Sentinel Lymph Node Detection Research Articles

New Alternative Techniques for Sentinel Lymph Node Biopsy.

Background and Objectives: This review paper highlights the key alternatives to the blue dye/radioisotope method of sentinel lymph node biopsy (SLNB). It analyses the research available on these alternative methods and their outcomes compared to the traditional techniques. Materials and Methods: This review focused on fifteen articles, of which five used indocyanine green (ICG) as a tracer, four used magnetic tracers, one used one-step nucleic acid amplification (OSNA) and Metasin (quantitative reverse transcriptase-polymerase chain reaction), one used the photosensitiser talaporfin sodium, one used sulphur hexafluoride gas microbubbles, one used CT-guided lymphography and two focused on general SLNB technique reviews. Results: Of the 15 papers analysed, the sentinel node detection rates were 69-100% for indocyanine green, 91.67-100% for magnetic tracers, 81% for talaporfin sodium, 9.3-55.2% for sulphur hexafluoride gas microbubbles, 90.5% for CTLG and 82.7-100% for one-step nucleic acid amplification. Conclusions: Indocyanine green fluorescence (ICG) and magnetic tracers have been proven non-inferior to traditional blue dye and isotope regarding SLNB localisation. Further studies are needed to investigate the use of these techniques in conjunction with each other and the possible use of language learning models. Dedicated studies are required to assess cost efficacy and longer-term outcomes.

A new bimodal approach for sentinel lymph node imaging in prostate cancer using a magnetic and fluorescent hybrid tracer

PurposeTo obtain initial data on sentinel lymph node (SLN) visualisation by pre-operative magnetic resonance imaging (MRI) and intra-operative bimodal SLN identification using a new magnetic fluorescent hybrid tracer in prostate cancer (PCa) patients.MethodsTen patients at > 5% risk for lymph node (LN) invasion were included. The day before surgery, a magnetic fluorescent hybrid tracer consisting of superparamagnetic iron oxide nanoparticles (SPION) and indocyanine green was transrectally injected into the prostate. Five hours after injection, transversal pelvic MRI scans were recorded and T2*-weighed images were screened for pelvic LNs with SPION uptake. Intra-operatively, magnetically active and/or fluorescent SLNs were detected by a handheld magnetometer and near-infrared fluorescence imaging (FI). Extended pelvic lymph node dissection (PLND) and radical prostatectomy completed the surgery. All resected specimens were checked ex situ for magnetic activity and fluorescence and were histopathologically examined.ResultsPre-operative MRI identified 145 pelvic LNs with SPION uptake. In total, 75 (median 6, range 3‒13) magnetically active SLNs were resected, including 14 SLNs not seen on MRI. FI identified 89 fluorescent LNs (median 8.5, range 4‒13) of which 15 LNs were not magnetically active. Concordance of the different techniques was 70% for pre-operative MRI vs. magnetometer-guided PLND and 88% for magnetic vs. fluorescent SLN detection.ConclusionThese are the first promising results of bimodal, magnetic fluorescent SLN detection in PCa patients. Our magnetic fluorescent hybrid approach provides the surgeon a pre-operative lymphatic roadmap by using MRI and intra-operative visual guidance through the application of a fluorescent lymphatic agent. The diagnostic accuracy of our new hybrid approach has to be evaluated in further studies.Trial registrationDRKS00032808. Registered 04 October 2023, retrospectively registered.

INTRA- AND EARLY POSTOPERATIVE RESULTS OF BIOPSY OF SIGNAL LYMPH NODE UNDER CONTROL OF ICG MAPPING IN PATIENTS WITH ENDOMETRIAL CANCER OF INITIAL STAGES

