Sentinel Lymph Node Identification Rate Research Articles

Clinical Application of Multimodal Sentinel Lymph Node Mapping Method in Patients with Breast Cancer Undergoing Neoadjuvant Chemotherapy: An Interim Analysis.

After neoadjuvant chemotherapy (NAC), the SLN identification rate is lower and has a higher false-negative rate than that at upfront surgery. This clinical trial aimed to confirm the effectiveness of sentinel lymph node (SLN) surgery by determining the lymph node identification rate using multimodal SLN marker methods in patients with advanced breast cancer undergoing NAC. This clinical study is a prospective single-center randomized controlled trial involving patients with breast cancer receiving NAC. Patients are randomized (1:1:1) into arm A that involves the use of radioisotope (RI) plus indocyanine green fluorescence (ICG-F); arm B, RI plus vital dye; and, arm C, ICG-F plus vital dye. A total of 348 patients are needed. An interim analysis was performed on 50% of the patients enrolled. The primary outcome of this trial was the SLN identification rate. Among the 164 total patients (median age 51 years), T2 and N1 were the most common clinical stages. The identification rate of SLN was 95% in arm A, 92% in arm B, and 79% in arm C. To assess superior efficacy, the one-sided endpoint was set at α < 0.0056. Arms A and C showed a difference of 0.1597 in the detection rate (p = 0.0055). The use of ICG-F plus vital dye for SLNB was the least effective. The results show that the choice of tracer should be radioisotope in combination with one of the other tracers to have the highest SLN identification rate when SLNB cannot be implemented conventionally due to the circumstances of each institution.

99mTc-Tilmanocept vs. Sulfur Colloid for Sentinel Node Biopsy for Melanoma in the Head and Neck.

The objective of the study is to compare sentinel lymph node (SLN) identification rates and performance characteristics of lymphoscintigraphy using 99mTc-sulfur colloid (SC) and 99mTc-tilmanocept (TL) for head and neck cutaneous melanoma.This study is a retrospective study, conducted at a single, tertiary care cancer center.Patients underwent sentinel lymph node biopsy (SLNB) for head and neck cutaneous melanoma, using SC or TL, between October 2014 and February 2019. Differences in SLN identification rates and performance characteristics between the groups were examined using the Mann-Whitney, or Fisher's exact test. Sixty patients underwent SLNB, of which 19 employed TL. There were no significant differences between SC vs. TL in operative duration (116 vs. 127min, P = 0.97), radiation dose (530 vs. 547μCi, P = 0.27), median number of SLNs removed (3 vs. 2, P = 0.32), or median follow-up (46.3 vs. 38.4months, P = 0.11). The rates of positive SLNs (17% vs. 37%, P = 0.11), intraoperative non-localization (12% vs. 16%, P = 0.70), and false-negative SLNB (5% each, P = 1.00) were not significantly different between groups. In patients with head and neck melanoma undergoing SLNB, 99mTc-tilmanocept may not differ from 99mTc-sulfur colloid in identifying SLNs or other performance characteristics. The added expense related to 99mTc-tilmanocept and lack of favorable performance data should urge caution in its adoption and promote further examination of its value in similar patient cohorts.

The Value of Percutaneous Contrast-Enhanced Ultrasound in Sentinel Lymph Node Identification, Metastatic Status and Burden Diagnosis in Early Breast Cancer.

