Fluorescence-guided Sentinel Node Biopsy Research Articles

Sentinel lymph node biopsy in breast cancer: the role of ICG fluorescence after neoadjuvant chemotherapy.

The purpose of this study was to evaluate the feasibility and safety of indocyanine green (ICG) fluorescence as an alternative to traditional sentinel lymph node biopsy (SLNB) techniques in breast cancer (BC) patients undergoing neoadjuvant chemotherapy (NAC). Specifically, the study aimed to assess sentinel node identification rates and the effectiveness of ICG in axillary staging without the use of radioactive tracers. This retrospective study included 71 BC patients treated with NAC, who underwent SLNB using ICG fluorescence between 2020 and 2024. ICG was injected intradermally around the nipple-areolar complex, and the lymphatic pathways were visualized with a fluorescence camera. SN identification rate (IR) and retrieval of three or more SNs were the primary and secondary endpoints, respectively. Statistical analyses were performed using the Mann-Whitney U test for continuous variables and Fisher's exact test for categorical variables. ICG-guided SNs were identified in 91.5% of patients, with a median retrieval time of 25min (range: 10-50). Three or more SNs were successfully collected among 66.2% of cases and 38% of patients achieved a complete pathological response to NAC, while 53.5% had partial responses. Metastatic SNs were found in 21.1% of patients, and no serious intraoperative or postoperative complications were observed. ICG fluorescence-guided SLNB proved to be a feasible and promising method for SNs identification among BC patients after NAC. While ICG shows potential as an alternative to traditional techniques, further studies are required to confirm these findings and to establish ICG role in post-NAC axillary staging.

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

BackgroundNear-infrared (NIR) fluorescence-guided surgery with indocyanine green (ICG) has been demonstrated to provide high sensitivity in sentinel lymph node biopsy (SLNB) for breast cancer but has several limitations, such as unstable pharmacokinetics, limited fluorescence brightness, and undesired diffusion to neighboring tissues. This paper investigates the use of Voluven® as the solvent for ICG fluorescence-guided SLNB (ICG-SLNB).MethodsThe photophysical properties of ICG in water and Voluven® were evaluated in laboratory experiments and in a mouse model. Nine patients with early breast cancer underwent subareolar injection of diluted ICG (0.25 mg/ml) for ICG-SLNB. Six of the nine patients received ICG dissolved in Voluven® (ICG:Voluven®), while three were administered ICG dissolved in water (ICG:water); a repetitive injection-observation protocol was followed for all patients. The mapping image quality was evaluated.ResultsLaboratory experiments and in vivo mouse study showed improved fluorescence and better targeting using Voluven® as the solvent. ICG-SLNB with a repetitive injection-observation protocol was successfully performed in all nine patients. ICG:Voluven® administration had an overall better signal-to-background ratio (SBR) in sequential sentinel lymph nodes. The rates of transportation within the lymphatics were also improved using ICG:Voluven® compared with ICG:water.ConclusionsFrom basic research to animal models to in-human trial, our study proposes a repetitive injection-observation technique with ICG:Voluven®, which is characterized by better transportation and more stable mapping quality for ICG-SLNB in breast cancer patients.

ICG fluorescence-guided sentinel lymph node biopsy in early breast cancer – a single-center initial experience

ICG fluorescence-guided sentinel lymph node biopsy in early breast cancer – a single-center initial experience

Indocyanine Green Fluorescence-Guided Sentinel Node Biopsy during Surgery for Breast Cancer

Indocyanine Green Fluorescence-Guided Sentinel Node Biopsy during Surgery for Breast Cancer

Methylene Blue Near-Infrared Fluorescence Imaging in Breast Cancer Sentinel Node Biopsy.