Biopsy of sentinel lymph nodes (SNL) with the use of indocyanine green (ICG) as an indicator is becoming a standard method for evaluating the lymphatic reservoir in endometrial cancer in patients in the early stages.
 The purpose of the study. To conduct a comparative assessment of іntra- and early postoperative results in patients with endometrial cancer of initial stages when performing systemic lymphadenectomy and ICG mapping for the detection of SLNs.
 Materials and methods. The study included 98 patients (2017-2022) with morphologically verified endometrial cancer with low and mediumintermediate risks of metastasis. Removal of lymph nodes was carried out in two ways: 1)systemic lymphadenectomy (group 1); 2) ICG mapping for detection of SLN in the pelvic area (group 2).
 Results. The time of the operation for 1 group is longer - (63.7 ± 14.8) min. than for the second - (36.4 ± 8.9) min. In group 1, intraoperative lesions of the obturator nerve were detected in 2 patients (4.5%), postoperative complications also were observed: lymphocysts 3 (7.5%), lymphostasis 2 (5.5%), prolonged lymphorrhea 4 (9.5%) and. There were no complications in group 2. In both groups, there were no bleedings and intraoperative injuries of the pelvic organs. In group 1, the average number of extracted LVs was 8.5±2 on each side; positive LNs were found in 3 (8%) patients, the remaining 38 (92%) were negative. Identification of the localization of LN was not carried out; since their evacuation from the abdominal cavity was carried out in a single block - 32 (80%), in 8 (20%) - fragmentary (which still does not allow identification of the position of the LN). No metastases were detected in group 2; in 40 (70 %) patients, SLN was detected on both sides, 11 (20 %) - on one side, and 6 (10 %) - not detected. In these 10% of patients, systemic lymph node dissection was performed. The most common localizations of LN are the external iliac vessels and the obturator area on both sides.
 Conclusions. SLN biopsy should be used more often in early-stage endometrial cancer. The SLN technique can be used in patients with low and intermediate risk of lymphatic metastases to reduce the frequency of complications associated with systemic lymph node dissection. This technique can be used for patients with a higher risk of metastasis (in particular, average and high-average) in the presence of concomitant comorbid pathology. Its advantages are: reducing the trauma of the procedure, surgical comorbidity (lymphorrhea, lymphocysts, vascular and nerve injury), reducing the time of surgical intervention (which reduces the risk of infectious complications), reduction of blood loss, shortening of hospitalization, faster recovery, improvement of cosmetic effect and equivalence of oncological results.

Mapping sentinel lymph nodes in early-stage ovarian cancer (MELISA) trial - a further step towards lymphadenectomy replacement

ObjectiveSistematic pelvic and para-aortic lymphadenectomy is part of the staging surgery for early-stage epithelial ovarian cancer, with no therapeutic value. The Mapping Sentinel Lymph Nodes In Early-Stage Ovarian Cancer (MELISA) trial prospectively assessed the SLN detection rate and the diagnostic accuracy of the SLN mapping technique in patients with early-stage epithelial ovarian cancer. MethodsThis prospective, single-arm study included patients diagnosed with early-stage epithelial ovarian cancer (FIGO stages I and II), via either primary surgery or re-staging surgery. SLN mapping was performed by injecting 0.2 mL of 37-mBq 99mTc-nanocoloid albumin and 2 mL of 2.5 mg/mL indocyanine green into the infundibulopelvic and utero-ovarian ligaments. After removal of SLNs, a complete systematic pelvic and para-aortic lymphadenectomy was performed. SLN Ultrastaging analysis was applied. The primary outcome was the overall SLN detection rate, either with one or both tracers. Secondary outcomes were the diagnostic accuracy of detecting lymph node metastases and factors that may influence SLN detection. ResultsThirty patients were included. SLNs were identified in 27 patients (90%). Detection rates in primary and re-staging surgery were 89% and 92%, respectively. Para-aortic drainage was the predominant lymphatic spread, observed in 26 of 27 patients. Ultrastaging pathologic reports listed 1 SLN with macrometastasis, 1 with micrometastasis, and 5 with isolated tumor cells; the sensitivity of SLN mapping was 100%, with a false-negative rate of 0%. Univariate analysis showed a nonsignificant higher proportion of patients with uterine fibroids, adenomyosis, and endometriosis (100%, 67%, 67%, respectively) in patients in whom SLNs were not detected. ConclusionSLN mapping has a high detection rate (90%) and is an accurate technique for detecting lymph node involvement in early-stage epithelial ovarian cancer. SLN mapping is a potential alternative to systematic lymphadenectomy to reduce associated morbidity, but further research is needed to evaluate the impact of SLN mapping on oncologic outcomes and its cost-effectiveness.

