Intraoperative Sentinel Lymph Node Detection Research Articles

The role of sentinel lymph node mapping in small animal veterinary medicine: A comparison with current approaches in human medicine.

The relevance of regional lymph node (LN) assessment to quantify the metastatic spread of cancer is well recognized in veterinary oncology. Evaluation of LNs is critical for tumour staging. However, sampling the correct LN may not be possible without sentinel lymph node (SLN) mapping. Methods for diagnostic imaging and intraoperative detection of SLNs are well established in human medicine, in particular, the combination of lymphoscintigraphy and intraoperative application of blue dyes. Nevertheless, alternative imaging techniques are available and have gained increasing interest. Successful implementation of these techniques in dogs have been reported in both clinical and experimental studies. This review aims to provide an overview of SLN mapping techniques in human and veterinary medicine.

Precise intraoperative sentinel lymph node biopsies guided by lymphatic drainage in breast cancer.

The purpose of this study was to present a novel surgical method for intraoperative precise sentinel lymph node biopsy (SLNB) and to determine its clinical efficacy and sensitivity in breast cancer patients. The sentinel lymph nodes (SLNs) were preoperatively evaluated by axillary ultrasound. The intraoperative detection of SLNs was guided by lymphatic drainage pathway. The lymphatic vessels and SLNs were visualized. During operation, we searched for all the true SLNs (trSLNs), para-SLNs (paSLNs) and post-SLNs (poSLNs) followed lymphatic drainage ducts. After precisely locating the lymphatic channels and lymph node, all the lymph nodes that firstly receive lymphatic drainage are designated as trSLNs. We precisely distinguished the trSLNs, paSLNs and poSLNs. We found the average number of trSLNs ranged from1 to 6. In addition, we assessed the novel technique in a total of 125 breast cancer patients. trSLNs were successfully identified in all patients (detection rate: 100 %). The accuracy of trSLNs is 99.2%. Data from our study strongly suggest that our method is a feasible and effective for the detection of precise trSLNs in breast cancer with real-time observations. (ClinicalTrials.gov number, NCT02651142).

Utility of single-photon emission tomography/computed tomography for sentinel lymph node localization in breast cancer patients.

Sentinel lymph node (SLN) mapping is currently a routine technique in breast cancer management and preoperative scintigraphic imaging plays a crucial role in the process of SLN detection. The guidelines recommend performing planar acquisition and optional single-photon emission tomography/computed tomography (SPECT/CT) imaging. The aim of this study was to verify whether routine performing of SPECT/CT in addition to planar imaging increases the sensitivity of SLN detection in patients with early-stage breast cancer. The secondary aims were to compare radionuclide SLN imaging with intraoperative SLN detection and identify clinical and histopathological factors affecting the SLN detection rate. A total of 153 early-stage breast cancer patients underwent lymph node scintigraphy in the years 2007-2013. Breast cancer patients with staging T1-2N0M0 were included. Planar and SPECT/CT lymphoscintigraphy were performed on the day before the surgery. The data on presence or absence of SLN, their number and localization were recorded for both methods and compared with each other as well as with intraoperative blue dye staining and histopathological findings. SPECT/CT identified SLN in 119/153 and planar scintigraphy in 114/153 patients. Identification rates were 77.7 and 74.5%, respectively. Intraoperative lymph node assessment identified SLN in 76/126 cases with an identification rate of 60.3%. Identification rates for second echelon lymph node were 34.6% for hybrid imaging and 21.2% for planar scintigraphy. Statistical analysis did not yield a significant difference in diagnostic accuracy between these methods; however, the Wilcoxon signed-rank test showed that SPECT/CT significantly increases SLN identification rate compared with planar scintigraphy and intraoperative detection. Histopathological examination of excised SLN showed that 22 nodes were metastatic. SPECT/CT visualized all of these, whereas planar imaging and intraoperative lymph node detection procedure visualized 19 and 18, respectively. No clinical and histopathological factors affecting SLN detection rate were identified. Hybrid SPECT/CT lymphatic mapping yields a high SLN detection rate in patients with early-stage breast cancer and provides lymph node localization details. It identifies more SLN than planar imaging and intraoperative SLN detection. However, its limited superiority over the remaining two methods does not support its routine use for SLN localization. We suggest using SPECT/CT for SLN detection in case of equivocal planar imaging results.

