Novel techniques for sentinel lymph node biopsy in breast cancer: a systematic review

Small Molecules for Multi-Wavelength Near-Infrared Fluorescent Mapping of Regional and Sentinel Lymph Nodes in Colorectal Cancer Staging

Assessing lymph node (LN) status during tumor resection is fundamental for the staging of colorectal cancer. Current guidelines require a minimum of 12 LNs to be harvested during resection and ultra-staging regional lymph nodes by sentinel lymph node (SLN) assessment is being extensively investigated. The current study presents novel near-infrared (NIR) fluorescent dyes for simultaneous pan lymph node (PanLN; regional) and SLN mapping. PanLN-Forte was intravenously injected in mice and assessed for accumulation in regional LNs. SLN800 was injected intradermally in mice, after which the collection and retention of fluorescence in SLNs were measured using indocyanine green (ICG) and its precursor, SLN700, as references. LNs in the cervical, inguinal, jejunal, iliac, and thoracic basins could clearly be distinguished after a low dose intravenous injection of PanLN-Forte. Background fluorescence was significantly lower compared to the parent compound ZW800-3A (p < 0.001). SLN700 and SLN800 specifically targeted SLNs with fluorescence being retained over 40-fold longer than the current clinically used agent ICG. Using SLN700 and SLN800, absolute fluorescence in SLN was at least 10 times higher than ICG in second-tier nodes, even at 1 hour post-injection. Histologically, the fluorescent signal localized in the LN medulla (PanLN-Forte) or sinus entry (SLN700/SLN800). PanLN-Forte and SLN800 appear to be optimal for real-time NIR fluorescence imaging of regional and SLNs, respectively.

Comparisons of ICG-fluorescence with conventional tracers in sentinel lymph node biopsy for patients with early-stage breast cancer: A meta-analysis

Radioisotopes (RI) and blue dye (BD) are routinely used markers for staining during sentinel lymph node biopsy (SLNB) in breast cancer. Compared with traditional tracers, tracer performance of indocyanine green (ICG) has been controversial. A total of 21 studies were selected from the PubMed, EMBASE and Cochrane Library databases. Detection ability was judged based on four endpoints: i) The identification rate (IR) of the patients; ii) the IR of the sentinel lymph nodes (SLNs); iii) the IR of the positive SLNs; and iv) the false negative rate (FNR). Compared with BD, ICG was superior in terms of the IR of the patients [odds ratio (OR)=7.17; 95% CI, 3.98-12.94), the IR of the SLNs (OR=8.84; 95% CI, 6.71-11.66) and FNR (OR=0.20; 95% CI, 0.08-0.48) using a fixed-effects model. There was a significant difference in both the IR of the positive SLNs (OR=21.32; 95% CI, 2.84-160.14) and FNR (OR=0.46; 95% CI, 0.23-0.91) in the ICG vs. RI group. Furthermore, when using ICG at the recommended dose, a significant difference was found in the IR of the patients (OR=1.77; 95% CI, 1.09-2.85) and the IR of the SLNs (OR=21.62; 95% CI, 5.23-89.43) using a fixed-effects model. In the ICG vs. BD combined with RI group, there were no differences in either the IR of the patients (OR=5.10; 95% CI, 0.24-107.48) or the IR of SLNs (OR=5.10; 95% CI, 0.60-256.66). In conclusion, ICG was a better tracer compared with BD or RI alone and was not a worse tracer compared with BD combined with RI. The use of the recommended dose of ICG had an improved tracer effect. ICG is expected to be widely used in SLNB in view of its clinical advantages.

Comparison of indocyanine green fluorescence and methylene blue dye in the detection of sentinel lymph nodes in breast cancer

Background

Previous studies have shown that sentinel lymph node biopsy (SLNB) can be successfully performed using methylene blue (MB); however, this method still has some drawbacks. Indocyanine green (ICG) fluorescence imaging, as a selective method, has the potential for guiding SLNB. This study aimed to compare the clinical sensitivity and efficacy between ICG and MB in SLNB in breast cancer.

Methods

A prospective study of 70 patients with biopsy-proven invasive breast cancer was conducted. Under the guidance of ICG and MB, administered by injection, SLNs were examined and removed. The detection rates, total number of SLNs detected, mean number of SLNs detected, and number of positive SLNs were compared between ICG and MB.