Detection and dissection of sentinel nodes in endometrial endometrioid cancer with indocyanine green using PinPoint laparoscopy: Analysis of the learning curve

ObjectiveEarly-stage endometrial endometrioid adenocarcinoma is managed through laparoscopic total hysterectomy with bilateral salpingo-oophorectomy and pelvic lymphadenectomy. Detection of positive nodes is rare, and lymphadenectomy may involve complications. Pelvic sentinel lymph node dissection can prevent complete dissection. Herein, we evaluated the learning curve of sentinel lymph node dissection using indocyanine green.Study design: All surgeries for endometrial endometrioid adenocarcinoma were performed laparoscopically with indocyanine green to detect sentinel nodes. The primary outcome was the ability to identify and resect sentinel lymph nodes on each side. The secondary outcome was correspondence between the frozen section histology of the nodes with the final histology. ResultsAmong 31 patients with endometrial endometrioid adenocarcinoma treated between October 2018 and August 2020, 29 who underwent laparoscopy using indocyanine green were enrolled. Complete lymphadenectomy was performed in 16 patients. Failure to recognize sentinel nodes on right and left sides occurred in 10.34% and 0% of cases, respectively. The median number of recognized and dissected sentinel nodes was 1 on both sides (range 0–5). One patient had a lymph node positive for malignancy on histology (3.45%) on both sides. There were 13 and 14 cases of negative frozen sections on the right and left sides, respectively, and 1 case of a positive frozen section with positive whole pelvic lymph nodes. ConclusionSentinel node dissection using indocyanine green in endometrial endometrioid adenocarcinoma has a distinct learning curve; however, it is practical and achievable for skilled surgeons.

Current applications of indocyanine green (ICG) in abdominal, gynecologic and urologic surgery: a meta-review and quality analysis with use of the AMSTAR 2 instrument.

Indocyanine green (ICG) is an injectable fluorochrome that has recently gained popularity as a means of assisting intraoperative visualization during laparoscopic and robotic surgery. Many systematic reviews and meta-analyses have been published. We conducted a meta-review to synthesize the findings of these studies. PubMed and Embase were searched to identify systematic reviews and meta-analyses coping with the uses of ICG in abdominal operations, including Metabolic Bariatric Surgery, Cholecystectomy, Colorectal, Esophageal, Gastric, Hepato-Pancreato-Biliary, Obstetrics and Gynecology (OG), Pediatric Surgery, Surgical Oncology, Urology, (abdominal) Vascular Surgery, Adrenal and Splenic Surgery, and Interdisciplinary tasks, until September 2023. We submitted the retrieved meta-analyses to qualitative analysis based on the AMSTAR 2 instrument. We identified 116 studies, 41 systematic reviews (SRs) and 75 meta-analyses (MAs), spanning 2013-2023. The most thoroughly investigated (sub)specialties were Colorectal (6 SRs, 25 MAs), OG (9 SRs, 15 MAs), and HPB (4 SRs, 12 MAs). Interestingly, there was high heterogeneity regarding the administered ICG doses, routes, and timing. The use of ICG offered a clear benefit regarding anastomotic leak prevention, particularly after colorectal and esophageal surgery. There was no clear benefit regarding sentinel node detection after OG. According to the AMSTAR 2 tool, most meta-analyses ranked as "critically low" (34.7%) or "low" (58.7%) quality. There were only five meta-analyses (6.7%) that qualified as "moderate" quality, whereas there were no "high" quality reviews. Regardless of the abundance of pertinent literature and reviews, surgeons should be cautious when interpreting their results on ICG use in abdominal surgery. Future reviews should focus on ensuring methodological vigor; establishing clear protocols of ICG dose, route of administration, and timing; and improving reporting quality. Other sources of data (e.g., registries) and novel methods of data analysis (e.g., machine learning) might also contribute to an enhanced role of ICG as a decision-making tool in surgery.

Evaluation of the efficacy of using indocyanine green associated with fluorescence in sentinel lymph node biopsy.

