Sentinel Lymph Node Detection Rate Research Articles

Comparison of SPECT-CT with intraoperative mapping in cervical and uterine malignancies

IntroductionThe objective was to evaluate whether hybrid imaging combining single photon emission tomography with computed tomography (SPECT/CT) provides additional clinical value for dectection of sentinel lymph nodes (SLNs) compared with...

Abstract PS1-52: A prospective comparison of skin staining after sentinel lymph node biopsy, using blue ink (PB) and superparamagnetic iron oxide nanoparticles (SPIO) tracers

Abstract Background: Superparamagnetic iron oxide (SPIO) nanoparticles is a magnetic sentinel lymph node (SN) tracer. Since no radioisotope (technetium, Tc99) is used, there is no need for a nuclear medicine department. Compared to the use of Patent Blue V® (PB), no allergic reactions have been reported so far. However, a long lasting skin staining has been observed. We compared skin staining in women who were injected with both SPIO (MagTrace®) and PB. Methods: SPIO, Tc99 and PB were injected in all women in the SentiDose study (2017-2019), a SPIO dose optimizing trial, including six Swedish hospitals. For PB, a 1.0ml sub/intradermal, peri-areolar injection was administred. For SPIO either a 1.5ml retro-areolar (Cohort 1.5, n=163) or a 1.0ml peri-tumoral (Cohort 1.0, n=164) interstitial injection was administred. Staining was assessed by telephone interviews at 6, 12 and 24 months post surgery, and mean size calculations only included women with a stain. Mastectomy cases (n=63) were excluded from the analysis. SN detection rates will be reported elsewhere. Results: In Cohort 1.5, 27.7% (33/119) of the women had a SPIO stain and 25.2% (30/119) a PB stain at 6 months (p=0.66). The mean stain sizes were 13.4 and 9.1cm2 (p=0.16), respectively. At 12 months, 20.8% still had a SPIO stain and 17.6% a PB stain (p=0.91), with mean sizes of 4.1 and 3.7 cm2 (p=0.73), respectively. At 24 months, from the 11 women followed so far, all 3 with an earlier SPIO stain and 7 of 8 with an earlier PB stain are now stain free. In Cohort 1.0, 16.5% (25/145) had a SPIO stain and 16.9% (24/139) had a PB stain at 6 months (p=0.94). The mean stain sizes were 11.8 and 8.4 cm2 (p=0.42), respectively. Nine women were not injected with PB. After 12 months, 15.9% still had a SPIO stain and 12.4% a PB stain (p=0.42). The mean sizes were 5.1 and 2.6 cm2 (p=0.99), respectively. Comparing all women at 6 months, 22.0% had a SPIO stain and 20.5% a PB stain (p=0.12) with mean sizes 12.5 and 8.6 cm2 (p=0.83), respectively. At 12 months, 17.8% had a residual SPIO stain and 14.9% a PB stain (p=0.37) with mean sizes 4.6 and 3.3 cm2 (p=0.16), respectively. The difference in incidence of SPIO staining between Cohort 1.5 and Cohort 1.0 was statistically significant at 6 months, but not at 12 months, 27.7% vs. 16.5%, (p=0.04) and 20.8% vs 15.9% (p=0.28), respectively. The difference in SPIO stain sizes between the cohorts was neither significant at 6 months, 13.4 vs 11.8 cm2(p=0.61) nor at 12 months, 4.1 vs 5.1 cm2 (p=0.30). Conclusion: No statistically significant differences in incidence or stain size were observed between SPIO and PB. The 2-year follow up will be completed during 2021. The 1.0ml compared to 1.5ml SPIO dose, resulted in fewer but equally large stains at 6 months, but there was no difference at 1 year. Table 1. Skin staining after SPIO and Patent Blue (PB) for sentinel lymph node detectionTracerStaining/SizeStaining/Size6 months12 monthsSPIO 1.5ml, n=11927.7%/13.4cm220.8%/4.1cm2SPIO 1.0ml, n=14516.5%/11.8 cm215.9%/5.1 cm2PB, n=25820.5%/8.6 cm214.9%/3.3 cm2 Citation Format: Madeleine Warnberg, Andreas Karakatsanis, Fredrik Nilsson, Christine Obondo, Lida Pistiolis, Imad Mohammad, Carlos Dussan Luberth, Staffan Eriksson, Abdi-Fatah Hersi, Fredrik Wärnberg. A prospective comparison of skin staining after sentinel lymph node biopsy, using blue ink (PB) and superparamagnetic iron oxide nanoparticles (SPIO) tracers [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-52.

