 2 (1, 5). Furthermore, methylene blue identified 627 SLNs, with a median of 3 (1, 12). However, CEUS detected a significantly lower number of SLNs than those identified by methylene blue (p < 0.001). Additionally, metastasis frequency was substantially higher for the combined CEUS and methylene blue method (66.3%, 53/80) compared to methylene blue approach alone (39.5%, 58/147) (p < 0.001). Conclusion Combining CEUS with methylene blue is expected to improve the accuracy of axillary staging in breast cancer patients while reducing surgical trauma and postoperative complications.

The Use of Contrast-Enhanced Sonography for Therapy Monitoring of Metastatic Lymph Nodes: A Systematic Review

Metastatic cervical lymph nodes are a frequent finding in head and neck squamous cell carcinoma (HNSCC). If a non-surgical approach is primarily chosen, a therapy response evaluation of the primary tumor and the affected lymph nodes is necessary in the follow-up. Supplementary contrast-enhanced ultrasound (CEUS) can be used to precisely visualize the microcirculation of the target lesion in the neck, whereby malignant and benign findings differ in their uptake behavior. The same applies to many other solid tumors. For various tumor entities, it has already been shown that therapy monitoring is possible through regular contrast-enhanced sonography of the primary tumor or the affected lymph nodes. Thus, in some cases, maybe in the future, a change in therapy strategy can be achieved at an early stage in the case of non-response or, in the case of therapy success, a de-escalation of subsequent (surgical) measures can be achieved. In this paper, a systematic review of the available studies and a discussion of the potential of therapy monitoring by means of CEUS in HNSCC are presented.

Diagnostic accuracy of de-escalated surgical procedure in axilla for node-positive breast cancer patients treated with neoadjuvant systemic therapy: A systematic review and meta-analysis

BACKGROUND

More initial clinical node-positive breast cancer patients achieve axillary pathological complete response (ax-pCR) after neoadjuvant systemic therapy (NST). Restaging axillary status and performing de-escalated surgical procedures to replace routine axillary lymph nodes dissection (ALND) is urgently needed. Targeted axillary lymph node biopsy (TLNB) is a novel de-escalated surgical strategy marking metastatic axillary nodes before NST and targeted dissection and biopsy intraoperatively to tailor individual axillary management.

METHODS

This study provided a systematic review and meta-analysis to evaluate the feasibility and diagnosis accuracy of TLNB. Prospective and retrospective clinical trials on TLNB were searched from Pubmed, Embase, and Cochrane. Identification rate (IFR), false-negative rate (FNR), negative predictive value (NPV), and rate of ax-pCR were the outcomes of this meta-analysis.

RESULTS

One thousand nine hundred and twenty patients attempted TLNB, with an overall IFR of 93.5% (95% confidence interval [CI] 90.1%-96.2%). IFR of three nodal marking methods, namely iodine seeds, clips, and carbon dye, was 95.6% (95% CI 91.2%-98.7%), 91.7% (95% CI 87.3%-95.4%), and 97.1% (95% CI 89.1%-100.0%), respectively. Of them, 847 patients received ALND, with an overall FNR of 5.5% (95% CI 3.3%-8.0%), and NPV ranged from 90.1% to 96.1%. Regression analysis showed that the overlap of targeted and sentinel biopsied nodes might associate with IFRs and FNRs.

CONCLUSION

TLNB is a novel, less invasive surgical approach to distinguish initial node-positive breast cancer that achieves negative axillary conversion after NST. It yields an excellent IFR with a low FNR and a high NPV. A combination of preoperative imaging, intraoperative TLNB with SLNB, and postoperative nodal radiotherapy might affect the future treatment paradigm of primary breast cancer with nodal metastases.

Advanced diagnostic imaging of sentinel lymph node in early stage breast cancer

Sentinel lymph node biopsy has been regarded as the standard procedure for early staging breast cancer. One of the key steps is to locate the sentinel lymph node (SLN). The recommended method is the joint use of blue dye and radioisotope. However, due to radionuclide radiation and high cost, it is urgent to develop more convenient and sensitive imaging methods to accurately locate SLN. This article discusses the advancement of accurately locating SLN by isotope tracer imaging, magnetic tracer method, computed tomographic lymphography, and trans-lymphatic contrast-enhanced ultrasound, as well as proposing new propose for clinical diagnosis.

