Prospective evaluation of the limitations of near-infrared imaging in detecting axillary sentinel lymph nodes in primary breast cancer

Predictive value of methylene blue combined with indocyanine green in sentinel lymph node metastasis in breast cancer: a prospective pilot cohort study

Background

The status of sentinel lymph nodes is crucial for prognosis and treatment decisions in breast cancer patients. This study aimed to evaluate the predictive value of combined methylene blue and indocyanine green for sentinel lymph node metastasis in breast cancer.

Methods

This prospective cohort study enrolled 90 clinically node-negative breast cancer patients. Methylene blue and indocyanine green were injected locally before surgery. Sentinel lymph nodes were grouped based on fluorescence intensity and methylene blue staining. A binary logistic regression model was established using 285 lymph node groups to predict metastatic risk.

Results

A total of 475 lymph nodes were identified, with 33 being metastatic. The metastatic risk reached 70% for partially blue-stained and weakly fluorescent lymph nodes between 1-2 cm. The model revealed associations between lymph node size, dye staining patterns, and metastatic risks (P<0.05). The AUC of the ROC curve was 0.855.

Conclusions

The staining pattern of combined methylene blue and indocyanine green could predict risks of sentinel lymph node metastasis and facilitate rapid intraoperative identification of high-risk lymph nodes.

A new fluorescenttargeting tracer contrasts dual tracers in sentinel lymph node biopsy of breast cancer

Purpose: To explore the clinical application value of indocyanine green (ICG)-rituximab in sentinel lymph node biopsy. Methods: This study included 156 patients with primary breast cancer: 50 patients were enrolled in dose-climbing test, and 106 patients were enrolled in verification test. This was to compare the consistency of ICG-rituximab and combined method in the detected lymph nodes. Results: According to the verification test, the imaging rate of ICG-rituximab was 97.3%. Compared with the combined method, the concordance rate of fluorescence method was 0.991 (28 + 78/107; p < 0.001). Conclusion: For ICG-rituximab as a fluorescent targeting tracer, the optimal imaging dose of ICG 93.75 μg/rituximab 375 μg can significantly reduce the imaging of secondary lymph nodes. Compared with the combined method, it has a higher concordance rate.

Indocyanine green fluorescence versus blue dye, technetium-99M, and the dual-marker combination of technetium-99M + blue dye for sentinel lymph node detection in early breast cancer-meta-analysis including consistency analysis

BACKGROUND

Axillary sentinel lymph node biopsies are standard of care in patients with breast cancer and no clinically apparent metastases. Traditionally, technetium-99m, blue dye, or both have been used to identify sentinel lymph nodes. However, blue dyes miss up to 40% of sentinel lymph nodes, while technetium-99m use is complex, costly, and exposes patients to radiation. Over the past decade, studies have consistently found the biologically inert fluorescent indocyanine green to be 95% to 100% sensitive in detecting breast cancer sentinel lymph nodes, yet indocyanine green remains infrequently used.

METHODS

We conducted an extensive meta-analysis comparing indocyanine green against blue dye, technetium-99m, and the dual-marker combination of technetium-99m + BD. Unlike prior meta-analyses that only assessed either per-case or per-node sentinel lymph node detection, we analyzed the following 5 metrics: per-case and per-node sentinel lymph node detection and metastasis-positive sentinel lymph node sensitivity, and mean number of sentinel lymph nodes/case. We further examined the consistency and magnitude of between-study superiority and statistically significant within-study superiority of each marker against others.

RESULTS

For every metric and analysis approach, indocyanine green was clearly superior to blue dye and at least non-inferior, if not superior, to technetium-99m and technetium-99m + blue dye. Assessing the consistency of superiority by at least 2.0%, indocyanine green was superior to blue dye 73 times versus 1, to technetium-99m 42 times versus 9, and to technetium-99m + blue dye 6 times versus 0. Within-study statistically significant differences favored indocyanine green over blue dye 29 times versus 0 and over technetium-99m 11 times versus 2.