Optimizing Dose and Timing in Magnetic Tracer Techniques for Sentinel Lymph Node Detection in Early Breast Cancers: The Prospective Multicenter SentiDose Trial.

Simple SummarySuperparamagnetic iron oxide (SPIO) nanoparticles have comparable performance to the combination of radioisotope and blue dye (RI + BD) for sentinel lymph node (SLN) biopsy in breast cancer. In this multicenter prospective study, lower SPIO doses (undiluted 1.5 vs. 1.0 mL) in different timeframes (perioperative vs. 1–7 days preoperative) and injection sites (subareolar vs. peritumoral) were compared to the previous standard (diluted 2.0 mL perioperatively) from the earlier Nordic trial. RI + BD were co-administered as background. In total, 534 patients were analyzed. SPIO SLN detection rates were similar (97.5% vs. 100% vs. 97.6%, p = 0.11) and respectively non-inferior to the dual technique. Significantly more SLNs were retrieved in the preoperative 1.0 mL cohort compared with 1.5 mL and the Nordic cohorts (2.18 vs. 1.85 vs. 1.83, p = 0.003). Thus, SPIO at 1.5 and 1.0 mL was non-inferior to both Sienna+® and the dual technique for SLN detection.Superparamagnetic iron oxide nanoparticles (SPIO) are non-inferior to radioisotope and blue dye (RI + BD) for sentinel lymph node (SLN) detection. Previously, 2 mL SPIO (Sienna+®) in 3 mL NaCl was used. In this dose-optimizing study, lower doses of a new refined SPIO solution (Magtrace®) (1.5 vs. 1.0 mL) were tested in different timeframes (0–24 h perioperative vs. 1–7 days preoperative) and injections sites (subareolar vs. peritumoral). Two consecutive breast cancer cohorts (n = 328) scheduled for SLN-biopsy were included from 2017 to 2019. All patients received isotope ± blue dye as back-up. SLNs were identified primarily with the SentiMag® probe and thereafter a gamma-probe. The primary endpoint was SLN detection rate with SPIO. Analyses were performed as a one-step individual patient-level meta-analysis using patient-level data from the previously published Nordic Trial (n = 206) as a third, reference cohort. In 534 patients, the SPIO SLN detection rates were similar (97.5% vs. 100% vs. 97.6%, p = 0.11) and non-inferior to the dual technique. Significantly more SLNs were retrieved in the preoperative 1.0 mL cohort compared with 1.5 and the 2.0 mL cohorts (2.18 vs. 1.85 vs. 1.83, p = 0.003). Lower SPIO volumes injected up to 7 days before the operation have comparable efficacy to standard SPIO dose and RI + BD for SLN detection.

Sentinel node mapping using indocyanine green and near-infrared fluorescence imaging technology for endometrial cancer: A prospective study using a surgical algorithm in Indian patients.

Background:Indocyanine green (ICG) fluorescence with high-definition, three-dimensional imaging systems is emerging as the latest strategy to reduce trauma and improve surgical outcomes during oncosurgery.Materials and Methods:This is a prospective study involving 100 patients with carcinoma endometrium who underwent robotic-assisted Type 1 pan-hysterectomy, with ICG-directed sentinel lymph node (SLN) biopsy from November 2017 to December 2019. The aim was to assess the feasibility and diagnostic accuracy of SLN algorithm and to evaluate the location and distribution of SLN in pelvic, para-aortic and unusual areas and the role of frozen section.Results:The overall SLN detection rate was 98%. Bilateral detection was possible in 92% of the cases. Right side was detected in 98% of the cases and left side was visualised in 92% of the cases. Complete node dissection was done where SLN mapping failed. The most common location for SLN in our series was obturator on the right hemipelvis and internal iliac on the left hemipelvis. SLN in the para-aortic area was detected in 14% of cases. In six cases, SLN was found in atypical locations, that is pre-sacral area. Eight patients had SLN positivity for metastasis and underwent complete retroperitoneal lymphadenectomy. Comparison of final histopathological report with frozen section reports showed no false negatives.Conclusions:SLN mapping holds a great promise as a modern staging strategy for endometrial cancer. In our experience, cervical injection was an optimal method of mapping the pelvis. ICG showed a high overall detection rate, and bilateral mapping appears to be a feasible alternative to the more traditional methods of SLN mapping in patients with endometrial cancer. The ICG fluorescence imaging system is simple and safe and may become a standard in oncosurgery in view of its staging and anatomical imaging capabilities. This approach can reduce the morbidity, operative times and costs associated with complete lymphadenectomy while maintaining prognostic and predictive information.

