Meta-analysis Comparing Fluorescence Imaging with Radioisotope and Blue Dye-Guided Sentinel Node Identification for Breast Cancer Surgery

Assessing the benefit of using indocyanine green in addition to methylene blue for breast cancer sentinel lymph node biopsy

In recent years, indocyanine green (ICG) fluorescence has been widely used as a new tracer in sentinel lymph node biopsy (SLNB) for breast cancer. This self-controlled study identified the benefits in SLNB between methylene blue (MB) tracer alone and MB combined with ICG fluorescence imaging (MB + ICG) dual tracing modality in patients with breast cancer. One hundred seventy-nine SLNB with MB + ICG dual tracing in 178 cN0 breast cancer patients were enrolled, and their clinical data were analyzed. The results showed that the identification rate (IR) of sentinel lymph nodes (SLNs) by MB staining alone was 92% (165/179), the mean number of detected SLNs was 2.1 ± 1.2, the rate of ≥3 SLNs was 33% (55/165), and the number of positive (metastatic) lymph nodes was 40. The IR of SLN by MB + ICG dual tracing imaging was 93.9% (168/179), the mean number of detected SLNs was 3.8 ± 1.8, the rate of ≥3 SLNs was 70.8% (119/168), and the number of positive lymph nodes was 40. Compared to MB staining alone, because of the addition of ICG fluorescence imaging, SLN status changed from N0 to N1 or the number of positive SLNs increased in 9 patients, and there was an alteration of axillary management from SLNB to axillary lymph node dissection in 4 patients. Although MB + ICG dual tracing did not significantly improve the IR of SLNs, it increased the average number of SLNs, rate of ≥3 SLNs, number of positive SLNs. This may reduce the false negative rate of SLNB and lead to an alteration in axillary management.

Detection capability of the Medical Imaging Projection System for sentinel lymph node biopsy in patients with breast cancer with and without neoadjuvant chemotherapy: a retrospective study

BACKGROUND

The Medical Imaging Projection System (MIPS) projects fluorescence ICG images on the surgical field. In this study, we aimed to assess sentinel lymph node (SLN) identification by the MIPS in patients with and without neoadjuvant chemotherapy (NAC) administration and compare the utility of the MIPS with the radioisotope (RI) method.

METHODS

We retrospectively reviewed medical records of patients with primary breast cancer who underwent SLN biopsy using the MIPS at Kyoto University Hospital between April 2020 and December 2024. The primary endpoint was the identification rate of SLNs. The secondary endpoints included the number of positive SLNs and SLNs detected per patient.

RESULTS

The analysis included 470 procedures (448 patients), of which 56 (11.9%) were conducted after NAC. The identification rate of SLNs by the MIPS was 99.6% (95% confidence interval [CI], 98.5-99.9) in all procedures and 98.2% (95% CI, 90.6-99.7) after NAC. The median number of SLNs identified per patient was 3 (range, 2-4) by the MIPS and 2 (range, 1-3) by the RI method (P < 0.001). No significant difference was observed in the number of SLNs between patients who received NAC and those who did not (3 vs 3, P = 0.84). Seventy-eight positive SLNs were excised, all of which were accurately identified by the MIPS.

CONCLUSIONS

This study suggested that the identification rate of SLNs by the MIPS was high regardless of the presence or absence of preceding systemic chemotherapy.

How to do indocyanine green fluorescence-guided axillary sentinel lymph node biopsy in breast cancer: the sunrise effect

Indocyanine green fluorescence-guided axillary sentinel lymph node biopsy.

Indocyanine Green Fluorescence Plus Blue Dye for Sentinel Lymph Node Biopsy in Patients Undergoing Neoadjuvant Chemotherapy for Breast Cancer: A Multicenter, Prospective Cohort Study

BACKGROUND

Sentinel lymph node biopsy (SLNB) using radioisotope tracer plus blue dye is the gold standard after neoadjuvant chemotherapy (NAC) in initially cN1 breast cancer patients, but clinical use still has limitations. This study aims to examine diagnostic performance of dual indocyanine green (ICG) and methylene blue tracing for SLNB in patients who have completed NAC for breast cancer with initially cN1 disease.

METHODS

Adult women (20-80 years of age) scheduled to undergo NAC for biopsy-proven cT0-3N1M0 primary invasive breast cancer were consecutively enrolled in this prospective, multicenter, cohort study. Upon the completion of NAC, SLNB was conducted using ICG and methylene blue, followed by axillary lymph node dissection. The primary outcome was the detection rate (DR); secondary outcomes included the false-negative rate (FNR) and adverse events associated with the use of tracers.

RESULTS

A total of 156 patients were enrolled; all underwent SLNB after NAC. The median number of lymph nodes retrieved during SLNB was 3 (range: 0-11). The DR was 97.4% (152/156; 95% CI, 93.6%-99.0%). The FNR was 6.7% (4/60; 95% CI, 2.6%-15.9%). Negative predictive value was 95.7% (88/92; 95% CI, 89.4%-98.3%). In the subgroup analysis stratified by ycN status, FNR was 4.0% (1/25; 95% CI, 0.7%-19.5%) and 8.6% (3/35; 95% CI, 3.0%-22.4%) in the ycN0 and ycN+ subgroups, respectively. No allergic reaction was reported.

CONCLUSIONS

SLNB with ICG plus methylene blue achieved a high DR and a very low FNR in breast cancer patients with initially cN1 disease.

TRIAL REGISTRATION

ClinicalTrials.gov (https://www.

CLINICALTRIALS

gov/), NCT02869815.

Transcutaneous sentinel lymph node detection in skin melanoma with near-infrared fluorescence imaging using indocyanine green

The aim of the study is to assess whether indocyanine green (ICG) fluorescence can replace technetium in the preoperative detection of sentinel lymph nodes (SLN) from cutaneous melanoma. The current golden standard for SLN detection is the radioisotope technetium. A promising alternative is fluorescence imaging (FLI) using ICG. In this study, we enrolled patients undergoing sentinel lymph node biopsy (SLNB) for skin melanoma at the Erasmus Medical Center between November 2022 and July 2023. The SLNB procedure was performed as a standard of care. After general anesthesia, ICG was injected intradermally around the primary tumor site. Both the patient and the surgeon were not blinded for the location of the SLN. FLI was performed before incision, in vivo after incision, and ex vivo. Fluorescent SLNs were confirmed using the gamma probe in all cases. Thirty-two patients were included in this study, and a total of 39 SLNs were harvested. The transcutaneous detection rate of ICG was 21.9%. The combined ex vivo ICG fluorescence and technetium uptake was 94.9%. One SLN contained only ICG (2.6%) and one SLN contained only technetium-uptake (2.6%). FLI using ICG resulted in a relatively low transcutaneous detection, which means that exclusive use of this technique in its present form is not feasible. However, we did find a high accumulation of ICG in the SLN, indicating the potential of ICG in combination with other imaging techniques.