Simple SummaryCurrently the gold standard for sentinel node biopsy in breast cancer patients is radioactive nanocolloid and a blue dye. In the age of fluorescence guided surgery new fluorophores are used and methylene blue presents some fluorescent properties. This study is the first in a clinical series presenting the possible use of methylene blue as a fluorescent dye for the identification of sentinel nodes in breast cancer sentinel node biopsy. We presented a feasibility of this new method and also in additional experiments because of the quenching effect limitation, found possible dilution of methylene blue presenting improved fluorescence. Introduction: Fluorescence-based navigation for breast cancer sentinel node biopsy is a novel method that uses indocyanine green as a fluorophore. However, methylene blue (MB) also has some fluorescent properties. This study is the first in a clinical series presenting the possible use of MB as a fluorescent dye for the identification of sentinel nodes in breast sentinel node biopsy. Material and methods: Forty-nine patients with breast cancer who underwent sentinel node biopsy procedures were enrolled in the study. All patients underwent standard simultaneous injection of nanocolloid and MB. We visualized and assessed the sentinel nodes and the lymphatic channels transcutaneously, with and without fluorescence, and calculated the signal-to-background ratio (SBR). We also analyzed the corresponding fluorescence intensity of various dilutions of MB. Results: In twenty-three patients (46.9%), the location of the sentinel node, or the end of the lymphatic path, was visible transcutaneously. The median SBR for transcutaneous sentinel node location was 1.69 (range 1.66–4.35). Lymphatic channels were visible under fluorescence in 14 patients (28.6%) prior to visualization by the naked eye, with an average SBR of 2.01 (range 1.14–5.6). The sentinel node was visible under fluorescence in 25 patients (51%). The median SBR for sentinel node visualization with MB fluorescence was 2.54 (range 1.34–6.86). Sentinel nodes were visualized faster under fluorescence during sentinel node preparation. Factors associated with the rate of visualization included diabetes (p = 0.001), neoadjuvant chemotherapy (p = 0.003), and multifocality (p = 0.004). The best fluorescence was obtained using 40 μM (0.0128 mg/mL) MB, but we also observed a clinically relevant dilution range between 20 μM (0.0064 mg/mL) and 100 μM (0.032 mg/mL). Conclusions: For the first time, we propose the clinical usage of MB as a fluorophore for fluorescence-guided sentinel node biopsy in breast cancer patients. The quenching effect of the dye may be the reason for its poor detection rate. Our analysis of different concentrations of MB suggests a need for a detailed clinical analysis to highlight the practical usefulness of the dye.

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

Radio isotopes and blue dyes alone or in combination are the most commonly used tracer agents in sentinel node (SN) biopsy for early breast cancer. Recent studies have found fluorescence method using indocyanine green (ICG) as a promising technology with fewer disadvantages. Retrospective analysis of our database that included patients with clinically node-negative breast cancer scheduled for breast surgery and SN biopsy between 2016 and January 2021. Patients who underwent detection using fluorescence-ICG were included in this study. A total of 47 patients were included. Median age was 50 (range: 24-78) years. Mean tumor size was 3.4 ± 1.5 cm. All patients received ICG injection and 11 received a combination of ICG and blue dye. Forty-five successful SN identifications with ICG were performed and 99 nodes retrieved. Eleven procedures were undertaken after initial systemic therapy. Twenty-four patients had at least one positive SN for malignancy. Mean follow up was 29.2 months and no axillary recurrence was noted during the study period. ICG appears to be a feasible and accurate method for SN biopsy with high identification rate. This is the first study of ICG in sentinel node biopsy in a North African population.

Long-term results of fluorescence and indigo carmine blue dye-navigated sentinel lymph node biopsy.

Sentinel lymph node biopsy is widely applied for the management of clinically node-negative breast cancer, and a radioisotope with a blue dye are most often used as tracers. Fluorescence of indocyanine green could also potentially be used as tracer. This study aimed to demonstrate the long-term survival results of fluorescence-guided sentinel lymph node biopsy. Patients with clinically node-negative breast cancer who underwent surgery as initial treatment were included in this study. Both fluorescence of indocyanine green and indigo carmine blue dye were used as tracers. Axillary lymph node dissection was omitted unless metastasis was pathologically proven in sentinel nodes. Breast cancer recurrence and death were recorded and prognostic factors were identified using disease-free survival and overall survival data. A total of 565 patients were analyzed. There were 14 (2.5%) patients whose sentinel nodes could not be identified, yielding an identification rate of 97.5%. Axillary dissection was performed in 90 patients. Forty-three recurrences including 6 ipsilateral axilla recurrence and 13 deaths were observed during the median 83months of follow-up period. Seven-year disease-free and overall survival were 92.4% and 97.3%, respectively. Multivariate analyses demonstrated that pre-menopausal status and invasive lobular carcinoma were significant unfavorable prognostic factors of disease-free survival. Half of ipsilateral axilla recurrences occurred within 5years after surgery and these recurrences were correlated with inappropriate adjuvant therapy. Fluorescence-guided sentinel lymph node biopsy demonstrated favorable prognostic results and could be alternative to the radioisotope for clinically node-negative breast cancer.

