Sentinel Lymph Node Identification Research Articles

Sentinel Lymph Node Mapping in Lung Cancer: A Pilot Study for the Detection of Micrometastases in Stage I Non-Small Cell Lung Cancer.

Lymphadenectomy represents a fundamental step in the staging and treatment of non-small cell lung cancer (NSCLC). To date, the extension of lymphadenectomy in early-stage NSCLC is a debated topic due to its possible complications. The detection of sentinel lymph nodes (SLNs) is a strategy that can improve the selection of patients in which a more extended lymphadenectomy is necessary. This pilot study aimed to refine lymph nodal staging in early-stage NSCLC patients who underwent robotic lung resection through the application of innovative intraoperative sentinel lymph node (SLN) identification and the pathological evaluation using one-step nucleic acid amplification (OSNA). Clinical N0 NSCLC patients planning to undergo robotic lung resection were selected. The day before surgery, all patients underwent radionuclide computed tomography (CT)-guided marking of the primary lung lesion and subsequently Single Photon Emission Computed Tomography (SPECT) to identify tracer migration and, consequently, the area with higher radioactivity. On the day of surgery, the lymph nodal radioactivity was detected intraoperatively using a gamma camera. SLN was defined as the lymph node with the highest numerical value of radioactivity. The OSNA amplification, detecting the mRNA of CK19, was used for the detection of nodal metastases in the lymph nodes, including SLN. From March to July 2021, a total of 8 patients (3 female; 5 male), with a mean age of 66 years (range 48-77), were enrolled in the study. No complications relating to the CT-guided marking or preoperative SPECT were found. An average of 5.3 lymph nodal stations were examined (range 2-8). N2 positivity was found in 3 out of 8 patients (37.5%). Consequently, pathological examination of lymph nodes with OSNA resulted in three upstages from the clinical IB stage to pathological IIIA stage. Moreover, in 1 patient (18%) with nodal upstaging, a positive node was intraoperatively identified as SLN. Comparing this protocol to the usual practice, no difference was found in terms of the operating time, conversion rate, and complication rate. Our preliminary experience suggests that sentinel lymph node detection, in association with the accurate pathological staging of cN0 patients achieved using OSNA, is safe and effective in the identification of metastasis, which is usually undetected by standard diagnostic methods.

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.

Results of Using Intraoperative Sentinel Lymph Node Identification in the Surgical Management of Stage IA-IIA Non-Small Cell Lung Cancer

Results of Using Intraoperative Sentinel Lymph Node Identification in the Surgical Management of Stage IA-IIA Non-Small Cell Lung Cancer

Abstract PO1-22-11: Use of magnetic tracer and magnetic resonance imaging for sentinel lymph node detection after breast cancer recurrence and previous axillary surgery: The SentiRecur feasibility study

Abstract Background: Preoperative imaging increases the chance of finding the sentinel lymph node (SLN) in patients with previous axillary surgery. Current clinical routine for preoperative localization is Technetium (Tc99) and lymphoscintigraphy. An alternative method has been proposed using superparamagnetic iron oxide nanoparticles (SPIO) and non-contrast enhanced magnetic resonance imaging (MRI) of the axillae. In this feasibility study, SPIO+MRI was used in parallel with Tc99+scintigraphy for SLN localization. Methods: Twenty patients with recurrent breast cancer and previous axillary surgery at Sahlgrenska and Linkoping University Hospitals scheduled for SLN-biopsy will be included. All patients received Tc99+scintigraphy as per standard practice. In addition, a SPIO injection and bilateral axillary MRI was performed up to four weeks before surgery. Both preoperative and perioperative SLN-detection rates were studied. Rates and number of concordant SLNs were presented as percentages. Results: So far, ten patients received both SPIO+MRI and Tc99+scintigraphy. The SLN-detection rates per patient were 70% (7/10) for SPIO+MRI and 50% (5/10) for Tc99+scintigraphy, respectively. The perioperative SLN-detection rates per patient were 60% (6/10) for SPIO using the magnetic probe (SentiMagTM) and 30% (3/10) for Tc99 using a gamma-probe. In total, eleven SLNs were detected with SentiMag and four with gamma-probe. Of all SLNs, only four (36%) contained both SPIO and Tc99. Conclusion(s): Although preliminary, the results suggest that Tc99+scintigraphy may be replaced by the magnetic technique for detecting SLNs after earlier axillary surgery. The magnetic technique enables logistic advantages as tracer injection and SLN identification during a wider time frame. Table 1. Sentinel lymph node detection in patients with recurrent breast cancer Table 1. Sentinel lymph node detection in patients with recurrent breast cancer Citation Format: Eva VikhePatil, Kian Chin, Amalia SegerbardPlanoudis, Carlos Dussan, Henrik Leonhardt, Pontus Zaar, Pantelis Gialis, Fredrik Wärnberg. Use of magnetic tracer and magnetic resonance imaging for sentinel lymph node detection after breast cancer recurrence and previous axillary surgery: The SentiRecur feasibility study [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-22-11.

