Subcutaneous Lymphatic Channels Research Articles

Vulval Lymphangiectasia Post-radiotherapy in Cervical Cancer

Cutaneous lymphangiectasia is a benign cutaneous disorder of dilatation of the dermal and subcutaneous lymphatic channels, which occurs rarely on the vulva. It can be congenital or acquired developing secondary to tuberculosis, surgery, and radiotherapy. We report the case of a 58-year-old female patient who gives a history of cervical cancer, for which she underwent hysterectomy and postsurgery radiotherapy 3 years back, now presenting with multiple lumps over the vulva, which discharged clear fluid for 1 year. Acquired vulval lymphangiectasia develops 7–15 years postradiotherapy or surgery commonly, while in our case, it developed earlier. On local examination, there were multiple shiny translucent and hyperpigmented “frog-spawn like” vesicles and papules present over the lower midabdomen, mons pubis, and labia majora. Diagnosis of vulval lymphangiectasia was made on the clinical findings and biopsy. Biopsy revealed dilated lymphatic channels in the superficial and deep dermis. CO2 laser treatment was done for the patient.

Lymphangioma circumscriptum Associated with Port-Wine Stain

Lymphangioma circumscriptum (LC) is a rare benign disorder involving the deep dermal and subcutaneous lymphatic channels. We present a case of a 32-year old 26 weeks pregnant female with multiple fluid filled vesicles over the vulvae of one year duration with itching. The lesions had increased in size after the onset of pregnancy. The patient also had a large port-wine stain (PWS) over the right buttock extending up to the perineum. The biopsy report was consistent with LC.

Lymphangioma circumscriptum of the vulva: a rare case report

Lymphangioma circumscriptum (LC) is a rarely seen benign disease that involves deep dermal and subcutaneous lymphatic channels. It is seen as a group of lesions in the shape of thin-walled translucent saccules resembling frog eggs. Although the most frequently seen form of cutaneous lymphangioma is seen in the infantile period, it may occur at any age. The most common locations of these lesions are the proximal parts of extremities that contain a rich lymphatic network such as axilla, shoulder, inguinal region, and perineum. Vulvar involvement is quite rare and usually develops secondary to a radical hysterectomy, pelvic lymphadenectomy, radiotherapy, and Crohn's disease. Here, an extraordinary case of LS with an obscure cause is presented.

Skin Malignancies of the Ear.

The ear is a high-risk location for skin cancer due to frequent sun exposure. The ear’s anatomical features, such as thin skin overlying cartilage, minimal subcutaneous tissue, and close proximity to subcutaneous lymphatic channels, confer increased risk of invasion and metastasis. Cutaneous neoplasms of the ear are common, and the auricle is the third most common site for basal cell carcinomas (BCCs). Squamous cell carcinomas (SCCs) also commonly develop on the ear, and they may be more prevalent than BCCs.1 They tend to behave aggressively with high rates of recurrence and metastasis.2,3 Due to the occult location of crevices of the external ear and the potential for a lesion to develop on the posterior aspect, late diagnosis is common. The purpose of this study was to review skin malignancies of the ear in our institution over a 5-year period looking at tumor characteristics, demographics, excision margins, recurrence, and metastatic spread.

Combined use of indocyanine green fluorescence and methylene blue dye versus methylene blue dye alone for sentinel lymph node biopsy in breast cancer patients.

e12006 Background: Methylene blue (MB) dye is widely used in China for sentinel lymph node biopsy (SLNB). Recently indocyanine green (ICG) was reported to be an innovative fluorescent tracer that could be visualized by near-infrared camera. In this study we compared the efficacy of combined use of ICG fluorescence and methylene blue eye versus methylene blue alone for SLNB in breast cancer patients. Methods: Two hundred and sixteen consecutive early breast cancer patients in our hospital underwent SLNB from December 2010 to May 2012, 107 patients received combined use of ICG and MB as the lymphatic mapping tracer and 109 patients received MB alone. In combination group, sentinel lymph nodes were identified by ICG fluorescence using a near-infrared camera and/or blue dye, while in blue dye alone group sentinel lymph nodes were identified as blue nodes along the blue lymphatic vessel. Intra-operative frozen section analysis was performed, followed by conventional histopathologic examination. Results: In combination group, subcutaneous lymphatic channels were successfully visualized in all the patients, 325 sentinel lymph nodes were identified in 105 patients. While in blue dye alone group, 242 SLNs were found in 100 patients. The detection rate was 98.1% vs. 91.7 %(p=0.033), the average number of SLNs was 3.1 versus 2.4(p<0.001). 29 metastatic SLNs were found in 19 patients by combination method vs. 21 metastatic SLNs in 17 patients by MB alone. No axillary recurrence was observed in either group during 16 months of median follow-up. Conclusions: The combined use of ICG fluorescence and MB enables visualized and more sensitive SLN detection than MB alone.