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.

Low-cost Fluorescein as an Alternative to Radio-colloid for Sentinel Lymph Node Biopsy-a Prospective Validation Study in Early Breast Cancer.

Sentinel lymph node biopsy (SLNB) using radio-pharmaceutical (RP) and a blue dye is gold standard for axillary staging in clinically node-negative early breast cancer. High costs and limited availability of RP and/or gamma probe are major deterrents in performing SLNB in developing countries. Fluorescence-guided SLNB can obviate the need for RP and gamma probe. Fluorescein is an inexpensive fluorescent lymphatic tracer. In this study, we compared SLN identification rate (SLN-IR) and false negative rates (FNR) of fluorescein-guided SLNB and radio-guided SLNB using 99mTc-Sulfur-colloid, in isolation, or in combination with methylene blue dye (MBD). Sixty-five cN0 early and large operable breast cancer patients underwent validation SLNB using fluorescein (and blue LED light), 99mTc-Sulfur-colloid (and gamma probe) and MBD. Inj Fluorescein 4% was injected, 1ml each peri-tumoral and sub-areolar five minutes before axillary incision. Axillary dissection was performed irrespective of SLNB histology. The SLN-IR and FNR with various tracers and their combinations were compared. The mean number of SLNs identified was 3.5 ± 1.8 (range 1-6). The SLN-IR using RP alone was 94%, fluorescein alone was 92%, and MBD alone was 82%. The SLN-IR using fluorescein plus MBD combination was 95.4%, compared to 97% using MBD plus RP combination. FNR was 6.3% using fluorescein plus MBD, as well as RP plus MBD combinations. SLN-IR of > 90% and SLN-FNR of < 10% using fluorescein plus MBD combination are in acceptable range, and are comparable to that of RP plus MBD combination. Fluorescein can replace RP for performing SLNB, in combination with MBD.

SENTINEL LYMPH NODE BIOPSY USING FLUORESCENT LYMPHOGRAPHY IN CT1-4N0M0 BREAST CANCER PATIENTS: HIGH DIAGNOSTIC CAPABILITIES

Breast cancer cT1-4N0M0 patients usually require a sentinel lymph node biopsy. Sentinel lymph node biopsy with indocyanine green fluorescence detection is a modern technique with a high lymph node detection rate. However, the false-negative rate was not evaluated adequately. Our objective was to determine node detection rate and the false-negative rate. 99 patients with 100 cases of breast cancer cT1-4N0M0 were operated on. The axillary part of an operation consisted of indocyanine green fluorescence-guided SLN biopsy and an axillary lymphadenectomy of levels I-II or I-П-Ш. A signal lymph node was detected in 98 cases (98 %). In 28 (28.6%) cases out of 98, metastases in signal lymph nodes were found. Other than sentinel lymph node had metastatic lesion only in 35.7% in SLN N+ cases. False negative result occurred in 1 case of 28 (3.6%). The application of indocyanine green fluorescence-guided sentinel lymph node biopsy in cN0 breast cancer patients allows for a high signal lymph node detection rate and a low false negative rate.

Abstract PD2-02: Indocyanine green fluorescence-guided video-assisted sentinel node biopsy: A prospective comparative study and cost-analysis

