Endoscopic Sentinel Node Biopsy Research Articles

Efficacy of vaginal natural orifice transluminal endoscopic sentinel lymph node biopsy for endometrial cancer: a prospective multicenter cohort study.

Natural orifice transluminal endoscopic surgery (NOTES) is performed increasingly often despite the lack of high-quality evidence confirming its safety, especially for malignant diseases. The aim of this prospective study is to verify that vaginal NOTES (vNOTES) can be performed safely and effectively in early endometrial cancer staging surgery. This prospective study was conducted in two tertiary hospitals in southern China from January 2021 to May 2022. A total of 120 patients with stage I endometrial cancer were included. vNOTES or multiport laparoscopic staging surgery was selected according to each patient's wishes. The primary outcome was the sentinel lymph node detection rate, analyzed by a noninferiority test. The secondary outcomes were perioperative outcomes. Among the 120 patients enrolled, 57 underwent vNOTES, and 63 underwent multiport laparoscopy. The patient-specific detection rates of sentinel lymph nodes were 94.73 and 96.82% in the vNOTES and laparoscopy groups, respectively. Additionally, the bilateral detection rates were 82.46 and 84.13%, and the side-specific detection rates were 88.60 and 90.48% in these two groups, respectively. All three detection rates in the vNOTES group were noninferior to those of laparoscopy group at a noninferiority cutoff of -15%. The median operation times of the vNOTES and laparoscopy groups were 132.35 and 138.73min ( P =0.362), and the median estimated blood loss were 75 and 50ml ( P =0.096), respectively. No intraoperative complications occurred in either group. The pain scores on the Numerical Rating Scale at both 12h and 24h after operation were significantly lower in the vNOTES group ( P <0.001) and the median postoperative hospital stay was significantly shorter in the vNOTES group ( P =0.001). This study illustrates the potential applicability of vNOTES in gynecological malignancy surgery by demonstrating its safety and effectiveness in endometrial cancer staging. However, its long-term survival outcomes require further exploration.

Three-dimensional visual technique based on CT lymphography data combined with methylene blue in endoscopic sentinel lymph node biopsy for breast cancer

BackgroundThe combined application of blue dye and radioisotopes is currently the primary mapping technique used for sentinel lymph node biopsy (SLNB) in breast cancer patients. However, radiocolloid techniques have not been widely adopted, especially in developing countries, given the strict restrictions on radioactive materials. Consequently, we carried out a retrospective study to evaluate the feasibility and accuracy of three-dimensional visualization technique (3DVT) based on computed tomography-lymphography (CT-LG) in endoscopic sentinel lymph node biopsy (ESLNB) for breast cancer.MethodsFrom September 2018 to June 2020, 389 patients who underwent surgical treatment of breast cancer in our department were included in this study. The CT-LG data of these patients were reconstructed into digital 3D models and imported into Smart Vision Works V1.0 to locate the sentinel lymph node (SLN) and for visual simulation surgery. ESLNB and endoscopic axillary lymph node dissection were carried out based on this new technique; the accuracy and clinical value of 3DVT in ESLNB were analyzed.ResultsThe reconstructed 3D models clearly displayed all the structures of breast and axilla, which favors the intraoperative detection of SLNs. The identification rate of biopsied SLNs was 100% (389/389). The accuracy, sensitivity, and false-negative rate were 93.83% (365/389), 93.43% (128/137), and 6.57% (9/137), respectively. Upper limb lymphedema occurred in one patient 3 months after surgery during the 12-month follow-up period.ConclusionsOur 3DVT based on CT-LG data combined with methylene blue in ESLNB ensures a high identification rate of SLNs with low false-negative rates. It, therefore, has the potential to serve as a new method for SLN biopsy in breast cancer cases.

The Feasibility of Sentinel Lymph-Node, Mapped with Indocyanine Green, Biopsy in Endometrial Cancer Patients: A Prospective Study

Background and objectives. Systematic pelvic lymphadenectomy (LND) is an essential part of lymph-node status evaluation in endometrial cancer (EC) patients to tailor the adjuvant treatment. However, it is associated with the post-operative lymphatic complications and does not improve the outcomes of the disease. Indocyanine green (ICG) mapped sentinel lymph-node biopsy (SLB) has recently been introduced into the clinical practice as an alternative for the surgical lymph-node evaluation in EC patients with the potential to decrease LND related complications. The aim of our study was to evaluate the feasibility of ICG mapped SLB in low, intermediate, and high-risk EC patients in a center with no previous experience on endoscopic SLB procedure. Materials and Methods: The prospective study was performed. 170 patients with histologically confirmed EC were included. Sentinel lymph-nodes (SLs) were mapped with ICG dye and removed ahead of the total laparoscopic hysterectomy. Low-risk patients received only SLB, while SLB and LND were performed for intermediate and high-risk patients. Results: The overall detection rate of SLs was 88.8%. Bilateral mapping was achieved in 68.2% of the patients. The overall detection rate for low-risk patients was 93.7%, 85.0% for the intermediate-risk group, and 100% for high-risk patients (p = 0.232). The most common anatomical sites of SLs were the external iliac (45.8% on the right and 46.6% on the left) and obturator regions (20.9% and 25.6%, respectively). Positive lymph-nodes were found in 8 (4.7%) patients. The sensitivity of SLB was 75.0% and negative predictive value (NPV)—97.2%. Conclusions: Even in the center with no previous experience, sentinel lymph-node biopsy using ICG mapping is feasible. However, the favorable outcomes might be associated with the learning process of newly established method.