Lymphangioma circumscriptum in the scrotum: a case report

IntroductionLymphangioma circumscriptum is a rare benign skin disorder involving hamartomatous lymphatic malformation of deep dermal and subcutaneous lymphatic channels. It is a therapeutic challenge for the dermatologist when it occurs at common sites such as axilla, shoulder, groin and buttocks and a diagnostic challenge for the surgeon when it occurs at rare sites such as the scrotum. Surgical treatment is the most commonly used method to treat scrotal lymphangioma circumscriptum but there are high rates of recurrence.Case presentationWe report the case of a 30-year-old Pakistani man who presented with scrotal swelling which was clinically misinterpreted as an infectious disorder. Later on re-resection of deeper tissue was performed to prevent recurrence. He is still being followed-up on a regular basis.ConclusionAwareness of the occurrence of lymphangioma circumscriptum in the scrotum in adult men without prior disease is mandatory to avoid missing the diagnosis and to ensure proper treatment.

Cutaneous lymphangiectasia of the vulva secondary to tuberculosis

Cutaneous lymphangiectasia, also called as acquired lymphangioma, is a benign cutaneous disorder involving the dermal and subcutaneous lymphatic channels. It can rarely occur on the vulva. We describe a 35-year-old woman who came with multiple raised lesions over the vulva and left upper thigh of 1 year duration. She gave history of getting treated for multiple swellings that developed over right side of the neck and inguinal regions on both sides three decades ago. On local genital examination, the patient had a large polypoidal growth involving both sides of the vulva, left upper thigh, and over pubic area. Multiple linear scars were present over the upper thighs and groin bilaterally. The patient underwent simple vulvectomy and left thigh growth excision. Histopathological examination of the vulvectomy specimen confirmed our diagnosis.

P3-07-10: Sentinel Lymph Node Navigation Surgery Using Combination of Indocyanine Green Fluorescence and Blue Dye for Breast Cancer Patients.

Abstract Background: Sentinel lymph node (SLN) biopsy is now widely accepted for staging the axilla in breast cancer patients. Several methods are presently used to detect SLNs. Combined use of blue dye and radiocolloid has previously been described as a superior method for detecting SLNs in breast cancer patients, but radiocolloid is not generally available in Japan. SLN detection guided by indocyanine green (ICG) fluorescence could emerge as a new and effective method for SLN biopsy. The aim of this study was to evaluate SLN biopsy using combination of ICG fluorescence and blue dye methods for breast cancer patients. Material and Methods: We enrolled 75 patients with clinically node-negative breast cancer. An isosulfan blue dye solution (5ml) was injected subcutaneously just above the tumor and in the periareolar area after the induction of anesthesia. The injection site was massaged for five minutes and ICG (2ml) was then injected subcutaneously just above the tumor and in the periareolar area before starting the surgical procedure. Subcutaneous lymphatic channels draining from the areola to the axilla were visualized with a fluorescence imaging system (Photodynamic Eye: PDE, Hamamatsu Photonics Corporation, Japan) under fluorescence within several minutes. SLNs were dissected under direct visualization supported by fluorescence and dye navigation and diagnosed by intraoperative frozen section with hematoxylin and eosin staining. Any patient with a positive SLN underwent immediate axillary lymph node dissection (ALND). Results: SLNs were detected in all 75 patients. The fluorescence imaging identified 2.6 SLNs in 74 (98.7%) of 75 patients. The blue dye identified 1.6 SLNs in 68 (90.1%) of 75 patients. Twelve of the 75 (16.0%) patients had metastatic SLNs and ALND was immediately performed. No metastasis revealed in any non-SLN in eight of these 12 patients. Metastatic SLNs were detected by the ICG fluorescence and not by blue dye in four of these 12 patients. Discussion: The combination of ICG fluorescence and blue dye method had two advantages: it could reveal lymph flow on the surface before we determined the skin incision line; and it had a high SLN detection rate. In hospitals where radioisotopes are unavailable, a combination of the two methods would be advantageous. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-10.