Abstract Background: Currently the standard techniques for sentinel node (SLN) detection in breast cancer are radioisotope (RI) and blue dye, but both methods present some drawbacks. Indocyanine green (ICG) fluorescence has been recently proposed as an alternative technique. However, the equipment to detect ICG fluorescence is not widely accessible, limiting the potential and the diffusion of this encouraging technique. The aim of this study was to assess the feasibility, accuracy and healthcare costs of a novel approach for SLN biopsy by a video-assisted ICG-guided technique. Methods: A prospective study was performed enrolling 335 breast cancer patients: SLN was detected with RI in 194 cases, with ICG in 70 cases, and with ICG plus RI in 71 cases. ICG fluorescence was detected using a laparoscope with a near-infrared filter, and a video-assisted SLN biopsy was performed by approaching the camera in the axillary cavity. Detection rates were compared between ICG and RI. Healthcare costs were analyzed considering surgery and hospitalization times, stratified by type of surgery. Results: In ICG + RI group, ICG detected 90.9% of metastatic SLNs, while RI and ICG + RI detected 100% of them. Detection rate was 100% with ICG + RI, 95.1% with RI and 92.7% with ICG. More SLNs per patient were identified with ICG and ICG + RI compared to RI (&amp;lt;0.0001). Healthcare costs were equivalent among the 3 groups. ICG (n = 70)RI (n = 194)ICG + RI (n = 71)p value (ICG vs. RI)p value (RI vs ICG + RI)p value (ICG vs ICG + RI)Number of identified sentinel nodes8019582 Patients with 1 SLN61 (87.1%)193 (99.5%)61 (85.9%)&amp;lt;0.001&amp;lt;0.0011Patients with &amp;gt;1 SLN9 (12.9%)1 (0.5%)10 (14.1%) Missing of metastatic SLN Yes1 (1.4%)0 (0.0%)0 (0.0%)0.2710.49No69 (98.6%)194 (100.0%)71 (100.0%) SLN status Negative/ITC63 (77.8%)149 (76.4%)71 (86.6%)0.340.170.23Micrometastasis5 (6.2%)22 (11.3%)5 (6.1%) Macrometastasis13 (16.0%)24 (12.3%)6 (7.3%) Mastectomy + SLN biopsy + Axillary dissection Operative times (min)113.3 (±30.1)139 (±32.3)123.3 (±25.2)0.250.460.68Hospitalization (days)4.7 (±1.2)6.7 (±1.7)5.7 (±1.5)0.090.380.42Total cost per patient4,145.2€ (±787.9€)5,723€ (±1,099.9€)5,005.2€ (±966.3€)0.040.330.29Mastectomy + SLN biopsy Operative times (min)119.4 (±33.9)89.3 (±32.1)103.8 (±18.5)0.050.250.27Hospitalization (days)4.6 (±1.2)4.6 (±0.7)3.9 (±1.4)10.120.3Total cost per patient4,123.3€ (±794.9€)4,053.6€ (±494.6€)3,731.4€ (±896.5€)0.790.280.37Lumpectomy + SLN biopsy + Axillary dissection Operative times (min)96.9 (±28.9)111.5 (±31.8)92 (±10.4)0.260.190.73Hospitalization (days)4 (±1.5)4.7 (±1.6)4 (±2)0.280.391Total cost per patient3,589.9€ (±971.1€)4,268€ (±1,037.2€)3,714.6€ (±1,269.9€)0.110.300.85Lumpectomy + SLN biopsy Operative times (min)70.9 (±32.3)67.4 (±17.9)66.8 (±20.4)0.340.840.43Hospitalization (days)2.2 (±0.9)2.2 (±0.6)2.1 (±0.4)10.260.46Total cost per patient2,271.9€ (±611.4€)2,383.1€ (±399.4€)2,338.6€ (±289.1€)0.140.450.47 Conclusions: Video-assisted ICG fluorescence-guided SLN biopsy is a feasible technique with comparable efficacy compared to RI. Combining ICG and RI resulted in a significantly higher detection rate and identification of more SLNs per patients, providing a more accurate staging of the axilla. Citation Format: Sorrentino L, Mazzucchelli S, Truffi M, Pietropaolo G, Sartani A, Foschi D, Corsi F. Indocyanine green fluorescence-guided video-assisted sentinel node biopsy: A prospective comparative study and cost-analysis [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD2-02.