Clinical significance of MSKCC nomogram on guiding the application of touch imprint cytology and frozen section in intraoperative assessment of breast sentinel lymph nodes.

The widely practiced intra-operative methods for rapid evaluation and detection of sentinel lymph node (SLN) status include frozen section (FS) and touch imprint cytology (TIC). This study optimized the use of TIC and FS in the intra-operative detection of breast SLNs based on the Memorial Sloan Kettering Cancer Center (MSKCC) nomogram. Three hundred forty-two SLNs were removed from 79 patients. SLN metastatic probability was assessed by the MSKCC nomogram. The SLNs underwent intra-operative TIC and FS, as well as routine post-operative paraffin sections (RPSs). The relationships between TIC, FS, and SLN metastatic probability were analyzed. Overall, TIC was more sensitive than FS (92.31% vs. 76.92%), while TIC specificity was inferior to FS specificity (84.85% vs. 100%). In addition, the best cut-off value for TIC based on the MSKCC nomogram was inferior to the best FS cut-off value (22.5% vs. 34.5%). All patients with a MSKCC value <22.5% in the present study were negative based on FS and RPS, while the true-negative and false-positive rates for TIC were 92.5% and 7.5%, respectively. Thus, early breast cancer patients, based on a MSKCC value <22.5%, can safely avoid FS, but should have TIC performed intra-operatively. Patients with a MSKCC value >22.5% should have TIC and FS to determine the size of metastases, whether or not to proceed with axillary lymph node dissection, and to avoid easily missed metastases.

Sentinel lymph node mapping using SPECT/CT and gamma probe in endometrial cancer: an analysis of parameters affecting detection rate

SPECT/CT after pericervical injection of technetium-99m-nanocolloid was shown to be suitable for sentinel lymph node (SLN) mapping in endometrial cancer (EC). The aim of this study was to analyze factors affecting successful SLN detection by means of SPECT/CT such as imaging findings, patient characteristics and tumor biology in a large cohort of patients. One hundred and forty-five consecutive patients suffering from EC who received pre-surgical SLN mapping at our institution between 2011 and 2016 were included in this analysis. SPECT/CT data of abdomen and pelvis (mean 4:20±1:20h p.i.) were acquired after pericervical injection of technetium-99m-nanocolloid (mean 230±45MBq) in all patients. Surgical staging was performed on the day after. Acquisition parameters, patient characteristics, SPECT/CT findings as well as histopathological results were collected. A total of 282 SLNs were identified by means of SPECT/CT. Overall, preoperative and intraoperative SLN detection rates were 86%, 76% and 74% respectively. The most important factor associated with failure to detect SLNs was the presence of high bone marrow on SPECT/CT (p=0.005). Peritoneal/abdominal radioactivity was also associated with missed SLN detection in SPECT/CT (p=0.02). However, the presence of liver/spleen uptake on its own was not predictive for detection failure. Low numbers of detected SLNs in SPECT/CT were slightly related with older age and lower injected activity. No significant influence was found for the parameters of tumor histology and stage, lymph node involvement and the time gap between injection and imaging. Venous drainage as indicated by bone marrow uptake is the most important factor associated with scintigraphic SLN detection failure. Moreover, high peritoneal and abdominal activity was also associated with detection failure. Thus, meticulous application of the radiotracer is crucial in EC.

Fluorescence-Based Molecular Imaging of Porcine Urinary Bladder Sentinel Lymph Nodes.