The feasibility and added value of indocyanine green tracing in guiding sentinel lymph node biopsy for breast cancer

OBJECTIVE

To compare the effectiveness of combined (indocyanine green [ICG]+ blue dye) tracing versus blue dye alone in guiding sentinel lymph node biopsy (SLNB) in breast cancer.

METHODS

A total of 112 female patients (mean ± SD age: 51.9 ± 11.9 years) with clinically node-negative (cN0) early-stage breast cancer were evaluated based on SLN tracing technique including methylene blue + ICG (n = 17), isosulfan blue + ICG (n = 19) and methylene blue alone (n = 76). Mapping patterns of each SLN, the number of total lymph nodes (TLNs) removed, including metastatic and hyperplastic lymph nodes, and the metastatic lymph node detection rate were analyzed for each tracing technique.

RESULTS

SLN detection rate was 100 % with complementary use of ICG. No significant difference was noted between methylene blue + ICG, isosulfan + ICG and methylene blue alone groups in terms of the mean ± SD number of TLNs removed (3.9 ± 2.5, 4.7 ± 3 and 3.7 ± 2.3, respectively) and metastatic lymph node detection rates (16.0 %, 16.25 % and 13.98 %, respectively). Complementary use of ICG revealed the N0 stage for 66.6 % of cases considered as Nx (cannot be detected) on blue dye alone. Also, 20.0 % of N0 and 11.1 % of N1 cases on blue dye were diagnosed with more advance nodal status (N1 and N2 respectively) after complementary use of ICG.

CONCLUSIONS

The combined tracing (ICG + blue dye) seems valuable not only in terms of the SLN detection rates and lymph node yield but also has an added value in providing more accurate nodal stating and thus a proper final tumor staging with considerable therapeutic implications.

Indocyanine Green Marking of Axillary Sentinel Lymph Nodes in Early Breast Cancer

Axillary sentinel lymph node excision (SLNE) in breast cancer patients with clinically node-negative disease may be carried out using different tracers. The standard tracer is technetium colloid (99mTc). Indocyanine green (ICG) can be used as an alternative. This study aimed to evaluate the clinical usefulness of this fluorescent dye in a standardized setting.

A prospective, single-center cohort study carried out at the University Gynecological Hospital of Rostock from September 2023 to May 2024 carried out sentinel lymph node marking using only ICG in patients with breast malignancies. The ICG injection was administered immediately after the induction of anesthesia. Detection of the sentinel lymph node (SLN) was done using a laparoscopy system suitable for ICG. The aim was to determine the detection rate (DR) for SLNs marked exclusively using ICG and to record any complications. The costs of using ICG to mark SLNs were compared with those for 99mTc marking.

During the study period, contraindications against marking with ICG were ascertained for five (3.8%) of 132 patients with planned SLNE. A total of 100 SLNEs were carried out after ICG marking in patients who met the inclusion criteria in the context of the study. A median of two SLNs were resected. The detection rate (DR) for SLNs was 98.0%. SLNs were identified in all obese patients. No serious systemic side effects occurred following ICG injection. Transient skin discoloration in the area around the injection site were observed in eight patients. The direct cost of ICG marking was 62.73 Euros, which was 170.36 Euros lower than the cost of 99mTc marking.

The detection rate of axillary SLNs marked using ICG is high and the method is cost-effective, has few side effects and can also be used in obese patients. Contraindications against the administration of ICG are rare. Marking with ICG is a good alternative to the 99mTc method and offers advantages in terms of costs, logistics, no exposure to radiation, and patient comfort.

A systematic review and meta-analysis of diagnostic performance of fluorescein-guided sentinel lymph node biopsy in early breast cancer

BACKGROUND

Evaluation of axillary lymph nodes status in cN0 axilla is performed by sentinel lymph node biopsy (SLNB) utilizing a combination of radioactive isotope and blue dye or alternative to isotope like Indocyanine green (ICG). Both are very resource-intensive; which has prompted development of low-cost technique of Fluorescein Sodium (FS)-guided SLNB. This systematic review and meta-analysis evaluate the diagnostic performance of FS-guided SLNB in early breast cancer.

OBJECTIVES

The objective was to evaluate the diagnostic performance of FS for sentinel lymph node biopsy.

METHODS

Eligibility criteria: Studies where SLNB was performed using FS.

INFORMATION SOURCES

PubMed, EMBASE, Cochrane library and online clinical trial registers. Risk of bias: Articles were assessed for risk of bias using the QUADAS-2 tool.

SYNTHESIS OF RESULTS

The main summary measures were pooled Sentinel Lymph Node Identification Rate (SLN-IR) and pooled False Negative Rate (FNR) using random-effects model.

RESULTS

A total of 45 articles were retrieved by the initial systematic search. 7 out of the 45 studies comprising a total of 332 patients were included in the meta-analysis. The pooled SLN-IR was 93.2% (95% confidence interval [CI], 0.87-0.97; 87% to 97%). Five validation studies were included for pooling the false negative rate and included a total of 211 patients. The pooled FNR was 5.6% (95% confidence interval [CI], 2.9-9.07).

CONCLUSION

Fluorescein-guided SLNB is a viable option for detection of lymph node metastases in clinically node negative patients with early breast cancer. It achieves a high pooled Sentinel Lymph Node Identification Rate (SLN-IR) of 93% with a false negative rate of 5.6% for the detection of axillary lymph node metastasis.

Weishaar's classification system for nodal metastasis in sentinel lymph nodes: Clinical outcome in 94 dogs with mast cell tumor

BACKGROUND

The therapeutic role and prognostic relevance of lymphadenectomy in mast cell tumor (MCT) has historically been evaluated on regional rather than sentinel lymph nodes.

HYPOTHESIS/OBJECTIVES

To update information about the association of histological nodal (HN) classes with clinical outcome in dogs with MCT after tumor excision and extirpation of normal-sized sentinel nodes (SLN) guided by radiopharmaceutical.

ANIMALS

Ninety-four dogs with histologically-confirmed treatment-naïve MCT (71 cutaneous, 22 subcutaneous and 1 conjunctival MCT) were included if without: distant metastases, lymphadenomegaly, concurrent mixed cutaneous, and subcutaneous MCT.

METHODS

This was a monoistitutional cohort study. Tumors characteristics were retrieved and SLNs were classified according to Weishaar's system. Incidence of MCT-related events (local, nodal, distant relapse), de novo MCT or other tumors and death (MCT-related and non-MCT-related), were recorded. Incidence curves were compared among the HN classes.

RESULTS

Twenty-seven dogs had HN0, 19 HN1, 37 HN2, and 11 HN3 SLN. Thirteen (2 HN0, 4 HN2, and 7 HN3) received adjuvant chemotherapies. Kiupel high grade, increasing number of SLN and lymphocentrums were associated with higher HN classes. Five dogs died for MCT-related causes: 1 low-grade (HN0) and 1 subcutaneous (HN3) had a local relapse, 2 high-grade had distant relapse (HN3-HN0) and 1 dog developed disease progression from a de novo subcutaneous MCT. No nodal relapse was registered. Fourteen dogs developed de novo MCTs.