A systematic review and meta-analysis of diagnostic performance of fluorescein-guided sentinel lymph node biopsy in early breast cancer.

Evaluation of axillary lymph nodes status in cN0 axilla is performed by sentinel lymph node biopsy (SLNB) utilizing a combination of radioactive isotope and blue dye or alternative to isotope like Indocyanine green (ICG). Both are very resource-intensive; which has prompted development of low-cost technique of Fluorescein Sodium (FS)-guided SLNB. This systematic review and meta-analysis evaluate the diagnostic performance of FS-guided SLNB in early breast cancer. The objective was to evaluate the diagnostic performance of FS for sentinel lymph node biopsy. Eligibility criteria: Studies where SLNB was performed using FS. PubMed, EMBASE, Cochrane library and online clinical trial registers. Risk of bias: Articles were assessed for risk of bias using the QUADAS-2 tool. The main summary measures were pooled Sentinel Lymph Node Identification Rate (SLN-IR) and pooled False Negative Rate (FNR) using random-effects model. A total of 45 articles were retrieved by the initial systematic search. 7 out of the 45 studies comprising a total of 332 patients were included in the meta-analysis. The pooled SLN-IR was 93.2% (95% confidence interval [CI], 0.87-0.97; 87% to 97%). Five validation studies were included for pooling the false negative rate and included a total of 211 patients. The pooled FNR was 5.6% (95% confidence interval [CI], 2.9-9.07). Fluorescein-guided SLNB is a viable option for detection of lymph node metastases in clinically node negative patients with early breast cancer. It achieves a high pooled Sentinel Lymph Node Identification Rate (SLN-IR) of 93% with a false negative rate of 5.6% for the detection of axillary lymph node metastasis.

Sentinel Lymph Node Biopsy after Neoadjuvant Chemotherapy in Breast Cancer Patients with Positive Nodes Using Low-Cost Dual Dye Technique: Identifying Factors Associated with Adequate False Negative Rate Threshold

&lt;b&gt;&lt;i&gt;Background:&lt;/i&gt;&lt;/b&gt; In this study, we evaluated the feasibility of the sentinel lymph node (SLN) identification rate (SLN-IR) of fluorescein-guided sentinel lymph node biopsy (SLNB) in combination with methylene blue dye (MBD) and factors which can lead to a false negative rate (FNR) threshold of 10%. &lt;b&gt;&lt;i&gt;Methods:&lt;/i&gt;&lt;/b&gt; This was a prospective cross-sectional non-randomized validation study in patients with post-neoadjuvant chemotherapy (NACT) clinically node negative axilla who were node positive prior to start of NACT. Patients underwent validation of SLNB using fluorescein (and blue LED light) and MBD. Axillary dissection was performed irrespective of SLNB histology. SLIN-IR and FNR were assessed and compared with various molecular subtypes. &lt;b&gt;&lt;i&gt;Results:&lt;/i&gt;&lt;/b&gt; The SLNs were identified in 102 out of 120 (85%) post-NACT patients. The median number of sentinel lymph nodes identified was 2 (range 1–3). The SLN-IR using MBD was 85%, FD was 82.5%, and combined MBD FD was 85%. Two or more SLNs were removed in 72 patients and 11 patients had tumor in the rest of the axilla, resulting in an FNR of 17.4%. An FNR was 25% in case only one SLN was found, and it was 11.42% if two or more than two SLNs were excised. &lt;b&gt;&lt;i&gt;Conclusions:&lt;/i&gt;&lt;/b&gt; This cohort study found that use of low-cost dual dyes in patients with positive axillary disease, rendered cN0 with NACT, with 2 or more negative SLNs with SLNB alone, results in an FNR of 11.4%. Her 2 positive and TNBC with 2 or more negative SLNs are associated with an FNR of &amp;lt;10%. However, the number of such patients was small and further studies with larger sample size are warranted to confirm these findings.