The primary objective was to test the ability of a laparoscopic camera system to detect the fluorescent signal emanating from sentinel lymph nodes (SLNs) approximately 2 d after injection and imaging of a positron-emitting molecular imaging agent into the submucosa of the porcine urinary bladder. Methods: Three female pigs underwent a submucosal injection of the bladder with fluorescent-tagged tilmanocept, radiolabeled with both 68Ga and 99mTc. One hour after injection, a pelvic PET/CT scan was acquired for preoperative SLN mapping. Approximately 36 h later, robotic SLN mapping was performed using a fluorescence-capable camera system. After identification of the fluorescent lymph nodes, a pelvic lymph node dissection was completed with robotic assistance. All excised nodal packets (n = 36) were assayed for 99mTc activity, which established a lymph node as an SLN. 99mTc activity was also used to calculate the amount of dye within each lymph node. Results: All of the SLNs defined by the ex vivo γ-well assay of 99mTc activity were detected by fluorescence mode imaging. The time between injection and robotic SLN mapping ranged from 32 to 38 h. A total of 5 fluorescent lymph nodes were detected; 2 pigs had 2 fluorescent lymph nodes and 1 pig exhibited a single lymph node. Four of the 5 SLNs exhibited increased SUVs of 12.4-139.0 obtained from PET/CT. The dye content of the injection sites ranged from 371 to 1,441 pmol, which represented 16.5%-64.1% of the injected dose; the amount of dye within the SLNs ranged from 8.5 to 88 pmol, which was equivalent to 0.38%-3.91% of the administered dose. Conclusion: Fluorescent-labeled 68Ga-tilmanocept allows for PET imaging and real-time intraoperative detection of SLNs during robotic surgery.

РАДИОНУКЛИДНЫЕ МЕТОДЫ ИССЛЕДОВАНИЯ В ДИАГНОСТИКЕ РАКА ГОРТАНИ И ГОРТАНОГЛОТКИ

Introduction. The choice of adequate treatment for cancer patients and their survival rates signifcantly depend on the precise detection of the primary tumor and the assessment of the extent of cancer involvement. Despite advances in the treatment of laryngeal/hypopharyngeal cancer, many aspects of this problem are still unresolved. The purpose of the study. Diagnostic capabilities of nuclear medicine imaging in the detection and assessment of the spread of laryngeal/hypopharyngeal cancer were studied. Material and methods. The study included 40 patients with histologically verifed laryngeal/ hypopharyngeal cancer, 10 patients with tumor recurrence after completion of therapy and 20 patients with benign laryngeal lesions. Single photon emission computed tomography (SPECT) was performed 20 minutes after the injection of 99mTc-methoxy-isobutyl-isonitrile (MIBI). Sentinel lymph nodes (SLNs) were detected in 26 patients after submucosal injections of 99mTc-Tehneft or 99mTc-Alotech around the tumor. In 18 hours after the injection of 99mTc-Tehneft and 99mTc-Alotech, SPECT was performed. In 24 hours after the injection of 99mTc-Tehneft and 99mTc-Alotech, intraoperative SLN detection was performed using Gamma Finder II. Results. SPECT with 99mTc-MIBI revealed laryngeal and hypopharyngeal tumors in 38 of the 40 patients. The 99mTc-MIBI uptake in metastatic lymph nodes was visualized in 2 (17 %) of the 12 patients. 28 SLNs were detected by SPECT and 31 SLNs were identifed using the intraoperative gamma probe. The percentage of lymphotropic radiopharmaceuticals in the SLN was 5–10 % of the radioactivity in the injection site by SPECT and 12–33 % by intraoperative gamma probe detection. Conclusion. SPECT with 99mTc-MIBI is an effective tool for the diagnosis of laryngeal/hypopharyngeal cancer. The sensitivity, specifcity and accuracy of this technique were 95, 80 and 92 %, respectively. The use of 99mTc-Tehnefte and 99mTc-Alotech for the detection of SLN in laryngeal/hypopharyngeal cancer patients was characterized by high effcacy, while intraoperative detection was more sensitive, being 80 and 100 %, respectively.