CONCLUSION/DISCUSSION

Low grade/low-risk MCT with nonpalpable and normal sized SLN have a favorable outcome independently from the HN. Result should be considered strictly related to the successful SLN detection guided pre- and intraoperative by radiopharmaceutical markers.

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.

Clinical Efficacy of Laparoscopic Sentinel Node Navigation Surgery for Stomach Preservation in Patients With Early Gastric Cancer: 5-year Results of the SENORITA Trial

OBJECTIVE

This study aimed to compare laparoscopic standard gastrectomy (LSG) and laparoscopic sentinel node navigation surgery (LSNNS) for EGC in terms of 5-year long-term oncologic outcomes.

SUMMARY BACKGROUND DATA

The oncological safety of LSNNS for early gastric cancer (EGC) has not been confirmed. Three-year disease-free survival (DFS), which is the primary endpoint of the phase III multicenter randomized controlled clinical trial (SEntinel Node ORIented Tailored Approach [SENORITA] trial), did not show the non-inferiority of LSNNS relative to LSG.

METHODS

The SENORITA trial, a multicenter randomized clinical trial, was designed to show that LSNNS is non-inferior to LSG in terms of 3-year DFS. In the present study, we collected 5-year follow-up data from 527 patients recruited in the SENORITA trial as the full analysis set (FAS). Disease-free survival (DFS), overall survival (OS), disease-specific survival (DSS), and recurrence patterns were evaluated using the FAS of both LSG (n=269) and LSNNS (n=258).

RESULTS

The 5-year DFS was not significantly different between the LSG and LSNNS groups (P=0.0561). During the 5-year follow-up, gastric cancer-related events, such as metachronous cancer, were more frequent in the LSNNS group than in the LSG group. However, ten recurrent cancers in the remnant stomach of both groups were curatively resected by additional gastrectomy and one by additional endoscopic resection. Two of the 198 patients who underwent local resection for stomach preservation based on the LSNNS results developed distant metastasis. However, there was no statistically significant difference in the 5-year OS and DSS (P=0.7403 and P=0.9586, respectively) between the two groups.

CONCLUSION

The 5-year DFS, DSS and OS did not differ significantly between the two groups. Considering the benefits of LSNNS on postoperative quality of life, LSNNS could be recommended as an alternative treatment option for EGC.

Evolution of Indocyanine Green Fluorescence in Breast and Axilla Surgery: An Australasian Experience

The evolution of indocyanine green (ICG) fluorescence in breast and axilla surgery from an Australasian perspective is discussed in this narrative review with a focus on breast cancer and reconstruction surgery. The authors have nearly a decade of experience with ICG in a high-volume institution, which has resulted in publications and ongoing future research evaluating its use for predicting mastectomy skin flap perfusion for reconstruction, lymphatic mapping for sentinel lymph node (SLN) biopsy, and axillary reverse mapping (ARM) for prevention of lymphoedema. In the authors' experience, routine use of ICG angiography during breast reconstruction postmastectomy was demonstrated to be cost-effective for the reduction of ischemic complications in the Australian setting. A novel tracer combination, ICG-technetium-99m offered a safe and effective substitute to the "gold standard" dual tracer for SLN biopsy, although greater costs were associated with ICG. An ongoing trial will evaluate ARM node identification using ICG fluorescence during axillary lymph node dissection and potential predictive factors of ARM node involvement. These data add to the growing literature on ICG and allow future research to build on this to improve understanding of the potential benefits of fluorescence-guided surgery in breast cancer and reconstruction surgery.

Lymphovascular invasion is a significant risk factor for non-sentinel nodal metastasis in breast cancer patients with sentinel lymph node (SLN)-positive breast cancer: a cross-sectional study

BACKGROUND

A connection between lymphovascular invasion and axillary lymph node metastases in breast cancer has been observed, but the findings are inconsistent and primarily based on research in Western populations. We investigated the association between lymphovascular invasion and non-sentinel lymph node (non-SLN) metastasis in breast cancer patients with sentinel lymph node (SLN) metastasis in western China.

METHODS

This study comprised 280 breast cancer patients who tested positive for SLN through biopsy and subsequently underwent axillary lymph node dissection (ALND) at The People's Hospital of Guangxi Zhuang Autonomous Region between March 2013 and July 2022. We used multivariate logistic regression analyses to assess the association between clinicopathological characteristics and non-SLN metastasis. Additionally, we conducted further stratified analysis.

RESULTS

Among the 280 patients with positive SLN, only 126 (45%) exhibited non-SLN metastasis. Multivariate logistic regression demonstrated that lymphovascular invasion was an independent risk factor for non-SLN in breast cancer patients with SLN metastasis (OR = 6.11; 95% CI, 3.62-10.32, p < 0.05). The stratified analysis yielded similar results.

CONCLUSIONS

In individuals with invasive breast cancer and 1-2 positive sentinel lymph nodes, lymphovascular invasion is the sole risk factor for non-SLN metastases. This finding aids surgeons and oncologists in devising a plan for local axillary treatment, preventing both over- and undertreatment.

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.

A Novel Injection Protocol Using Voluven®-Assisted Indocyanine Green with Improved Near-Infrared Fluorescence Guidance in Breast Cancer Sentinel Lymph Node Mapping-A Translational Study

BACKGROUND

Near-infrared (NIR) fluorescence-guided surgery with indocyanine green (ICG) has been demonstrated to provide high sensitivity in sentinel lymph node biopsy (SLNB) for breast cancer but has several limitations, such as unstable pharmacokinetics, limited fluorescence brightness, and undesired diffusion to neighboring tissues. This paper investigates the use of Voluven® as the solvent for ICG fluorescence-guided SLNB (ICG-SLNB).

METHODS

The photophysical properties of ICG in water and Voluven® were evaluated in laboratory experiments and in a mouse model. Nine patients with early breast cancer underwent subareolar injection of diluted ICG (0.25 mg/ml) for ICG-SLNB. Six of the nine patients received ICG dissolved in Voluven® (ICG:Voluven®), while three were administered ICG dissolved in water (ICG:water); a repetitive injection-observation protocol was followed for all patients. The mapping image quality was evaluated.

RESULTS

Laboratory experiments and in vivo mouse study showed improved fluorescence and better targeting using Voluven® as the solvent. ICG-SLNB with a repetitive injection-observation protocol was successfully performed in all nine patients. ICG:Voluven® administration had an overall better signal-to-background ratio (SBR) in sequential sentinel lymph nodes. The rates of transportation within the lymphatics were also improved using ICG:Voluven® compared with ICG:water.