Methylene Blue as Inexpensive and Reliable Sole Sentinel Lymph Node Mapping Agent for Patients with Invasive Ductal Carcinoma.

Background:Invasive ductal cancer (IDC) represents about 75% of all breast malignancies. There are many breast cancer prognostic factors, but the ones that have the most impact on the survival rates in advanced breast cancer are tumor size and regional lymph node involvement. Axillary lymph node dissection (ALND) has particularly important and undoubtful role in current surgical options for breast cancer treatment. With the introduction of sentinel lymph node biopsy (SLNB) for breast cancer patients it was possible to identify those to whom regional spread of the disease did not occur at the time of surgery, and thus spare them an unnecessary ALND procedure.Objective:To determine the rate of sentinel lymph node (SLN) detection using only methylene blue dye as a mapping agent, as well as to correlate the number of positive SLNs with the number of positive non-sentinel lymph nodes (non-SLNs).Methods:The study represents a prospective study that included 50 female patients with histologically confirmed invasive ductal carcinoma (IDC) who underwent SLNB using only methylene blue dye as the mapping agent, while the detection and harvest of SNL was done by visual control only. All patients also underwent an obligatory complete ALND, which was as that time the institutional oncological protocol for surgical treatment of histologically confirmed IDC. The final data such as tumor size, SLN and non-SLN status were obtained by further analysis of pathohistological reports from tumor biopsy and other surgical specimens.Results:The accuracy rate of SLN detection was 98%. The number of detected SLN was in the range of 1 to 6, with an average of 2 for each patient. The number of positive SLN was in significant correlation with the number of tumor-affected non-SNL (p<0,001). Further analysis showed that for each increase in the number of positive SLN by 1, the risk of positive non-SLN increased 6-fold, OR=6,22 (p<0,001).Conclusion:Use of methylene blue dye as a sole mapping agent when performing SLNB in patients with IDC is a reliable and effective method that can be safely implemented in medical institutions that lack availability of nuclear medicine services or significant monetary funds.

Paraaortic sentinel lymph node detection in intermediate and high-risk endometrial cancer by transvaginal ultrasound-guided myometrial injection of radiotracer (TUMIR).

ObjectiveWe aimed to evaluate the accuracy of sentinel lymph node (SLN) mapping with transvaginal ultrasound-guided myometrial injection of radiotracer (TUMIR) to detect lymph node (LN) metastases, in patients with intermediate and high-risk endometrial cancer (EC), focusing on its performance to detect paraaortic involvement.MethodsProspective study including women with preoperative intermediate or high-risk EC, according to ESMO-ESGO-ESTRO consensus, who underwent SLN mapping using the TUMIR approach. SLNs were preoperatively localized by planar and single photon emission computed tomography/computed tomography images, and intraoperatively by gamma-probe. Immediately after SLN excision, all women underwent systematic pelvic and paraaortic lymphadenectomy by laparoscopy.ResultsThe study included 102 patients. The intraoperative SLN detection rate was 79.4% (81/102). Pelvic and paraaortic drainage was observed in 92.6% (75/81) and 45.7% (37/81) women, respectively, being exclusively paraaortic in 7.4% (6/81). After systematic lymphadenectomy, LN metastases were identified in 19.6% (20/102) patients, with 45.0% (9/20) showing paraaortic involvement, which was exclusive in 15.0% (3/20). The overall sensitivity and negative predictive value (NPV) of SLNs by the TUMIR approach to detect lymphatic involvement were 87.5% and 97.0%, respectively; and 83.3% and 96.9%, for paraaortic metastases. After applying the MSKCC SLN mapping algorithm, the sensitivity and NPV were 93.8% and 98.5%, respectively.ConclusionThe TUMIR method provides valuable information of endometrial drainage in patients at higher risk of paraaortic LN involvement. The TUMIR approach showed a detection rate of paraaortic SLNs greater than 45% and a high sensitivity and NPV for paraaortic metastases in women with intermediate and high-risk EC.