New fluorescence imaging method for sentinel lymph node biopsy in patients with early breast cancer.

e11578 Background: Indocyanine green (ICG) is a popular diagnostic reagent for the examination of hepatic function and cardiac output. In this study, based on the fluorescence characteristics of ICG, we present a new method that enables the detection of sentinel lymph nodes (SLN) with high sensitivity using ICG fluorescence imaging. Methods: Fluorescence images were obtained using the fluorescence imaging system, the Photodynamic Eye (Hamamatsu Photonics Co., Japan). A 0.5% ICG solution combined with Indigocarmine was intradermally injected for 0.3 ml in the areola closest to a tumor. Subcutaneous lymphatic channels draining from the areola to the axilla or other directions were visible by fluorescence imagings immediately. The point where the fluorescence disappeared was identified on the skin, and the skin has been pressed with the capsule. The point of fluorescence seemed was then incised, and the SLN were then dissected by fluorescence navigation. Results: This study enrolled 202 patients with clinically node-negative breast cancer. Their average age was 53.9 years (ranged from 29 to 82 years). Sixty five patients were premenopausal, and 137 patients were postmenopausal. There were five cases of Tis lesions and 117 cases with T1 lesions and 80 cases with T2 lesions. Subcutaneous lymphatic channels and SLN were successfully visualized in all patients. One lymphatic channel to the axilla was 53%, two channels were 32%, and three channels were 16%. The channels to other directions were not seen. The number of fluorescent SLN ranged from 1 to 6 (mean: 3.1), and blue dyed SLN ranged from 0 to 3 (mean: 1.2). In the latter, SLN were not identified in 76 patients (identification rate: 62.4%). Twenty three patients had lymph node metastases pathologically. All of them were recognized by fluorescence imagings, but, in 10 patients, lymph nodes with metastases were not identified by a blue dye. Conclusions: The fluorescence imaging method is therefore considered to be a new and effective method for SLN mapping, which allows easy, highly sensitive and real-time imaging-guided SLN mapping in patients with early breast cancer. The current results show that SLN mapping guided by ICG fluorescence imaging could therefore be a promising tool.

Indocyanine green fluorescence imaging system for sentinel lymph node biopsies in early breast cancer patients

This study presents a new method that enables the detection of sentinel lymph nodes (SLN) with high sensitivity using indocyanine green (ICG) fluorescence imaging. This study enrolled 128 patients with clinically node-negative breast cancer. Fluorescence imaging was obtained after ICG was injected into the areola. Subcutaneous lymphatic channels were immediately visible. Lymphatic channels and SLN were successfully visualized in all patients. One lymphatic channel was 60%, two channels were 24%, and three channels were 16%. The number of fluorescence SLN ranged from 1 to 6, and blue-dyed SLN ranged from 0 to 3. In the latter, SLN were not identified in 44 patients. Nineteen patients had pathologically identified lymph node metastases. All of them were recognized by fluorescence imaging, but 8 patients had lymph nodes with metastases were not identified by dye method. This ICG fluorescence imaging technique is feasible and safe for detecting SLN in a less invasive manner than conventional mapping, with real-time observations.