Sentinel lymph node identification using NIR-II ultrabright Raman nanotags on preclinical models

Surface-enhanced Raman spectroscopy (SERS) nanotags have garnered much attention as promising bioimaging contrast agent with ultrahigh sensitivity, but their clinical translation faces challenges including biological and laser safety. As breast sentinel lymph node (SLN) imaging agents, SERS nanotags used by local injection and only accumulation in SLNs, which were removed during surgery, greatly reduce biological safety concerns. But their clinical translation lacks pilot demonstration on large animals close to humans. The laser safety requires irradiance below the maximum permissible exposure threshold, which is currently not achievable in most SERS applications. Here we report the invention of the core-shell SERS nanotags with ultrahigh brightness (1 pM limit of detection) at the second near-infrared (NIR-II) window for SLN identification on pre-clinical animal models including rabbits and non-human primate. We for the first time realize the intraoperative SERS-guided SLN navigation under a clinically safe laser (1.73 J/cm2) and identify multiple axillary SLNs on a non-human primate. No evidence of biosafety issues was observed in systematic examinations of these nanotags. Our study unveils the potential of NIR-II SERS nanotags as appropriate SLN tracers, making significant advances toward the accurate positioning of lesions using the SERS-based tracer technique.

Multimodal ultrasound imaging: a method to improve the accuracy of sentinel lymph node diagnosis in breast cancer.

This study assessed the utility of multimodal ultrasound in enhancing the accuracy of breast cancer sentinel lymph node (SLN) assessment and compared it with single-modality ultrasound. Preoperative examinations, including two-dimensional ultrasound (2D US), intradermal contrast-enhanced ultrasound (CEUS), intravenous CEUS, shear-wave elastography (SWE), and surface localization, were conducted on 86 SLNs from breast cancer patients. The diagnostic performance of single and multimodal approaches for detecting metastatic SLNs was compared to postoperative pathological results. Among the 86 SLNs, 29 were pathologically diagnosed as metastatic, and 57 as non-metastatic. Single-modality ultrasounds had AUC values of 0.826 (intradermal CEUS), 0.705 (intravenous CEUS), 0.678 (2D US), and 0.677 (SWE), respectively. Intradermal CEUS significantly outperformed the other methods (p<0.05), while the remaining three methods had no statistically significant differences (p>0.05). Multimodal ultrasound, combining intradermal CEUS, intravenous CEUS, 2D US, and SWE, achieved an AUC of 0.893, with 86.21% sensitivity and 84.21% specificity. The DeLong test confirmed that multimodal ultrasound was significantly better than the four single-modal ultrasound methods (p<0.05). Decision curve analysis and clinical impact curves demonstrated the superior performance of multimodal ultrasound in identifying high-risk SLN patients. Multimodal ultrasound improves breast cancer SLN identification and diagnostic accuracy.

Abstract 4135: First demonstration of magnetic particle imaging for sentinel lymph node identification