DISCUSSION

For sentinel lymph node detection in patients with breast cancer with no clinically apparent metastases, indocyanine green is clearly and consistently superior to blue dye and either non-inferior or superior to technetium-99m and technetium-99m + blue dye.

Accuracy of ICG compared with technetium-99 m for sentinel lymph node biopsy in vulvar cancer

PURPOSE

Sentinel lymph node biopsy with radioactive tracer is the standard-of-care in lymph node status assessment in vulvar cancer. Indocyanine green fluorescence-ICG is a promising detection method, due to its advantages over technetium-99 m. In vulvar cancer, the procedure is controversial due to study heterogeneity and the small sample size in previous studies. This study evaluates ICG sentinel lymph node detection compared with the criterion-standard with technetium (dual modality method).

METHODS

Preoperative technetium and intraoperative ICG for sentinel lymph node have been prospectively evaluated in early-stage vulvar cancer. The primary endpoint was to determine accuracy in the detection rate for ICG compared with technetium. Secondary objectives included tracer modality relationship with obesity, tumor size and location.

RESULTS

In total, 75 patients participated at 8 centers; 38 had lateral and 37 had midline vulvar tumors. The overall sentinel lymph node detection rate was 85.3 % for technetium and 82.7 % for ICG. For lateral tumors, the detection rate was 84.2 % vs. 89.5 %, while it was 86.5 % vs. 75.7 % for middle tumors, using technetium and ICG, respectively. The median sentinel node harvest was 1.7 (range 1-4), with 24 % metastatic involvement. The sensitivity and positive predictive value for ICG based on the standard technique with technetium was 91.08 % (95 % CI, 83.76-95.84) and 94.8 % (95 % CI, 84.84-96.48), respectively. No significant differences were found comparing the two tracers in patients with midline lesions, obesity (body mass index ≥ 30) and tumor size ≥ 2-4 cm.

CONCLUSION(S)

ICG shows comparable performance parameters to the gold-standard of radioisotope localization.

Clinical use of Indocyanine green fluorescence method for sentinel lymph node biopsy in breast cancer in France in 2021

INTRODUCTION

Indocyanine green (ICG) for axillary sentinel lymph node (SLN) detection in early breast cancer is at least equivalent to radioisotopic and/or colorimetric techniques. This procedure has not yet been recommended by learned societies in France. Following the recent drug approval of Infracyanin ® in this indication, we wished to study the use of ICG in France.

METHODS

We conducted a web-based survey among members of multiple French breast cancer societies throughout November 2021. The survey assessed the profile of the respondent, the use or not of ICG for the detection of SLN in breast cancer, the technique used and the opinion of non-users and their expectations on the subject.

RESULTS

Seventy-five surgeons participated. More than a third (37 %) have been using ICG for the detection of SLN in breast cancer for 2 to 3 years. Technique was highly variable. According to 82.1 % of the respondents, less than 20 procedures are necessary to master the use of ICG. The main advantage reported for this method is the reduction of organizational constraints. The obstacles to the use of the ICG are the near infra-red camera equipment, but also the lack of validation by the French guidelines. Among non-users, 83 % would like to develop this technique in their center and 72.3 % are interested in training on this subject.

CONCLUSION

This work highlights the need for French learned societies to take a stand on this issue but also the need to carry out studies on the technical aspects in order to standardise practices.

An Updated Review on the Emerging Role of Indocyanine Green (ICG) as a Sentinel Lymph Node Tracer in Breast Cancer

Sentinel lymph node biopsy (SLNB) has become the standard of care for clinically node-negative breast cancer and has recently been shown by clinical trials to be also feasible for clinically node-positive patients treated with primary systemic therapy. The dual technique using both radioisotope (RI) and blue dye (BD) as tracers for the identification of sentinel lymph nodes is considered the gold standard. However, allergic reactions to blue dye as well as logistics issues related to the use of radioactive agents, have led to research on new sentinel lymph node (SLN) tracers and to the development and introduction of novel techniques in the clinical practice. Indocyanine green (ICG) is a water-soluble dye with fluorescent properties in the near-infrared (NIR) spectrum. ICG has been shown to be safe and effective as a tracer during SLNB for breast cancer and accumulating evidence suggests that ICG is superior to BD and at least comparable to RI alone and to RI combined with BD. Thus, ICG was recently proposed as a reliable SLN tracer in some breast cancer clinical practice guidelines. Nevertheless, there is lack of consensus regarding the optimal role of ICG for SLN mapping. Specifically, it is yet to be determined whether ICG should be used in addition to BD and/or RI, or if ICG could potentially replace these long-established traditional SLN tracers. This article is an updated overview of somerecent studies that compared ICG with BD and/or RI regarding their accuracy and effectiveness during SLNB for breast cancer.