Abstract P3-01-15: Sentinel lymph node biopsy by indocyanine green fluorescence detection in breast cancer cT1-4N0M0 patients. Frequency of false-negative results is low

Abstract Breast cancer cT1-4N0M0 patients are usually need in a sentinel lymph node biopsy (SLNB). SLNB by indocyanine green (ICG) fluorescence detection is a modern technique possessing high level of lymph node detection rate, but frequency of false-negative results was not evaluated adequately. Objective was to determine main diagnostic characteristics of the ICG fluorescence-guided SLNB in BC cT1-4N0M0 patients: node detection rate and frequency of false-negative results. Methods: 99 patients with 100 cases of breast cancer cT1-4N0M0 (T1 – 43, T2 – 55, T3 – 1, T4 – 1) were operated, axillary part of operation consisted from the ICG fluorescence-guided SLNB and axillary lymphadenectomy of levels I–II or I–II–III. 12 patients had neoadjuvant chemotherapy and 8 – neoadjuvant hormonotherapy. Photodynamic Eye C9830 (Hamamatsu Photonics K.K) was using for emit near infrared radiation and fluorescent image registration. 2 ml 0.25% solution of ICG were injected inra- and sub- cutaneous periareolary or in a tumor projection, 2-5 minutes later it can be see fluorescent way to axillary. The procedure starting from injection of the ICG to the identification of a signal lymph node takes 15–30 minutes. Results. Transcutaneous fluorescent lymphatic duct was visible in all 100 procedures, but not lymphatic node. Last can be found usually in a wound after Fascia superficialis and Fascia axillaris dissection. A signal lymph node was detected in 98 cases (98 %). Mean amount of sentinel lymphatic nodes = 1.9±0.1 (1-7 nodes). Mean amount of lymphatic nodes took with axillary dissection = 10.5±0.5 (5-26 nodes). In 28 (28.6%) cases of 98 were found to have metastases in signal lymph nodes. Other than signal lymph nodes had metastatic lesion only in 35.7% in signal lymph nodes N+ cases. False negative result occurred in 3 (3.1%) cases of 98, including 2 with metastases in signal lymph node finding by plan histological investigation, but not at froze section. No cases of allergic reactions or other adverse effects were diagnosed with standard subcutaneous use of indocyanine. Conclusion. Fluorescence technique of the detection of signal lymph nodes has its own methodological issues: in most cases a signal lymph node is not visualized through the skin, it should be visualized in surgical wound using the course of lymphatic duct as guidance. Application of ICG fluorescence-guided SLNB in cN0 breast cancer patients allows high signal lymph node detection rate and low false negative rate, - 3%. Acknowledgments. The authors thank Professor Gordon C. Wishart for the Sentinel Lymph Node Detection by ICG Fluorescence Technique teaching. Citation Format: Portnoy SM, Kuznetsov AV, Shakirova NM, Kozlov NA, Maslyaev AV, Karpov AV, Kampova-Polevaya EB, Mistakopulo MG, Egorov YS, Anurova OA, Shendrikova TA, Gornostaeva AS. Sentinel lymph node biopsy by indocyanine green fluorescence detection in breast cancer cT1-4N0M0 patients. Frequency of false-negative results is low [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-01-15.

Indocyanine green detects sentinel lymph nodes in early breast cancer.

ObjectiveTo explore the clinical value of indocyanine green (ICG) for the fluorescence-guided detection of sentinel lymph nodes (SLNs) during sentinel lymph node biopsy (SLNB) in patients with early breast cancer.MethodsThis retrospective study included female patients with breast cancer. Patients were administered methylene blue and ICG using standard techniques. All SLNs that were collected during surgery were submitted for pathological examination. SLNs were defined as those that were either fluorescent, blue, fluorescent and blue or palpably suspicious. Surgical complications, axillary recurrence, distant metastasis and overall survival rates were observed postoperatively.ResultsA total of 60 patients were enrolled in the study. The fluorescence detection rate of SLNs was 100% (n = 177), with a mean of 2.95 SLNs per patient. The methylene blue staining rate was 88.3% (n = 106), with a mean of 1.77 SLNs per patient. Pathological assessment of intraoperative frozen specimens revealed SLN metastases in 10 patients, who immediately underwent axillary lymph node dissection. No patient had axillary recurrence or distant metastases, with a survival rate of 100%. Patients who underwent SLNB showed good appearance in the axillary wound, with no limited shoulder joint abduction and upper limb oedema.ConclusionFluorescence-guided SLNB has several advantages and is suitable for clinical application.

Diagnostic Performance of Indocyanine Green-Guided Sentinel Lymph Node Biopsy in Breast Cancer: A Meta-Analysis.