Minimally Invasive Surgery and Sentinel Lymph Node Biopsy – a Modern Standart of Uterine Confined Endometrial Cancer Treatment: Reviewing Literature and Presenting the National Cancer Institute Experience

Objectives. To find out sentinel lymph node detection rate of low-risk endometrial cancer patients. To compare postoperative complications rate, lenght of a surgery, lenght of hospital stay and sensitivity of detecting lymph node metastasis between minimally invasive surgery with sentinel lymph node biopsy and abdominal surgery with systemic pelvic lymphadenectomy. Methods. Retrospective analysis of low-risk endometrial cancer patients, treated in National Cancer Institute (n = 103) history cases from 2018 10 untill 2019 12. I group – laparoscopic hysterectomy with sentinel lymph node biopsy (n = 35); II group – abdominal hysterectomy with systemic pelvic lymphadenectomy (n = 68). Both groups were homogeneous according to clinicopathological features. Results. Sentinel lymph node were detected in 97.1% cases. Sentinel lymph nodes in both sides were detected in 85.7% cases. Metastasis in regional lymph nodes were detected in 2 cases (5.7%) in group I and none group II. Postoperative complications rate in group I were 3.8% and 13% in group II. Conclusions. There are significantly less postoperative complications in endoscopic surgery with sentinel node biopsy for low-risk endometrial cancer treatment, also this method is more accurate in surgical staging in National Cancer Institute.

Anatomic Asymmetry in Sentinel Lymph Node Detection in Endometrial Cancer

To determine whether the concomitant use of indocyanine green (ICG) with technetium-99m-filtered sulfur colloid (Tc99m-FSC) improves bilateral sentinel lymph node (SLN) detection rate in endometrial cancer and whether anatomic concordance of pelvic lymph nodes exists and can be used to predict SLN location in cases of unilateral mapping failure. Retrospective cohort study. Tertiary academic medical center in Holon, Israel. Patients diagnosed with endometrial cancer, who underwent SLN mapping with Tc99m-FSC, ICG, or both, at our center between 2014 and 2019. A total of 111 patients were included in the study. SLN mapping using Tc99m-FSC was performed in 101 (91.9%) patients, and ICG injection was given to 64 (57.6%) patients of whom 55 (49.5%) received both. We compared SLN detection rates (unilateral and bilateral) and anatomic symmetry for each method alone and for a combination of the 2. The overall detection rate for unilateral SLNs was 96.4%; 96.9% with ICG, 93.1% with gamma-probe, and 98.2% by combining both methods. The total bilateral detection rate was 72.1%, with ICG performing better as a single tracer than Tc99m-FSC (75% vs 63.4%, respectively). In 55 women in whom both tracers were used, the bilateral detection rate was significantly higher compared with Tc99m-FSC alone. Symmetric pelvic anatomic concordance of SLN was found in only 35 of 80 patients with bilateral SLN detection (43.8%). The combination of preoperative radioisotope injection and intraoperative ICG administration may yield the best bilateral SLN detection rate. In cases of unilateral mapping failure, one cannot rely on the anatomic location of the ipsilateral SLN detected to harvest the complementary node because the symmetric concordance is poor.

Magnetic resonance-guided ROLL/SNOLL in breast cancer patients treated with neoadjuvant chemotherapy

PurposeTo describe the results of MRI (Magnetic Resonance Image) guided ROLL (Radioguided Occult Lesion Localization) and SNOLL (Sentinel Node Occult Lesion Localization) in the localization of residual disease after neoadjuvant chemotherapy for breast cancer, as well as assessing the surgical results obtained and disease free survival. MethodsProspective observational analysis of 132 patients with 136 tumors, treated with neoadjuvant chemotherapy at our Hospital between 2011−2017. Residual disease was localized with MRI guided ROLL/SNOLL technique. We analyzed technical aspects of localization, and variables corresponding to surgical procedures and events occurred during follow-up. ResultsThe median tumor size was of 20,5mm (Interquartilic Range (IQR): 14−28). The majority (96,3%) were invasive ductal carcinomas. Sentinel lymph node detection rate was 98,9%. Complete pathological response (CPR) in the breast was achieved in 58,1% of cases. The rate of affected margins in 89 cases operated by conservative surgery was 2,2%. With a median follow-up of 50 months (IQR: 37–61) we found a 7,4% rate of relapses. Of these, 7 were loco-regional and 3 at distant sites. The estimated mean of disease-free survival time was 83,2 months (Confidence Interval (CI) 95%: 79.6–86,6). ConclusionsMRI guided ROLL/SNOLL is a great tool for breast cancer residual disease localization following neoadjuvant chemotherapy. In addition, this technique attains good loco-regional control of the diseases and has excellent surgical results.