Initial experience in sentinel lymph node detection in pancreatic cancer

BackgroundThe local recurrence of pancreatic cancer is around 30% when complete resection can be achieved. Extended lymphatic resections may improve survival, but increases severe morbidity. As accurate patient selection should be mandatory, a new method is presented for pancreatic sentinel lymph node (SLN) detection with lymphoscintigraphy and gamma probe. Materials and methodsSeven patients with cT2N0M0 pancreatic head cancer were enrolled between 2009 and 2012 in this prospective study. One day prior to surgery, preoperative lymphoscintigraphy with echoendoscopic intratumoural administration of Tc99m-labelled nanocolloid was performed, with planar and SPECT-CT images obtained 2h later. Gamma probe detection of SLN was also carried out during surgery. ResultsRadiotracer administration was feasible in all patients. Scintigraphy images showed inter-aortocaval lymph nodes in 2 patients, hepatoduodenal ligament lymph nodes in 1, intravascular injection in 3, intestinal transit in 5, and main pancreatic duct visualisation in 1. Surgical resection could only be achieved in 4 patients owing to locally advanced disease. Intraoperative SLN detection was accomplished in 2 patients, both with negative results. Only in one patient could SLN be confirmed as truly negative by final histopathological analysis. ConclusionsThis new method of pancreatic SLN detection is technically feasible, but challenging. Our preliminary results with 7 patients are not sufficient for clinical validation.

Macrophage-Targeted Indocyanine Green-Neomannosyl Human Serum Albumin for Intraoperative Sentinel Lymph Node Mapping in Porcine Esophagus

The sentinel lymph node (SLN) concept has been proposed to avoid unnecessary invasive LN dissection in surgery for esophageal cancer. This study evaluated a new macrophage-targeting fluorescent agent, indocyanine green-neomannosyl human serum albumin (ICG:MSA), for SLN mapping using a custom-made intraoperative color and fluorescence-merged imaging system (ICFIS) in porcine esophagus. The LN targeting ability of ICG:MSA, indocyanine green-human serum albumin (ICG:HSA), and ICG was examined invitro using the U937 differentiated monocyte cell line and invivo in a mouse footpad model using fluorescence imaging. SLN identification in rabbit esophagus was then performed using ICG:MSA, ICG:HSA, and ICG. Finally, intraoperative SLN detection was conducted in porcine esophagus after esophagoscopic injection of ICG:MSA. The fluorescence signal of U937 cells treated by ICG:MSA was significantly higher than that of ICG or ICG:HSA (ICG: 1.0 ± 0.37; ICG:HSA: 3.4 ± 0.28, ICG:MSA: 6.8 ± 1.61; ICG to ICG:HSA, p= 0.03; ICG:HSA to ICG:MSA, p= 0.04; ICG to ICG:MSA, p= 0.0009). ICG:MSA was retained in popliteal LNs as long as 3 h, while ICG rapidly diffused through the entire mouse lymphatic system within 5 min. Esophageal SLN was detected within 15 min after injection of either ICG or ICG:MSA, but ICG:MSA provided more distinguishable images of LNss than ICG in rabbit esophagus. The SLN was also successfully detected in all porcine esophagus; the mean number of SLNs identified per esophagus was 1.6 ± 0.55. ICG:MSA has more specific macrophage-targeting properties, which could overcome the limitation of the low SLN retention of ICG, and could provide more precise real-time SLN detection during esophageal cancer surgery.