BackgroundThe diagnostic performance of indocyanine green (ICG) fluorescence-guided sentinel lymph node biopsy (SLNB) for the presence of metastases in breast cancer remains unclear.ObjectiveWe performed a meta-analysis to investigate the diagnostic performance of ICG-guided SLNB.MethodsEligible studies were identified from searches of the databases PubMed and EMBASE up to September 2015. Studies that reported the detection rate of ICG fluorescence-guided SLNB with full axillary lymph node dissection and histological or immunohistochemical examinations were included. A meta-analysis was performed to generate pooled detection rate, sensitivity, specificity, false negative rate, diagnostic odds ratio (DOR) and a summary receiver operator characteristic curve (SROC).ResultsNineteen published studies were included to generate a pooled detection rate, comprising 2594 patients. The pooled detection rate was 0.98 (95% confidence interval [CI], 0.96–0.99). Six studies finally met the criteria for meta-analysis, which yielded a pooled sensitivity of 0.92 (95% CI, 0.85–0.96), specificity 1 (95% CI, 0.97–1), and DOR 311.47 (95% CI, 84.11–1153.39). The area under the SROC was 0.9758. No publication bias was found.ConclusionICG fluorescence-guided SLNB is viable for detection of lymph node metastases in breast cancer. Large-scale randomized multi-center trials are necessary to confirm our results.

Abstract P3-01-03: Optimal concentration of indocyanine green in near-infrared fluorescence guided sentinel lymph node biopsy in breast cancer

Abstract Background: Near-infrared (NIR) fluorescence-guided sentinel lymph node biopsy (SLNB) using indocyanine green (ICG) has been successfully applied in various kinds of cancers, especially in breast cancer. Optimizing the concentration of ICG without using human serum albumin in natural lymphatic system is still required. Methods: 25mg of ICG was diluted with distilled water (DW) or normal saline (NS). Dilution concentrations used for measurement were 0.25μg/mL, 0.5μg/mL, 2.5μg/mL, 5.0μg/mL, 25μg/mL, and 250μg/mL. The brightness of fluorescence was measured by an image system called Visual Navigator (SH System, Korea). We used graphic software (GIMP, version 2.8.14, The GIMP Team) to measure the brightness. We assumed that drained serous lymphatics from a breast cancer patient can reflect a natural lymphatic condition injected with ICG in the operation field. Drained lymphatics were mixed to reduce the concentration of ICG by half that was diluted with DW or NS. We also measured the brightness of fluorescence diluted with DW or NS that was mixed with drained lymphatics. After this screening test, we subdivided the range which brightness was measured as 100 and adjusted the intensity of illumination for more specific results. Results: Highest brightness values were measured as 100 between 2.5μg/mL and 25μg/mL concentration of ICG with DW dilution in screening settings, and the values of brightness were measured as 100 between 2.5μg/mL and 5.0μg/mL concentration of ICG with NS dilution. When drained lymphatics were mixed together, the values of brightness were measured as 100 between 2.5μg/mL and 25μg/mL concentration of ICG with DW or NS dilution. After subdividing the ICG concentration to 2.5μg/mL, 3.13μg/mL, 5.0μg/mL, 6.25μg/mL, 12.5μg/mL and 25μg/mL with adjusting the intensity of illumination, the highest brightness value was measured as 76 in 5.0μg/mL concentration of ICG with DW dilution. When diluting with NS, the highest brightness value was measured as 61 in 5.0μg/mL ICG concentration. After mixing with drained lymphatics, the highest brightness value was both 79 in 5.0μg/mL concentration of ICG with DW and NS dilution. Conclusions: This study showed a practically optimal ICG concentration range in fluorescence guided SLNB. The optimal range of ICG concentration is from 3.13μg/mL to 6.25μg/mL with DW or NS dilution. Although 5.0μg/mL met the best result, adjustment for individual settings may be considered. Citation Format: Paik H-J, Yi HW, Park S, Ryu JM, Nam SJ, Lee JE, Kil WH, Lee SK, Bae SY, Kim SW. Optimal concentration of indocyanine green in near-infrared fluorescence guided sentinel lymph node biopsy in breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-01-03.