MR lymphography with superparamagnetic iron oxide for sentinel lymph node mapping of N0 early oral cancer: A pilot study.

The purpose of this pilot study was to evaluate the usefulness of magnetic resonance lymphography (MRL) with superparamagnetic iron oxide (SPIO) in sentinel lymph node (SLN) mapping of clinically N0 early oral cancer, and to conduct a comparative study of this MRL with CT lymphography (CTL). CTL and MRL were performed for SLN mapping before surgery for 20 patients with clinically N0 early oral cancer. The detection rate, number, and location of SLNs in CTL and MRL were evaluated. Furthermore, optimal scanning/imaging timing in MRL was examined. SLNs were detected by CTL in 18 (90%) patients, and the total and mean number of SLN were 35 and 1.8, respectively. All SLNs could be detected 2 min and 3.5-5 min after contrast medium injection. In all patients, SLNs were detected by MRL at 10 min after SPIO injection, and the total and mean number of SLN was 53 and 2.7, respectively. MRL at 30 min after the injection showed additional 18 secondary lymph nodes. MRL with SPIO is safe and useful imaging for the detection of SLNs in clinically N0 early oral cancer, and the optimal imaging timing is 10 min after SPIO injection.

A DROP-IN Gamma Probe for Robot-assisted Radioguided Surgery of Lymph Nodes During Radical Prostatectomy

BackgroundThe DROP-IN gamma probe was introduced to overcome the restricted manoeuvrability of traditional laparoscopic gamma probes. Through enhanced manoeuvrability and surgical autonomy, the DROP-IN promotes the implementation of radioguided surgery in the robotic setting. ObjectiveTo confirm the utility and safety profile of the DROP-IN gamma probe and to perform a comparison with the traditional laparoscopic gamma probe and fluorescence guidance. Design, setting, and participantsTwenty-five prostate cancer patients were scheduled for a robot-assisted sentinel lymph node (SN) procedure, extended pelvic lymph node dissection, and prostatectomy at a single European centre. Surgical procedureAfter intraprostatic injection of indocyanine green (ICG)-99mTc-nanocolloid (n = 12) or 99mTc-nanocolloid + ICG (n = 13), SN locations were defined using preoperative imaging. Surgical excision of SNs was performed under image guidance using the DROP-IN gamma probe, the traditional laparoscopic gamma probe, and fluorescence imaging. MeasurementsIntraoperative SN detection was assessed for the different modalities and related to anatomical locations. Patient follow-up was included (a median of 18 mo). Results and limitationsOverall, 47 SNs were pursued in vivo by the DROP-IN gamma probe, of which 100% were identified. No adverse events related to its use were observed. In vivo fluorescence imaging identified 91% of these SNs. The laparoscopic gamma probe identified only 76% of these SNs, where the detection inaccuracies appeared to be related to specific anatomical regions. ConclusionsOwing to improved manoeuvrability, the DROP-IN probe yielded improved SN detection rates compared with the traditional gamma probe and fluorescence imaging. These findings underline that the DROP-IN technology provides a valuable tool for radioguided surgery in the robotic setting. Patient summaryRadioguided robot-assisted surgery with the novel DROP-IN gamma probe is feasible and safe. It enables more efficient intraoperative identification of sentinel lymph nodes than can be achieved with a traditional laparoscopic gamma probe. The use of the DROP-IN probe in combination with fluorescence imaging allows for a complementary optical confirmation of node localisations.

ROLL/SNOLL guiado por resonancia magnética en pacientes con cáncer de mama tratadas con quimioterapia neoadyuvante

PurposeTo describe the results of MRI (magnetic resonance image) guided ROLL (radioguided occult lesion localization) and SNOLL (sentinel node occult lesion localization) in the localization of residual disease after neoadjuvant chemotherapy for breast cancer, as well as assessing the surgical results obtained and disease free survival. MethodsProspective observational analysis of 132 patients with 136 tumors, treated with neoadjuvant chemotherapy at our hospital between 2011-2017. Residual disease was located presurgically with MRI guided ROLL/SNOLL technique. We analyzed technical aspects of localization, and variables corresponding to surgical procedures and events occurred during follow-up. ResultsThe median tumor size was of 20.5mm (interquartilic range [IQR]: 14-28). The majority (96.3%) were invasive ductal carcinomas. Sentinel lymph node detection rate was 98.9%. Complete pathological response (CPR) in the breast was achieved in 58.1% of cases. The rate of affected margins in 89 cases operated by conservative surgery was 2.2%. With a median follow-up of 50 months (IQR: 37-61) we found a 7.4% rate of relapses. Of these, seven were loco-regional and three at distant sites. The estimated mean of disease-free survival time was 83.2 months (Confidence Interval [CI] 95%: 79.6-86.6). ConclusionsMRI guided ROLL/SNOLL is a great tool for breast cancer residual disease localization following neoadjuvant chemotherapy. In addition, this technique attains good loco-regional control of the diseases and has excellent surgical results.