Results

The SLN detection rate was 100% and 93% (65/70) for ICG and MB, respectively. More SLNs were detected in the ICG group (243) than in the MB group (169). The mean number of SLNs detected with ICG and MB was 3.5±1.73 and 2.4±1.49, respectively. Moreover, there was a statistically significant difference between the number of SLNs detected using the two methods (t=6.648, P<0.05). Additionally, SLN metastasis was detected in 18 patients using ICG and 14 patients using MB; these patients immediately underwent axillary lymph node dissection (ALND). No postoperative complications were reported.

Conclusions

ICG demonstrated a higher detection rate and better accuracy, as well as a lower false negative rate, than MB in detecting SLNs in breast cancer. ICG has potential as an alternative tool that could be clinically applied to detect SLNs in breast cancer patients.

Optimizing breast cancer surgery during the COVID-19 pandemic

The COVID-19 pandemic poses current and future challenges in the maintenance of surgical operating capacity. In the United Kingdom surgery has continued—in a reduced capacity—through the establishment of regional ‘cancer hubs’ using independent sector facilities to treat public healthcare patients. It is essential that these scarce operating facilities available are optimally utilized and that logistical challenges that result from remote operating away from the surgeon’s primary hospital site are considered. These issues are best addressed through the application of currently available medical technology and enhanced training in advanced oncoplastic techniques, which extend the limits of breast conservation.

Metastatic status of sentinel lymph nodes in breast cancer determined with photoacoustic microscopy via dual-targeting nanoparticles

Detection of sentinel lymph nodes (SLNs) is critical to guide the treatment of breast cancer. However, distinguishing metastatic SLNs from normal and inflamed lymph nodes (LNs) during surgical resection remains a challenge. Here, we report a CD44 and scavenger receptor class B1 dual-targeting hyaluronic acid nanoparticle (5K-HA-HPPS) loaded with the near-infra-red fluorescent dye DiR-BOA for SLN imaging in breast cancer. The small sized (~40 nm) self-assembled 5K-HA-HPPSs accumulated rapidly in the SLNs after intradermal injection. Compared with normal popliteal LNs (N-LN), there were ~3.2-fold and ~2.4-fold increases in fluorescence intensity in tumour metastatic SLNs (T-MLN) and inflamed LNs (Inf-LN), respectively, 6 h after nanoparticle inoculation. More importantly, photoacoustic microscopy (PAM) of 5K-HA-HPPS showed a significantly distinct distribution in T-MLN compared with N-LN and Inf-LN. Signals were mainly distributed at the centre of T-MLN but at the periphery of N-LN and Inf-LN. The ratio of PA intensity (R) at the centre of the LNs compared with that at the periphery was 5.93 ± 0.75 for T-MLNs of the 5K-HA-HPPS group, which was much higher than that for the Inf-LNs (R = 0.2 ± 0.07) and N-LNs (R = 0.45 ± 0.09). These results suggest that 5K-HA-HPPS injection combined with PAM provides a powerful tool for distinguishing metastatic SLNs from pLNs and inflamed LNs, thus guiding the removal of SLNs during breast cancer surgery.

A randomized study comparing different doses of superparamagnetic iron oxide tracer for sentinel lymph node biopsy in breast cancer: The SUNRISE study

INTRODUCTION

The non-radioactive method that uses the magnetic tracer (SPIO/Sienna) has shown to be a feasible technique for the SLN detection in breast cancer patients. The aim of this study is to assess the efficacy of different doses of a new magnetic tracer Sienna XP (Magtrace) compared to Tc-99 m and to evaluate its non-inferiority.

METHODS

Patients diagnosed with early-stage breast cancer cT1-3 N0, from October 2016 to August 2018 were eligible and consecutively randomized to three different doses of new SPIO used: group 1 (1 mL), group 2 (1.5 mL) and group 3 (2 mL).

RESULTS

A total of 135 patients were included in the study, 45 in each group. Detection of SLNs with the three doses of Sienna XP (1 mL, 1.5 mL and 2 mL) showed non-inferior rates compared to the conventional technique with radiotracer (p = 0.654). Concordance by patients with SLN positive was 100% for all groups. 83 (70.3%) patients reported skin staining at one month postoperatively, significantly lower in group 1 (p = 0.042). At 6 months follow up, group 1 remains with significantly lower skin discoloration (p = 0,01). In multivariate analysis, dose of 2 mL showed statistically significant for the skin staining. The majority of patients (70%) felt that skin discoloration does not represent a problem.

CONCLUSION

The use of the Sienna XP magnetic tracer at 1 mL is not inferior to higher doses of magnetic tracer neither is inferior to radiotracer. 1 mL of magnetic tracer resulted in significantly less skin discoloration compared to higher doses.