CONCLUSIONS

From basic research to animal models to in-human trial, our study proposes a repetitive injection-observation technique with ICG:Voluven®, which is characterized by better transportation and more stable mapping quality for ICG-SLNB in breast cancer patients.

Comparison of Sentinel Lymph Node Biopsy by Blue Dye Conjunction With Indocyanine Green or Radioisotope in Early-Stage Breast Cancer: A Prospective Single-Center Observational Study

Background

Although radioisotope (RI) combined with blue dye (BD) is the standard technique for sentinel lymph node (SLN) biopsy in breast cancer, the use of RI is limited at some institutions due to the specific equipment needed. Indocyanine green (ICG) fluorescence detection has been developed as a potential substitute for RI method. However, reports on the sensitivity of ICG and RI techniques in detecting SLN are inconsistent; hence, the present study was designed to compare the clinical efficacy between the combined method of ICG + BD (ICG-B) and RI + BD (RI-B).

Methods

A prospective observational study was performed that identified 138 breast cancer patients who had undergone lymphatic mapping and SLN biopsy with ICG-B or RI-B. The SLN detection rate, positive SLN counts, and lymph node metastasis between the 2 groups were compared.

Results

A total of 71 patients were recruited in the ICG-B group, while 67 were recruited in the RI-B group. The SLN detection rate was 100% in both the ICG-B and RI-B groups. Lymph node metastasis was found in 13 patients using ICG-B and in 12 patients using the RI-B technique (18.31% vs 17.91%, respectively; P = .61). No significant differences were observed in the positive SLN counts (3.12 ± 2.01 vs 3.33 ± 2.24, P = .37) between the 2 groups.

Conclusions

Indocyanine green combined with BD has an equal efficacy compared with RI plus BD when performing an axillary SLN biopsy in breast cancer. The ICG plus BD procedure is a promising alternative to traditional standard mapping methods.

Novel Dual Tracer Indocyanine Green and Radioisotope Versus Gold Standard Sentinel Lymph Node Biopsy in Breast Cancer: The GREENORBLUE Trial

BACKGROUND

The methods for sentinel lymph node (SLN) biopsy in breast cancer have been variable in type and number of tracers. Some units have abandoned the use of blue dye (BD) due to adverse reactions. Fluorescence-guided biopsy with indocyanine green (ICG) is a relatively novel technique. This study compared the clinical efficacy and costs between novel dual tracer ICG and radioisotope (ICG-RI) with "gold standard" BD and radioisotope (BD-RI).

METHODS

Single-surgeon study of 150 prospective patients with early breast cancer undergoing SLN biopsy (2021-2022) using ICG-RI compared with a retrospective cohort of 150 consecutive previous patients using BD-RI. Number of SLNs identified, rate of failed mapping, identification of metastatic SLNs, and adverse reactions were compared between techniques. Cost-minimisation analysis performed by using Medicare item numbers and micro-costing analysis.

RESULTS

Total number of SLNs identified with ICG-RI and BD-RI was 351 and 315, respectively. Mean number of SLNs identified with ICG-RI and BD-RI was 2.3 (standard deviation [SD] 1.4) and 2.1 (SD 1.1), respectively (p = 0.156). There were no cases of failed mapping with either dual technique. Metastatic SLNs were identified in 38 (25.3%) ICG-RI patients compared with 30 (20%) BD-RI patients (p = 0.641). There were no adverse reactions to ICG, whereas four cases of skin tattooing and anaphylaxis were associated with BD (p = 0.131). ICG-RI cost an additional AU$197.38 per case in addition to the initial cost for the imaging system.

CLINICAL TRIAL REGISTRATION

 ACTRN12621001033831.

CONCLUSIONS

Novel tracer combination, ICG-RI, provided an effective and safe alternative to "gold standard" dual tracer. The caveat was the significantly greater costs associated with ICG.

Intraoperative Utilization of Indocyanine Green (ICG) Dye for the Assessment of Ovarian Perfusion-Case Report and Review of the Literature

The assessment of ovarian perfusion after detorsion is crucial in the surgical management of patients with ovarian torsion. In current routine clinical practice, the surgical decision (preservation of the ovary versus oophorectomy) is based on the subjective impression of the surgeon. Intraoperative indocyanine green (ICG) angiography has been shown to sufficiently reflect tissue perfusion with a potential impact on the surgical procedure. Currently, there are only sparse data available on the utilization of ICG in the surgical treatment of ovarian torsion. Here, we describe the successful intraoperative use of ICG in a 17-year-old female patient with ovarian torsion who underwent ovary-preserving surgery. Further, a systematic literature review was performed. Based on the data available to date, the use of ICG in the surgical treatment of ovarian torsion is feasible and safe. The extent to which this might reduce the necessity for oophorectomy has to be evaluated in further investigations.

Carbon nanoparticles localized clipped node dissection combined with sentinel lymph node biopsy with indocyanine green and methylene blue after neoadjuvant therapy in node positive breast cancer in China: initial results of a prospective study

BACKGROUND

This study aimed to evaluate the feasibility of applying carbon nanoparticles (CNs) to visualize clip-marked metastatic nodes in combination with indocyanine green (ICG) and methylene blue (MB) as sentinel lymph node (SLN) tracers for targeted axillary dissection (TAD) after neoadjuvant therapy (NAT).

METHODS

This feasibility trial enrolled 40 patients with node-positive breast cancer, and 38 patients completed NAT and surgery were included in the final analysis. Before NAT or surgery, clip-marked nodes were localized with CNs by ultrasonography. After NAT, the clip-marked nodes were removed under the guidance of carbon-tattooing and confirmed by radiography. SLNs were mapped with ICG and MB. Axillary lymph node dissection (ALND) was performed for all patients after TAD.

RESULTS

The clip-marked nodes were retrieved in all patients. The SLN identification rate was 100%. 29 of 38 clipped-nodes were SLNs. The false-negative rate was 6.25% (2/32,95% CI:1.09% ~ 22.22%) for TAD nodes and 9.38% (3/32,95% CI 3.24%-24.22%) for SLNs, and 18.75% for clipped-nodes (6/32, 95% CI:7.86% ~ 37.04%). No adverse events were reported during clip placement, CNs localization, or the TAD procedure.

CONCLUSIONS

The TAD procedure with CNs to locate and visualize clipped nodes as well as SLN tracing with ICG and MB has good accessibility in China, and this technique could be easily mastered by experienced surgeons. The modified TAD technique has also demonstrated good predictive ability for residual axillary lesions after NAT, and is worth of further evaluation.