The aim of this study was to evaluate the value of percutaneous contrast-enhanced ultrasound (PCEUS) in the identification and characterization of sentinel lymph node (SLN). A total of 102 breast cancer patients were collected and underwent preoperative PCEUS, which was used to identify SLN and lymphatic drainage. SLNs were classified into 4 enhancement patterns, including 6 subtypes: homogeneous (I), featured inhomogeneous (II) including inhomogeneous hypoenhancement (IIa) and annular or semi-annular enhancement (IIb), focal filling defect (III) including filling defect area < 50% (IIIa) and filling defect area ≥ 50% (IIIb), and no enhancement (IV). The enhancement patterns of SLNs were compared with the final pathological diagnosis. The identification rate of SLNs using PCEUS was 100% (102/102); the rate of identification of LCs was 100% (102/102), and the coincidence rate was 98.0% (100/102). Four lymphatic drainage patterns (LDPs) including 5 subtypes were found: single LC/single SLN(74.5%), multiple LCs/ single SLN (13.7%) including 2 subtypes:2 LCs/1 SLN and 3 LCs/1 SLN, single LC/multiple SLNs (7.8%), and multiple LCs/multiple SLNs (3.9%). A total of 86.3% (44/51) of patients without axillary metastasis could be safely selected for types I, IIa, and IIb, while the axillary metastasis rates of types III and IV were 74.4%and 87.5%, respectively (P < .001). Compared with grayscale US, the PCEUS significant improvement in diagnosing metastatic SLNs (.794 versus .579, P < .001). For the SLN metastatic burden, Types I, IIa, IIb, and IIIa had ≤2 SLNs metastases, with a pathological coincidence rate of (64/67, 95.5%), and types IIIb and IV had >2 SLNs metastases, with a pathological coincidence rate of (25/35, 71.4%) (P < .001). The AUC of PCEUS for the diagnosis of SLN metastatic status and burden was .794 and .879, respectively (P < .001). PCEUS has a high identification rate for SLN and has good potential for diagnosing SLN metastatic status and burden by enhancement patterns.

Tumescent anesthesia use for cutaneous malignancies does not impact sentinel node identification but decreases estimated blood loss

Sentinel node biopsy is performed to stage clinically and radiographically occult regional disease in cases of malignancy, including cutaneous cancer such as melanoma. The use of tumescent anesthesia with sentinel node biopsy for cutaneous malignancies has not been well studied. Therefore, we aimed to compare the rate of successful sentinel node identification and estimated blood loss between patients who underwent sentinel node biopsy with and without the use of tumescent anesthesia. A retrospective review was conducted of a prospectively maintained single-institution database of all patients who underwent reconstruction after the extirpation of a cutaneous malignancy over an 18-month period. Patient demographics, tumor histology, and characteristics, indication for and success of sentinel node biopsy, use of tumescent anesthesia, and total estimated blood loss were examined. Sentinel node biopsy was performed in 15 of 39 patients (38.5%) receiving tumescent anesthesia compared with 6 of 26 patients (23.1%) not receiving it (p=0.19). Sentinel node biopsy had a success rate of 100% in the tumescent and nontumescent anesthesia groups. The mean estimated blood loss in the tumescent anesthesia group was 36.7mL versus 59.6mL in the nontumescent anesthesia group (p<0.001). Complication rates were comparable between the tumescent anesthesia (12.8%) and nontumescent anesthesia (19.2%) groups (p=0.48). The use of tumescent anesthesia in cutaneous malignancy extirpation and immediate reconstruction was not associated with a decreased sentinel node identification rate or change in complication rates. However, tumescent anesthesia was associated with a decrease in the estimated blood loss.

Carbon nanoparticles localized clipped node dissection combined with sentinel lymph node biopsy with indocyanine green and methylene blue after neoadjuvant therapy in node positive breast cancer in China: initial results of a prospective study