Assessment of Sentinel Lymph Node Biopsy vs Lymphadenectomy for Intermediate- and High-Grade Endometrial Cancer Staging

Whether sentinel lymph node biopsy (SLNB) can replace lymphadenectomy for surgical staging in patients with high-grade endometrial cancer (EC) is unclear. To examine the diagnostic accuracy of, performance characteristics of, and morbidity associated with SLNB using indocyanine green in patients with intermediate- and high-grade EC. In this prospective, multicenter cohort study (Sentinel Lymph Node Biopsy vs Lymphadenectomy for Intermediate- and High-Grade Endometrial Cancer Staging [SENTOR] study), accrual occurred from July 1, 2015, to June 30, 2019, with early stoppage because of prespecified accuracy criteria. The study included patients with clinical stage I grade 2 endometrioid or high-grade EC scheduled to undergo laparoscopic or robotic hysterectomy with an intent to complete staging at 3 designated cancer centers in Toronto, Ontario, Canada. All patients underwent SLNB followed by lymphadenectomy as the reference standard. Patients with grade 2 endometrioid EC underwent pelvic lymphadenectomy (PLND) alone, and patients with high-grade EC underwent PLND and para-aortic lymphadenectomy (PALND). The primary outcome was sensitivity of the SLNB algorithm. Secondary outcomes were additional measures of diagnostic accuracy, sentinel lymph node detection rates, and adverse events. The study enrolled 156 patients (median age, 65.5 years; range, 40-86 years; median body mass index [calculated as weight in kilograms divided by height in meters squared], 27.5; range, 17.6-49.3), including 126 with high-grade EC. All patients underwent SLNB and PLND, and 101 patients (80%) with high-grade EC also underwent PALND. Sentinel lymph node detection rates were 97.4% per patient (95% CI, 93.6%-99.3%), 87.5% per hemipelvis (95% CI, 83.3%-91.0%), and 77.6% bilaterally (95% CI, 70.2%-83.8%). Of 27 patients (17%) with nodal metastases, 26 patients were correctly identified by the SLNB algorithm, yielding a sensitivity of 96% (95% CI, 81%-100%), a false-negative rate of 4% (95% CI, 0%-19%), and a negative predictive value of 99% (95% CI, 96%-100%). Only 1 patient (0.6%) was misclassified by the SLNB algorithm. Seven of 27 patients with node-positive cancer (26%) were identified outside traditional PLND boundaries or required immunohistochemistry for diagnosis. In this prospective cohort study, SLNB had acceptable diagnostic accuracy for patients with high-grade EC at increased risk of nodal metastases and improved the detection of node-positive cases compared with lymphadenectomy. The findings suggest that SLNB is a viable option for the surgical staging of EC.

Sentinel Lymph Node Biopsy for Early Stage Endometrial and Cervical Cancer Performed By Surgeons in Training

Study Objective The aim of this study was to evaluate the results of the sentinel lymph node (SLN) biopsy performed by doctors in training. Design Prospective single-armed interventional study. Setting All sequential patients treated in a referral cancer center, from 2016 to 2020. IRB approved. Patients or Participants 126 patients, over 18y.o., with a prior diagnosis of initial endometrial (EC) or cervical (CC) cancer. Interventions Patients were submitted to SLN biopsy performed by surgical oncology residents or gynecologic oncology fellows, under direct supervision of a qualified preceptor. SLN was detected with blue dye with or without scintigraphy. Measurements and Main Results Patients underwent surgery by laparotomy - 22 surgeries (17.46%), by laparoscopy - 86 (81.13%) and by robotic - 18 (16.98%). SLN detection rate was 84.1% (n=106), bilateral in 53% (n=67) and mostly in younger patients (59.7% under 60y.o., p=0.022). There was a higher failure rate (non or unilateral detection) among older than 60y.o. (p=0.0075, CI:0.1656-0.7928, OR:0.3664). Among non-smokers, there was a greater bilateral detection of LNS (60.3%), and, among smokers, more cases of detection failure (59.4%). In 3 cases, the SLN was not identified, and there were positive pelvic nodes in the lymphadenectomy. There were no cases with positive nodes at lymphadenectomy with a negative SLN (false-negative). Mean surgical time was 217min and mean blood loss 116cc. Four patients had grade 3 complications, and none died. Conclusion We have demonstrated that residents and fellows can safely perform SLN biopsy for initial CC and EC under the direct supervision of a trained surgeon. Detection rates were aligned to the literature, and there were no false negatives. Lymph node positivity, age over 60y.o. and smoking were associated with a higher SLN non-detection rate.