Endoscopic sentinel node biopsy using indocyanine green in early stage vulvar cancer

Introduction: Video-endoscopic lymphadenectomy is progressively emerging as an appealing strategy in patients with vulvar cancer; at the same time, sentinel node biopsy (SNB) is currently recognized as standard of care in patients with early stage vulvar cancer (ESVC). Therefore, the integration of endoscopic approaches and SNB appears as an intriguing horizon, and we present here the first endoscopic SNB using indocyanine green (ICG) performed in a patient with ESVC.

Endoscopic sentinel lymph node biopsy using indocyanine green-neomannosyl human serum albumin.

The aim of this study was to determine the possibility of endoscopic sentinel lymph node biopsy of the head and neck region using indocyanine green-neomannosyl human serum albumin (ICG:MSA) and a custom-made intraoperative color-and-fluorescence-merged imaging system (ICFIS). Using mouse and rabbit models of tongue cancer, we performed sentinel lymph node biopsy using an ICG:MSA tracer and custom imaging system equipped with an endoscope. ICG:MSA was localized to the cervical lymph node on the ipsilateral side for up to 30 minutes compared to ICG tracer (ICG n = 3, IGC:MSA n = 3). Detection of sentinel lymph nodes was attempted after injecting ICG:MSA in the mouse tongue cancer model (n = 3). During the operation, lymph nodes were easily identified and resected using ICFIS without the aid of other magnifiers. In the rabbit tongue cancer model (n = 3), the ICFIS equipped with 30-degree endoscopy was used to confirm the feasibility of endoscopic sentinel lymph node biopsy. The entire sentinel lymph node biopsy procedure was performed using the ICFIS with the 30-degree endoscope. We detected and dissected sentinel lymph nodes in the rabbit model without the other sentinel lymph node detection tools. We confirmed the usefulness of sentinel lymph node biopsy using a near infrared fluorescence technique and endoscopic system. Avoidance of radiation exposure and shine-through phenomena, which are problems of sentinel lymph node biopsy using conventional radioisotopes, are advantages of our surgical technique. By combining the endoscopic system with a sentinel lymph node biopsy procedure, we avoided visible neck scars, which lead to excellent cosmetic outcomes. NA. Laryngoscope, 128:E135-E140, 2018.

Endoscopic sentinel lymph node biopsy and endoscopic axillary lymphadenectomy without liposuction in patients with early stage breast cancer

BackgroundOur purpose was to present a new method of endoscopic sentinel lymph node biopsy (ESLNB) and endoscopic axillary lymphadenectomy (EALND) without liposuction for treating early-stage breast cancer, and compare results with traditional open dissection. MethodsThe medical records of patients with early-stage breast cancer who underwent EALND/ESLNB without liposuction or traditional open dissection between March 2015 and September 2016 were retrospectively reviewed. Outcomes between the 2 groups were compared. ResultsA total 65 patients with a mean age of 41.2 ± 9.3 years (range, 23–60 years) were included. Thirty-three patients underwent traditional open lymph node dissection and 32 patients underwent endoscopic treatment. The 2 groups were similar with respect to age, body mass index (BMI), menopausal status, tumor location, and tumor disease stage (all, p > 0.05). The mean operating time was significantly higher in the endoscopic group (91.2 vs. 75.2 min, p = 0.022), while the mean blood loss was significantly lower (28.7 vs. 37.0 ml, p = 0.034). The mean number of SLNs harvested in the open (2.4 ± 1.6) and the endoscopic (2.3 ± 1.4) groups were not different (p = 0.829), with a sentinel lymph node retrieval rate of 80%. The mean number of axillary lymph nodes harvested in the open (13.8 ± 3.3) and the endoscopic (13.3 ± 3.1) groups were not different (p = 0.457). Scars were minimal in the endoscopic group. ConclusionESLNB and EALND without liposuction for early-stage breast cancer is feasible, has a low complication rate, a lymph node harvest rate similar to that of open dissection, and has good cosmetic results. Future studies, however, are required to evaluate oncological outcomes.

75. Endoscopic sentinel node biopsy and axillary dissection for early breast cancer can be navigated by the fusion image of 3D-CT lymphography and SPECT-CT