Evaluation of Surgical Aid of Methylene Blue in Addition to Intraoperative Gamma Probe for Sentinel Lymph Node Extirpation in 116 Canine Mast Cell Tumors (2017-2022)

Methylene Blue (MB) is combined with radiopharmaceutical for intraoperative sentinel lymph node (SLN) mapping, but its role during SLN extirpation has not been investigated yet in veterinary medicine. The aim of this study was to assess whether MB increased surgical detection of SLN beyond the use of intraoperative gamma-probe (IGP) alone in clinically node-negative dogs with mast cell tumors (MCTs) following the detection of sentinel lymphocentrums (SLCs) via preoperative planar lymphoscintigraphy. Dogs enrolled underwent MCT excision and SLC exploration guided by both MB and IGP. Data recorded for each SLN were staining (blue/non-blue), radioactivity (hot/non-hot), and histopathological status (HN0-1 vs. HN2-3). A total of 103 dogs bearing 80 cutaneous, 35 subcutaneous, and 1 mucocutaneous MCTs were included; 140 SLCs were explored, for a total of 196 SLNs removed. Associating MB with IGP raised the SLNs detection rate from 90% to 95%. A total of 44% of SLNs were metastatic: 86% were blue/hot, 7% were only blue, 5% were only hot, and 2% were non-blue/non-hot. All HN3 SLNs were hot. Combining MB with IGP can increase the rate of SLN detection in dogs with MCTs; nonetheless, all lymph nodes identified during dissection should be removed, as they might be unstained but metastatic.

Fluorescence Imaging to Identify and Preserve Fifth Intercostal Sensory Nerves during Bilateral Nipple-sparing Mastectomies

The use of nipple-sparing mastectomies has increased steadily over the past 10-15 years. However, one major source of patient dissatisfaction with both skin- and nipple-sparing mastectomies is lost skin and/or nipple sensation postoperatively due to intraoperative, iatrogenic sensory nerve injury. We summarize the case of a 41-year-old woman with BRCA(+) breast cancer who underwent bilateral, risk-reducing nipple-sparing mastectomies, immediately followed by bilateral, direct-to-implant breast reconstruction, in whom a prototype fluorescent imaging camera was used to facilitate sensory nerve identification and preservation. Preoperatively, tactile and thermal quantitative sensory testing were performed using a 30-gauge needle to determine baseline sensory function over both breasts. Then, nipple-sparing mastectomies and direct-to-implant reconstruction were performed. Using a laterally-displaced submammary approach, the anterior intercostal artery perforator neurovascular pedicle was preserved. Then a prototype camera, which emits near-ultraviolet light, was used to detect nerve autofluorescence. Intraoperatively under near-ultraviolet light, both the fifth intercostal nerve and its sensory branches auto-fluoresced clearly, so that surgery was completed without apparent injury to the fifth intercostal nerve or any of its branches. Postoperatively, the patient reported full sensory function throughout both breasts and both nipple-areolar complexes, which was confirmed on both tactile and thermal sensory testing at 3-month follow-up. The patient experienced no complications and rated her overall satisfaction with surgery on both breasts as 10 out of 10. To our knowledge, this is the first time sensory nerve auto-fluorescence has been reported to reduce the likelihood of intraoperative, iatrogenic nerve injury and preserve sensory function.

Fluorescence-guided surgery: comprehensive review

BACKGROUND

Despite significant improvements in preoperative workup and surgical planning, surgeons often rely on their eyes and hands during surgery. Although this can be sufficient in some patients, intraoperative guidance is highly desirable. Near-infrared fluorescence has been advocated as a potential technique to guide surgeons during surgery.

METHODS

A literature search was conducted to identify relevant articles for fluorescence-guided surgery. The literature search was performed using Medical Subject Headings on PubMed for articles in English until November 2022 and a narrative review undertaken.

RESULTS

The use of invisible light, enabling real-time imaging, superior penetration depth, and the possibility to use targeted imaging agents, makes this optical imaging technique increasingly popular. Four main indications are described in this review: tissue perfusion, lymph node assessment, anatomy of vital structures, and tumour tissue imaging. Furthermore, this review provides an overview of future opportunities in the field of fluorescence-guided surgery.

CONCLUSION

Fluorescence-guided surgery has proven to be a widely innovative technique applicable in many fields of surgery. The potential indications for its use are diverse and can be combined. The big challenge for the future will be in bringing experimental fluorophores and conjugates through trials and into clinical practice, as well as validation of computer visualization with large data sets. This will require collaborative surgical groups focusing on utility, efficacy, and outcomes for these techniques.

Diagnostic accuracy of combined optical- and radio-guided SNB for neck staging of oral squamous cell carcinoma lesions in the anterior oral cavity

PURPOSE

The purpose was to investigate the diagnostic performance of bimodal optical and radio-guided sentinel node biopsy (SNB) for oral squamous cell carcinoma (OSCC) sub-sites in the anterior oral cavity.

METHODS

Prospective study of 50 consecutive patients with cN0 OSCC scheduled for SNB was injected with the tracer complex Tc99m:ICG:Nacocoll. A near-infrared camera was applied for optical SN detection. Endpoints were modality for intraoperative SN detection and false omission rate at follow-up.

RESULTS

In all patients, a SN could be detected. In 12/50 (24%) of cases, the SPECT/CT showed no focus in level 1, but intraoperatively a SN in level 1 was optically detected. In 22/50 cases (44%), an additional SN was identified only due to the optical imaging. At follow-up, the false omission rate was 0%.

CONCLUSION

Optical imaging appears to be an effective tool to allow real-time SN identification comprising level 1 unaffected by possible interference of radiation site from the injection.

Selective Axillary Dissection after Neoadjuvant Chemotherapy in Patients with Lymph-Node-Positive Breast Cancer (CLYP Study): The Radio-Guided Occult Lesion Localization Technique for Biopsy-Proven Metastatic Lymph Nodes

(1) Background: To help to refine the accuracy of sentinel lymph node biopsy (SLNB) in breast cancer (BC) patients with biopsy-proven nodal disease prior to neoadjuvant chemotherapy (NACT), a method of marking the biopsy-proven positive LN at diagnosis to enable its removal during surgery was proposed. The aim of this study was to evaluate the accuracy of the Radio-Guided Occult Lesion Localization (ROLL) technique of biopsy-proven metastatic LN in nodal staging after NACT among node-positive BC patients. (2) Methods: Patients with invasive BC and biopsy-proven axillary metastases receiving NACT were enrolled. A clip marker was placed on the sampled LN (clipped lymph node, CLN) before NACT. Before surgery, the ROLL procedure (radioactive tracer injection into CLN under ultrasound guidance) was performed, and the CLN was surgically resected. The correspondence between the CLNs and SLNs was evaluated. The pathologic findings of the CLNs and SLN(s) were compared with remaining axillary nodes at ALND to determine false negative rates (FNRs). (3) Results: Seventy-two patients were analyzed. Surgery successfully identified the CLN in 70/72 procedures (97.2%). For 60/72 patients who underwent ALND, the FNRs dropped from 19.35% for SLNB to 3.13% for CLN biopsy. (4) Conclusions: The ROLL procedure got CLNs is accurate in axillary nodal staging after NACT in node-positive BC patients at diagnosis.