New techniques versus standard mapping for sentinel lymph node biopsy in breast cancer: a systematic review and meta-analysis

New tracers for sentinel lymph node biopsy (SLNB), as indocyanine green (ICG), superparamagnetic iron oxide (SPIO) and micro bubbles, have been recently introduced in clinical practice showing promising but variable results. We reviewed the available evidence comparing these new techniques with the standard tracers to evaluate their safety. To identify all available studies, a systematic search was performed in all electronic databases. Data regarding sample size, mean number of SLN harvested for patient, number of metastatic SLN and SLN identification rate of all studies were extracted. No significant differences were found in terms of SLNs identification rates between SPIO, RI and BD but with a higher identification rate with the use of ICG. No significant differences were also found for the number of metastatic lymph nodes identified between SPIO, RI and BD and the mean number of SLNs identified between SPIO and ICG versus conventional tracers. A statistically significant differences in favor of ICG was reported for the comparison between ICG and conventional tracers for the number of metastatic lymph nodes identified. Our meta-analysis demonstrates that the use of both ICG and SPIO for the pre-operative mapping of sentinel lymph nodes in breast cancer treatment is adequately effective.

Axillary reverse mapping using near-infrared fluorescence imaging in invasive breast cancer (ARMONIC study)

BACKGROUND

Axillary lymph node dissection (ALND) in patients with breast cancer has potential side effects, including upper-limb lymphedema. Axillary reverse mapping (ARM) is a technique that enables discrimination of the lymphatic drainage of the upper limb in the axillary lymph node basin from that of the breast. We aimed to evaluate ARM node identification by near-infrared (NIR) fluorescence imaging during total mastectomy with ALND and then to analyze potential predictive factors of ARM node involvement.

METHODS

The study enrolled 119 patients diagnosed with invasive breast cancer with an indication for ALND. NIR imaging using indocyanine green dye was performed in 109 patients during standard ALND to identify ARM nodes and their corresponding lymphatic ducts.

RESULTS

94.5% of patients had ARM nodes identified (95%CI = [88.4-98.0]). The ARM nodes were localized in zone D in 63.4% of cases. Metastatic axillary lymph nodes were found in 55% in the whole cohort, and 19.4% also had metastasis in ARM nodes. Two patients had metastatic ARM nodes but not in the remaining axillary lymph nodes. No serious adverse events were observed. Only the amount of mitosis was significantly associated with ARM node metastasis.

CONCLUSIONS

ARM by NIR fluorescence imaging could be a reliable technique to identify ARM nodes in real-time when ALND is performed. The clinical data compared with ARM node histological diagnosis showed only the amount of mitosis in the diagnostic biopsy is a potential predictive factor of ARM node involvement.

CLINICAL TRIAL REGISTRATION

NCT02994225.

Near-Infrared Fluorescence Axillary Reverse Mapping (ARM) Procedure in Invasive Breast Cancer: Relationship between Fluorescence Signal in ARM Lymph Nodes and Clinical Outcomes

Simple Summary

Near-infrared fluorescence axillary reverse mapping (ARM) is a promising procedure for identification and preservation of arm lymphatic drainage during axillary lymph node dissection (ALND). We included 109 patients to analyze the indocyanine green fluorescence signal in ARM lymph nodes after resection. The fluorescence signal from ARM lymph nodes were compared with clinical findings to determine the importance of this criterion on the potential management of patients with ALND. ARM lymph nodes were identified in 94.5% of cases. The mean normalized fluorescence signal intensity value was 0.47 with no significant signal difference between metastatic and non-metastatic ARM lymph nodes. Only the preoperative diagnosis of metastasis in the axillary nodes of patients was significantly associated with a higher ARM node fluorescence signal intensity. Although preliminary results did not show that fluorescence signal intensity is a reliable diagnostic tool, the NIR fluorescence ARM procedure may be useful for ARM lymph node identification.