BackgroundThis study aimed to evaluate the feasibility of applying carbon nanoparticles (CNs) to visualize clip-marked metastatic nodes in combination with indocyanine green (ICG) and methylene blue (MB) as sentinel lymph node (SLN) tracers for targeted axillary dissection (TAD) after neoadjuvant therapy (NAT).MethodsThis feasibility trial enrolled 40 patients with node-positive breast cancer, and 38 patients completed NAT and surgery were included in the final analysis. Before NAT or surgery, clip-marked nodes were localized with CNs by ultrasonography. After NAT, the clip-marked nodes were removed under the guidance of carbon-tattooing and confirmed by radiography. SLNs were mapped with ICG and MB. Axillary lymph node dissection (ALND) was performed for all patients after TAD.ResultsThe clip-marked nodes were retrieved in all patients. The SLN identification rate was 100%. 29 of 38 clipped-nodes were SLNs. The false-negative rate was 6.25% (2/32,95% CI:1.09% ~ 22.22%) for TAD nodes and 9.38% (3/32,95% CI 3.24%-24.22%) for SLNs, and 18.75% for clipped-nodes (6/32, 95% CI:7.86% ~ 37.04%). No adverse events were reported during clip placement, CNs localization, or the TAD procedure.ConclusionsThe TAD procedure with CNs to locate and visualize clipped nodes as well as SLN tracing with ICG and MB has good accessibility in China, and this technique could be easily mastered by experienced surgeons. The modified TAD technique has also demonstrated good predictive ability for residual axillary lesions after NAT, and is worth of further evaluation.

Investigating a Technologist-Driven Injection Technique in Lymphoscintigraphy at a Single Rural Center: A Retrospective Audit.

Our aim was to investigate the effectiveness of the technologist-driven injection technique of lymphoscintigraphy used at a rural hospital in Australia to identify the correct lymph node for sentinel lymph node biopsy (SLNB) in early-stage breast cancer patients. Methods: A retrospective audit was conducted using imaging and medical record data from 145 eligible patients who underwent preoperative lymphoscintigraphy for SLNB at a single center throughout 2013 and 2014. The lymphoscintigraphy technique included a single periareolar injection with subsequent dynamic and static images as required. Descriptive statistics, sentinel node identification rates, and imaging-surgery concordance rates were generated from the data. Additionally, χ2 analysis was used to examine the relationships between age, previous surgical intervention, and injection site and time until a sentinel node is visualized. The technique and statistical results were directly compared against multiple similar studies in the literature. Results: The sentinel node identification rate was 99.3%, and the imaging-surgery concordance rate was 97.2%. The identification rate was significantly higher than those of similar studies in the literature, and concordance rates were similar across studies. The findings demonstrated that age (P = 0.508) and previous surgical intervention (P = 0.966) did not influence the time it takes to visualize a sentinel node. Injection site did appear to have a statistically significant effect (P = 0.001), with injections in the upper outer quadrant correlating with increased times between injection and visualization. Conclusion: The reported lymphoscintigraphy technique for identifying sentinel lymph nodes for SLNB in early-stage breast cancer patients can be justified as an accurate and effective method that is time-sensitive and has outcomes comparable to those of successful studies in the literature.

THE COMPARISON OF RADIOCOLLOID, BLUE DYE AND A COMBINED METHOD FOR SENTINEL LYMPH NODE BIOPSY IN EARLY-STAGE BREAST CANCER

This study aims to compare the performance of radiocolloid, blue dye and a combined method for sentinel lymph node biopsy in early breast carcinoma. One hundred seventy-two clinically node-negative, early-stage breast cancer patients who underwent combined method sentinel lymph node biopsy (SLNB) with 99mTc-nanocolloid and blue dye were recruited. The peri-areolar injection is the method used in both techniques. The hot node contained only radiocolloid, the blue node contained only blue dye, and the hot-blue node contained both tracers. The detection, metastatic, and failure rate of the combined, radiocolloid, and blue dye methods were determined by analysing the number of hot and blue nodes in all patients, all excised nodes, and metastatic nodes. The association between clinicopathological factors and the detection of sentinel lymph nodes (SLN) was analysed. The overall SLN detection rate was 98.2% (169/172) for radiocolloid, 95.9% (165/172) for blue dye, and 99.4% (171/172) for the combined method. The metastatic rate was 19.2% (33/172). Among the 33 metastatic-node cases, the combined, radiocolloid and blue dye method failed to identify 1, 1 and 4 cases, respectively. Therefore, the failure rate of the combined, radiocolloid, and blue dye method was 3.0% (1/33), 3.0% (1/33) and 12.1% (4/33), respectively. No significant association between clinicopathological factors and SLN detection was observed. The combined method of SLNB yielded the highest detection rate when compared to the radiocolloid-alone and blue-dye-alone methods. The radiocolloid method detected more SLN than the blue dye method. Therefore, incorporating the radiocolloid method in the blue dye method will improve the SLN identification rate and reduce the failure rate of metastatic detection.