Outcomes of Sentinel Node Biopsy for Women with Breast Cancer After Neoadjuvant Therapy: Systematic Review and Meta-Analysis of Real-World Data

BACKGROUND

Evidence on the accuracy of sentinel lymph node biopsy (SLNB) after neoadjuvant therapy (NAT) for patients with breast cancer is inconclusive. This study reviewed the real-world data to determine the acceptability of SLNB after NAT.

METHODS

The study searched for articles in the PubMed, EMBASE, and Cochrane Library databases. The primary outcomes were the identification rate for sentinel lymph nodes (SLNs) and the false-negative rate (FNR) for SLNB. The study also evaluated the FNR in subgroups defined by tumor stage, nodal stage, hormone receptor status, human epidermal growth factor receptor-2 status, tumor response, mapping technique, and number of SLNs removed.

RESULTS

The study retrieved 61 prospective and 18 retrospective studies with 10,680 initially cN± patients. The pooled estimate of the identification rate was 0.906 (95 % confidence interval [CI], 0.891-0.922), and the pooled FNR was 0.118 (95 % CI, 0.103-0.133). In subgroup analysis, the FNR was significantly higher for the patients with estrogen receptor (ER)-negative status and fewer than three SLNs removed. The FNR did not differ significantly between the patients with and those without complete tumor response. Among the patients with initial clinical negative axillary lymph nodes, the incidence of node metastasis was 26.8 % (275/1041) after NAT.

CONCLUSION

Real-world evidence indicates that the FNR of SLNB after NAT in breast cancer is 11.8 %, exceeding only slightly the commonly adopted threshold of 10 %. The FNR is significantly higher for patients with ER-negative status and removal of fewer than three SLNs. Using a dual tracer and removing at least three SLNs may increase the accuracy of SLNB after NAT.

Techniques for sentinel node biopsy in breast cancer

INTRODUCTION

Sentinel node biopsy (SNB) is the standard of care in women with breast cancer (BC) and clinically non suspicious axillary lymph nodes (LNs), due to its high negative predictive value (NPV) in the assessment of nodal status. SNB has significantly reduced complications related to the axillary lymph node dissection, such as lymphedema and upper limb dysfunction.

EVIDENCE ACQUISITION

The gold standard technique for SNB is the blue dye (BD) and technetium labelled nanocolloid (Tc-99m) double technique. However, nuclear medicine is not available in all Institutions and several new tracers and devices have been proposed, such as indocyanine green (ICG) and superparamagnetic iron oxides (SPIO). All these techniques show an accuracy and detection rate not inferior to that of the standard technique, with different specific pros and cons. The choice of how to perform a SNB primarily depends on the surgeon's confidence with the procedure, the availability of nuclear medicine and the economic resources of the Institutions. In this setting, new tracers, hybrid tracers and imaging techniques are being evaluated in order to improve the detection rate of sentinel lymph nodes (SNs) and minimize the number of unnecessary axillary surgeries through an accurate preoperative assessment of nodal status and to guide new minimally invasive diagnostic procedures of SNs. In particular, the contrast-enhanced ultrasound (CEUS) is an active field of research but cannot be recommended for clinical use at this time.

EVIDENCE SYNTHESIS

The ICG fluorescence technique was superior in terms of DR, as well as having the lowest FNR. The DR descending order was SPIO, Tc, dual modality (Tc/BD), CEUS and BD.

CONCLUSIONS

This paper is a narrative review of the most common SNB techniques in BC with a focus on recent innovations.

Feasibility and reliability of sentinel lymph node biopsy after neoadjuvant chemotherapy in breast cancer patients with positive axillary nodes at initial diagnosis: An up-to date meta-analysis of 3,578 patients

Purpose

Neoadjuvant chemotherapy (NACT) is increasingly adopted in the therapy of breast cancer (BC) patients with positive axillary nodes (cN+), but the reliability and feasibility of sentinel lymph node biopsy (SLNB) following NACT are still controversial. The objective of the present study is to conduct an updated meta-analysis on this issue.

Methods

A literature search was performed using PubMed, Cochrane, Embase, and Web of Science to identify papers published from January 1, 2000 to October 22, 2020 to research SLNB after NACT in BC patients. Studies that met the quality standard were enrolled for this meta-analysis.