Abstract P1-01-12: A Novel Method for Sentinel Lymph Node Biopsy by Indocyanine Green Fluorescence Technique in Breast Cancer

Abstract Background: Sentinel lymph node (SLN) biopsy is the standard method to assess the actual axillary lymph node status in breast cancer. Currently dye techniques, radioisotope techniques or combined techniques are usually used for SLN detection. Recently, near infrared fluorescence imaging has been applied clinically in a breast cancer patient to identify SLN. In this study, the feasibility of SLN biopsy using the indocyanine green (ICG) technique were evaluated. Methods: The study involved four hundreds eleven patients with clinically node negative early breast cancer who underwent SLN in three institutes. A combination of ICG as a fluorescence emitting source and blue dyes were injected in the subareolar area and lymphatic flows were traced with a charge coupled device camera and a real-time image guided surgery enabled to identify the fluorescence image of SLN after meticulous dissection. Results: The subcutaneous lymphatic channels were detected precisely in all cases. The identification rate of SLN was 99%, (408/411) with a mean number of 2.3±1.2 (range, 1-9) nodes identified per patient. Only one SLN harvested in 30.1% of patients, two in 29.4%, three in 23.9% and four or more in 15.9% of patients. Thirty nine cases (9.5%) had SLNs involved and all of them were ICG positive and 30 of 39 patients (77%) had one SLN involved. Conclusions: This ICG fluorescence method is simple and achieves a high SLN identification rate. This technique does not require a facility equipped to use radioisotopes. This means that SLN biopsies could even be performed in a small hospital. Orderly and sequential dissection along the lymphatic flow may provide higher sensitivity compared with the conventional radioisotope method. A direct comparison between the radioisotope and ICG fluorescence methods is now required. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-12.

A Novel Approach for Sentinel Lymph Node Identification Using Fluorescence Imaging and Image Overlay Navigation Surgery in Patients with Breast Cancer

We reported a novel technique of sentinel lymph node (SLN) identification using fluorescence imaging of indocyanine green injection. Furthermore, to obtain safe and accurate identification of SLN during surgery, we introduce the image overlay navigation surgery and evaluate its efficacy. This study enrolled 50 patients with a tumors <2 cm in diameter. Initially, we obtained three-dimensional (3-D) imaging from multidetector-row computed tomography (MD-CT) by volume rendering. It was projected on the patient's operative field with the clear visualization of lymph node (LN) through projector. Then, the dye of indocyanine green (ICG) was injected subdermally in the areola. Subcutaneous lymphatic channels draining from the areola to the axilla were visible by fluorescence imaging immediately. Lymphatic flow was reached after LN revealed on 3-D imaging. After incising the axillary skin on the point of LN mapping, SLN was then dissected under the guidance of fluorescence imaging with adequate adjustment of sensitivity and 3-D imaging. Lymphatic channels and SLN were successfully identified by Photodynamic eye (PDE) in all patients. And the sites of skin incision also were identical with the LN being demonstrated by 3-D imaging in all patients. The mean number of SLN was 3.7. The image overlay navigation surgery was visually easy to identify the location of SLN from the axillary skin. There were no intra- or postoperative complications associated with SLN identification. This combined navigations of fluorescence and 3-D imaging revealed more easy and effective to detect SLN intraoperatively than fluorescence imaging alone.

Indocyanine green fluorescence imaging system for sentinel lymph node biopsy in early breast cancer patients.

649 Background: Sentinel lymph nodes (SLN) biopsy is a useful method to assess axillary lymph node status in early breast cancer. Indocyanine green (ICG) fluoresces by irradiating the excitation light when it unites with the serum protein. In the study, we present a novel method that allows the detection of SLN with high sensitivity using ICG fluorescence imaging. Methods: A 0.5% ICG solution combined with indigo carmine was intradermally injected for 0.3 mL in the areola closest to a tumor. Fluorescence imaging device (Photodynamic Eye: Hamamatsu Photonics Co.) was obtained using a charge coupled camera and light emitting diodes at 760 nm as the light source. Subcutaneous lymphatic channels draining from the areola to the axilla or other directions were visible by fluorescence imagings immediately. The SLN were then dissected by fluorescence navigation. Results: This study enrolled 175 patients with clinically node-negative breast cancer. Their average age was 52.8 years (ranged from 29 to 82 years). Sixty one patients were premenopausal, and 114 patients were postmenopausal. There were 112 cases with T1 lesions and 63 cases with T2 lesions. Subcutaneous lymphatic channels and SLN were successfully visualized in all patients. One lymphatic channel to the axilla was 55% (95/175), two channels were 29% (51/175), and three channels were 15% (27/175). The channels to other directions were not seen. The number of fluorescence SLN ranged from 1 to 6 (mean: 3.1), and blue dyed SLN ranged from 0 to 3 (mean: 1.2). In the latter, SLN were not identified in 64 patients (identification rate: 63.4%). Twenty three patients had lymph node metastases pathologically. All of them were recognized by fluorescence imagings, but, in 12 patients, lymph nodes with metastases were not identified by a vital dye. A significant correlation was seen between BMI and the time to arrival at the axilla. Conclusions: This ICG fluorescence imaging system presents a novel method for SLN mapping, which allows easy, highly sensitive and real-time imaging-guided SLN mapping in patients with early breast cancer. We hope that this method will provide with detection rate and negative predictive value in SLN navigation surgery. No significant financial relationships to disclose.