Application of fluorescence endoscopy with methylene blue dye and indocyanine green dual-tracer method in sentinel lymph node biopsy for women with breast cancer.

Indocyanine green (ICG) allows for the real-time visualization of lymphatic drainage and provides favorable performance for sentinel lymph node (SLN) mapping. However, the limited ability of tissue penetration of the near-infrared fluorescence of ICG may lead to the failure of lymph node detection in the traditional open approach of sentinel lymph node biopsy (SLNB) for breast cancer, especially in overweight or obese patients. To accurately and quickly detect SLNs, we applied fluorescence endoscopy with a dual-tracer method using ICG and methylene blue dye (MBD) in SLNB for breast cancer. We conducted this study to assess the feasibility and application value of this method in minimally invasive surgery. A total of 117 patients who received dual-tracer injection of ICG and MBD prior to endoscopic SLNB from November 2020 to September 2021 were examined in this study. The number of SLNs identified, the SLN identification rate, the time to identify the first SLN, the procedure duration, and the postoperative morbidity were analyzed. Biopsied SLNs could be identified in 116 patients (99.15%) with an average number of 5.12±1.87 per patient. Blue-stained SLNs were found in 99 patients (84.62%) and fluorescent SLNs in 112 patients (95.73%). A total of 34 patients (29.06%) had positive SLNs. In 6 cases (5.13%), the positive SLNs were only stained with ICG fluorescence. In 1 case (0.85%), the positive SLNs were only blue-stained with no fluorescence staining. The mean durations for the identification of the first SLN and endoscopic SLNB were 7.14±6.31 and 37.75±16.94 min, respectively. Upper-limb lymphoedema was observed 5 cases (4.27%) during a median follow-up period of 10 months. The fluorescence endoscopy method assisted by dual tracer facilitates SLN detection with a comparatively short procedure duration and low complication rate. This approach could serve as a new method for SLNB for patients with breast cancer.

Staging LaParoscopy to Assess Lymph NOde InvoLvement in Advanced GAstric Cancer (POLA)-Study protocol for a single-arm prospective observational multicenter study.

In the era of neoadjuvant chemotherapy in advanced gastric cancer (GC), the role of staging laparoscopy (SL) will become more established. However, despite guidelines recommendations, SL for optimal preoperative staging remains underutilized. Diagnostic value of near-infrared (NIR) / indocyanine green (ICG) guided sentinel node (SN) mapping in GC confirmed its technical feasibility, however no data exist regarding its potential role in pathological nodal staging. To the best of our knowledge, current study is the first to evaluate the role of ICG in nodal staging of advanced GC patients undergoing SL. This single-arm prospective observational multicenter study was approved by the Bioethical Committee of Medical University of Lublin (Ethic Code: KE-0254/331/2018). The protocol is registered at clinicaltrial.gov (NCT05720598), and the study results will be reported according to the Strengthening of Reporting of Observational Studies in Epidemiology (STROBE) statement. The primary endpoint of this study is the identification rate of ICG-guided SN in advanced GC patients. The secondary endpoints include pathological and molecular assessment of retrieved SNs and other pretreatment clinical variables potentially associated with SL: pattern of perigastric ICG distribution according to patients' pathological and clinical characteristics, neoadjuvant chemotherapy compliance, 30-day morbidity, and mortality. POLA study is the first to investigate the clinical value of ICG-enhanced sentinel node biopsy during staging laparoscopy in advanced GC patients in a Western cohort. Identifying pN status before multimodal treatment will improve GC staging process.