S S37 Background: Neoadjuvant chemo radiation therapy (CRT) is the standardmanagement strategy for patientswith rectal cancer. The conventionally accepted interval between CRT& surgery is six to eight weeks. A number of retrospective studies have postulated that a delay in surgery beyond six weeks may result in further tumour downgrading and may improve surgical outcome. However there remains a concern that longer interval may result in tumour progression compromising the oncological safety. It may also result in greater fibrosis and make the surgery difficult. Since the effect of delayed interval has never been evaluated adequatelya randomized control trial was designed to evaluate the effect of delay in surgery after CRT. Material and methods: A total of 134 cases (67 in each arm) of locally advanced carcinoma rectum will be recruited from 1/August/ 2012 to 31/July/2015(Three years). Eligible patients after receiving CRT undergo response assessment and are randomized into two groups, control group (short arm, SA) & the test group (long arm, LA). Patients in SA undergo surgery at 6-8 weeks while patients in LA undergo surgery at 10-12 weeks post CRT. Total duration of the study will becompletion of follow up of three years from the date of recruitment of the last patient. The primary end point is to assess the long term impact of delaying surgery after CRT in locally advanced rectal cancers in terms of Disease free survival & overall survival. A planned interim analysis was performed after recruitment of the first sixty cases to evaluate pathological response & perioperative morbidity and mortality. Results: A total of sixty patients (31-long arm, 29-short arm) were recruited out of which 57 underwent final analysis (29-LA, 28-SA). The mean time interval between CRT and surgery was 51.93 days in the SA and 74.38 days in the LA.No significant differencewas observed in the duration of surgery (SA-180min, LA-194min), perioperative wound infections (SA-17.24%, LA-20.68%) or urinary complications. Three patients in each arm developed postoperative anastomotic leak for which a diversion was required. Pathological analysis does not reveal any significant difference in terms of mean tumour regression grading (LA-2.89, SA-2.88), Pathological complete response and circumferential resection margin positivity. Conclusion: The interim analysis reveals that Delay in surgery post CRT is not associated with increased perioperative morbidity & mortality. However no further down staging of tumor was observed after prolonging the interval for surgery. The effect of increased time interval in terms of long term loco regional control and distant metastasis remains to be evaluated and will be available at the completion of study No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2014.08.070 74. GIST may have a higher incidence of second primary cancers which negatively impact upon survival M. Smith, A.L. Mahar, C.H. Law, Y.J. Ko 1 The Royal Marsden NHS Foundation Trust, Academic Surgery, London, United Kingdom Queen’s University, Public Health Sciences, Kingston, Canada Odette Cancer Centre Sunnybrook Health Sciences Centre, Surgical Oncology, Toronto, Canada Odette Cancer Centre Sunnybrook Health Sciences Centre, Medical Oncology, Toronto, Canada Background: A higher incidence of second primary cancer (SPC) has been reported in patients diagnosed with gastrointestinal stromal tumors (GIST). We aimed to identify patients with GIST who develop a SPC, quantify the risk of additional malignancy and evaluate the impact upon survival. Material and methods: Individuals diagnosed with GIST from 20012009 were identified from the SEER database. Standardized incidence ratios (SIR) were calculated using SEER*Stat software (V.7.1.0). Cox-proportional hazards and logistic regression identified predictors of survival and SCP. Results: 1705 cases of GISTwere identified, with 181 (10.6%) patients developing SPC overall. The risk of SCP was significantly higher in our cohort than expected (SIR 1.36; 1.08-1.7 95% CI). Older age (p<0.0001) and extra-oesophagogastric GIST (p1⁄40.0027) were significant predictors of SPC. Colorectal cancer was the commonest synchronous cancer (30%). Median time to diagnosis of metachronous SPC was 21.9 months, the commonest sites being urinary system in men (SIR 2.39; 1.03-4.72 95% CI) and colon (SIR 2.96 1.19-6.09; 95% CI) in women. Overall 5-year survival was 65%. A synchronous SCP associated with reduced overall survival (HR 1.55 1.05-2.3 95% CI, p1⁄40.04). Conclusion: Patients with GIST have a higher incidence of SPC when compared with to the general population. Older age and primary disease site are predictors of SPC. 10.6% of our cohort developed a SPC, with urinary tract being the commonest site overall. Colon cancer was the commonest synchronous cancer, and women were at an increased risk of metachronous colon cancer. Synchronous SCP was associated with a poorer overall survival. At diagnosis and during surveillance of GIST, screening for colon and urinary tract cancers may be considered. No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2014.08.071 75. Endoscopic sentinel node biopsy and axillary dissection for early breast cancer can be navigated by the fusion image of 3D-CT lymphography and SPECT-CT K. Yamashita, K. Yanagihar, H. Takei 1 Nippon Medical School, Dept. of Breast Surgery, Tokyo, Japan Background: 3D-CT mammary lymphography (LG) can image the detail lymphatic map from the breast gland to the axillary nodes (AN) and can enable us to detect the precise sentinel node (SN) and to perform the endoscopic SN biopsy easily. It can also detect the second and the third SN on the lymphatic map. These nodes biopsy will contribute to omit AN dissection on the SN-positive patients. Then we try to overlay the fusion image of SPECT on the endoscopic view, and evaluate its real-time navigation of endoscopic surgery. Methods: 3D-CT LG was performed by the subcutaneous injection of 2 ml Iopamidol 300 above the tumor and near areola, and by taking CT images at 1 minute. They were reconstructed to produce a 3D image of lymph ducts and lymph nodes by thevolume renderingmethod. SPECTwas performed by injection of 99mTc phytate 74mBq and taking images after 2 hours. SN biopsy and AN dissection were performed by dye and RI method using endoscope with the optical trocar Visiport through only 1 cm long skin incision, and overlaying 3D-CT image on the endoscopic view with the SPECT. Results:We have performed the endoscopic SN biopsy on 350 patients. The SNmetastasis was found on 80 patients: single SNmetastasis on 32, the second SN on 8, and the third SN on 7. The fusion image of 3D-CT LG and SPECTenable us to identify the anatomical position of SN onANmap by RI detector probe, and to introduce the endoscope by the overlay system. It also enable us to get the second SN easily. The axillary node metastasis was not observed on the patients without second SN metastasis. There was no false negative study. There is no local recurrence at 10 years after surgery. Conclusions: The overlay of 3D-CT LG on the endoscopic view improves the identification rate of SN and the manipulation of the endoscopic surgery. We are developing this visual processing technique to apply the real-time navigation for the endoscopic partial mastectomy. No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2014.08.072 76. Optimal treatment of the axilla after positive sentinel lymph node biopsy in primary invasive breast cancer patients (surgery versus radiotherapy)eOTOASOR trial: 5 years follow-up of a randomized clinical trial A. Savolt, Z. Matrai, C.S. Polgar, N. Udvarhelyi, G. Rubovszky, E. Kovacs, P. Musonda, G. Peley 1 National Institute of Oncology, Department of Breast and Sarcoma Surgery, Budapest, Hungary