Sentinel Lymph Node Biopsy in Breast Cancer with 99mTc-Tilmanocept: A Multicenter Study on Real-Life Use of a Novel Tracer

99mTc-tilmanocept is a novel radiopharmaceutical for sentinel lymph node (SLN) biopsy in breast cancer. Our aim was to describe results with 99mTc-tilmanocept in a heterogeneous group of breast cancer patients scheduled for SLN biopsy. Methods: Radiotracer preparation followed the manufacturer's indications. Local protocols for SLN detection within 9 participant centers were not changed for the entire duration of the study. In total, 344 patients with T1-T4, N0-N2 breast cancer (352 lesions) were included. Superficial (intradermal or periareolar) or deep (peritumoral or intratumoral) injections were performed. The doses were adjusted depending on the scheduled time for surgery. Results: Lymphoscintigraphy was able to depict at least 1 SLN in 339 of 352 breast lesions (96.3%), and the intraoperative SLN detection rate reached 97.2%. On univariable analysis, SLN detection rates did not differ by age, clinical T or N stage, tumor location, histologic subtype, or prior neoadjuvant therapy. Lymphoscintigraphy showed higher SLN detection in patients with a normal weight (body mass index < 25) than in those who were overweight or obese (body mass index ≥ 25), at 99.2% versus 94.6%, respectively (P = 0.031). The proportion of patients with preoperative lymphoscintigraphic detection or excised SLNs was higher with superficial than deep injections. Reinjected cases were significantly lower when superficial injection was chosen first (P < 0.001). Injection site and the tumor markers human epidermal growth factor receptor 2 and estrogen receptor had an impact on preoperative SLN visualization and intraoperative localization. In 80 cases, SLN biopsy resulted in a positive lymph node. During a mean follow-up of 19 mo, no axillary recurrences were observed. Conclusion: Whatever the protocol, 99mTc-tilmanocept showed good results in a heterogeneous breast cancer population, although the best results were achieved when a superficial injection was chosen.

Hybrid Indocyanine Green–99mTc-nanocolloid for Single-photon Emission Computed Tomography and Combined Radio- and Fluorescence-guided Sentinel Node Biopsy in Penile Cancer: Results of 740 Inguinal Basins Assessed at a Single Institution

BackgroundSentinel node (SN) biopsy in penile cancer (PeCa) is typically performed using 99mTc-nanocolloid and blue dye. Recent reports suggested that the hybrid (radioactive and fluorescent) tracer indocyanine green (ICG)-99mTc-nanocolloid may improve intraoperative optical SN identification. ObjectiveThe current study aimed to confirm the reliability of ICG-99mTc-nanocolloid and to assess whether blue dye is still of added value. Design, setting, and participantsA total of 400 ≥T1G2N0 PeCa patients were staged with SN biopsy at a single European centre. SNs were preoperatively identified with lymphoscintigraphy and single-photon emission computed tomography. Intraoperatively, SNs were detected via gamma tracing, blue staining, and fluorescence imaging. Outcome measurements and statistical analysisAll patients (n=400, 740 groins) received ICG-99mTc-nanocolloid. Intraoperative SN identification rates were retrospectively evaluated. In those patients who received ICG-99mTc-nanocolloid and blue dye (n=266, 492 groins), SN visualisation rates were compared using the McNemar test. Results and limitationsIn total, 740 groins were assessed. No tracer-related (allergic) reactions were reported. All preoperatively defined SNs (n=1163) were localised intraoperatively. Of all excised SNs, 98% were detectable with gamma probe and 96% were visible with fluorescence imaging. In the analysis of the patients who received ICG-99mTc-nanocolloid and blue dye, fluorescence imaging yielded a 39% higher SN detection rate than blue dye (95% confidence interval 36–43%, p<0.001). Of the SNs that were tumour positive, 100% were intraoperatively visualised by fluorescence imaging, whereas merely 84% of the positive nodes stained blue. ConclusionsThis study confirms that ICG-99mTc-nanocolloid is a reliable SN tracer for PeCa that significantly improves optical SN detection over blue dye. Patient summaryHybrid indocyanine green (ICG)-99mTc-nanocolloid is a safe and reliable sentinel node (SN) tracer, as established in this large series of 400 penile cancer patients (740 groins). It enables accurate pre- and intraoperative SN identification and significantly improves SN detection rate compared with blue dye, without staining the surgical field or the need for an additional injection.