Abstract

The near-infrared (NIR) fluorescence axillary reverse mapping (ARM) procedure is a promising tool to identify and preserve arm lymphatic drainage during axillary lymph node dissection (ALND). The ARMONIC clinical trial was conducted to validate the technique on a large cohort of patients and to analyze the predictive clinical factors for ARM lymph node metastasis. For the first time, the fluorescence signal intensity from the ARM lymph nodes was measured and correlated with clinical findings. A total of 109 patients with invasive breast cancer and indications of mastectomy and ALND underwent the NIR fluorescence ARM procedure. Indocyanine green was administered by intradermal injection followed by intraoperative identification and resection of the ARM lymph nodes with NIR fluorescence camera guidance. The fluorescence signal intensity and signal distribution were then measured ex vivo and compared with clinical outcomes. ARM lymph nodes were successfully identified by fluorescence in 94.5% of cases. The mean normalized fluorescence signal intensity value was 0.47 with no significant signal difference between metastatic and non-metastatic ARM lymph nodes (p = 0.3728). At the microscopic level, the fluorescence signal distribution was focally intense in lymphoid tissue areas. Only the preoperative diagnosis of metastasis in the axillary nodes of patients was significantly associated with a higher ARM node fluorescence signal intensity (p = 0.0253), though it was not significantly associated with the pathological nodal (pN) status (p = 0.8081). Based on an optimal cut-off fluorescence value, the final sensitivity and specificity of the NIR fluorescence ARM procedure for ARM lymph node metastatic involvement were 64.7% and 47.3%, respectively. Although our preliminary results did not show that fluorescence signal intensity is a reliable diagnostic tool, the NIR fluorescence ARM procedure may be useful for ARM lymph node identification. Clinical trial registration: NCT02994225.

A Prospective Self-Controlled Study of Indocyanine Green, Radioisotope, and Methylene Blue for Combined Imaging of Axillary Sentinel Lymph Nodes in Breast Cancer

Purpose

This self-controlled study aimed to clarify whether indocyanine green (ICG) could be an alternative tracer in the absence of radioisotope (RI) for combined imaging of axillary sentinel lymph node (SLN) in breast cancer.

Methods

Primary breast cancer, clinically axillary node-negative patients (n = 182) were prospectively enrolled from March 2015 to November 2020. ICG, methylene blue (MB), and RI were used to perform axillary sentinel lymph node biopsy (SLNB). The main observation index was the positivity of ICG + MB vs. RI + MB in axillary SLNB; the secondary observation indicators were the axillary SLN detection rate, mean number of axillary SLNs detected, mean number of metastatic axillary SLNs detected, and safety.

Results

All 182 patients had axillary SLNs; a total of 925 axillary SLNs were detected. Pathological examination confirmed metastatic axillary SLN in 42 patients (total of 79 metastatic SLNs). Positivity, detection rate of SLNs, detection rate of metastatic SLNs, and the number of metastatic SLNs detected were comparable with RI+MB and ICG+MB (p > 0.05). The mean number of axillary SLNs detected was significantly higher with ICG+MB than with RI+MB (4.99 ± 2.42 vs. 4.02 ± 2.33, p < 0.001). No tracer-related adverse events occurred.

Conclusions

ICG appears to be a safe and effective axillary SLN tracer, and a feasible alternative to RI in combined imaging for axillary SLN of breast cancer.