74. GIST may have a higher incidence of second primary cancers which negatively impact upon survival

S S37 Background: Neoadjuvant chemo radiation therapy (CRT) is the standardmanagement strategy for patientswith rectal cancer. The conventionally accepted interval between CRT& surgery is six to eight weeks. A number of retrospective studies have postulated that a delay in surgery beyond six weeks may result in further tumour downgrading and may improve surgical outcome. However there remains a concern that longer interval may result in tumour progression compromising the oncological safety. It may also result in greater fibrosis and make the surgery difficult. Since the effect of delayed interval has never been evaluated adequatelya randomized control trial was designed to evaluate the effect of delay in surgery after CRT. Material and methods: A total of 134 cases (67 in each arm) of locally advanced carcinoma rectum will be recruited from 1/August/ 2012 to 31/July/2015(Three years). Eligible patients after receiving CRT undergo response assessment and are randomized into two groups, control group (short arm, SA) & the test group (long arm, LA). Patients in SA undergo surgery at 6-8 weeks while patients in LA undergo surgery at 10-12 weeks post CRT. Total duration of the study will becompletion of follow up of three years from the date of recruitment of the last patient. The primary end point is to assess the long term impact of delaying surgery after CRT in locally advanced rectal cancers in terms of Disease free survival & overall survival. A planned interim analysis was performed after recruitment of the first sixty cases to evaluate pathological response & perioperative morbidity and mortality. Results: A total of sixty patients (31-long arm, 29-short arm) were recruited out of which 57 underwent final analysis (29-LA, 28-SA). The mean time interval between CRT and surgery was 51.93 days in the SA and 74.38 days in the LA.No significant differencewas observed in the duration of surgery (SA-180min, LA-194min), perioperative wound infections (SA-17.24%, LA-20.68%) or urinary complications. Three patients in each arm developed postoperative anastomotic leak for which a diversion was required. Pathological analysis does not reveal any significant difference in terms of mean tumour regression grading (LA-2.89, SA-2.88), Pathological complete response and circumferential resection margin positivity. Conclusion: The interim analysis reveals that Delay in surgery post CRT is not associated with increased perioperative morbidity & mortality. However no further down staging of tumor was observed after prolonging the interval for surgery. The effect of increased time interval in terms of long term loco regional control and distant metastasis remains to be evaluated and will be available at the completion of study No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2014.08.070 74. GIST may have a higher incidence of second primary cancers which negatively impact upon survival M. Smith, A.L. Mahar, C.H. Law, Y.J. Ko 1 The Royal Marsden NHS Foundation Trust, Academic Surgery, London, United Kingdom Queen’s University, Public Health Sciences, Kingston, Canada Odette Cancer Centre Sunnybrook Health Sciences Centre, Surgical Oncology, Toronto, Canada Odette Cancer Centre Sunnybrook Health Sciences Centre, Medical Oncology, Toronto, Canada Background: A higher incidence of second primary cancer (SPC) has been reported in patients diagnosed with gastrointestinal stromal tumors (GIST). We aimed to identify patients with GIST who develop a SPC, quantify the risk of additional malignancy and evaluate the impact upon survival. Material and methods: Individuals diagnosed with GIST from 20012009 were identified from the SEER database. Standardized incidence ratios (SIR) were calculated using SEER*Stat software (V.7.1.0). Cox-proportional hazards and logistic regression identified predictors of survival and SCP. Results: 1705 cases of GISTwere identified, with 181 (10.6%) patients developing SPC overall. The risk of SCP was significantly higher in our cohort than expected (SIR 1.36; 1.08-1.7 95% CI). Older age (p<0.0001) and extra-oesophagogastric GIST (p1⁄40.0027) were significant predictors of SPC. Colorectal cancer was the commonest synchronous cancer (30%). Median time to diagnosis of metachronous SPC was 21.9 months, the commonest sites being urinary system in men (SIR 2.39; 1.03-4.72 95% CI) and colon (SIR 2.96 1.19-6.09; 95% CI) in women. Overall 5-year survival was 65%. A synchronous SCP associated with reduced overall survival (HR 1.55 1.05-2.3 95% CI, p1⁄40.04). Conclusion: Patients with GIST have a higher incidence of SPC when compared with to the general population. Older age and primary disease site are predictors of SPC. 10.6% of our cohort developed a SPC, with urinary tract being the commonest site overall. Colon cancer was the commonest synchronous cancer, and women were at an increased risk of metachronous colon cancer. Synchronous SCP was associated with a poorer overall survival. At diagnosis and during surveillance of GIST, screening for colon and urinary tract cancers may be considered. No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2014.08.071 75. Endoscopic sentinel node biopsy and axillary dissection for early breast cancer can be navigated by the fusion image of 3D-CT lymphography and SPECT-CT K. Yamashita, K. Yanagihar, H. Takei 1 Nippon Medical School, Dept. of Breast Surgery, Tokyo, Japan Background: 3D-CT mammary lymphography (LG) can image the detail lymphatic map from the breast gland to the axillary nodes (AN) and can enable us to detect the precise sentinel node (SN) and to perform the endoscopic SN biopsy easily. It can also detect the second and the third SN on the lymphatic map. These nodes biopsy will contribute to omit AN dissection on the SN-positive patients. Then we try to overlay the fusion image of SPECT on the endoscopic view, and evaluate its real-time navigation of endoscopic surgery. Methods: 3D-CT LG was performed by the subcutaneous injection of 2 ml Iopamidol 300 above the tumor and near areola, and by taking CT images at 1 minute. They were reconstructed to produce a 3D image of lymph ducts and lymph nodes by thevolume renderingmethod. SPECTwas performed by injection of 99mTc phytate 74mBq and taking images after 2 hours. SN biopsy and AN dissection were performed by dye and RI method using endoscope with the optical trocar Visiport through only 1 cm long skin incision, and overlaying 3D-CT image on the endoscopic view with the SPECT. Results:We have performed the endoscopic SN biopsy on 350 patients. The SNmetastasis was found on 80 patients: single SNmetastasis on 32, the second SN on 8, and the third SN on 7. The fusion image of 3D-CT LG and SPECTenable us to identify the anatomical position of SN onANmap by RI detector probe, and to introduce the endoscope by the overlay system. It also enable us to get the second SN easily. The axillary node metastasis was not observed on the patients without second SN metastasis. There was no false negative study. There is no local recurrence at 10 years after surgery. Conclusions: The overlay of 3D-CT LG on the endoscopic view improves the identification rate of SN and the manipulation of the endoscopic surgery. We are developing this visual processing technique to apply the real-time navigation for the endoscopic partial mastectomy. No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2014.08.072 76. Optimal treatment of the axilla after positive sentinel lymph node biopsy in primary invasive breast cancer patients (surgery versus radiotherapy)eOTOASOR trial: 5 years follow-up of a randomized clinical trial A. Savolt, Z. Matrai, C.S. Polgar, N. Udvarhelyi, G. Rubovszky, E. Kovacs, P. Musonda, G. Peley 1 National Institute of Oncology, Department of Breast and Sarcoma Surgery, Budapest, Hungary