Sentinel lymph node biopsy is the technique recommended for the axillary staging of patients with breast cancer in the initial stages without clinical axillary involvement. Three techniques are widely used globally to detect sentinel lymph nodes: patent blue, the radiopharmaceutical technetium 99 with gamma probe, and the combination of these two. To evaluate the sentinel lymph node detection rate with an innovative technique: indocyanine green (ICG) associated with fluorescence in breast cancer patients, and compare it with patent blue and a combination of patent blue and indocyanine green. 99 patients were sequentially (not randomly) allocated into 3 arms with 33 patients submitted to sentinel lymph node techniques. One arm underwent patent blue dying, the other indocyanine green, and the third received a combination of both. The detection rates between arms were compared. The detection rate in identifying the sentinel lymph node was 78.8% with patent blue, 93.9% with indocyanine green, and 100% with the combination. Indocyanine green identified two sentinel nodes in 48.5% of patients; the other groups more commonly had only one node identified. The mean time to sentinel lymph node identification was 20.6 ± 10.7 SD (standard deviation) minutes among patients submitted to the patent blue dye, 8.6 ± 6.6 minutes in the indocyanine green arm, and 10 ± 8.9 minutes in the combined group (P<0.001; Student's test). The mean surgery time was 69.4 ± 16.9; 55.1 ± 13.9; and 69.4 ± 19.3 minutes respectively (P<0.001; Student's test). The sentinel lymph node detection rate by fluorescence using indocyanine green was 93.9%, considered adequate. The rates using patent blue, indocyanine green, and patent blue plus indocyanine green (combined) were significantly different, and the indocyanine green alone is also acceptable, since it has a good performance in sentinel lymph node identification and it can avoid tattooing, with a 100% sentinel lymph node detection rate when combined with patent blue.

Outcomes of Breast-Conserving Therapy in Patients With Inflammatory Breast Cancer: A Meta-Analysis

IntroductionInflammatory breast cancer (IBC) is a rare and aggressive form of breast cancer. Currently, patients who respond to neoadjuvant chemotherapy (NAC) are treated with mastectomy and axillary lymph node dissection. This study aimed to synthesize real-world data to evaluate the feasibility of breast-conserving therapy (BCT), sentinel lymph node (SLN), and sentinel lymph node biopsy (SLNB) for patients with IBC who respond to NAC. MethodsPubMed, Embase, and Cochrane Library databases were searched for relevant articles. Clinical studies that compared mastectomy with BCT for IBC treatment were reviewed. The primary outcomes were local recurrence rate and 5-y survival rate in patients with IBC who responded to NAC. Furthermore, the SLN detection rate and false-negative rate (FNR) for SLNB were also evaluated. ResultsIn the final analysis, 17 studies were included. The pooled estimates of the local recurrence rate for mastectomy and no surgical intervention were 18.6% and 15.9%, respectively (P = 0.956). Five-y survival was similar for mastectomy, partial mastectomy, and no surgical intervention (45.8%, 57.1%, and 39.4%, respectively). The pooled estimates of the SLN detection rate and FNR for SLNB were 81.9% and 21.8%, respectively. ConclusionsAmong patients with IBC who respond to NAC, the local recurrence and 5-y survival rates in those undergoing BCT are noninferior to the rates in those undergoing mastectomy; therefore, BCT could be a feasible option for surgical management. However, a poor SLN detection rate and a high FNR were found in patients undergoing SLNB. Further large-scale clinical studies are required to confirm our findings.

Laparoscopic Sentinel Lymph Node Mapping Using NIR Fluorescence with ICG in Early Endometrial Cancer: Experience at a Tertiary Care Oncology Centre

Objective: To determine the detection rates and location of sentinel nodes as well as to determine intraoperative and postoperative surgico-pathological outcomes in endometrial cancer patients who underwent laparoscopic staging with sentinel node biopsy using ICG dye. Materials and Methods: This retrospective study was conducted in a tertiary care oncology centre, Amrita Institute of medical sciences, Kochi from April 2021 to March 2023. All cases of biopsy proven early stage endometrial carcinoma that underwent laparoscopic staging with SLN mapping using the ICG dye were included. All histological types were included, as long as the disease was confined to the uterus, clinically and on MRI. Results: A total of 80 patients were found eligible for the study. Only the patients with apparent uterine confined disease on preoperative MRI were selected for sentinel mapping, 80 % of whom had IA disease on MRI, and 20 % had IB, 13.5 % were high grade histology.The overall SLN detection rate was 93.75%, and bilateral detection rate was 92.5 %. Most common location was external iliac in 40.8% cases. Only 1 patient was found to harbour nodal micro metastasis on ultrastaging. Final histopathology identified stage IA in 63 (78.75%) patients, IB in 14 (17.5%), Stage II in 2 (2.5%) and Stage IIIC1 in 1 (1.25%) patient. Conclusion: Laparoscopic staging with SLNB using ICG is a practicable approach for uterine limited disease on preoperative evaluation. It extends the benefits of minimally invasive surgery to these patients, while overcoming the limitations of prohibitive cost or availability of expensive robotic equipment.