PD42-01 MAGNETOMETER GUIDED SENTINEL LYMPHADENECTOMY AFTER INTRAPROSTATIC INJECTION OF SUPERPARAMAGNETIC IRON OXIDE NANOPARTICLES IN INTERMEDIATE- AND HIGH-RISK PROSTATE CANCER PATIENTS

INTRODUCTION AND OBJECTIVES: Sentinel lymph node (SLN) dissection (sPLND) in prostate cancer (PCa) is commonly performed after injection of radiolabeled tracers. This procedure requires nuclear medicine and exposes patients, as well as surgical staff, to radiation. We demonstrated the feasibility and safety of intraoperative SLN detection in PCa patients using a handheld magnetometer after intraprostatic injection of superparamagnetic iron oxide nanoparticles (SPIONs). This study determined whether this new technique can accurately determine LN stage in intermediateand high-risk PCa patients. METHODS: Enrolled 50 patients with intermediateand highrisk PCa (PSA >10 ng/ml and/or Gleason score 7; median PSA 10.78 ng/ml, IQR 7.41-19.18 ng/ml) in a prospective single center study (02/2015-09/2015). After transrectal intraprostatic SPIONs (Sienna+ ) injection a day earlier, patients underwent a magnetometer (SentiMag ) guided sPLND which was completed with an extended PLND as a reference, followed by radical retropubic prostatectomy. SLNs were detected both in vivo and ex vivo. Detection rate (number of patients with detected SLNs/total number operated) and sensitivity (number of patients with positive SLNs/total number of LN+ patients) were calculated. SLNs and LN metastases and their locations were recorded. RESULTS: At least one SLN was detected in all patients (detection rate 100%). A total of 460 SLNs (median 9, IQR 5.25-12.75) were identified, and in all 1143 LNs (median 22.5, IQR 19-26) were removed. Histopathology confirmed LN metastases in 18 patients (36%) having 43 positive LNs in total (median 2, IQR 1-3). Pathological analysis of ex vivo detected SLNs correctly categorized all LN+ patients (sensitivity 100%). However, intraoperative SLN detection missed one LN+ patient in which one positive SLN could not be detected resulting in a sensitivity of 94.4% (17/18). The anatomic distribution of SLNs was as follows: fossa obturatoria 32.17%, external iliac 31.09%, internal iliac 25.22%, periprostatic 5%, presacral 2.39%, perirectal 0.87%, perivesical 0.87, and other regions 2.39%. Of the LN metastases, 32.6% were localized in the external iliac, 25.6% in the fossa obturatoria, 23.3% in the internal iliac, 9.3% perivesical, 7.0% presacral, and 2.3% periprostatic. CONCLUSIONS: Our study indicate that this new magnetometer guided, radiation-free sentinel procedure which can be performed alone by an urologist has a high sensitivity for nodal staging in PCa patients at intermediateand high-risk for LN involvement. The reliability of intraoperative SLN detection by using this magnetometer system has to be verified in further studies.

Initial experience in sentinel lymph node detection in pancreatic cancer.

The local recurrence of pancreatic cancer is around 30% when complete resection can be achieved. Extended lymphatic resections may improve survival, but increases severe morbidity. As accurate patient selection should be mandatory, a new method is presented for pancreatic sentinel lymph node (SLN) detection with lymphoscintigraphy and gamma probe. Seven patients with cT2N0M0 pancreatic head cancer were enrolled between 2009 and 2012 in this prospective study. One day prior to surgery, preoperative lymphoscintigraphy with echoendoscopic intratumoural administration of Tc(99m)-labelled nanocolloid was performed, with planar and SPECT-CT images obtained 2h later. Gamma probe detection of SLN was also carried out during surgery. Radiotracer administration was feasible in all patients. Scintigraphy images showed inter-aortocaval lymph nodes in 2 patients, hepatoduodenal ligament lymph nodes in 1, intravascular injection in 3, intestinal transit in 5, and main pancreatic duct visualisation in 1. Surgical resection could only be achieved in 4 patients owing to locally advanced disease. Intraoperative SLN detection was accomplished in 2 patients, both with negative results. Only in one patient could SLN be confirmed as truly negative by final histopathological analysis. This new method of pancreatic SLN detection is technically feasible, but challenging. Our preliminary results with 7 patients are not sufficient for clinical validation.