O1-7-6 - Endoscopic Sentinel Node Biopsy Can Be Navigated by the Fusion Image of 3D-Ct Lymphography and Spect-Ct

Background: 3D-CT mannmary lymphography (LG) can image the detail lymphatic map from the breast gland to the axillary nodes (AN) and can enable us to detect the precise sentinel node (SN) and to perform the endoscopic SN biopsy easily. It can also detect the second and the third SN on the lymphatic map. These node biopsy will contribute to omit AN dissection on the SN-positive patients. Now we try to overlay the fusion image of SPECT on the endoscopic view, and evaluate its real-time navigation of endoscopic surgery.Methods: 3D-CT LG was performed by the subcutaneous injection of 2 ml Iopamidol 300 above the tumor and near areola, and by taking CT images at 1 minute. They were reconstructed to produce a 3D image of lymph ducts and lymph nodes by the volume rendering method. SPECT was performed by injection of 99mTc phytate 74mBq and taking images after 2 hours. SN biopsy and AN dissection were performed by dye and RI method using endoscope with the optical trocar Visiport through only 1 cm long skin incision, and overlaying 3D-CT image on the endoscopic view with free-hand SPECT.Results: We have performed the endoscopic SN biopsy on 350 patients. The SN metastasis was found on 80 patients: single SN metastasis on 32, the second SN on 8, and the third SN on 7. The fusion image of 3D-CT LG and SPECT enable us to identify the anatomical position of SN on AN map by RI detector probe, and to introduce the endoscope by the overlay system. It also enable us to get the second SN easily. The axillary node metastasis was not observed on the patients without second SN metastasis. There was no false negative study. There is no local recurrence at 10 years after surgery.Discussions: The overlay of 3D-CT LG on the endoscopic view improve the identification rate of SN and the manipulation of the endoscopic surgery. We are developing these visual processing technique to apply the real-time navigation for the endoscopic partial mastectomy.

Comparison of long-term results of endoscopic video-assisted breast surgery (VABS) between trans-axillary retro-mammary appcoach (TARM) and periareolar approach.

167 Background: The breast conserving surgery (BCS) and the sentinel node (SN) biopsy became to be recognized as the standard treatment for early breast cancers. We have reported about cosmetic effectiveness and lower infestation of the video-assisted breast surgery (VABS) for the breast diseases. We devised the trans-axillary retro-mammary (TRAM) approach of VABS. It needs only one skin incision in the axilla and can treat any tumor of the breast without making any injuries on the breast skin. We evaluated the aesthetic results and the curability of this surgical method. Methods: We have performed VABS on 300 patients since December 2001. The newly devised TARM was performed on 120 patients of early breast cancer, stage I and II. After endoscopic SN biopsy, we elongated the axillary skin incision to 2.5 cm. We dissected major pectoral muscle fascia to detach retromammary tissue behind the tumor. We cut the mammary gland with clear surgical margin, and removed it through the axillary port. The breast reconstruction was made by filling absorbable oxydized cellulose. The postoperative aesthetic results were evaluated by ABNSW. Results: BCS was performed on 286 patients (26 after preoperative chemotherapy) and skin-sparing mastectomy on 14. There was no serious complication after surgery. Surgical margin was minimally positive in 2. The original shapes of the breast were preserved well. The follow-up is 126 months at maximum and 74 months on average. There is 3 locoregional recurrences and 14 distant metastases. 5-year survival rate is 97.3%. With regard to TARM, The skin incision only in the axilla made better looks and shapes of the breast. It could be applied for tumors in any area of the breast without tumor nipple extension. The reconstruction with oxidized cellulose needs no excessive detachment of the skin beyond the surgical margin. The postoperative esthetic results were excellent and better. The sensory disturbance was minimal. All patients expressed great satisfaction. Conclusions: VABS can be considered as a good surgical procedure concerning locoregional control and esthetics. TARM is better on the patients without tumor nipple extension.