Indocyanine green (ICG) fluorescence imaging versus radioactive colloid for sentinel lymph node identification in patients with breast cancer.

674 Background: The usefulness of ICG fluorescence imaging produced by near-infrared ray for sentinel lymph node (SLN) identification in patients with breast cancer has been revealed. We herein compared and evaluated the outcomes between ICG fluorescence imaging with dye (ICG) and radioactive colloid with dye (RAC) in SLN identification in patients with operable breast cancer. Methods: Between March 2004 and December 2009, 309 patients with a tumor less than 3 cm in diameter and node-negative consisted of 149 patients in ICG and 160 in RAC were enrolled in this study. The mean age was 55 years in ICG and 54 in RAC. In the former, ICG was injected subdermally in the areola. Subcutaneous lymphatic channels draining from the areola to the axilla were visible by fluorescence imagings (Photodynamic eye: PDE, Hamamatsu Photonics Co.) immediately. After incising the axillary skin 1 cm cranial side from the disappeared point of fluorescence image, SLN was then dissected under the guidance of fluorescence with adequate adjustment of sensitivity. In the latter, radioactive colloid was injected subdermally in the areola the day before. After incising the axillary skin on the strong point of gamma probe (Navigator GPS power probe), SLN was then dissected under the guidance of gamma probe. Results: There were no significant differences between age, cancer stage and surgical procedures. The identification rate was 98.7% in ICG and 96.9% in RAC, respectively. The mean number of SLN was 3.7 (range: 1-11) in ICG and 2.0 (range 1-5) in RAC. The lymph node metastasis was revealed in 13.4% of ICG group and 13.8% of RAC group. The false negative rate was 0.67% in ICG and 0.62% in RAC. There were no intra- or postoperative complications associated with SLN identification. The cost was $46,007 (PDE: $46,000, ICG: $6.7) in ICG and $60,030 (GPS: $60,000, RAC: $30) in RAC. There were no significant differences in surgical outcomes between both methods. Conclusions: The evaluation of ICG fluorescence imaging is equal to that of radioactive colloid. In particular, ICG fluorescence imaging for SLN identification will be a greatly helpful tool for institutions without radioactive equipment. No significant financial relationships to disclose.

A Novel Method for Sentinel Lymph Node Biopsy by Indocyanine Green Fluorescence Technique in Breast Cancer

We investigated the feasibility of sentinel lymph node (SLN) biopsy using indocyanine green (ICG) technique in 411 patients with early breast cancer at three institutes. ICG, a fluorescence source, and blue dye were injected into the subareolar area to enable real-time image-guided surgery and identification of SLN fluorescence after meticulous dissection. The subcutaneous lymphatic channels were precisely detected in all cases. SLN identification rate was 99% (408/411) with a mean of 2.3 nodes identified per patient. Thirty-nine cases (9.5%) had SLNs involved and all of them were ICG positive. Thus, the ICG technique has a high SLN identification rate comparable with that of the radioisotope method.

Sentinel Lymph Node Navigation Surgery with Indocyanine Green Fluorescence in Early Breast Cancer.