Fluorescence-guided lymph node sampling is feasible during up-front or delayed nephrectomy for Wilms tumor

BACKGROUND

Lymph node sampling is critical to surgical staging in Wilms tumor; failure to sample lymph nodes is associated with under-staging and an increased incidence of local relapse. However, no standard lymphatic mapping method is currently being utilized for Wilms tumor to aid identification of regional draining lymph nodes. Herein, we describe the use of fluorescence-guided lymphatic mapping for Wilms tumor.

MATERIALS AND METHODS

Two tertiary level referral centers independently began indocyanine green (ICG) fluorescence-guided nodal mapping. In one center, this was achieved with ipsilateral intra-parenchymal (IP) injection of ICG during minimally invasive tumor nephrectomy (MIN) following neoadjuvant chemotherapy and in the other, with Peri‑Hilar (PH) injection during upfront, open tumor nephrectomy (ON). Successful lymph node mapping was defined as the presence of fluorescence signal in draining lymph nodes.

RESULTS

Eight patients (median age of 2.5 years) underwent fluorescence-guided lymphatic mapping (four IP and four PH injection). Lymphatic mapping was successful in seven patients (88%) including each of the four patients with IP injection.

CONCLUSIONS

Fluorescence-guided lymphatic mapping of Wilms tumor drainage is feasible by both IP injection and PH injection techniques. However, whether lymphatic mapping improves the precision of lymph node sampling is unknown and should be studied in prospective trials.

Indocyanine Green Is a Safe and Effective Alternative to Radioisotope in Breast Cancer Sentinel Lymph Node Biopsy regardless of Patient Body Mass Index

INTRODUCTION

A recent meta-analysis [Lancet Oncol. 2010;11:908-909] has confirmed high sensitivity of indocyanine green (ICG) fluorescence mapping for sentinel node detection in early breast cancer. Concerns have previously been raised regarding the efficacy in patients with high body mass index (BMI).

MATERIALS AND METHODS

All consecutive patients undergoing sentinel lymph node biopsies (SLNBs) for early breast cancer in NHS Tayside were included in a prospective audit of surgical and pathology findings. All patients included in the study received dual injection of patent blue dye and ICG. Approval was obtained from the local Caldicott guardian for collection and use of personal data.

RESULTS

Of 239 cases, all were female patients of mean age 62 years (range 27-93). In 4.2% (10/239) of cases, neither blue dye nor ICG was present in the axilla. Of the remaining 229 SLNB cases in this series, surgeons documented retrieval of 451 nodes, with a mean surgical nodal count per case of 1.97 (range 1-5) and pathological nodal count of 2.15 (range 0-7). Eighty three cases were performed in patients with BMI 30-39.9 and 21 cases with BMI ≥40, with nodal detection rates of 96.4% (80/83) and 95.2% (20/21), respectively, in these groups of patients. Twenty percent (48/229) of cases had nodal metastases on histopathology.

CONCLUSIONS

This is a large single-center study which demonstrates the safety and accuracy of the combined ICG and blue dye technique for SLNB in breast cancer. This is represented by nodal detection rates and node positivity rates which are comparable to previous multicenter studies of standard SLNB regardless of BMI.

Sentinel Lymph Node Biopsy Is Feasible in Dogs with Scars from Prior Local Excision of Solid Malignancies

Simple Summary

Sentinel lymph node (SLN) excision is gaining relevance in the management of various canine malignancies due to its recognized impact on staging and treatment choices. However, the technologies to perform SLN mapping are only available to a few referral centers, and there is increasing demand for secondary nodal staging after prior tumor excision at the primary care institution. This retrospective study investigated the feasibility and usefulness of SLN biopsy in dogs with surgical scars resulting from the removal of various solid tumors referred for further staging and/or adjuvant treatment options. Thirty-three dogs with 34 scars underwent SLN biopsy at a median of 50 days after primary tumor excision. An SLN was identified for 31/34 scars, translating to a detection rate of 91.2%. Metastases were identified with histopathology in 13/31 dogs (41.9%) and they all had an excision of a mast cell tumor. SLN biopsy should be suggested in dogs presenting with scars from prior solid tumor excision, considering the observed detection rate and the importance of knowing the metastatic status of the SLN in oncological diseases.

Abstract

Sentinel lymph node (SLN) biopsy is a well-established staging tool in canine oncology. This study aims to explore the feasibility of SLN biopsy in dogs with scars from prior excised solid malignancies that were referred for further tumor staging and/or adjuvant treatment options. Mapping was either performed using radiopharmaceutical, methylene blue, and/or near-infrared fluorescent (NIRF) imaging. Thirty-three dogs with 34 scars from prior excision of the mast cell tumor (MCT) (n = 29), soft tissue sarcoma (n = 2), oral melanoma (n = 1), subungual melanoma (n = 1), and mammary adenocarcinoma (n = 1) were retrospectively enrolled. Primary treatment consisted of curative intent/wide tumor excisions in 50.0% of dogs and marginal excision in the remaining 50.0%. The median time between tumor excision and SLN biopsy was 50 days (range 17–110 days). The procedure was successful in 31/34 scars, translating to a detection rate of 91.2%. The SLN did not correspond to the regional lymph node in 19/31 scars (61.3%). SLN metastases were histologically identified in 13/31 (41.9%) dogs, all of them affected by MCT. Based on our results, SLN biopsy using lymphoscintigraphy/methylene blue and/or NIRF is feasible in dogs presenting with scars from the prior surgical excision of solid tumors, and should be suggested for accurate nodal staging.

Short-term and long-term outcomes of indocyanine green for sentinel lymph node biopsy in early-stage breast cancer

Background

Indocyanine green (ICG) is becoming a frequently used sentinel lymph node (SLN) tracer of breast cancer in China. However, there is still a lack of data on its safety. We reported the clinical outcome of ICG as a tracer of SLN over a median 67-month follow-up period to evaluate its feasibility in clinically node-negative patients with breast cancer.

Methods

A total of 194 consecutive patients underwent sentinel lymph node biopsy (SLNB) with ICG, radioisotopes (RI) and methylene blue (MB), or with ICG and MB. The SLN mapping data by each tracer was recorded, and safety outcomes were analyzed through follow-up.

Results

With the triad mapping (N = 44), the identification rate of SLN by ICG was 95.5%, slightly higher than that of MB (86.4%) and comparable with RI (95.5%) and combined methods (95.5%, 100%) (p = 0.068). Analysis of all candidates (N = 194) demonstrated that the identification rate of SLN by ICG or by ICG and MB was 99%, significantly higher than that by MB (92.8%) (p < 0.0001). No tracer-related allergic reaction and permanent skin staining of ICG were observed. Local disease progression was reported in 2 of the 194 patients at the ipsilateral axilla. After remedial axillary lymph node dissection, no disease progression was detected at follow-up.

Conclusions

ICG as an SLN tracer is more accurate than MB and comparable to the combined methods and has good clinical safety. ICG can be considered a useful supplement or suitable alternative to traditional tracers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02719-7.