Feasibility of Magnetic Technique for Axillary Staging after Neoadjuvant Therapy in Breast Cancer Patients

PURPOSE

Optimal axillary staging after neoadjuvant chemotherapy (NAC) in node-negative breast cancer is an area of controversy. Sentinel node biopsy with Technetium-sulphur colloid (99m Tc) alone or with blue dye is the recommended technique for evaluating axilla in these patients. However, this technique has drawbacks such as limited access to nuclear departments and timing limitations related to Tc injection exposing patients to unnecessary radiation. Superparamagnetic iron oxide nanoparticles (SPIO) may represent a valid option for SLN biopsy. In this study, we assessed the feasibility of the magnetic technique (Sentimag) with combination of isosulfan blue dye in breast cancer patients who received NAC.

METHODS

The study sample consisted of 54 female breast cancer patients who received NAC. Sentinel node localization was performed using magnetic technique and blue dye. Sentinel node identification rate (IFR) of magnetic technique was calculated and postoperative complications were assessed.

RESULTS

Sentinel lymph node was detected in 52 patients with Sentimag method (identification rate = 96.3%, 95% CI: 87.4-98.9%). Blue dye was successful to find SLN in 38 patients (identification rate = 70%). The most common histologic type was invasive ductal (n = 51; 94.4%). Mean tumor size was 2.1 cm after NAC. Most of patients had T2 (n = 30; 55.5%) and HER2 + positive (n = 49; 90.7%) cancer.

CONCLUSION

Sentimag which is a magnetic technique appears to be safe, easy to perform with minimal adverse effects, may be an alternative and accurate technique in patients with NAC, especially in breast units where nuclear medicine unit is not available.

Supplemental data for this article is available online at https://doi.org/10.1080/08941939.2022.2038737 .

Diagnostic value of indocyanine green fluorescence guided sentinel lymph node biopsy in vulvar cancer: A systematic review

INTRODUCTION

Sentinel lymph node biopsy (SLN) helps define lymph node status, a major prognostic factor in vulvar cancer. The aim of the current systematic review was to assess the use of indocyanine green (ICG) coupled with near-infrared (NIR) fluorescence imaging in SLN mapping in vulvar cancer in terms of technique used, feasibility and accuracy.

DATA SOURCES

We performed a systematic review using bibliographic citations from PubMed, Clinical Trials.gov, Embase, Cochrane Library, and Web of Science databases. MeSH terms for SLN, ICG and vulvar cancer were combined and restricted to the English language. The final search was performed on May 28, 2020. The primary outcome was to determine if the use of ICG alone in detecting SLN in women with vulvar cancer is as accurate as the gold standard dual labeling technique.

RESULTS

Of the 34 studies initially identified, 13 were included for analysis. The SLN detection rate with ICG and NIR fluorescence ranged from 89.7 to 100%. No studies demonstrated the superiority of other detection techniques compared to ICG and NIR imaging. Lower SLN detection rates were found in studies with the most metastatic lymph nodes. No consensus was reached concerning the optimal use of ICG in terms of: injection timing or site; concentrations or volume of ICG; or use of human serum albumin or hybrid tracer. No adverse events were reported.

CONCLUSION

ICG for SLN mapping appears to be safe in women with vulvar cancer with a detection rate similar to the current techniques. A large prospective randomized controlled study with optimization of the technique is necessary to homogenize current practice and determine the true value of ICG in vulvar cancer.

PROSPERO ID

CRD42020178261.

Indocyanine green for sentinel lymph node detection in early breast cancer: Prospective evaluation of detection rate and toxicity-The FLUOBREAST trial

INTRODUCTION

Detection of sentinel lymph node in early breast cancer is commonly based on the combination of patent blue dye and a radioisotope 99m Technetium. Each of these two tracers has advantages and disadvantages leading to the development of the use of indocyanine green.

METHODS

We conducted a prospective clinical trial to compare the detection rate of indocyanine green with 99mTe. Each patient undergoing a sentinel lymph node biopsy for an early breast cancer received both indocyanine green and radioisotopes. The trial was registered: FLUOBREAST EudraCT N 2015-000698-11, ClinicalTrials.gov: NCT02875626.

RESULTS

Among a total of 88 patients, 77 were assessable for a total of 205 nodes. Detection rates were 93% for the isotope and 96% for the indocyanine green. The combined detection rate was 99%. The overall concordance rate per patient was 91%. The median number of excised sentinel nodes was 2.3 for each tracer and 2.7 for the combined method (P = .21). All the macrometastatic nodes were detected by both indocyanine green and radioisotopes. The median time between incision of the axilla and removal of the last node was 14 minutes. There was neither allergy nor radio-sensitization linked with the use of indocyanine green.