Abstract Background: Sentinel lymph node (SLN) biopsy is a minimally invasive and effective method for assessing axillary lymph node status in breast cancer. Currently dye techniques, radioisotope techniques or combined techniques are used for SLN detection and recently, near infrared fluorescence imaging has been applied clinically in a breast cancer patient to identify SLN. The concept of this technique is to detect the subcutaneous lymphatic flow from the areola toward the axilla in real time and identify SLN as florescence spot. Our aim in this study is evaluate the feasibility of SLNB by using the ICG technique and the effect of Body Mass Index (BMI) on the number of SLN identify. Methods: The study involved one hundred patients with clinically node negative early breast cancer who were assigned to SLNB, bilateral SLNB were performed on seven of them. A combination of indocyanine green as a fluorescence emitting source and patent blue dyes were injected in the periareolar area and a charge coupled device camera equipped with a cut filter was used, first to trace the subcutaneous lymphatic channels then to identify the florescence image of SLN after meticulous dissection. Both of them were seen in real time on a TV monitor. According to their florescence imaging and the blue color, the LNs were classified as SLN which is either double positive (ICG+/ Dye+) or single positive (ICG+/Dye- or ICG-/ Dye+) and para SLN which is double negative (ICG-/Dye -). Results: The subcutaneous lymphatic channels were detected precisely in all cases. The identification rate of SLN was 100%, (107/107) with a mean number of 3.7 nodes (rang-1 - 12), double positive nodes were found in 83.2% (89/107) with a mean number of 1.5 (range 0-6). The single positive SLNs, i.e. ICG+/ Dye- or ICG-/ Dye+ were found in (87/107) and (4/107) respectively. In twenty six cases (24.3%), the SLNs were involved and all of them were ICG positive. BMI is negatively correlated with number of double positive SLN identified (r= -0.19, P = .02). Conclusion: The ICG and patent blue dye technique gives high sensitivity and provides a comparable result to the dye and radioactive technique. Obesity may reduce the number of double positive SLNs identified. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1017.

A novel approach for sentinel lymph node identification using fluorescence imaging and image overlay navigation surgery in patients with breast cancer

624 Background: We reported a novel technique of sentinel lymph node (SLN) identification using fluorescence imaging of indocyanine green injection. Furthermore, to obtain safe and accurate identification of SLN during surgery, we introduce the image overlay navigation surgery and evaluate its efficacy. Methods: This study enrolled 30 patients with a tumor less than 3 cm in diameter. Initially we obtained three-dimensional (3-D) imaging from MD-CT by volume rendering of Osirix (Macintosh, Apple Inc.). It was projected on the patient’ operative field with the clear visualization of LN through the micro projector (Mpro 110, Sumitomo 3M). And then the dye of indocyanine green was injected subdermally in the areola. Subcutaneous lymphatic channels draining from the areola to the axilla were visible by fluorescence imagings (Photodynamic eye: PDE, Hamamatsu Photonics Co.) immediately. Lymphatic flow was reached after LN revealed on 3-D imaging. After incising the axillary skin on the point of LN mapping, SLN was then dissected under the guidance of fluorescence and 3-D imaging with adequate adjustment of sensitivity. Results: Lymphatic channels and SLN were successfully identified by PDE in all patients. And the sites of skin incision were also identical with the LN being demonstrated by 3-D imaging in all patients. The mean number of SLN was 2.8. The adjustment of sensitivity of PDE provide with the reduction of operation time. The image overlay navigation surgery was visually easy to identify the location of SLN from the axillary skin. There were no intra- or postoperative complications associated with SLN identification. Conclusions: This combined navigations of fluorescence and 3-D imagings revealed more easy and effective to detect SLN intraoperatively than fluorescence imaging alone. The operator's demand was satisfied with the introduction of image overlay navigation surgery consisted of augmented reality and mixed reality, and it may be practical in the various surgical fields. No significant financial relationships to disclose.