Validation sentinel lymph node biopsy study in cN0 axilla using low-cost dual dye technique: potential solution for resource poor settings

BACKGROUND

Sentinel lymph node biopsy (SLNB) using radio-pharmaceutical and a blue dye is gold standard for axillary staging in clinically node-negative breast cancer. High costs and limited availability of radio-pharmaceutical and/or gamma probe are major deterrents in performing SLNB in developing countries. In this study, we evaluated feasibility of SLN identification (SLN-IR) of fluorescein-guided (FG) SLNB in combination with methylene blue dye (MBD).

METHODS

This was a prospective cross-sectional non-randomized validation study in patients with clinically node-negative axilla. Patients underwent validation SLNB using fluorescein (and blue LED light) and MBD. Axillary dissection was performed irrespective of SLNB histology. SLIN-IR and False Negative Rate (FNR) were assessed for both groups.

RESULTS

The SLNs were identified in 29 (96.6%) pre-chemotherapy patients and 23 (82%) post Neoadjuvant Chemotherapy (NACT) patients. The median number of sentinel lymph nodes identified was 3 (range of 1-5) in pre-chemotherapy patients and 1 (range of 1-3) in post NACT patients. The SLN-IR using MBD was 90%, FD was 86.7% and combined MBD FD was 96.7% in pre-chemotherapy patients. The SLN-IR using MBD was 82%, FD was 71% and combined MBD FD was 82% in in post NACT patients. The false negative rate (FNR) in pre-chemotherapy group was 8.0% (MBD), 8.3% (FD) and 7.4% (MBD + FD). The FNR in post NACT group was 8.7% (MBD), 10% (FD) and 8.7% (MBD + FD).

CONCLUSION

This prospective validation study showed adequate SLN-IR and FNR using low-cost dual dyes in early breast cancer patients and can be used in low resource settings. However, SLNB in post NACT axilla though viable along with a satisfactory FNR, is associated with low identification rate and needs further evaluation.

Regional Lymph Node Metastasis and Axillary Surgery of Microinvasive Breast Cancer: A Population-Based Study

Microinvasive breast cancer (MBC for short) is a rare entity with the decision of axillary surgery under debate in clinical practice. We aimed to unravel the lymph node metastasis (LNM) rate, axillary surgery, and prognosis of MBC based on 11,692 patients derived from the Surveillance Epidemiology and End Results (SEER) database between 2003 and 2015. In this retrospective study, 19.5% (2276/11,692) of patients received axillary lymph node dissection (ALND), 80.5% (9416/11,692) received non-ALND. In the total cohort, 10-year breast cancer-specific survival (BCSS) was 96.3%, and the LNM rate was 6.4% (754/11,692). Multivariate analyses showed that LNM had the strongest predictive weight (N3, HR 14.200, 95% CI 7.933−25.417; N2, HR 12.945, 95% CI 7.725−21.694; N1, HR 3.05, 95% CI 2.246−4.140, all p < 0.001). Kaplan−Meier analyses showed that ALND did not confer a survival benefit on 10-year BCS in patients with N0 (94.7% vs. 97.1%, p < 0.001) and in patients with 1−2 positive nodes (92.1% vs. 89.5%, p = 0.355), respectively, when compared to non-ALND. Our study demonstrated that the vast majority of MBC have a low LNM rate and excellent prognosis; patients with LNM showed poor prognosis. Assessment of lymph node status is necessary, and non-ALND surgery is required and sufficient for MBC with 0−2 positive nodes.

Sentinel Lymph Node Methods in Breast Cancer

Breast cancer is the most frequent cancer diagnosed in women worldwide. Accurate lymph node staging is essential for both prognosis (of early-stage disease) and treatment (for regional control of disease) in patients with breast cancer. The sentinel lymph nodes are the regional nodes that directly drain lymph from the primary tumor. No imaging modality is accurate enough to detect lymph node metastases when a primary breast cancer is at an early stage (I or II), but sentinel lymph node biopsy is a highly reliable method for screening axillary nodes and for identifying metastatic (including micro-metastatic) disease in regional lymph nodes. Despite the widespread use of sentinel lymph node biopsy for early-stage breast cancer, relevant variations have been described regarding practical aspects of the procedure, and some variability has initially been reported regarding the rates of intraoperative sentinel lymph node identification and of false-negative findings, most likely because of differences in the size of the populations being investigated and in lymphatic mapping techniques. Nevertheless, using adequate learning curves and once a multidisciplinary team is experienced with the procedure, improved levels of accuracy are achieved.

Indocyanine-based near-infrared lymphography for real-time detection of lymphatics in a cat with multiple mast cell tumours

Case summary

An 11-year-old female domestic shorthair cat was presented with cutaneous mast cell tumours (MCTs) localised at the right temporal region, the left buccal region and on the third digit of the right thoracic limb. Staging was negative and locoregional lymph nodes appeared normal, based on clinical findings. During surgery, real-time indocyanine green (ICG)-based lymphography was performed to detect the cutaneous draining pattern of all the primary MCTs. ICG was injected intracutaneously in four quadrants around each tumour, and a clear lymphogram was visible shortly after injection. Using near-infrared lymphography (NIR-L) for guidance, all lymphadenectomies were performed in 12 mins or less, with a maximal incision length of 3.5 cm. The smallest resected node was 0.9 cm in diameter. All MCTs were classified as low-grade cutaneous MCT. All four ICG-positive lymph nodes were considered premetastatic or metastatic. The only ICG-negative resected node was also negative for tumour cells. No complications related to NIR-L were recorded.

Relevance and novel information

This is the first description of NIR-L in a cat with MCT. Application was straightforward and ICG enrichment only occurred in the metastatic nodes, suggesting correct identification of lymphatic draining patterns. Of note, as previously described in dogs, we did detect nodal metastasis, despite low-grade primary tumours. The clinical relevance should be evaluated in future studies.

A Randomized Prospective Non-Inferiority Trial of Sentinel Lymph Node Biopsy in Early Breast Cancer: Blue Dye Compared with Indocyanine Green Fluorescence Tracer

Simple Summary

This randomized study was conducted to evaluate sentinel lymph node biopsy with indocyanine green (ICG) compared with blue dye as a tracer in women with early breast cancer without any sign of lymph node invasion. ICG is a fluorescent tracer well known in medical practice for 50 years that is used as tracer of sentinel lymph nodes in numerous types of cancers other than breast cancer. This tracer is cheaper than radioactive tracers, with an easy learning curve.