Evaluation of Dual Dye Technique for Sentinel Lymph Node Biopsy in Breast Cancer: Two-Arm Open-Label Parallel Design Non-Inferiority Randomized Controlled Trial.

Radioisotope and blue dye are standard agents for performing sentinel lymph node (SLN) biopsy in breast cancer. The paucity of nuclear medicine facility poses logistic challenge. This study evaluated performance of radioisotope & methylene blue (MB) with indocyanine green (ICG) and MB for SLNB. This randomized controlled trial was conducted from December 2019 to July 2022 comparing SLN identification proportions of radioisotope-blue dye [Group A] with dual dye (MB + ICG; Group B]. Secondary objective included time required and cost effectiveness of performing SLNB. Sample size of 70 (35 in each arm) was calculated. Upfront operable node negative early breast cancer was included in the study. Clinico-demographic data, number & type of SLN, time taken were noted. Cost analysis was done including the equipment, manpower & consumables. Chi-square/Fisher exact test was used to compare proportion between two groups. p value of less than 0.05 was considered to represent statistical significance. Seventy patients randomized to either group were similar in clinico-demographic and tumor characteristics. SLN identification rate (IR) was 91.43% in group A and 100% in group B. Overall IR of MB, radioisotope and ICG were 91.43%, 91.43% and 100%, respectively. Mean number of SLNs identified were 3 in group A and 4 in group B. Median time required for SLNB was 12min and 14min in either group, respectively. Cost of performing SLNB was higher in Group B. SLNB using dual dye is non-inferior to radioisotope-blue dye in upfront operable early breast cancer. Trial registration number Clinical Trial registry India CTRI/2020/02/023503.

Safety and Efficacy of Mitoxantrone Hydrochloride Injection for Identification of Axillary Sentinel Lymph Nodes in Patients with Primary Breast Cancer.

The dual technique using blue dye in combination with a radioisotope is considered the gold standard for identifying sentinel lymph nodes (SLNs) in patients with breast cancer. Unfortunately, not all cancer centres have access to radioactive material, which jeopardizes the SLN identification rate and patient safety. We aimed to assess the safety and efficacy of mitoxantrone hydrochloride injection (MHI) for identifying axillary SLNs in patients with primary breast cancer. We have conducted a prospective non-randomized analysis of patients diagnosed with invasive breast cancer who agreed to participate in the study between December 2019 and December 2022. We have used the patient's medical records to collect the data. We have used the SLN intraoperative identification rate as a marker for the efficacy of the technique and both the immediate and delayed complication rates and routine blood tests as markers for the safety of the technique. Out of the 296 patients, 289 (97.6%) had their SLNs identified using MHI, while seven patients (2.3%) had four-node sampling carried out because the SLNs were not identified. Liver functions were not significantly affected by MHI, and there was no technique-related readmission or reported morbidity or mortality. We have found that the MHI technique is still inferior to the combined radioactive directed technique and patent blue V dye in SLN identification. Yet, it may serve as a safe and reliable alternative in cases where the radioactive technique is unavailable.

Can fluorescence-guided surgery improve optimal surgical treatment for ovarian cancer? A systematic scoping review of clinical studies

BackgroundThe predicament of achieving optimal surgical intervention faced by surgeons in treating ovarian cancer has driven research into improving intra-operative detection of cancer using fluorescent materials.ObjectiveTo provide a literature overview...

The importance of sentinel lymph node diagnostic biopsy from the lateral neck compartment in the surgical treatment of papillary thyroid cance.