CONCLUSIONS

Indocyanine green delivers a high detection rate and sensitivity for the sentinel lymph node biopsy in early breast cancer, with short operative time and a normal number of excised sentinel lymph nodes. Allergy is extremely rare and there is no toxicity. Indocyanine green could be an alternative to radioisotopes to provide an accurate staging of the axilla. Its routine use should be approved.

Comparison of indocyanine green fluorescence and methylene blue dye in the detection of sentinel lymph nodes in breast cancer

Background

Previous studies have shown that sentinel lymph node biopsy (SLNB) can be successfully performed using methylene blue (MB); however, this method still has some drawbacks. Indocyanine green (ICG) fluorescence imaging, as a selective method, has the potential for guiding SLNB. This study aimed to compare the clinical sensitivity and efficacy between ICG and MB in SLNB in breast cancer.

Methods

A prospective study of 70 patients with biopsy-proven invasive breast cancer was conducted. Under the guidance of ICG and MB, administered by injection, SLNs were examined and removed. The detection rates, total number of SLNs detected, mean number of SLNs detected, and number of positive SLNs were compared between ICG and MB.

Results

The SLN detection rate was 100% and 93% (65/70) for ICG and MB, respectively. More SLNs were detected in the ICG group (243) than in the MB group (169). The mean number of SLNs detected with ICG and MB was 3.5±1.73 and 2.4±1.49, respectively. Moreover, there was a statistically significant difference between the number of SLNs detected using the two methods (t=6.648, P<0.05). Additionally, SLN metastasis was detected in 18 patients using ICG and 14 patients using MB; these patients immediately underwent axillary lymph node dissection (ALND). No postoperative complications were reported.

Conclusions

ICG demonstrated a higher detection rate and better accuracy, as well as a lower false negative rate, than MB in detecting SLNs in breast cancer. ICG has potential as an alternative tool that could be clinically applied to detect SLNs in breast cancer patients.

Indocyanine Green Fluorescence Versus Blue Dye or Radioisotope Regarding Detection Rate of Sentinel Lymph Node Biopsy and Nodes Removed in Breast Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Either blue dye (BD) or radioisotope (RI) is mainly used for sentinel lymph node biopsy (SLNB) in breast cancer patients. Unlike the BD, RI has lower false-negative rate of SLNB. However, its lymphoscintigraphy, difficulty in preoperative injection, and undetected sentinel lymph nodes in some cases cause surgeons to rely only on BD. Currently, indocyanine green (ICG) fluorescence method (ICG-SLNB) is increasingly used as an alternative to the conventional mapping methods in many centers. This systematic review compared ICG with the conventional method of BD or RI in terms of detection rate of SLNB and the number of sentinel lymph nodes (SLNs) removed in.

METHODS

  We searched all relevant studies published between January 2000 and October 2019. All data on for evaluation of SLN detection rate, number of SLNs removed per patient, and tumor positive rate of SLNB were extracted.

RESULTS

A total of 30 studies, including 4,216 SLN procedures were retrieved. There was a statistically significant difference between ICG and BD method in terms of SLN detection rate (OR, 6.73; 95% CI, 4.20-10.78). However, there was no significant difference between ICG and RI in this regard (OR, 0.90; 95% CI, 0.40-2.03). The number of SLNs removed per patient were 2.35 (1.46-5.4), 1.92 (1.0-3.64), and 1.72 (1.35-2.08) for ICG, BD, and RI, respectively. Only in 8 studies, the tumor positive rates in SLNB could be analyzed (ICG, 8.5-20.7%; BD, 12.7-21.4%; RI, 11.3-16%).

CONCLUSION

ICG-SLNB could be an additional or an alternative method for axillary node mapping in breast cancer.<br />.