Radioactive nanosized colloids and indocyanine green identify the same sentinel lymph nodes in oral squamous cell carcinoma

PurposeNear-infrared fluorescence imaging using indocyanine green (ICG) combined with radioactive markers has the potential to improve sentinel lymph-node (SLN) mapping in oral squamous cell carcinoma (OSCC). This study aimed to evaluate the ability of 99mTc and ICG in identifying the sentinel lymph nodes in patients with early stage OSCC.MethodsData were collected prospectively, and a retrospective analysis of 15 patients with early stage OSCC and a cN0 neck was performed. All patients received peritumoral injection of 99mTc the day before surgery and ICG was administered intraoperatively. Intentionally, the application of the two different tracers were done by two different physicians with varying degrees of experience. The number of identified lymph nodes positive for 99mTc and ICG, the overlap or possible discrepancies of both methods, and the time until fluorescence signals of ICG were detected were noted.ResultsIn all patients, a 100% agreement in sentinel lymph-node identification was achieved, regardless of both the exact location of the peritumoral injection and the experience of the injecting surgeon. Time until ICG accumulation in the sentinel lymph node was consistently found to be between 1 and 3 min.ConclusionICG constitutes a viable and useful addition to 99mTc for intraoperative sentinel lymph-node detection in this study.

The rational of Cloquet lymph node as a sentinel lymph node in iliac dissection in lower limb melanoma

Background and aims Intraoperative lymphatic mapping and sentinel lymphadenectomy (LM/SL) is a growingly popular operating procedure for staging regional lymph nodes in early-stage melanoma. The groin is a promising area for this method since superficial groin dissection and iliac dissection have a significant risk of morbidity. There is currently no consensus on how best to treat cases with tumor-positive sentinel lymph nodes (SNs) during surgery involving these basins. Methods A total of 182 cases were treated using the LM/SL method. There was consistent detection of sentinel lymph nodes. SN dissection was performed on patients who had tumor in their SN. A hematoxylin and eosin stain was used to analyze the sentinel lymph nodes. Patient selection for SN dissection was based only on the presence of tumor in that node. Computerized database containing log-rank tests and Cox regression models for statistical analysis. Results 61% of the 182 cases were female, with an average age of 50 (range, 15–89). Tumor-positive SNs were detected in 21% of cases. 67% of cases were identified to have sentinel full lymph node dissection and a single tumor-positive lymph node after LM/SL, whereas 27% had 2 tumor-positive lymph nodes and 6% had 3 or more tumor-positive lymph nodes. Recurrence in the dissected basin occurs in just 4% of individuals with tumor-negative SNs. Cases whose lymph nodes tested negative for tumors had a significantly greater 5-year overall survival (mean±SD, 94% 5%) compared with those whose lymph nodes tested positive for tumors (meanSD, 75% 4%; P 0.01). Primary tumor thickness (P = 0.03), Tumor-positive SN (P 0.001) and ulceration (P = 0.001) were revealed to be important indicators of survival in multivariate studies using a Cox regression model. Conclusions This surgical treatment ought to become common for cases with early-stage melanoma of the lower extremities and trunk because the accuracy of LM/SL as judged by the infrequent recurrences implies that it should. When a tumor-positive SN is found in the groin, it is important to take a sample from the Cloquet node so that one may decide whether or not an iliac dissection is necessary.