Abstract Sentinel Lymph Node (LN) biopsy involves the identification and surgical removal of the first LN(s) that drain from a primary tumor to evaluate for metastasis by histopathology [1]. For several tumor types, the standard of care is to manage the regional LN basin separately from the primary tumor. For head and neck cancer, melanoma, and complex breast cancer cases, pre-surgical imaging is required to determine the number and location of LN(s) to remove. Most sentinel LN biopsies are performed with nuclear imaging, which relies on short-lived radiotracers and can have poor image quality, making it challenging to identify sentinel LNs in complex anatomies. An alternative and non-inferior workflow uses a non-radioactive iron oxide magnetic tracer (ferucarbotran) with a magnetic probe [2], however this tool can only be used intraoperatively. In this abstract we introduce magnetic particle imaging (MPI) as a pre-surgical imaging technology that detects iron oxides with high sensitivity at mm-scale resolution [3]. Our objective is to demonstrate that MPI provides sensitive and quantitative tracking of ferucarbotran pharmacokinetics from four anatomical sites to primary draining LNs in mice. Methods: Ferucarbotran was administered intradermally to C57BL/6 mice at a standard clinical dose of 0.675 mg Fe/kg to the forepaw, hindpaw, or base of tail, or tongue (n = 4). Full-body 2D and 3D imaging was performed after 20 mins, 24 h, and 48 h, and 144 h using MOMENTUM imager (Magnetic Insight Inc.). MPI signal was quantified at the injection site and draining LNs. LNs of interest were extracted to verify MPI signals ex vivo then were processed for Perl’s Prussian iron staining. Results: After 20 minutes, MPI signal was seen at the injection site and primary LNs. The pharmacokinetics of ferucarbotran to LNs varied based on administration site. For hindpaw, signal was present in the popliteal LN (1.4% of tracer). For forepaw, ferucarbotran accumulated in the primary axillary LN (9%). For base of the tail, signal was observed in inguinal LN (2%). For tongue, MPI signal was detected in cervical LNs (14%). In all mice, MPI signal at the injection site decreased over time and signal in primary LNs persisted for at least 6 days. Conclusions: We demonstrated MPI is a quantitative, hotspot imaging technique for identifying primary LNs. As iron oxide tracer pharmacokinetics varies with injection site, this imaging technique could provide fundamental information required for surgical planning. Unlike nuclear imaging, persistence of MPI signal for several days provides tremendous flexibility in clinical workflow and introduces the potential for an image-guide delayed SLN biopsy [4] . This preclinical LN imaging is timely as our team is actively building and testing the world’s first large-bore, clinical-scale MPI scanner.[1] Leong SP, Clin Exp Metastasis (2022). [2] Alvarado MD, et al. Ann Surg Oncol (2019). [3] Sarnitas EU, et al. J Magn Reson (2014). [4] Karakatsanis A, et al. Ann Surg Oncol (2023). Citation Format: Olivia C. Sehl, A. Rahman Mohtasebzadeh, Kelvin Guo, Petrina Kim, Benjamin Fellows, Marcela Weyhmiller, Paula J. Foster, Patrick W. Goodwill, Joan M. Greve. First demonstration of magnetic particle imaging for sentinel lymph node identification [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4135.

Clinicopathological factors associated with sentinel lymph node detection in non-small-cell lung cancer

BackgroundMapping of the pulmonary lymphatic system by near-infrared (NIR) fluorescence imaging might not always identify the first lymph node relay. The aim of this study was to determine the clinicopathologic factors allowing the identification of sentinel lymph nodes (SLNs) by NIR fluorescence imaging in thoracic surgery for non-small-cell lung cancer (NSCLC).MethodsWe conducted a retrospective review of 92 patients treated for suspected or confirmed cN0 lung cancer with curative intent who underwent an intraoperative injection of indocyanine green (ICG) either by direct peritumoral injection or by endobronchial injection using electromagnetic navigational bronchoscopy (ENB). After exclusion of patients for technical failure, benign disease and metastasis, we analyzed the clinicopathologic findings of 65 patients treated for localized-stage NSCLC, comparing the group with identification of SLNs (SLN-positive group) with the group without identification of SLNs (SLN-negative group).ResultsForty-eight patients (73.8%) were SLN-positive. Patients with SLN positivity were more frequently female (50%) than the SLN-negative patients were (11.8%) (p = 0.006). The mean value of diffusing capacity for carbon monoxide (DLCO) was lower among the patients in the SLN-negative group (64.7% ± 16.7%) than the SLN-positive group (77.6% ± 17.2%, p < 0.01). The ratio of forced expiratory volume in one second to forced vital capacity (FEV1/FCV) was higher in the SLN-positive group (69.0% vs. 60.8%, p = 0.02). Patients who were SLN-negative were characterized by a severe degree of emphysema (p = 0.003). There was no significant difference in pathologic characteristics. On univariate analyses, age, female sex, DLCO, FEV1/FVC, degree of emphysema, and tumor size were significantly associated with SLN detection. On multivariate analysis, DLCO > 75% (HR = 4.92, 95% CI: 1.27–24.7; p = 0.03) and female sex (HR = 5.55, 95% CI: 1.25–39.33; p = 0.04) were independently associated with SLN detection.ConclusionsAt a time of resurgence in the use of the sentinel lymph node mapping technique in the field of thoracic surgery, this study enabled us to identify, using multivariate analysis, two predictive factors for success: DLCO > 75% and female sex. Larger datasets are needed to confirm our results.