Sentinel lymph node identification using near-infrared fluorescence imaging and ultrasound in patients with breast cancer

605 Background: Recently, we reported a novel technique of sentinel lymph node (SLN) identification using near-infrared fluorescence imaging that provides high detection and low false-negative rates. Furthermore, we present the combination of near-infrared fluorescence imaging and ultrasound to obtain better outcomes. Methods: This study enrolled 91 patients with a breast tumor less than 3 cm in diameter. Their mean age was 52 years. Preoperative TNM stage was I in 61 cases, IIa in 21, and IIb in 9, respectively. Initially axillary lymph nodes were identified by ultrasound and their locations were marked on the axillary skin. And then the dye of indocyanine green was injected subdermally in the areola. Subcutaneous lymphatic channels draining from the areola to the axilla became visible by fluorescence imagings (Photodynamic eye: PDE, Hamamatsu Photonics Co.) immediately. After incising the axillary skin 1 cm cranial side from the disappeared point of fluorescence image, SLN was then dissected under the guidance of fluorescence with adequate adjustment of sensitivity. Results: Lymphatic channels and SLN were successfully identified by PDE in 89 patients (identification rate: 97.8%). The SLN of remaining two patients were compensated by ultrasound. The number of fluorescence SLN ranged from 0 to 11 (mean: 3.9). An adequate adjustment of sensitivity of PDE provided with less time-consuming to identify SLN. The identification rate of near-infrared fluorescence imaging and ultrasound was 93.4% (85/91). Twenty-two patients (24.2%) had lymph node metastases pathologically. One of them was not recognized by fluorescence imaging due to the whole massive metastasis of LN. There were no intra- or postoperative complications associated with SLN identification. Conclusions: This combination method was considered more effective to detect SLN intraoperatively than near-infrared fluorescence imaging alone. An adequate adjustment of sensitivity of PDE enabled a pin-point identification of SLN. No significant financial relationships to disclose.

Intraoperative identification of sentinel lymph nodes by near-infrared fluorescence imaging in patients with breast cancer

We present a novel method for sentinel lymph node (SLN) identification by fluorescence imaging that provides a high detection rate and a low false-negativity rate. Twenty-five breast cancer patients with tumors less than 3 cm in diameter were enrolled. A combination of indocyanine green and indigo carmine was injected subdermally in the areola. Subcutaneous lymphatic channels draining from the areola to the axilla were immediately showed by fluorescence imaging. After incising the axillary skin near the point of disappearance of the fluorescence, the SLN was dissected under fluorescence guidance. In all patients, the lymphatic channels and SLN were successfully visualized. The mean number of fluorescent SLN and blue-dyed SLN were 5.5 and 2.3. Eight patients were found to have lymph node metastases pathologically. All of them were recognized by fluorescence imaging. This method is feasible and safe for intraoperative detection of SLN allowing real-time observation without any need for training.

Intraoperative identification of sentinel lymph node guided by near-infrared fluorescence imaging for breast cancer patients

615 Background: Recently, radioactive tracer, a vital dye, or a combination of both has been applied intraoperatively to detect sentinel lymph nodes (SLN) for patients with early breast cancers. We present a novel method of SLN identification using near-infrared fluorescence imaging that provides with high detection and low false-negative rates. Materials and Methods: This study enrolled 52 patients with a tumor less than 3 cm in diameter. Their mean age was 54.7 years. Preoperative TNM stage was I in 35 cases, IIa in 12, and IIb in 5, respectively. Initially the combination dye of indocyanine green and indigocarmine was injected subdermally in the areola. Fluorescence imaging (photodynamic eye: Hamamatsu Photonics Co.) was obtained using a charge coupled device camera with a cut filter as the detector, and light emitting diodes at 760 nm as the light source. Subcutaneous lymphatic channels draining from the areola to the axilla or other directions were visible by fluorescence imagings immediately. After incising the axillary skin 1 cm cranial side from the disappeared point of fluorescence image, SLN was then dissected under the guidance of fluorescence. Results: In all but one patient, lymphatic channels and SLN were successfully visualized (identification rate: 98.1%). SLN was observed before skin incision in two patients. The number of fluorescence SLN ranged from 0 to 11 (mean: 4.7) and blue dyed SLN ranged from o to 6 (mean: 2.0). SLN was not identified in one patient in the former and 7 patients in the latter. Twelve patients had lymph node metastases pathologically. All of them were recognized by fluorescence imaging, however, three patients with metastatic LN were not identified by a vital dye. Conclusions: This method is feasible and safe to detect SLN intraoperatively with less invasive, real-time observation and no requirement of training. We are convinced that this method will provide with high detection and low false-negative rates in SLN navigation surgery. No significant financial relationships to disclose.