Comparison of long-term results of endoscopic video-assisted breast surgery (VABS) between transaxillary retromammary approach (TARM) and periareolar approach.

1112 Background: The breast conserving surgery (BCS) and the sentinel node (SN) biopsy became to be recognized as the standard treatment for early breast cancers. We have reported about cosmetic effectiveness and lower infestation of the video-assisted breast surgery (VABS) for the breast diseases. We devised the trans-axillary retro-mammary (TRAM) approach of VABS. It needs only one skin incision in the axilla and can treat any tumor of the breast without making any injuries on the breast skin. We evaluated the aesthetic results and the curability of this surgical method. Methods: We have performed VABS on 300 patients since December, 2001. The newly devised TARM was performed on 120 patients of early breast cancer, stage I and II. After endoscopic SN biopsy, we elongated the axillary skin incision to 2.5 cm. We dissected major pectoral muscle fascia to detach retromammary tissue behind the tumor. We cut the mammary gland with clear surgical margin, and removed it through the axillary port. The breast reconstruction was made by filling absorbable oxydized cellulose. The postoperative aesthetic results were evaluated by ABNSW. Results: BCS was performed on 286 patients (26 after preoperative chemotherapy) and skin-sparing mastectomy on 14. There was no serious complication after surgery. Surgical margin was minimally positive in 2. The original shapes of the breast were preserved well. The follow-up is 126 months at maximum and 74 months on average. There is 3 locoregional recurrences and 14 distant metastases. 5-year survival rate is 97.3%. With regard to TARM, The skin incision only in the axilla made better looks and shapes of the breast. It could be applied for tumors in any area of the breast without tumor nipple extension. The reconstruction with oxidized cellulose needs no excessive detachment of the skin beyond the surgical margin. The postoperative esthetic results were excellent and better. The sensory disturbance was minimal. All patients expressed great satisfaction. Conclusions: VABS can be considered as a good surgical procedure concerning locoregional control and esthetics. TARM is better on the patients without tumor nipple extension.

Abstract P4-10-08: Trans-Axillary Retro-Mammary Approach of Video-Assisted Breast Surgery Uses Single Port in the Axilla and Treats Any Tumors Even in the Medial or Lower Side of the Breast

Abstract Background: The breast conserving surgery and the sentinel node (SN) biopsy became to be recognized as the standard treatment for early breast cancers. We have reported about cosmetic effectiveness and lower infestation of the video-assisted breast surgery (VABS) for the breast diseases. When the tumor exists in the medial or lower side of the breast, we usually use the periareolar incision. However, it often makes deformation or malposition of nipple and areola, and sensory disturbance around them. We devised the trans-axillary retro-mammary (TRAM) approach of VABS. It needs only one skin incision in the axilla and can treat any tumor even in the medial or lower side of the breast without making any injuries on the breast skin. And it can preserve skin touch sensation. Methods: We have performed video-assisted breast surgery (VABS) on 300 patients since December, 2001. The newly devised TARM was performed on 120 patients of early breast cancer, stage I and II. After endoscopic sentinel lymph node biopsy, we elongated the axillary skin incision to 2.5 cm. We marked the surgical margin 2 cm apart from the tumor edge by injecting blue dye into subcutane and retromamma. We dissected major pectoral muscle fascia to detach retromammary tissue under the tumor. The working space was made by lifting traction sutures through the gland. We cut the proximal side of the gland vertically at dye marking points, and dissect skin flap over the tumor by tunnel method. Then we cut each sides of the gland vertically and removed it through the axillary port by using Endocatch, tumor collection bag. The breast reconstruction was done by filling absorbable fiber cotton, oxidized cellulose. Results: The tumor size was 2.2 cm on average. The patient age was 50.2 years. We had to take much care not harming the skin over the tumor. TRAM was performed without major complications. The working space was made only enough for the resection of the gland without excessive detachment of the surrounding subcutaneous tissue. The fifty tumors in the medial side of the breast were resected in success by TARM. Traction sutures made it easier to cut the mammary gland vertically. We did not experience any skin damages like burn. All surgical margins were negative. The operation time was needed 45 minutes longer than the conventional VABS operation, but the blood loss and other surgical stress factors were not significantly different. The postoperative esthetic results were good. The oxidized cellulose cotton was good for preserving the breast form, because it collects fluid to make temporal seroma and became a solid fibrous mass on six months after surgery. The average follow up period is 60 months. There was only two local recurrences. The sensory disturbance was minimal. All patients were satisfied with this operation. Conclusions: This newly devised TARM approach of VABS needs no injury on the whole breast, and can become to be a standard method of the breast conserving surgery for early breast cancer wherever it may exist in the breast. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-10-08.