Visualization Methods for Uterine Sentinel Lymph Nodes in Early-Stage Endometrial Carcinoma: A Comparative Analysis.

Sentinel lymph node (SLN) biopsy in early-stage endometrial cancer is recommended over systematic lymphadenectomy due to reduced morbidity and comparable detection rates. The main objective of this study was to compare the overall and bilateral detection rates of SLN in early-stage endometrial cancer using three techniques. a prospective cohort study was designed to detect the difference in SLN detection rate in three cohorts: Indocyanine green (ICG), methylene blue (MB), and tracer combination (ICG + MB). Mapping characteristics, detection rate, number of SLNs, and positive SLNs of the three cohorts were compared. A total of 99 patients were enrolled. A total of 109 SLN sites with 164 lymph nodes were detected. No differences were found between the three cohorts in terms of age, BMI, tumor diameter, or other histologic characteristics. The overall SLN detection rate (DR) was 54.3% in the MB group, 72.7% in ICG, and 80.6% in the ICG-MB group. Bilateral DR was 22.9%, 39.4%, and 54.8% in groups, respectively, with the MB method yielding significantly inferior results. The ICG-MB group demonstrated superior overall and bilateral detection rates, but a significant difference was found only in the MB cohort. Combining tracer agents can enhance the accuracy of SLN identification in initial-stage endometrial cancer without additional risk to the patient.

200 (PB-107) Poster - The INFLUENCE II study: identification of sentinel lymph nodes in breast cancer patients through non-invasively fluorescent imaging using indocyanine green: an international multicentre implementation study protocol

200 (PB-107) Poster - The INFLUENCE II study: identification of sentinel lymph nodes in breast cancer patients through non-invasively fluorescent imaging using indocyanine green: an international multicentre implementation study protocol

СОБСТВЕННЫЙ ОПЫТ ПРИМЕНЕНИЯ РАДИОФАРМАЦЕВТИЧЕСКОГО ПРЕПАРАТА 99mТс-СЕНТИСКАН ПРИ ВИЗУАЛИЗАЦИИ СТОРОЖЕВЫХ ЛИМФАТИЧЕСКИХ УЗЛОВ У БОЛЬНЫХ РАКОМ МОЛОЧНОЙ ЖЕЛЕЗЫ

Purpose: To study the capabilities of the new radiopharmaceutical 99mTc-sentiscan in the visualization of sentinel lymph nodes in patients with breast cancer. Material and methods: A survey of 178 people diagnosed with breast cancer. Patients were divided into two groups depending on the route of administration of the radiopharmaceutical. The day before surgical treatment, all subjects were injected with a radiopharmaceutical using a syringe with an activity of no more than 120 MBq, in a volume of 0.3‒0.4 ml. The visualized sentinel lymph nodes were marked on the skin using a patented device – «Device for external marking of sentinel lymph nodes during radionuclide visualization». Intraoperative search for sentinel lymph nodes was carried out using gamma detectors Gamma-Finder II or Radical, followed by urgent histological examination. Results: Radioisotope visualization of sentinel lymph nodes using the domestic radiopharmaceutical 99mTc-sentiscan: in the first group (the drug was administered peritumorally) was 100 %, the average number of visualized lymph nodes in this group was 2.2; in the second group (the drug was administered subareolarly) ‒ 99.1 %, the average number of visualized lymph nodes ‒ 2.6. In the first group of patients, metastatic lesions of sentinel lymph nodes were detected in 8 cases (13.1 %), and in the second group ‒ in 14 (11.9 %). All lymph nodes were mapped in the axillary region on the side of the tumor process. Conclusion: The possibility of the radiopharmaceutical 99mTc-sentiscan for the identification and biopsy of sentinel lymph nodes in patients with breast cancer was assessed. The use of the domestic 99mTc-sentiscan makes it possible to visualize sentinel lymph nodes in patients with breast cancer and detect their location in 99.1‒100 % of cases. Taking into account the results obtained, the expanded indications for the use of the radiopharmaceutical and the cost of the kits, 99mTc-sentiscan is more preferable for use in clinical practice.

