A Novel Approach for Sentinel Lymph Node Identification Using Fluorescence Imaging and Image Overlay Navigation Surgery in Patients with Breast Cancer

Abstract

We reported a novel technique of sentinel lymph node (SLN) identification using fluorescence imaging of indocyanine green injection. Furthermore, to obtain safe and accurate identification of SLN during surgery, we introduce the image overlay navigation surgery and evaluate its efficacy. This study enrolled 50 patients with a tumors <2 cm in diameter. Initially, we obtained three-dimensional (3-D) imaging from multidetector-row computed tomography (MD-CT) by volume rendering. It was projected on the patient's operative field with the clear visualization of lymph node (LN) through projector. Then, the dye of indocyanine green (ICG) was injected subdermally in the areola. Subcutaneous lymphatic channels draining from the areola to the axilla were visible by fluorescence imaging immediately. Lymphatic flow was reached after LN revealed on 3-D imaging. After incising the axillary skin on the point of LN mapping, SLN was then dissected under the guidance of fluorescence imaging with adequate adjustment of sensitivity and 3-D imaging. Lymphatic channels and SLN were successfully identified by Photodynamic eye (PDE) in all patients. And the sites of skin incision also were identical with the LN being demonstrated by 3-D imaging in all patients. The mean number of SLN was 3.7. The image overlay navigation surgery was visually easy to identify the location of SLN from the axillary skin. There were no intra- or postoperative complications associated with SLN identification. This combined navigations of fluorescence and 3-D imaging revealed more easy and effective to detect SLN intraoperatively than fluorescence imaging alone.