The aim of our study is to determine whether mapping the lymphatic drainage and diagnostic excision of lymph nodes from lateral neck compartment is able to detect ultrasound unknown metastases in this compartment early and thus favorably affect the prognosis of patients with papillary thyroid cancer (PTC). Lymph node involvement in the lateral neck compartment is seen in 30-60 % of patients with PTC at the time of diagnosis and affects the prognosis of patients in terms of disease recurrence. From June 2012 to December 2016, 154 patients with no evidence of lateral nodal involvement on imaging studies were treated with total thyroidectomy and central comparment neck dissection. A volume of 0.2 ml of Patent Blue dye was applied in the upper half of the thyroid gland with subsequent exposure of lymphatic drainage in the lateral compartment and 2-3 sentinel lymph nodes (SLN) were removed for frozen section (Group 1). In case of metastatic involvement, a lateral comparment neck dissection was performed. The reference groups were composed of aset of patients without detected lymphatic drainage (Group 2) and a set of patients who underwent lateral compartment neck dissection for preoperatively detected metastases in the lymph nodes (Group 3). The biochemical, structural and overall persistence of the disease at the time of administration of adjuvant radioiodine ablation was evaluated. The SLN identification rate was 95.45 %. In Group 1, a total of 32 patients had a positive SLN. Out of these, 24 patients had positive SLNs based on the analysis of frozen section, while in 8 patients, the positive diagnosis was confirmed through definitive histology. The comparison of data from the entire follow-up period in all three groups of patients revealed statistically significant differences in persistence of disease, namely in favor of Group 1. The percentage of reoperations for persistence and recurrence of disease was significantly lowest in Group 1 (2.04 %) compared to Groups 2 and 3 (6.94 % and 45.45 % respectively). The method is safe and sensitive for detecting unknown lymph node metastases in the lateral neck compartment, and may facilitate adecision to perform accurate surgical treatment of patients with PTC (Tab. 4, Fig. 2, Ref. 38).

Efficacy and prognosis of robotic surgery with sentinel node navigation surgery in endometrial cancer.

This study aimed to validate the surgical and oncologic outcomes of robotic surgery with sentinel node navigation surgery (SNNS) in endometrial cancer. This study included 130 patients with endometrial cancer, who underwent robotic surgery, including hysterectomy, bilateral salpingo-oophorectomy, and pelvic SNNS at the Department of Obstetrics and Gynecology of Kagoshima University Hospital. Pelvic sentinel lymph nodes (SLNs) were identified using the uterine cervix 99m Technetium-labeled phytate and indocyanine green injections. Surgery-related and survival outcomes were also evaluated. The median operative and console times and volume of blood loss were 204 (range: 101-555) minutes, 152 (range: 70-453) minutes, and 20 (range: 2-620) mL, respectively. The bilateral and unilateral pelvic SLN detection rates were 90.0% (117/130) and 5.4% (7/130), respectively, and the identification rate (the rate at which at least one SLN could be identified on either side) was 95% (124/130). Lower extremity lymphedema occurred in only 1 patient (0.8%), and no pelvic lymphocele occurred. Recurrence occurred in 3 patients (2.3%), and the recurrence site was the abdominal cavity, with dissemination in 2 patients and vaginal stump in one. The 3-year recurrence-free survival and 3-year overall survival rates were 97.1% and 98.9%, respectively. Robotic surgery with SNNS for endometrial cancer showed a high SLN identification rate, low occurrence rates of lower extremity lymphedema and pelvic lymphocele, and excellent oncologic outcomes.

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.

Contrast-enhanced lymphatic US can improve the preoperative diagnostic performance for sentinel lymph nodes in early breast cancer.