The use of blue dye alone for sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with initially node-positive breast cancer

IntroductionFalse-negative sentinel lymph node biopsy (SLNB) rates following neoadjuvant chemotherapy (NACT) in initially node-positive (cN1/2) breast cancer patients are high, but decrease when lymph nodes are clipped, ≥3 sentinel lymph nodes (SLN) are removed or dual-tracer localization (radioisotope and blue dye) is used. Radiotracer, however, is often unavailable and outcomes with blue dye alone are unknown. Materials and methodsInitially cT1-4, cN1/2 patients treated with NACT in 2013–2023 who underwent SLNB using blue dye alone were evaluated regarding SLN identification, axillary recurrence, disease-free and overall survival rates. ResultsOf 119 patients included, 19 remained cN1/2 after NACT. SLNB was performed using blue dye alone in 100 ycN0 cases (84%), with an identification rate of 96%. The SLN was negative in 70/119 cases (i.e. 59% avoided axillary dissection). The number of SLN detected was ≥3 in 55/70 cases (78%) (median 3.1; 1–6). Median age was 49 years (25–84). Most were T2 (n = 40, 57.1%), N1 (n = 64, 91.4%). Predominant subtypes were ERBB2 (52.9%) and triple-negative (20%). No axillary recurrence occurred over a median 36-month period. Five-year disease-free and overall survival were, respectively, 85.9% (95%CI: 74–99.8) and 96.3% (95%CI: 89.4–100). The ERBB2 subtype (1.99, 95%CI: 1.02–3.85, p = 0.04) and N1 lymph node status (2.58, 95%CI: 1.54–9.10, p = 0.03) were associated with a greater likelihood of undergoing SLNB alone without axillary dissection. ConclusionsSLNB with blue dye alone following NACT in initially cN1/2 patients avoided axillary dissection in almost 60% of cases, with no recurrences during the period evaluated. Longer follow-up studies are necessary.

Effectiveness of sentinel lymph node biopsy and bilateral pelvic nodal dissection using methylene blue dye in early-stage operable cervical cancer—A prospective study

ObjectiveTo evaluate the effectiveness of methylene blue dye in detecting sentinel lymph nodes (SLNs) in women with early-stage operable (defined as FIGO I-IIA) cervical cancer. It also aims to evaluate procedural challenges and accuracy. MethodThis prospective study, which focused on 20 women with early-stage cervical cancer, was carried out between June 2016 and December 2017. These patients had SLN mapping with methylene blue dye injections and thorough examinations, including imaging. All patients underwent radical hysterectomy and complete bilateral pelvic lymphadenectomy. No additional investigation was done on the lymph node in cases where a metastasis was found in the first H&E-stained segment of the sentinel node. Result20 patients were included in the analysis. The median age of the subjects was 53, and 95 % of them had squamous cell carcinoma. 90 % of the time, the identification of SLNs was effective, and 55 SLNs were found, of which 52.7 % were on the right side of the pelvis and 47.3 % on the left. The obturator group had the most nodes, followed by the external and internal iliac groups in descending order of occurrence. Metastasis was detected in 3 patients, resulting in a sensitivity of 100 % and a specificity of 93.75 % for SLN biopsy. Notably, no false-negative SLNs were found. Complications related to methylene blue usage included urine discoloration in 30 % of patients. ConclusionThis trial highlights the promising efficacy and safety of methylene blue dye alone for SLN identification in early-stage operable cervical cancer, with a notably higher success rate. Despite limitations like a small sample size, healthcare professionals and researchers can build upon the insights from this study to enhance cervical cancer management.