Use of indocyanine green fluorescence compared to radioisotope for sentinel lymph node biopsy in early-stage breast cancer: systematic review and meta-analysis

BACKGROUND

In early-stage breast cancer, indocyanine green (ICG)-fluorescence based sentinel lymph node (SLN) detection is being considered. This is a meta-analysis of SLN detection rates and sensitivity of ICG-fluorescence compared to radioisotope (RI), to evaluate its clinical applicability.

DATA SOURCES

Systematic review of full-text articles from PubMed and Scopus, of women with early breast cancer who underwent SLN mapping using ICG and RI concurrently was performed. The meta-analysis was performed using the Mantel-Haenszel method.

RESULTS

2301 patients from 19 studies were included. No significant difference was observed between ICG and RI for SLN detection (OR0.90,95%CI0.66-1.24) or sensitivity (OR1.23,95%CI0.73-2.05) with heterogeneity between studies (I² = 58%,P = 0.003). Sensitivity of dual mapping (ICG + RI) was significantly better compared to single mapping with RI (OR3.69,95%CI1.79-7.62) or ICG (OR3.32,95%CI1.52-7.24) alone with no heterogeneity between studies (I² = 0%,P = 0.004).

CONCLUSION

ICG-fluorescence could complement RI method or provide alternative in centers with poor accessibility to RI lymphoscintigraphy.

The Turkish SentiMAG feasibility trial: preliminary results

BACKGROUND

Sentinel node biopsy (SNB) is the standard of care for staging of the clinically and radiologically negative axillary lymph nodes in breast cancer patients. Sentinel node biopsy, with using Technetium-sulphur colloid (99 m Tc) alone or with blue dye is standard technique for evaluating axillary lymph nodes. This technique has drawbacks such as radiation exposure. Superparamagnetic iron oxide nanoparticles (SPIO) can represent a valid option for SNB. In this study; we tried to evaluate feasibility of new magnetic technique in Turkish early breast cancer patients.

MATERIAL AND METHODS

The study sample consists of 143 women affected by early breast carcinoma with clinically negative axillary lymph nodes. Sentinel node localization was performed using magnetic technique. Detection rate of magnetic technique was calculated and postoperative complications were assessed.

RESULTS

Results are based on 104 patients. Sentinel node identification rate was 99% (103/104, 95% CI 0.97-1.01) for magnetic technique. A median of two SNs per patient was removed. Major adverse reaction was the permanent skin coloration (7.1%).

CONCLUSIONS

The magnetic technique is a feasible method for detecting SN in breast cancer patients with minimal adverse effects. Magnetic technique may be alternative to standard technique especially in breast units, where nuclear medicine unit is not available.

Near-infrared fluorescence imaging for the prevention and management of breast cancer-related lymphedema: A systematic review

Sentinel lymph node identification by near infrared (NIR) fluorescence with indocyanine green (ICG) is recognized in the literature as a useful technique. NIR fluorescence technology could become key in the prevention and management of lymphedema after axillary dissection for breast cancer. Here, we conducted a systematic review focusing on ICG imaging to improve lymphedema prevention and treatment after axillary surgery. A systematic literature review was performed using MEDLINE and Embase to identify articles focused on ICG imaging for breast-cancer-related lymphedema (BCRL). Qualitative analysis was performed to summarize the characteristics of reported ICG procedures. In situ tissue identification and functionality assessment based on fluorescence signal were evaluated. Clinical outcomes were appraised when reported. Studies relating to axillary reverse mapping, lymphography and upper limb supermicrosurgery combined with ICG imaging were identified. We included a total of 33 relevant articles with a total of 2016 patients enrolled. ICG imaging for axillary reverse mapping was safe for all 951 included patients, with identification of arm nodes in 80%-88% of patients with axillary lymph nodes dissection. However, the papers discuss the oncologic safety of the approach and how - regardless of the contrast agent - concerns limit its adoption. ICG lymphography is openly supported in BCRL management, with 1065 patients undergoing this procedure in 26 articles. The technique is reported for lymphedema diagnosis, with high sensitivity and specificity, staging, intraoperative mapping and patency control in lymphaticovenular anastomosis. The substantial advantages/disadvantages of ICG imaging procedures are finally described.