ObjectivesTo evaluate the preoperative diagnostic value of contrast-enhanced lymphatic ultrasound (CEUS) for the sentinel lymph node (SLN) status in early breast cancer.Materials and methodsWe prospectively recruited 102 consecutive patients with clinically node-negative early breast cancer from July 2021 to October 2021. All patients underwent conventional US and percutaneous CEUS examinations. The CEUS of SLNs were classified into four enhancement patterns: homogeneous (I), featured inhomogeneous (II), focal defect (III), and no enhancement (IV). The diagnostic performance of conventional US and CEUS for SLN metastasis was assessed by receiver operating characteristic (ROC) curves and decision curves.ResultsA total of 78 women were enrolled in this study, including 55, 18, and 5 patients with negative axilla, 1–2, and ≥ 3 metastastic SLNs pathologically, respectively. The identification rate of SLNs by CEUS was 100%. Patterns I and II can select 91.7% (44/48) of patients with disease-free axilla, while patterns III and IV had higher percentages of metastasis (65.2%, p < 0.001 and 57.1%, p < 0.002, respectively). For the SLN metastatic burden, 100% (48/48) of patients with pattern I/II had ≤ 2 metastatic SLNs. Compared with conventional US, the CEUS enhancement patterns showed significant improvement in diagnosing metastatic SLNs (0.813 vs 0.601, p < 0.001). CEUS had greater clinical benefits and correctly reclassified 48% of metastatic SLNs (p < 0.001) without sacrificing the classification accuracy of negative SLNs (p = 0.25), and could improve prediction accuracy by 0.42 (p < 0.001).ConclusionsCEUS demonstrated better diagnostic performance and greater clinical benefits than conventional US for the preoperative diagnosis of SLNs, showing its potential to select candidates for precluding axillary surgery in early breast cancer.Key Points• The homogeneous and featured inhomogeneous enhancement of SLNs are highly suggestive of negative LNs, while focal defect (p < 0.001) and no enhancement (p < 0.002) patterns had higher percentages of metastasis.• The proportion of SLNs with highly suspicious signs on conventional US increases as the type of enhancement pattern increases (no suspicious signs in pattern I/II, 34.8% in pattern III, and 85.7% in pattern IV).• Compared with conventional US, CEUS improved the area under the receiver operating characteristic curve (0.813 vs. 0.601, p < 0.001) and had greater clinical benefits (IDI = 0.42, p < 0.001) for the diagnosis of axillary metastasis.

Short-term and long-term outcomes of indocyanine green for sentinel lymph node biopsy in early-stage breast cancer

BackgroundIndocyanine green (ICG) is becoming a frequently used sentinel lymph node (SLN) tracer of breast cancer in China. However, there is still a lack of data on its safety. We reported the clinical outcome of ICG as a tracer of SLN over a median 67-month follow-up period to evaluate its feasibility in clinically node-negative patients with breast cancer.MethodsA total of 194 consecutive patients underwent sentinel lymph node biopsy (SLNB) with ICG, radioisotopes (RI) and methylene blue (MB), or with ICG and MB. The SLN mapping data by each tracer was recorded, and safety outcomes were analyzed through follow-up.ResultsWith the triad mapping (N = 44), the identification rate of SLN by ICG was 95.5%, slightly higher than that of MB (86.4%) and comparable with RI (95.5%) and combined methods (95.5%, 100%) (p = 0.068). Analysis of all candidates (N = 194) demonstrated that the identification rate of SLN by ICG or by ICG and MB was 99%, significantly higher than that by MB (92.8%) (p < 0.0001). No tracer-related allergic reaction and permanent skin staining of ICG were observed. Local disease progression was reported in 2 of the 194 patients at the ipsilateral axilla. After remedial axillary lymph node dissection, no disease progression was detected at follow-up.ConclusionsICG as an SLN tracer is more accurate than MB and comparable to the combined methods and has good clinical safety. ICG can be considered a useful supplement or suitable alternative to traditional tracers.

Sentinel Lymph Node Biopsy by Lymphatic Flare Technique: a Feasibility Study-"The FLAIR Is in the FLARE".