Navigation surgery for intraoperative sentinel lymph node detection using Indocyanine green (ICG) fluorescence real-time imaging in breast cancer

A new sensitive fluorescence imaging system was developed for the real-time identification of sentinel lymph nodes (SLNs) in patients with early breast cancer. The purpose of this study was to evaluate the utility of a color charge-coupled device camera system for the intraoperative detection of SLNs and to determine its clinical efficacy and sensitivity in patients with operable breast cancer. We assessed a total of 168 patients diagnosed with or suspected of having early-stage breast cancer without metastasis in SLNs. The intraoperative detection of SLNs was performed using the conventional Indigo Carmine dye (indigotindisulfonate sodium) technique combined with a new Indocyanine green (ICG) imaging system (HyperEye Medical System: HEMS, MIZUHO IKAKOGYO, Japan) to map SLNs, in which the lymphatic vessels and SLNs were visualized transcutaneously with illuminating ICG fluorescence. Between January 2012 and May 2013, SLNs were successfully identified in all 168 patients (detection rate: 100%). By histopathology, the sensitivity was 93.8% for the detection of the metastatic involvement of SLNs (15 of 16 nodal-positive patients). After a median follow-up of 30.5 months, none of the patients presented with axillary recurrence. These results suggest that the HEMS imaging system is a feasible and effective method for the detection of SLNs in breast cancer. Furthermore, the HEMS device permitted the transcutaneous visualization of lymphatic vessels under light conditions, thus facilitating the identification and detection of SLNs without affecting the surgical procedure, together with a high sensitivity and specificity.

SPECT/CT for SLN dissection in vulvar cancer: Improved SLN detection and dissection by preoperative three-dimensional anatomical localisation

ObjectiveIn this study, we assessed the feasibility and clinical advantages of single photon emission computed tomography with CT (SPECT/CT) for sentinel lymph node (SLN) detection in vulvar cancer. MethodsThis is a unicentric prospective trial. Vulvar cancer patients underwent preoperative SLN marking (10MBq Technetium (TC)-99m-nanocolloid) and subsequent planar lymphoscintigraphy (LSG) and SPECT/CT for SLN visualization. Directly before surgery, a patent blue dye was injected. We assessed detection rates of SPECT/CT and those of planar LSG and intraoperative detection. We analyzed the sensitivity, negative predictive value and false negative rate. ResultsAt Hannover Medical School, 40 vulvar cancer patients underwent SLN dissection after preoperative LSG and SPECT/CT. The mean diameter of all tumors in final histology was 2.23 (0.1–10.5) cm with a mean tissue infiltration of 3.93 (0.25–11) mm.In preoperative imaging, SPECT/CT identified significantly more SLNs (mean 8.7 (1–35) LNs per patient) compared to LSG (mean 5.9 (0–22) LNs, p<0.01). In addition, SPECT/CT led to a high spatial resolution and anatomical localization of SLNs. Thus, SPECT/CT identified aberrant lymphatic drainage in 7/40 (17.5%) patients. There were no significant differences, but significant correlation was found between SPECT/CT and intraoperative SLN identification. Regarding inguino-femoral LNs, for all patients who underwent complete groin dissection, sensitivity was 100%, NPV was 100% and false negative rate was 0%. ConclusionSPECT/CT leads to higher SLN identification compared to LSG in vulvar cancer. Due to its higher spatial resolution and three-dimensional anatomical localisation of SLNs, SPECT/CT provides the surgeon with important additional information, facilitates intraoperative SLN detection and predicts aberrant lymphatic drainage.