Appropriate concentration setting for the intraoperative administration of indocyanine green for fluorescence imaging to identify the sentinel lymph node in early gastric cancer: a clinical pilot study.

Some prospective trials have demonstrated the feasibility of sentinel node (SN) biopsy in gastric cancer (GC) surgery. This study aimed to identify the appropriate concentration settings for the intraoperative injection of indocyanine green (ICG) for SN biopsy. Before the clinical studies, porcine model experiments explored the optimal concentration of ICG injected intraoperatively. Next, nine GC patients were enrolled in the clinical research. ICG (0.5ml) was injected intraoperatively into four quadrants of the submucosa around the tumor at various concentrations (0.5, 0.25, and 0.1mg/ml). The lymphatic basin dissection method was applied to the ICG-positive lymphatic areas. The number and location of the lymphatic basins and positive nodes were recorded intraoperatively. In the porcine model, the visibility gradually became clear at an ICG concentration higher than 0.1mg/ml. In the clinical study, the average number of detected lymphatic basins was 3.3, 1.7, and 1.7, respectively. The mean number of detected SNs was 14.7, 6.7, and 4.0, respectively. To improve the reproducibility of SN biopsy, it is essential to prepare the correct concentration setting of ICG. Under current conditions in which ICG is injected intraoperatively, a 0.1mg/ml concentration setting of ICG may be necessary and sufficient for SN identification.

An Updated Review on the Emerging Role of Indocyanine Green (ICG) as a Sentinel Lymph Node Tracer in Breast Cancer.

Sentinel lymph node biopsy (SLNB) has become the standard of care for clinically node-negative breast cancer and has recently been shown by clinical trials to be also feasible for clinically node-positive patients treated with primary systemic therapy. The dual technique using both radioisotope (RI) and blue dye (BD) as tracers for the identification of sentinel lymph nodes is considered the gold standard. However, allergic reactions to blue dye as well as logistics issues related to the use of radioactive agents, have led to research on new sentinel lymph node (SLN) tracers and to the development and introduction of novel techniques in the clinical practice. Indocyanine green (ICG) is a water-soluble dye with fluorescent properties in the near-infrared (NIR) spectrum. ICG has been shown to be safe and effective as a tracer during SLNB for breast cancer and accumulating evidence suggests that ICG is superior to BD and at least comparable to RI alone and to RI combined with BD. Thus, ICG was recently proposed as a reliable SLN tracer in some breast cancer clinical practice guidelines. Nevertheless, there is lack of consensus regarding the optimal role of ICG for SLN mapping. Specifically, it is yet to be determined whether ICG should be used in addition to BD and/or RI, or if ICG could potentially replace these long-established traditional SLN tracers. This article is an updated overview of somerecent studies that compared ICG with BD and/or RI regarding their accuracy and effectiveness during SLNB for breast cancer.

A SPECT/NIR Fluorescence Dual-Modality Imaging Agent Composed of Drugs and Hospital Available Isotope for Preoperative Sentinel Lymph Node Mapping and Intraoperative Biopsy.

Sentinel lymph node (SLN) mapping-guided biopsy is crucial for cancer staging and treatment. Optical/nuclide dual-modality imaging agents for mapping SLN are ideal for preoperative planning and intraoperative biopsy, which are enabled by penetration-depth unlimited nuclide imaging and dynamic real-time optical imaging, respectively. However, commonly reported dual-modality imaging agents are composed of novel but safety-unproven materials, making their quick clinical translation challenging. Herein, we report a novel nanoparticle composed of facile hospital-available drugs and isotope for single-photon emission computed tomography (SPECT)/near-infrared (NIR) fluorescence imaging to detect SLNs. Indocyanine green-human serum albumin (ICG-HSA) nanoparticles (NPs) were synthesized by ICG-induced HSA self-assembly and further 99mTc-labeling via a one-step, facile hospital-available method. After injecting 99mTc-ICG-HSA into the rats' forepaw pads, the rats' draining axillary lymph nodes were visualized by preoperative mapping with SPECT/CT and intraoperative biopsy with NIR fluorescence. The axillary lymph nodes of rats were identified by pathology and fluorescent staining after execution. Additionally, its toxicity testing and comparison with 99mTc-sulfur colloid imaging were also explored. The study reported a self-assembled 99mTc-ICG-HSA with a high radiochemical yield (85.6 ± 3.8%). Compared with conventional 99mTc-sulfur colloid, 99mTc-ICG-HSA NPs showed faster SLN identification, higher renal clearance, and lower hepatic retention. Furthermore, NIRF imaging allowed for the accurate visualization of the SLN and guided SLN biopsy intraoperatively. Notably, the 99mTc-ICG-HSA NPs were composed of hospital-available drugs and isotope, which are safe for acute toxicity evaluation by a certified institute. The proposed 99mTc-ICG-HSA NPs are safe and capable of noninvasive SLN identification and biopsy guidance with multi-modal imaging strategies and could be a promising tool for clinically assisted SLN biopsy.