Радионуклидная диагностика сторожевых лимфатических узлов при опухолях молочной железы с радиофармацевтическим лекарственным препаратом на основе меченого технецием-99m гамма-оксида алюминия

Аim: To analyze the results of radionuclide diagnostics of sentinel lymph nodes (SLN) in patients with breast cancer (BC) with the radiotracer Sentiscan, 99mTc (manufacturer “MedicorPharma-Ural”) using the multimodal SPECT/CT at the stage of visualization. Material and methods: The study was retrospective, it included 48 patients with BC with clinical stage T2-3N0M0, who underwent radionuclide diagnostics of SLN and SPECT/CT was performed at the imaging stage. The images were evaluated visually, the intensity of the radiotracer accumulation in the lymph nodes (LN) was analyzed, SUVmax was used as a quantitative parameter. Intraoperative detection of SLN with subsequent histological examination was also carried out with the calculation of the level of the radiotracer accumulation. Results: On tomoscintigrams, LNs were visualized in 43 patients out of 48, intraoperatively ‒ in 46 cases, in 2 patients, accumulation of the radiotracer in the LN projection was noted neither according to SPECT/CT, nor intraoperatively. When analyzing the intensity of the radiotracer accumulation according to SPECT/CT data, a rather large scatter of SUVmax‒35 [10‒104]. Sentinel were considered LNs with the level of the radiotracer accumulation in them of at least 10 % of the most intense node. According to SPECT/CT data, 165 lymph nodes were identified, the average number of lymph nodes detected in one patient was 2 [1‒3], the maximum number was 6 lymph nodes. In all patients, the lymph nodes were determined in the projection of the 1st level, in 25 cases ‒ in the projection of other zones of regional lymphatic outflow. The total number of lymph nodes removed during surgery was n=247, on average 3 [2‒5] lymph nodes were removed in one patient, with a maximum of 8 nodes. Conclusion: The sensitivity of radionuclide diagnostics of SLN with Sentiscan, 99mTc was 89.6 % according to SPECT/CT and 95.8 % according to the results of intraoperative detection. The use of multimodal imaging provides information on the exact anatomical localization of the lymph nodes. In the absence of scintigraphic visualization of the radiotracer redistribution in the lymphatic collector, intraoperative detection does not lose its relevance.

Sentinel lymph node detection in thyroid carcinoma using [68Ga]Ga-tilmanocept PET/CT: a proof-of-concept study

PurposeSentinel lymph node (SLN) biopsy is rarely used for thyroid carcinoma staging. This is due to challenges associated with conventional Tc-99m-labeled tracers, often producing a large hotspot at the injection site, potentially hiding nearby SLNs (shine-through effect). The aim of this study was to demonstrate the feasibility and effectiveness of SLN visualization using the new PET tracer [68Ga]Ga-tilmanocept.MethodsPatients with thyroid carcinoma underwent ultrasound-guided peritumoral injection of [68Ga]Ga-tilmanocept and ICG-[99mTc]Tc-nanocolloid. [68Ga]Ga-tilmanocept PET/CT scans were conducted at 15 min and 60 min post-injection to visualize the SLNs. SLN biopsy was performed using ICG-[99mTc]TC-nanocolloid for intraoperative identification. The corresponding lymph node level was resected for reference.ResultsSeven differentiated thyroid carcinoma (DTC) and 3 medullary thyroid carcinoma (MTC) patients were included, of which 6 were clinically node-negative. The median number of SLNs detected on [68Ga]Ga-tilmanocept PET/CT and resected was 3 (range 1–4) and 3 (range 1–5), respectively. Eight SLNs were found on PET/CT in the central compartment and 19 in the lateral compartment. The SLN procedure detected (micro)metastases in all patients except one. Seventeen of 27 pathologically assessed SLNs were positive, 8 negative, and 2 did not contain lymph node tissue, which led to upstaging in 5 out of 6 clinically node-negative patients.Conclusions[68Ga]Ga-tilmanocept PET/CT identified SLNs in all patients, mainly in the lateral neck. The SLNs were successfully surgically detected and resected using ICG-[99mTc]Tc-nanocolloid. This technique has the potential to improve neck staging, enabling more personalized treatment of thyroid cancer according to the lymph node status.Trial registration2021–002470-42 (EudraCT).

The Magnetic Technique-A Novel and Promising Method to Improve Axillary Staging Localisation from a Swedish Perspective.