Indocyanine green fluorescence-guided sentinel node biopsy: A meta-analysis on detection rate and diagnostic performance

BackgroundIndocyanine green (ICG) fluorescence-guided sentinel node biopsy (SLNB) has been successfully employed in various kinds of tumors. Clinical results of previous studies on this technique are at different levels of evidence. This Meta-analysis was conducted to provide a more precise estimation on its clinical performance. MethodsEligible studies were identified from systematical PubMed and EMBASE searches; data were extracted. A Meta-analysis was performed to generate pooled detection rate, sensitivity, specificity, diagnostic odds ratio (DOR) and summary receiver operator characteristic curves. ResultsFifteen published articles were included. Clinical data of 513 patients were obtained. The pooled detection rate, the pooled sensitivity, the pooled specificity, the pooled DOR and their 95% confidence intervals (95% CI) were 0.96 (0.91–0.99), 0.87 (0.79–0.92), 1.00 (0.99–1.00) and 150.13 (57.42–392.56), respectively. Significant heterogeneities existed among studies. Significant publication bias was found in detection rate. The concentration < 5 mg/ml subgroup and the injected volume ≥2 ml subgroup had higher DORs, sensitivities and detection rates than the concentration ≥ 5 mg/ml subgroup and the injected volume <2 ml subgroup, respectively. ConclusionBased on this Meta-analysis, this technique could be valued promising for detecting the presence of LN metastases. ICG injection with reduced concentration and larger volume may provide improved performance.

Valor añadido del trazador híbrido verde de indocianina-99mTc-nanocoloide para la biopsia del ganglio centinela en una serie de pacientes con drenaje en diferentes territorios anatómicos

Indocyanine green (ICG)-(99m)Tc-nanocolloid is a novel hybrid fluorescent radioactive tracer for sentinel node (SN) biopsy. This study has aimed to evaluate the added value of this novel versatile tracer in a series of patients with different malignancies.Twenty patients (with penile carcinoma, oral cavity tumors, melanoma) were consecutively included between March-May 2012. Planar lymphoscintigraphy was performed 15 min and 2h after injection of ICG-(99m)Tc-nanocolloid followed by SPECT/CT. Blue dye (1 ml) was injected in 14 patients in surgery room. Intraoperatively, SNs were localized using a gamma probe and visualized by optical SN-detection using blue dye and fluorescence imaging. Finally, a portable gamma camera was used to confirm complete SN removal.At least one SN was identified by SPECT/CT in all patients. All SNs (total 68, 100%) were excised using a combination of radio- and fluorescence guidance: 89.7% were intraoperatively localized with the gamma probe. The remaining SNs, located near the injection site, were localized using fluorescence imaging. During the surgery, 97% of the SNs were fluorescent while only 39.2% were stained blue. Ex vivo, all SNs were both radioactive and fluorescent. The SN was positive in 5 patients.Synchronous radio- and fluorescence guided SN biopsy is feasible using ICG-(99m)Tc-nanocolloid. This hybrid approach combines the beneficial properties of both modalities. Adding fluorescence imaging improves optical SN detection compared to blue dye. It has been shown to be especially useful in the localization of SNs near the injection site.

Added value of the hybrid tracer indocyanine green-99mTc-nanocolloid for sentinel node biopsy in a series of patients with different lymphatic drainage patterns

IntroductionIndocyanine green (ICG)-99mTc-nanocolloid is a novel hybrid fluorescent radioactive tracer for sentinel node (SN) biopsy. This study has aimed to evaluate the added value of this novel versatile tracer in a series of patients with different malignancies. Material and methodsTwenty patients (with penile carcinoma, oral cavity tumors, melanoma) were consecutively included between March and May 2012. Planar lymphoscintigraphy was performed 15min and 2h after injection of ICG-99mTc-nanocolloid followed by SPECT/CT. Blue dye (1ml) was injected in 14 patients in surgery room. Intraoperatively, SNs were localized using a gamma probe and visualized by optical SN-detection using blue dye and fluorescence imaging. Finally, a portable gamma camera was used to confirm complete SN removal. ResultsAt least one SN was identified by SPECT/CT in all patients. All SNs (total 68, 100%) were excised using a combination of radio- and fluorescence guidance: 89.7% were intraoperatively localized with the gamma probe. The remaining SNs, located near the injection site, were localized using fluorescence imaging. During the surgery, 97% of the SNs were fluorescent while only 39.2% were stained blue. Ex vivo, all SNs were both radioactive and fluorescent. The SN was positive in 5 patients. ConclusionSynchronous radio- and fluorescence guided SN biopsy is feasible using ICG-99mTc-nanocolloid. This hybrid approach combines the beneficial properties of both modalities. Adding fluorescence imaging improves optical SN detection compared to blue dye. It has been shown to be especially useful in the localization of SNs near the injection site.