P224 Prognostic impact of SNPs in or near the ZNF423 and CTSO genes in early breast cancer patients

Goals: To evaluate the usefulness of color charge coupled device (CCD) camera system (HyperEye medical system:HEMS), for the intraoperative detection of sentinel lymph nodes (SLN) in breast cancer (BC) patients. Methods: Intraoperative detection of SLN was performed using conventional blue dye technique combined with HEMS for mapping of SLNs. Indigo carmine (blue dye) mixed with Indocyanine green (ICG) was injected via the subareolar plexus, the search of SLN was guided by HEMs for stained lymphatic channels leading to stained LNs. All bright LNs with lighting near-infrared fluorescence and LNs at the end of a lymphatic channel are removed and designated as SLNs. Results: SLN identification was successful in 140 of 144 patients (detection rate: 97.3%). There were four false-negative cases in 144 patients (2.8%). After a median follow-up of 2.5 years none of the patients presented with axillary recurrence. No severe adverse events were observed. Conclusion: HEMS provides color imaging and that recognizes the lymphatic mapping and the location of SLN without the problem of a limited irradiation. This technique might be safety and effective in SLN identification. Disclosure of Interest: No significant relationships.

P223 Image-guided sentinel lymph node detection using near-infrared fluorescence in breast cancer

Goals: To evaluate the usefulness of color charge coupled device (CCD) camera system (HyperEye medical system:HEMS), for the intraoperative detection of sentinel lymph nodes (SLN) in breast cancer (BC) patients. Methods: Intraoperative detection of SLN was performed using conventional blue dye technique combined with HEMS for mapping of SLNs. Indigo carmine (blue dye) mixed with Indocyanine green (ICG) was injected via the subareolar plexus, the search of SLN was guided by HEMs for stained lymphatic channels leading to stained LNs. All bright LNs with lighting near-infrared fluorescence and LNs at the end of a lymphatic channel are removed and designated as SLNs. Results: SLN identification was successful in 140 of 144 patients (detection rate: 97.3%). There were four false-negative cases in 144 patients (2.8%). After a median follow-up of 2.5 years none of the patients presented with axillary recurrence. No severe adverse events were observed. Conclusion: HEMS provides color imaging and that recognizes the lymphatic mapping and the location of SLN without the problem of a limited irradiation. This technique might be safety and effective in SLN identification. Disclosure of Interest: No significant relationships.

Contribution of lymphoscintigraphy to intraoperative sentinel lymph node detection in early cervical cancer: Analysis of the prospective multicenter SENTICOL cohort

PurposeTo evaluate the contribution of preoperative lymphoscintigraphy to intraoperative lymphatic mapping (ILM) in early cervical cancer MethodsWe conducted an ancillary analysis of the multicenter prospective SENTICOL study in early cervical cancer. Radiocolloid was injected intracervically on the day before (long protocol) or morning of (short protocol) surgery, lymphoscintigraphy was performed, and the results of a centralized image review were communicated to the surgeons. ILM was performed on combined radioactivity/patent blue detection. Sentinel lymph nodes (SLNs) were electively sampled before routine bilateral pelvic lymphadenectomy by laparoscopy. ResultsOf 139 patients in the modified intention-to-diagnose analysis, 114 had centrally reviewed lymphoscintigrams, which showed 352 SLNs in 100 patients. Lymphoscintigraphy and ILM detection rates were 87.8% and 97.8%, respectively. Agreement between lymphoscintigraphy and ILM was low for the number of SLNs (κ=0.23; −0.04; 0.49) and bilateral SLNs (κ=0.36; 0.2; 0.52). No patient without SLNs by ILM had SLNs by lymphoscintigraphy. Lymphoscintigraphy identified substantial proportions of unusual drainage pathways. No patients with metastatic nodes had SLNs by lymphoscintigraphy but not by ILM in the relevant territory. In 1 of the 2 patients with false-negative SLN results, SLNs were bilateral by lymphoscintigraphy and unilateral by ILM. ConclusionAlthough the detection rate was lower by lymphoscintigraphy than by ILM, the substantial proportions of SLNs in unusual territories provided valuable guidance for the surgical exploration. Awareness of the limited agreement between lymphoscintigraphic and surgical detection might help surgeons decrease the false-negative rate.