The magnetic technique using superparamagnetic nanoparticles of iron oxide has been well established for sentinel lymph node detection. Its main advantage is in the context of logistics, with the possibility to inject several weeks before surgery and the possibility to give access to sentinel lymph node biopsy for women worldwide in places without nuclear medicine facilities. We have not yet seen the full potential of this technique, and new implications have been developed for breast tumour localisation with paramagnetic clips and axillary staging after neoadjuvant chemotherapy using paramagnetic clips inserted in lymph node metastases before chemotherapy. In this report, we have presented our experience of the magnetic technique starting in 2014, and we have highlighted our current and future research directions.

Predictors of Non-Sentinel Lymph Node Metastasis in Patients with Positive Sentinel Lymph Node in Early-Stage Cervical Cancer: A SENTICOL GROUP Study.

The goal of this study was to identify the risk factors for metastasis in the remaining non-sentinel lymph nodes (SLN) in the case of positive SLN in early-stage cervical cancer. An ancillary analysis of two prospective multicentric databases on SLN biopsy for cervical cancer (SENTICOL I and II) was performed. Patients with early-stage cervical cancer (FIGO 2018 IA to IIA1), with bilateral SLN detection and at least one positive SLN after ultrastaging, were included. 405 patients were included in SENTICOL I and Il. Fifty-two patients had bilateral SLN detection and were found to have SLN metastasis. After pelvic lymphadenectomy, metastatic involvement of non-SLN was diagnosed in 7 patients (13.5%). Patients with metastatic non-SLN were older (51.9 vs. 40.8 years, p = 0.01), had more often lympho-vascular space invasion (LVSI) (85.7% vs. 35.6%, p = 0.03), and had more often parametrial involvement (42.9% vs. 6.7%, p = 0.003). Multivariate analysis retained age (OR = 1.16, 95% IC = [1.01-1.32], p = 0.03) and LVSI (OR = 25.97, 95% IC = [1.16-582.1], p = 0.04) as independently associated with non-SLN involvement. Age and LVSI seemed to be predictive of non-SLN metastasis in patients with SLN metastasis in early-stage cervical cancer. Larger cohorts are needed to confirm the results and clinical usefulness of such findings.

Performance of a Nonlinear Magnetic Handheld Probe for Intraoperative Sentinel Lymph Node Detection: A Phantom Study

ObjectiveThis study investigates the performance of the DiffMag handheld probe (nonlinear magnetometry), to be used for sentinel lymph node detection. Furthermore, the performance of DiffMag is compared with a gamma probe and a first-order magnetometer (Sentimag®, linear magnetometry).MethodsThe performance of all three probes was evaluated based on longitudinal distance, transverse distance, and resolving power for two tracer volumes. A phantom was developed to investigate the performance of the probes for a clinically relevant situation in the floor of the mouth (FOM).ResultsConsidering the longitudinal distance, both DiffMag handheld and Sentimag® probe had comparable performance, while the gamma probe was able to detect at least a factor of 10 deeper. Transverse distances of 13, 11, and 51 mm were measured for the small tracer volume by the DiffMag handheld, Sentimag®, and the gamma probe, respectively. For the large tracer volume this was 21, 18, and 55 mm, respectively. The full width at half maximum, at 7 mm probe height from the phantom surface, was 14, 12, and 18 mm for the small tracer volume and 15, 18, and 25 mm for the large tracer volume with the DiffMag handheld, Sentimag®, and gamma probe, respectively.ConclusionsWith a high resolving power but limited longitudinal distance, the DiffMag handheld probe seems suitable for detecting SLNs which are in close proximity to the primary tumor. In this study, comparable results were shown using linear magnetometry. The gamma probe reached 10 times deeper, but has a lower resolving power compared with the DiffMag handheld probe.

A hybrid approach: a safe option for surgical treatment of early-stage cervical cancer.