Results

A total of 3578 participants from 27 trials were included in this meta-analysis. The pooled estimate of the identification rate (IR) for SLNB was 91 %, and the false negative rate (FNR) was 15 %. The pooled negative prediction value (NPV), accuracy, specificity, and sensitivity were 82 %, 89 %, 97 %, and 85 %, respectively. In subgroup analysis, the application of dual mapping could clearly decrease the FNR. The FNR was significantly high in the luminal types, and it declined as more sentinel lymph nodes (SLNs) were removed.

Conclusion

SLNB following NACT is now technically feasible for BC with cN+. However, it must be emphasized that the FNR is unacceptable high.

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We performed a meta-analysis to provide a consensus regarding the application of SLNB post-NACT in cN + patients.

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One comprehensive database search yielded 27 studies (3578 patients).

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The pooled estimate of IR for SLNB was 91 %, and FNR was 15 %.

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The application of dual mapping could clearly decrease the FNR.

Preoperative evaluation and influencing factors of sentinel lymph node detection for early breast cancer with contrast-enhanced ultrasonography: What matters

Sentinel lymph node (SLN) is important in the early diagnosis of breast cancer. We aimed to evaluate the role of contrast-enhanced ultrasonography (CEUS) in the preoperative evaluation for SLN and potentially influencing factors, to provide evidence to the management of breast cancer.Patients with breast cancer who treated in our hospital from May 2018 to May 2020 were selected. All patients underwent CEUS examination to find SLN and judged whether the lymph node had cancer metastasis. We evaluated the sensitivity, specificity, and accuracy of CEUS in predicting SLN, and its differences in pathological diagnosis results and related influencing factors were also analyzed.A total of 108 patients with breast cancer were included. And a total of 248 SLNs were detected. The sensitivity of CEUS to the preoperative evaluation of SLN was 84.67%, the specificity was 81.14%, the positive predictive value was 76.08%, and the negative predictive value was 89.27%, the positive likelihood ratio was 4.06, and the negative likelihood ratio was 0.14. The area under the curve of the preoperative evaluation of SLN in CEUS examination was 0.813 (95% confidence interval: 0.765-0.911), and there was significant difference in the size of SLNs between SLN-negative and SLN-positive groups (P = .043).Preoperative CEUS has good predictive value for the SLN detection in patients with breast cancer, and it is worthy of clinical application.

Comparison between B-mode ultrasonography and contrast-enhanced ultrasonography for the surveillance of early stage pancreatic cancer: a retrospective study

Background

Contrast-enhanced ultrasonography (CE-US) brings a higher signal-to-noise ratio and a higher sensitivity for slow flow than traditional B-mode ultrasonography (US). However, it remains unclear whether CE-US is also superior to B-mode US in detecting early-stage pancreatic cancer (PC).

Methods

This was a retrospective study enrolling patients suspected of pancreatic insufficiency between June 2015 and December 2019. Enrolled patients successively received B-mode US and CE-US examinations, and some their demographic and clinical data were collected. The diagnostic capacity of the two examinations was calculated and receiver operating characteristic (ROC) curves was used to compare the area under the curve (AUC). A subgroup analysis was performed to explore the effects of tumor size on the diagnostic accuracy of B-mode US and CE-US.

Results

There were 128 patients enrolled in this study; 74 patients were diagnosed as early-stage PC patients and the remaining 54 were diagnosed with benign pancreatic lesions. The mean size of the PC was 17.8±4.9 mm. The results revealed that 68 of the 74 PC patients were correctly diagnosed by CE-US, and all 54 patients with benign pancreatic lesions were also correctly diagnosed. Meanwhile, only 55 of the 74 PC patients and 50 of the 54 patients with benign pancreatic lesions were diagnosed correctly using B-mode US. The ROC curve showed that the AUCs of CE-US and B-mode US were 0.959 and 0.835, respectively. According to the subgroup analysis, CE-US exhibited better accuracy than B-mode US for smaller tumors (size <20 mm, P=0.002; size <10 mm, P=0.043; size <5 mm, P=0.025).

Conclusions

CE-US was clearly superior to the conventional B-mode US in detecting early-stage PC, especially smaller sized PC.