SPECT-fused 3D-CT mammary lymphography for endoscopic sentinel node biopsy.

e11041 Background: The endoscopic surgery for the breast diseases has been proven safe and aesthetic, and named as video- assisted breast surgery (VABS). We also applied it for the sentinel node (SN) biopsy. It needs only 1 cm-long skin incision and a narrow tunnel to SN. However, it sometimes has difficulty in detecting the dye-stained node. The radioisotope (RI) may not be uptaken by true SN. We firstly succeeded to fuse the single photon emission computed tomography (SPECT) with 3D-CT mammary lymphography (LG). It can show the detailed position of all SN with or without RI uptake. Methods: 3D-CT LG was performed to mark SN on the skin. Above the tumor and near the areola, 2 mL of Iopamidol 300 was injected subcutaneously. Images of CT scan were taken at 1 and 3 minutes after injection to produce a 3D image of lymph ducts and nodes. For the lymphoscintigraphy, 99mTc phytate 74mBq was injected, and SPECT was taken after 2 hours. We fused it with 3D-CT LG. SN biopsy was performed by dye and RI method The skin incision was made 1 cm long in the axilla on the marked position. The endoscopic view was made through the optical trocar Visiport and showed stained lymph ducts and SNs, which can be navigated by the RI detector probe. Results: We have performed VABS on 260 patients, SN biopsy by the dye-staining method on 50 patients, with 3D-CT LG on 160 patients, and SPECT fused 3D-CT LG on 20 patients. All RI positive SNs coincided with 3D-CT LG detected SNs. We could detect their position on the axillary lymphatic mapping by the RI detector probe during surgery. The average sampled number of SN was 2.3. The dye-negative SN and RI-negative SN could be removed endoscopically. The SN metastases were 45 (28%). The other non-SN of axillary nodes could be observed. There was no false negative study. The wound scars were inconspicuous and aesthetic. Conclusions: SPECT-fused 3D-CT LG facilitates the endoscopic SN biopsy, which is aesthetic and less invasive. No significant financial relationships to disclose.

Endoscopic Sentinel Lymph Node Biopsy in Breast Cancer Surgery: Feasibility and Accuracy of the Combined Radioisotope and Blue Dye

액와부림프절전이가없는조기유방암이증가하여우리나라에서 Purpose: Since its introduction in the mid-1990s, sentinel lymph node biopsy has been rapidly and widely adopted for the axillary staging of clinically node-negative breast cancer patients. However, there is some controversy in the clinical application because of its various identification rates and its false negative rates. The objective of this study was to assess the usefulness of endoscopic sentinel lymph node biopsy (ESNB) and to compare the value of two methods for identification of ESNB using blue dye only or a combination of blue dye and radioisotope. Methods: This study was carried out in 137 breast cancer patients (bilateral breast cancer, 3 cases) who underwent ESBN, at the Department of Surgery in Soonchunhyang University from May of 2007 to August of 2008. The technique involved the injection of 5 mL of 0.5% indigocarmine or Tc-99m tin colloid into subareolar plexus. The Visiport docked with a telescope was inserted through a low transverse axillary incison (1.0 cm in size) lateral to the pectoralis major. During the dissection, we identified sentinel nodes by following blue-stained lymphatic duct directly into blue-stained lymph nodes. We compared the value of two methods for identification of ESNB using blue dye only or a combination of blue dye and radioactive tracer. Results: The mean number of sentinel nodes was 1.27 (range, 1-4). The identification rate and false negative rate of the sentinel node were 94.3% (132/140) and 6.9% (3/43), respectively. We compared ESNB with using blue dye only (n=77) vs. a combination of blue dye and radioactive tracer (n=63). Sentinel lymph node identification rate were 90.9% (70/77) vs. 98.4% (62/63) (p=0.043). Conclusion: The endoscopic technique of sentinel node biopsy can keep better operative visual fields and is less invasive. The combination of blue dye and radioactive tracer was superior to blue dye only for identification rates.

Combined Sentinel Node Biopsy and Localized Sigmoid Resection Entirely by Natural Orifice Transluminal Endoscopic Surgery

We demonstrate localized sigmoidectomy with sentinel node biopsy performed entirely via natural orifice transluminal endoscopic surgery in a porcine model (see Video, Supplemental Digital Content 1, http://links.lww.com/A1170). To perform transluminal endoscopic sentinel node biopsy in the sigmoid mesocolon, a conventional double-channel gastroscope created both the gastrotomy and pneumoperitoneum enabling peritoneoscopy. The sigmoid colon was exposed by an intracolonic magnet under extracorporeal control while intraluminal colonoscopy performed lymphatic mapping via submucosal injection of methylene blue dye. After searching the mesocolon for blue-stained lymph channels, the sentinel nodes were resected and retrieved by the intraperitoneal fiberscope. Immediate thereafter localized sigmoidectomy was performed via an additional transcolonic access just above the rectosigmoid junction. With the circular stapler anvil placed early into the proximal colon, mesenteric dissection and proximal transection were performed using conventional laparoscopic instruments worked through a long standard trocar passed transanally through the colotomy. The specimen was delivered per ano (pull-through technique) and the distal margin cross-stapled extracorporeally, including the colotomy within the specimen. Stapled intestinal anastomosis was fashioned by passing a circular stapler transanally (thus returning the rectal stump to its anatomic position) and mating it with the in situ anvil. The gastrotomy was closed as previously described. The operative duration was 31.4 minutes and technical success was readily achieved. Patency and integrity of the anastomosis was confirmed by sigmoidoscopy. Oncologically propitious surgery for germinal colonic neoplasia may be encompassed by natural orifice transluminal endoscopic surgery. This provocative proposal challenges the conventional treatment paradigm for early stage colonic neoplasia although much further validation of the concepts involved is required.