The aim of the study was to describe the surgical treatment of early-stage cervical cancer (CC) via minimally invasive surgery (MIS) and a sequential hybrid approach combining MIS and mini-Pfannenstiel. Evaluate sentinel lymph node (SLN) detection using a hybrid tracer (ICG-99m Tc nanocolloid). Prospective, observational, descriptive, single-center study conducted at Son Espases University Hospital between January 2019 and September 2021. Patients with early-stage CC (FIGO 2018 IA1 with ILV-IIA1) who underwent surgical treatment with a follow-up of at least one year were included. Thirty early-stage CC patients were included, of whom four (13.3%) were upstaged due to positive SLNs. In these cases, laparotomy was avoided, and paraaortic lymphadenectomy was performed via MIS approach. Twenty-six patients had a radical hysterectomy: 15 underwent a hybrid approach, 10 laparoscopy, and one laparotomy. Patients undergoing laparoscopic surgery had a smaller estimated tumor size than those undergoing the hybrid approach. The overall SLN detection rate was 96.1%, with 88.5% of cases occurring bilaterally. Five out of 26 patients (19.2%) presented SLN macrometastases, and five (19.2%) had atypical drainage. Surgery refined staging in 33.3% (10/30) of cases. No recurrences were reported after an average follow-up of 32 months. MIS for SLN avoids laparotomy leading to rapid recovery and early adjuvant treatment initiation in nodal metastasis. In our study, tumor size is an important clinical implication in the surgical approach to be used. The hybrid tracer provided a high detection rate and combined the advantages of the two tracers. The hybrid approach has a quick recovery and optimal results.

Indocyanine green guided sentinel lymph node biopsy may have a high sensitivity for early (T1/T2) colon cancer: A prospective study in Indian patients.

Indocyanine green (ICG) dye guided near infrared fluorescence (NIR) imaging is a promising tool for mapping lymphatics. The aim of this study was to evaluate the role of ICG guided SLN biopsy in Indian colon cancer patients. Forty-eight patients of clinically staged T1-T3 node negative colon cancer underwent laparoscopic/open resection. Patients received colonoscopic peritumoral submucosal ICG injections for laparoscopic (n= 32) and subserosal injections for open resections (n= 16) followed by the detection of SLN using NIR camera. SLNs underwent conventional hematoxylin and eosin (H & E) staging with additional serial sectioning and immunohistochemistry for pancytokeratin antibody (ultra-staging). Detection rate and upstaging rate were the primary end points. Forty-eight patients were recruited. An average of 2.08 ± 1.27 SLNs were identified in 45 patients at a mean time of 8.2 ± 3.68 minutes with a detection rate of 93.75%. Mean age and mean BMI were 59.7 ± 12.54 years and 24.8 ± 4.09 kg/m2 , respectively. Eighteen patients had node positive disease, and SLN was false negative in four of these patients resulting in a sensitivity of 77.77% with a trend towards higher sensitivity for T1-T2 tumours (90% vs. 62.5%, p= 0.068). Upstaging rate was 10%. Negative predictive value (NPV) and accuracy of the procedure were 87.09% and 91.11%, respectively. ICG guided SLN biopsy can identify metastatic lymph nodes in colon cancer patients that can be missed on H & E staging with relatively higher sensitivity for early (T1/T2) tumours.

The use of Indocyanine Green (ICG) for sentinel lymph node detection in vulvar cancer (175)

The use of Indocyanine Green (ICG) for sentinel lymph node detection in vulvar cancer (175)

Role of Nuclear Sentinel Lymph Node Mapping Compared to New Alternative Imaging Methods.

With the emergence of sentinel node technology, many patients can be staged histopathologically using lymphatic mapping and selective lymphadenectomy. Structural imaging by using US, CT and MR permits precise measurement of lymph node volume, which is strongly associated with neoplastic involvement. Sentinel lymph node detection has been an ideal field of application for nuclear medicine because anatomical data fails to represent the close connections between the lymphatic system and regional lymph nodes, or, more specifically, to identify the first draining lymph node. Hybrid imaging has demonstrated higher accuracy than standard imaging in SLN visualization on images, but it did not change in terms of surgical detection. New alternatives without ionizing radiations are emerging now from "non-radiological" fields, such as ophthalmology and dermatology, where fluorescence or opto-acoustic imaging, for example, are widely used. In this paper, we will analyze the advantages and limits of the main innovative methods in sentinel lymph node detection, including innovations in lymphoscintigraphy techniques that persist as the gold standard to date.