Evaluation of the use of freehand SPECT for sentinel node biopsy in early stage oral carcinoma

Inadequate intraoperative visualization of the sentinel node can hamper its harvest. Freehand SPECT is a 3D tomographic imaging modality based on the concepts of SPECT, which can be used for intraoperative visualization and navigation towards the sentinel node in order to improve its localization and removal during surgery. The use of freehand SPECT was evaluated during 66 sentinel node biopsy procedures in early stage oral cancer patients. Intraoperative detection of sentinel nodes was compared with preoperative identified sentinel nodes on lymphoscinitigraphic examination. Additional value of freehand SPECT was subjectively scored by the surgeon directly following the biopsy procedure. Freehand SPECT was able to detect 94% of sentinel nodes intraoperatively. Most sentinel nodes not detected (7 out of 9) were located in level I of the neck. Freehand SPECT appeared to be of additional value for facilitating the intraoperative detection of the sentinel node in 24% of procedures. The use of the freehand SPECT system is feasible in the intraoperative detection of sentinel nodes in early stage oral cancer. Freehand SPECT provides helpful information facilitating the SN biopsy procedure in a quarter of cases. However, freehand SPECT cannot detect all SNs which are located in the vicinity of the injection site.

38. Intraoperative sentinel lymph node detection in gastric cancer using near-infrared fluorescence imaging and indocyanine green coupled to nanocolloid

38. Intraoperative sentinel lymph node detection in gastric cancer using near-infrared fluorescence imaging and indocyanine green coupled to nanocolloid

A novel method for intraoperative sentinel lymph node detection in prostate cancer patients using superparamagnetic iron oxide nanoparticles and a handheld magnetometer: the initial clinical experience.

BackgroundA sentinel lymph node (SLN) biopsy using superparamagnetic iron oxide nanoparticles (SPIOs) as a tracer instead of radioisotopes was first applied successfully in breast cancer. This study determined the feasibility of this new technique using SPIOs and a handheld magnetometer to detect SLNs in prostate cancer (PC).MethodsEnrolled 20 patients with intermediate and high-risk PC (PSA >10 and/or Gleason score >7) in a prospective study (12/2013–1/2014; DRKS00005473), following an ethics committee approval. After transrectal intraprostatic SPIOs injection a day earlier, patients (19/20) underwent magnetometer-guided sentinel lymphadenectomy (sPLND) and extended PLND, followed by radical prostatectomy. One patient was not operated because of an unrelated coagulation disorder. The ex vivo magnetic activity of all lymph nodes (LNs) removed was measured. The detection rate, rate of in vivo detected SLNs, and sensitivity of sPLND was established.ResultsNo adverse events attributable to SPIOs injection were observed. Identified 126 SLNs (median 7, IQR 4–9) and resected 334 LNs (median 17, IQR 14–19); 37 % (7/19) of the patients had LN metastases (median 1, IQR 1–3.5). The detection rate and rate of in vivo detected SLNs were 90 % (17/19) and 94 % (118/126) respectively. Using sPLND, all LN metastases were detected (15/15, sensitivity 100 %) in all patients identified with SLNs. One LN + patient showed no SLNs following transurethral prostate resection.ConclusionsThis is the first study using a magnetic tracer and magnetometer to detect SLNs in PC. Initial data indicate that this simple, radiation-free procedure is safe, feasible, and reliably identifies SLN and LN metastases in most patients.

Intérêt du repérage per-opératoire 3D des ganglions sentinelles dans le cancer du sein

The sentinel lymph node (SLN) is a standard for the surgical treatment of axillary localized breast cancer N0. It is based on a double isotopic and color detection. With a gamma detecting probe connected to an infrared camera, Déclipse SPECT system (Surgiceye®) is able to detect and locate any radioactive source in 3D. Mobile character for use in the operating room is particularly interesting for the intraoperative detection of SLN. We illustrate its usefulness in a clinical case where the preoperative identification of SLN by lymphoscintigraphy was not informative.