Trans-axillary retro-mammary gland route approach of videoassisted breast surgery can perform breast conserving surgery for cancers even in inner side of the breast

The endoscopic surgery for inner-side cancer of the breast is usually performed by periareolar approach, but it often makes deformation or malposition of nipple and areola. The trans-axillary approach is favorable without making any injuries on breast skin. Furthermore, we devised a new approach of retro-mammary route without subcutaneous exfoliation, from axillary skin incision, to preserve skin touch sensation. We have performed video-assisted breast surgery (VABS) on 200 patients since December 2001. The newly devised trans-axillary retromammary-route approach (TARM) was performed on 12 patients of early breast cancer. After endoscopic sentinel lymph node biopsy, we lengthened the axillary skin incision to 2.5 cm, and dissected retromammary tissue from superficial pectoral fascia onto major pectoral muscle below the tumor. The working space was made by lifting traction sutures through the gland. We cut the gland vertically at free margin 2 cm apart from the tumor edge, and dissect skin flap over the tumor. The breast reconstruction was done by filling absorbable fiber cotton. Traction sutures made it easier to cut the mammary gland vertically. We did not experience any skin damages like burn. All surgical margins were negative. The operation time was needed longer but the blood loss was not different. The postoperative esthetic results were good. The sensory disturbance was minimal. All patients were satisfied with this operation. This newly devised TARM approach need no injury on whole breast, and can become a single standard method for breast conserving surgery wherever the cancer situated.

Video-assisted axillary surgery for cancer: Non-randomized comparison with conventional techniques

Endoscopic techniques have been introduced in most of surgical disciplines including surgery for breast cancer. However, there is shortage of evidence-based guidelines and oncological outcome data. We present a controlled trial of endoscopic axillary surgery for breast cancer with mid-term oncologic results. Fifty cases of axilloscopy for sentinel node biopsy, axillary sampling or full axillary dissection were included. Sentinel node biopsy was accomplished with the blue dye technique. Full axillary dissection was performed with a three-port approach with gas insufflation without liposuction. Endoscopic axillary dissection significantly lowered duration of drainage and operative blood loss. Lymph node harvest with endoscopic approach was significantly lower than with open procedure. One case developed axillary recurrence. Endoscopic sentinel node biopsy yielded identification rate of 80%. Current data do not justify the oncological safety of resectional endoscopic procedures. Endoscopically assisted axillary cancer surgery is technically feasible. The technique is valuable to maximize utility of blue dye method for sentinel lymphadenectomy in areas with no access to radio-guided surgery.

Feasibility of endoscopic sentinel node biopsy in the porcine neck

To assess the feasibility of endoscopic sentinel node biopsy (SNB) using a tracer dye in a pig model. This was a prospective, nonrandomized experimental study in Yorkshire pigs. The posterolateral tongues of three animals were injected with a one-to-one solution of carbon dye to methylene blue dye. Endoscopic SNB was performed and stained lymph nodes identified and retrieved, followed by an open dissection to recover any remaining nodes. Specimens were analyzed by a pathologist for staining, size, and structural integrity. Six unilateral endoscopic SNBs were performed without complications. During endoscopic dissection, gross blue-staining of a sentinel node was noted in four of six dissections (66%). One of six sentinel nodes demonstrated histologic evidence of carbon staining. Structural integrity of all nodes was intact upon histological evaluation. Endoscopic cervical SNB in pigs is feasible but has limitations based on lymph node size and reliability of tracer dyes. Further study is warranted to perfect tracer dyes and retrieval methods to improve this technique.

Czy zabiegi endoskopowe stanowią przyszłość chirurgii szyi?

Summary The aim of the paper is to present the minimally invasive endoscopic video-assisted surgery for the neck on the basis of current literature. The different techniques include pure endoscopic procedures, open video-assisted approach and miniaccess. The preliminary material constitute of three patients who undergone endoscopic sentinel lymph node biopsy and one with colli lipoma. The authors describe the operating technique, instrumentation, indications, contraindications and advantages of this method. The endoscopic surgery offered a valuable approach for chosen lesions of the neck (solitary parathyroid adenoma, thyroid nodules less then 35 mm, submandibular gland sialolithiasis or tumors). The advantages include lower pain intensity within first hours following surgery, lower analgesia request rate, shorter scar length, higher early cosmetic satisfaction.

Endoscopic Sentinel Lymph Node Biopsy in a Porcine Model

The objective of this study was to investigate the feasibility of endoscopic sentinel lymph node biopsy in a porcine model. One hundred microcuries of technetium-labeled sulfa colloid (Tc-SC) was injected into the right and left ventrolateral surfaces of the oral tongue of six adult Yorkshire pigs. A handheld gamma probe was used to locate the region of focal radioactivity on the neck that corresponded to the sentinel lymph node (SLN). Next, 0.25 mL of isosulfan blue dye was injected into the Tc-SC injection sites on the tongue. Endoscopic SLN dissection was then performed using a combination of balloon dissection and CO2 insufflation. The operative time, blood loss, and radioactivity of the SLN were measured for each animal. The SLN was detected transcutaneously with the gamma probe, and endoscopic SLN excision was successful. Endoscopic visualization and an endoscopic gamma probe confirmed the presence of both isosulfan blue dye and radiopositivity in the SLN in each pig. The procedure lasted 22 to 61 minutes (median duration, 35 minutes). There was no measurable blood loss in any of the animals. Mean radioactivity measured 14,466 counts/second per lymph node. Endoscopic SLN biopsy for oral tongue lesions is feasible and warrants further study.