A new bimodal approach for sentinel lymph node imaging in prostate cancer using a magnetic and fluorescent hybrid tracer.

To obtain initial data on sentinel lymph node (SLN) visualisation by pre-operative magnetic resonance imaging (MRI) and intra-operative bimodal SLN identification using a new magnetic fluorescent hybrid tracer in prostate cancer (PCa) patients. Ten patients at > 5% risk for lymph node (LN) invasion were included. The day before surgery, a magnetic fluorescent hybrid tracer consisting of superparamagnetic iron oxide nanoparticles (SPION) and indocyanine green was transrectally injected into the prostate. Five hours after injection, transversal pelvic MRI scans were recorded and T2*-weighed images were screened for pelvic LNs with SPION uptake. Intra-operatively, magnetically active and/or fluorescent SLNs were detected by a handheld magnetometer and near-infrared fluorescence imaging (FI). Extended pelvic lymph node dissection (PLND) and radical prostatectomy completed the surgery. All resected specimens were checked ex situ for magnetic activity and fluorescence and were histopathologically examined. Pre-operative MRI identified 145 pelvic LNs with SPION uptake. In total, 75 (median 6, range 3‒13) magnetically active SLNs were resected, including 14 SLNs not seen on MRI. FI identified 89 fluorescent LNs (median 8.5, range 4‒13) of which 15 LNs were not magnetically active. Concordance of the different techniques was 70% for pre-operative MRI vs. magnetometer-guided PLND and 88% for magnetic vs. fluorescent SLN detection. These are the first promising results of bimodal, magnetic fluorescent SLN detection in PCa patients. Our magnetic fluorescent hybrid approach provides the surgeon a pre-operative lymphatic roadmap by using MRI and intra-operative visual guidance through the application of a fluorescent lymphatic agent. The diagnostic accuracy of our new hybrid approach has to be evaluated in further studies. DRKS00032808. Registered 04 October 2023, retrospectively registered.

Advantages of contrast-enhanced ultrasound in the localization and diagnostics of sentinel lymph nodes in breast cancer.

Sentinel lymph nodes (SLNs) are the first station of lymph nodes that extend from the breast tumor to the axillary lymphatic drainage. The pathological status of these LNs can predict that of the entire axillary lymph node. Therefore, the accurate identification of SLNs is necessary for sentinel lymph node biopsy (SLNB) to replace axillary lymph node dissection (ALND). The quality of life and prognosis of breast cancer patients are related to proper surgical treatment after the precise identification of SLNs. Some of the SLN tracers that have been identified include radioisotope, nano-carbon, indocyanine green (ICG), and methylene blue (MB). However, these tracers have certain limitations, such as pigmentation, radiation dangers, and the requirement for costly detection equipment. Ultrasound contrast agents (UCAs) have good specificity and sensitivity, and thus can compensate for some shortcomings of the mentioned tracers. This technique is also being applied to SLNB in patients with breast cancer, and can even provide an initial judgment on SLN status. Contrast-enhanced ultrasound (CEUS) has the advantages of high distinguishability, simple operation, no radiation harm, low cost, and accurate localization; therefore, it is expected to replace the traditional biopsy methods. In addition, it can significantly enhance the accuracy of SLN localization and shorten the operation time.