Abstract

Background: Indocyanine green (ICG) is a promising tracer for sentinel lymph node biopsy in early breast cancer. This randomized study was conducted to evaluate sentinel lymph node biopsy with ICG compared with blue dye as a tracer in woman with early breast cancer without any sign of lymph node invasion. Methods: Between January 2019 and November 2020, 240 consecutive women with early breast cancer were enrolled and randomized to sentinel lymph node biopsy using ICG or blue dye. The primary endpoint was the sentinel lymph node detection rate in both arms. Results: ICG was used in 121 patients and detected sentinel lymph nodes in all patients (detection rate, 100%; 95% CI: 96.9–100.0) while blue dye was used in 119 patients and detected sentinel lymph nodes in 116 patients (detection rate: 97.5%, 95% CI: 92.9–99.1). This analysis indicated the non-inferiority of ICG vs. blue dye tracer (90%CI: −1.9–6.9; p = 0.0009). Conclusion: ICG represents a new promising tracer to detect sentinel lymph nodes in early breast cancer with a detection rate similar to other conventional tracers, and is associated with easy learning and low cost. Our result suggest that this technique is a good alternative to avoid radioactive isotope manipulation.

A Propensity Score Matched Analysis of Superparamagnetic Iron Oxide versus Radioisotope Sentinel Node Biopsy in Breast Cancer Patients after Neoadjuvant Chemotherapy

The standard method for nodal staging in breast cancer (BC) patients after neoadjuvant chemotherapy (NAC) is sentinel lymph node biopsy (SLNB) with a radioisotope (RI) injection. However, SLNB after NAC results in high false-negative rates (FNR), and the RI method is restricted by nuclear medicine unit dependency. These limitations resulted in the development of the superparamagnetic iron oxide (SPIO) method, reducing FNR and presenting a comparable detection rate. This bi-institutional cohort comparison study aimed to assess the efficacy of SPIO and radioisotope SNLB in BC patients after NAC using Propensity Score Matching (PSM) analysis. The study group comprised 508 patients who underwent SLNB after NAC for ycT1-4N0M0 BC between 2013 and 2021 in two high volume centers. Data were retrieved from prospectively conducted databases. In the SPIO group, the median of retrieved sentinel lymph nodes (SLNs) was significantly higher than in the RI group (3 vs. 2; p < 0.0001). The SPIO method was associated with a significantly higher chance of retrieving at least three lymph nodes when compared to the RI method (71% vs. 11.3%; p < 0.0001). None of the analyzed demographic and clinical variables had a statistically significant influence on the efficacy of SLNs retrieval in the RI group, while in the SPIO group, patients with ≥three harvested SLNs had lower weight and decreased BMI. Based on this PSM analysis, SPIO-guided SLNB allowed the efficient retrieval and detection of SLNs in BC patients after NAC compared to RI.

A Propensity Score Matched Analysis of Superparamagnetic Iron Oxide versus Radioisotope Sentinel Node Biopsy in Breast Cancer Patients after Neoadjuvant Chemotherapy

Simple Summary

This Propensity Score Matched Analysis aimed to assess the efficacy of superparamagnetic iron oxide (SPIO) and radioisotope sentinel lymph node biopsy (SNLB) in breast cancer (BC) patients after neoadjuvant chemotherapy (NAC). One hundred and twenty-four patients were eligible for final analysis. In the SPIO group, the median of retrieved sentinel lymph nodes (SLNs) was significantly higher than in the RI group. The SPIO method was associated with a significantly higher chance of retrieving at least three SLNs when compared to the RI method. SPIO-guided SLNB allows efficient retrieval and detection of SLNs in BC patients after NAC when compared to RI.

Abstract

The standard method for nodal staging in breast cancer (BC) patients after neoadjuvant chemotherapy (NAC) is sentinel lymph node biopsy (SLNB) with a radioisotope (RI) injection. However, SLNB after NAC results in high false-negative rates (FNR), and the RI method is restricted by nuclear medicine unit dependency. These limitations resulted in the development of the superparamagnetic iron oxide (SPIO) method, reducing FNR and presenting a comparable detection rate. This bi-institutional cohort comparison study aimed to assess the efficacy of SPIO and radioisotope SNLB in BC patients after NAC using Propensity Score Matching (PSM) analysis. The study group comprised 508 patients who underwent SLNB after NAC for ycT1-4N0M0 BC between 2013 and 2021 in two high volume centers. Data were retrieved from prospectively conducted databases. In the SPIO group, the median of retrieved sentinel lymph nodes (SLNs) was significantly higher than in the RI group (3 vs. 2; p < 0.0001). The SPIO method was associated with a significantly higher chance of retrieving at least three lymph nodes when compared to the RI method (71% vs. 11.3%; p < 0.0001). None of the analyzed demographic and clinical variables had a statistically significant influence on the efficacy of SLNs retrieval in the RI group, while in the SPIO group, patients with ≥three harvested SLNs had lower weight and decreased BMI. Based on this PSM analysis, SPIO-guided SLNB allowed the efficient retrieval and detection of SLNs in BC patients after NAC compared to RI.

Diagnostic value of indocyanine green for sentinel lymph node mapping and lymph node metastasis in oral/oropharyngeal carcinoma

Indocyanine green (ICG) fluorescence-based sentinel lymph node (SLN) biopsy has been promoted to detect early metastasis of oral/oropharyngeal carcinoma, but its diagnostic value still remains unclear. In this letter, we identified 6 studies on ICG fluorescence based SLN in the detection of lymph node metastasis in oral/oropharyngeal carcinoma. For detection of metastatic lymph node, the overall sensitivity and specificity of the studies were 0.86 and 0.91, respectively. SROC curve was determined according to the combined sensitivity and specificity, and the overall area under the curve AUC was 0.93. On the whole, ICG fluorescence-based SLN biopsy showed promising effect for earlier detection and staging.

Indocyanine Green Fluorescence-Guided Sentinel Node Biopsy in Breast Cancer Within a North African Population: A Retrospective Study

Objective

Radio isotopes and blue dyes alone or in combination are the most commonly used tracer agents in sentinel node (SN) biopsy for early breast cancer. Recent studies have found fluorescence method using indocyanine green (ICG) as a promising technology with fewer disadvantages.

Materials and Methods

Retrospective analysis of our database that included patients with clinically node-negative breast cancer scheduled for breast surgery and SN biopsy between 2016 and January 2021. Patients who underwent detection using fluorescence-ICG were included in this study.

Results

A total of 47 patients were included. Median age was 50 (range: 24-78) years. Mean tumor size was 3.4 ± 1.5 cm. All patients received ICG injection and 11 received a combination of ICG and blue dye. Forty-five successful SN identifications with ICG were performed and 99 nodes retrieved. Eleven procedures were undertaken after initial systemic therapy. Twenty-four patients had at least one positive SN for malignancy. Mean follow up was 29.2 months and no axillary recurrence was noted during the study period.

Conclusion

ICG appears to be a feasible and accurate method for SN biopsy with high identification rate. This is the first study of ICG in sentinel node biopsy in a North African population.

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.

Severe anaphylactic reaction after blue dye injection for sentinel lymph node biopsy in breast surgery: Report of two cases and literature review

Anaphylactic reactions, and especially the severe ones (types III and IV), should be kept in mind as considerable adverse effects while using blue dyes for SLNB.