Clinical trial of combined radio- and fluorescence-guided sentinel lymph node biopsy in breast cancer

Combining radioactive colloids and a near-infrared (NIR) fluorophore permits preoperative planning and intraoperative localization of deeply located sentinel lymph nodes (SLNs) with direct optical guidance by a single lymphatic tracer. The aim of this clinical trial was to evaluate and optimize a hybrid NIR fluorescence and radioactive tracer for SLN detection in patients with breast cancer. Patients with breast cancer undergoing SLN biopsy were enrolled. The day before surgery, a periareolar injection of indocyanine green (ICG)-99mTc-radiolabelled nanocolloid was administered and a lymphoscintigram acquired. Blue dye was injected immediately before surgery. Intraoperative SLN localization was performed using a γ probe and the Mini-FLARE™ NIR fluorescence imaging system. Patients were divided into two dose groups, with one group receiving twice the particle density of ICG and nanocolloid, but the same dose of radioactive 99mTc. Thirty-two patients were enrolled in the trial. At least one SLN was identified before and during operation. All 48 axillary SLNs could be detected by γ tracing and NIR fluorescence imaging, but only 42 of them stained blue. NIR fluorescence imaging permitted detection of lymphatic vessels draining to the SLN up to 29 h after injection. Doubling the particle density did not yield a difference in fluorescence intensity (median 255 (range 98-542) versus 284 (90-921) arbitrary units; P = 0.590) or signal-to-background ratio (median 5·4 (range 3·0-15·4) versus 4·9 (3·5-16·3); P = 1·000) of the SLN. The hybrid NIR fluorescence and radioactive tracer permitted accurate preoperative and intraoperative detection of the SLNs in patients with breast cancer. NTR3685 (Netherlands Trial Register; http://www.trialregister.nl).

Nanocolloidal albumin-IRDye 800CW: a near-infrared fluorescent tracer with optimal retention in the sentinel lymph node

PurposeAt present, the only approved fluorescent tracer for clinical near-infrared fluorescence-guided sentinel node (SN) detection is indocyanine green (ICG), but the use of this tracer is limited due to its poor retention in the SN resulting in the detection of higher tier nodes. We describe the development and characterization of a next-generation fluorescent tracer, nanocolloidal albumin-IRDye 800CW that has optimal properties for clinical SN detectionMethodsThe fluorescent dye IRDye 800CW was covalently coupled to colloidal human serum albumin (HSA) particles present in the labelling kit Nanocoll in a manner compliant with current Good Manufacturing Practice. Characterization of nanocolloidal albumin-IRDye 800CW included determination of conjugation efficiency, purity, stability and particle size. Quantum yield was determined in serum and compared to that of ICG. For in vivo evaluation a lymphogenic metastatic tumour model in rabbits was used. Fluorescence imaging was performed directly after peritumoral injection of nanocolloidal albumin-IRDye 800CW or the reference ICG/HSA (i.e. ICG mixed with HSA), and was repeated after 24 h, after which fluorescent lymph nodes were excised.ResultsConjugation of IRDye 800CW to nanocolloidal albumin was always about 50% efficient and resulted in a stable and pure product without affecting the particle size of the nanocolloidal albumin. The quantum yield of nanocolloidal albumin-IRDye 800CW was similar to that of ICG. In vivo evaluation revealed noninvasive detection of the SN within 5 min of injection of either nanocolloidal albumin-IRDye 800CW or ICG/HSA. No decrease in the fluorescence signal from SN was observed 24 h after injection of the nanocolloidal albumin-IRDye 800CW, while a strong decrease or complete disappearance of the fluorescence signal was seen 24 h after injection of ICG/HSA. Fluorescence-guided SN biopsy was very easy.ConclusionNanocolloidal albumin-IRDye 800CW is a promising fluorescent tracer with optimal kinetic features for SN detection.Electronic supplementary materialThe online version of this article (doi:10.1007/s00259-012-2080-5) contains supplementary material, which is available to authorized users.