A cost-effectiveness analysis of sentinel lymph node detection in vulvar cancer by preoperative lymphoscintigraphy versus intraoperative detection alone

ObjectiveTo determine cost-effectiveness of preoperative lymphoscintigraphy (LSG) for detection of inguinofemoral sentinel lymph nodes (SLN). MethodWe compared the use of preoperative LSG prior to SLN excision versus omission of preoperative LSG. The two outcomes were death or survival. Costs associated with the procedure were determined by CPT code and published estimates. Cost analysis was performed using Treeage software, and incremental cost-effectiveness ratios (ICERs) were calculated. The measure of effectiveness was incremental survival benefit. ICER thresholds for considering LSG to be cost-effective were based on the value of a statistical life (VSL). ResultsUsing a baseline probability of 0.93 for finding SLN with LSG, our model estimated LSG costs were $2783.84 with 84.7% survival. Our model then estimated the cost and survival without LSG by varying the SLN detection rate. Survival was equivalent when probability of SLN detection without LSG was 0.93. If detection without LSG was >0.93, not performing LSG was the dominant strategy. Costs were equal when probability of finding SLN without LSG was 0.6. For any SLN detection without LSG below 0.6, performing LSG was the dominant strategy. Formal cost-effectiveness analysis was performed using ICERs for probabilities from 0.60 to 0.93. In this range, costs were higher with LSG, but survival was improved. As long as the incremental detection with LSG was at least 1.05% to 1.47% higher, LSG was cost-effective with ICERs below the VSL. ConclusionIn our model, LSG is cost-effective as long as it increases detection of SLN by at least 1.05–1.47%.

Laparoscopic sentinel node mapping with intracervical indocyanine green injection for endometrial cancer: the SENTIFAIL study – a multicentric analysis of predictors of failed mapping

ObjectivesLaparoscopy is commonly used for endometrial cancer treatment, and sentinel lymph node (SLN) mapping has become the standard procedure for nodal assessment. Despite the standardization of the technique, there is...

Nonliposuction Endoscopic Sentinel Lymph Node Biopsy Through the Periareolar Incision.

Background. Sentinel lymph node biopsy (SLNB) has been an alternative to axillary lymph node dissection as a standard procedure for breast cancer patients with clinically negative lymph nodes. Endoscopic technique has been developed for over 20years but remains to be mastered by a slice of surgeons. Suction and squeezing in the liposuction endoscopic procedures may increase risk of local recurrence and metastasis. In this study, we present our method of SLNB procedure through the periareolar incision which improves the shape of the breast-conserving surgery. Patients and Procedures. Twenty-eight breast cancer patients with clinically negative lymph nodes received this procedure. Methylene blue dye and technetium-99m sulfur colloid were used to be the tracker of sentinel lymph nodes (SLNs). Periareolar incision was the main surgical technique. The STORZ HD endoscopic system and some special instruments were used during the operation. Results. SLNs can be accurately located and biopsied under an endoscope without additional incisions. The SLNs detection rate, sensitivity, and false-negative rate are 88%, 80%, and 11.1%, respectively. And, the complications such as paresthesia and upper limb lymphedema are similar compared with traditional breast-conserving surgery (10.7% vs 9.8% and 7.1% vs 7.8%). Conclusion. Endoscopic technique can be used to accurately assess the status of SLNs in patients with breast cancer. Nonliposuction endoscopic breast-conserving surgery is one of the safe and alternative surgical procedures for early breast cancer.

Superparamagnetic iron oxide: a novel tracer for sentinel lymph node detection in vulvar cancer

ObjectivesSuperparamagnetic techniques for sentinel lymph node (SLNs) biopsy in breast cancer is well recognized but remains novel in the literature in relation to early stage vulvar cancer. The aim of...