Sentinel lymph node (SLN) biopsy is a standard procedure in evaluating the status of node negative axilla. Numerous techniques have been described in literature. We hereby describe a new technique of intradermal injection of blue dye called the lymphatic flare technique. The study was conducted in two phases over a year from August 2020 to May 2021with an internal audit to validate and standardize the technique in January 2021. Between August 2020 and December 2020, 32 patients were evaluated for validation of this technique by two senior surgeons, which yielded a SLN identification rate of 93.75% (30 out of 32). After validating, standardizing, and educating the entire surgical team of the technique, another consecutive 27 patients were evaluated. The SLN identification rate increased to 100% (27 out of 27). Overall, SLN positivity for cancer was 16.6% (10 out of 60). SLN identification by the lymphatic flare technique is feasible, accurate, and reproducible.

Axillary sentinel lymph node identification using superparamagnetic iron oxide versus radioisotope in early stage breast cancer: The UK SentiMag trial (SMART study)

Background & ObjectivesSentinel lymph node biopsy (SLNB) is an accurate and reliable method for staging the axilla in early breast cancer. The gold standard technique for localizing the sentinel lymph node (SLN) is the use of radioisotope with or without blue dye. However, this technique has its limitations. Various alternatives have been explored to overcome the disadvantages of the standard SLNB technique and superparamagnetic iron oxide mapping agents have garnered significant attention. The SMART study aims to compare the magnetic technique using the superparamagnetic iron oxide particles (SPIO, Sienna+®) to the radioisotope technique (Tc99) +/− blue dye, for SLN identification in patients with early breast cancer. MethodsA prospective, multicenter study was done that recruited 109 clinically node-negative early-stage breast cancer patients from five centres in the United Kingdom (UK). The patients received radioisotope ± blue dye injections, followed by intraoperative injection of magnetic tracer prior to SLNB. The sentinel node identification rate was compared between the magnetic and standard techniques to evaluate detection rate (per patient and per node), non-inferiority and concordance. ResultsData was analysed for 107 patients. The per patient detection rate was 98.13% (105/107) when using the magnetic tracer and 92.26% (103/107) when using the standard technique. The nodal detection rate was 93.07% (188/202 nodes) when using the magnetic tracer and 96.53% (195/202) when using the standard technique. Of the 31 patients with positive sentinel lymph nodes (SLNs), all 31 (100%) were detected by both techniques. ConclusionOur study demonstrates that the magnetic technique is a feasible method for SLNB, with an identification rate that is not inferior to the standard technique. The magnetic technique offers a suitable alternative to the standard technique thereby avoiding the need for the complexities of nuclear medicine, the hazards of radiation and the anaphylaxis risk of blue dye.

The value of sentinel lymph-node biopsy after neoadjuvant therapy: an overview.

We conducted a systematic review to analyse the performance of the sentinel lymph-node biopsy (SLNB) after the neoadjuvant chemotherapy, compared to axillary lymph-node dissection, in terms of false-negative rate (FNR) and sentinel lymph-node identification rate (SLNIR), sensitivity, negative predictive value (NPV), need for axillary lymph-node dissection (ALND), morbidity, preferences, and costs. MEDLINE, Embase, Scopus, and The Cochrane Library were searched. We assessed the quality of the included systematic reviews using AMSTAR2 tool, and estimated the degree of overlapping of the individual studies on the included reviews. Six systematic reviews with variable quality were selected. We observed a very high overlapping degree across the included reviews. The FNR and the SLNIR were quite consistent (FNR 13-14%; SLNIR ~ 90% or higher). In women with initially clinically node-negative breast cancer, the FNR was better (6%), with similar SLNIR (96%). The included reviews did not consider the other prespecified outcomes. It would be reasonable to suggest performing an SLNB in patients treated with NACT, adjusting the procedure to the previous marking of the affected lymph node, using double tracer, and biopsy of at least three sentinel lymph nodes. More well-designed research is needed. PROSPERO registration number: CRD42020114403.