Accuracy of CEUS-guided sentinel lymph node biopsy in early-stage breast cancer: a study review and meta-analysis

Objective

To investigate whether preoperative localization of sentinel lymph node (SLN) by contrast-enhanced ultrasound (CEUS) can further improve the accuracy of sentinel lymph node biopsy (SLNB).

Method

Collect published literatures or conference reports by searching electronic databases. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) evaluation method is used to evaluate the quality of the screened literatures. The pooled risk ratio of cancer metastasis of SLN identified by CEUS (CE-SLN) compared with SLN not identified by CEUS (nonCE-SLN) is calculated, and the pooled diagnostic accuracy of CE-SLN for pathological status of all SLNs is also evaluated.

Result

Through search and screening, a total of 16 studies were included, of which five and seven studies, respectively, entered the meta-analysis of metastatic risk ratio and diagnostic accuracy. The localization rate of preoperative CEUS for sentinel lymph nodes was 70 to 100%. The meta-analysis shows that the risk of metastasis of SLN identified by CEUS is significantly higher than that not identified by CEUS, 26.0% vs 4.6%, and risk ratio (RR) is 6.08 (95% CI 4.17–8.85). In early-stage breast cancer, the pathological status of CE-SLN is a good representative of all SLNs, with a pooled sensitivity of 98% (95% CI 0.94–1.00), pooled specificity of 100% (95% CI 0.99–1.00), diagnostic odds ratio (DOR) of 2153.18 (95% CI 476.53–9729.06), and area under the subject receiver operating characteristic (SROC) curve of 0.9968.

Conclusion

In early-stage breast cancer, preoperative localization of SLN by CEUS is expected to further improve the accuracy of sentinel lymph node biopsy (SLNB).

Moving a neodymium magnet promotes the migration of a magnetic tracer and increases the monitoring counts on the skin surface of sentinel lymph nodes in breast cancer

Background

We suspected that moving a small neodymium magnet would promote migration of the magnetic tracer to the sentinel lymph node (SLN). Higher monitoring counts on the skin surface before making an incision help us detect SLNs easily and successfully. The present study evaluated the enhancement of the monitoring count on the skin surface in SLN detection based on the magnet movement in a sentinel lymph node biopsy (SNB) using superparamagnetic iron oxide (SPIO) nanoparticles.

Methods

After induction of general anesthesia, superparamagnetic iron oxide nanoparticles were injected sub-dermally into the subareolar area or peritumorally. The neodymium magnet was moved over the skin from the injection site to the axilla to promote migration of the magnetic tracer without massage. A total of 62 patients were enrolled from February 2018 to November 2018: 13 cases were subjected to magnet movement 20 times (Group A), 8 were subjected to 1-min magnet movement (Group B), 26 were given a short (about 5 min) interval from injection to 1-min magnet movement (Group C), and 15 were given a long (about 25 min) interval before 1-min magnet movement using the magnetometer’s head (Group D). In all cases, an SNB was conducted using both the radioisotope (RI) and SPIO methods. The monitoring counts on the skin surface were measured by a handheld magnetometer and compared among the four groups. Changes in the monitoring count by the interval and magnet movement were evaluated.

Results

The identification rates of the SPIO and RI methods were 100 and 95.2%, respectively. The mean monitoring counts of Group A, B, C, and D were 2.39 μT, 2.73 μT, 3.15 μT, and 3.92 μT, respectively (p < 0.0001; Kruskal-Wallis test). The monitoring counts were higher with longer magnet movement and with the insertion of an interval. Although there were no relationships between the monitoring count on the skin surface and clinicopathologic factors, magnet movement strongly influenced the monitoring count on the skin surface.

Conclusion

Moving a small neodymium magnet is effective for promoting migration of a magnetic tracer and increasing monitoring counts on the skin surface.

Trial registration

UMIN, UMIN000029475. Registered 9 October 2017

Can Low-cost Indo Cyanine Green Florescence Technique for Sentinel Lymph Node Biopsy Replace Dual Dye (Radio-colloid and Blue Dye) Technique in Early Breast Cancer: A Prospective Two-arm Comparative Study

BACKGROUND

The objective of this study was to assess the detection and accuracy of sentinel lymph node (SLN) biopsy (SLNB) using the low-cost indocyanine green (ICG) fluorescence method and to compare this method with the gold standard dual-dye method (radio-colloid + methylene blue dye [MB]).

MATERIALS AND METHODS

One hundred patients with node-negative early breast cancer assessed clinically and by ultrasound axilla underwent an SLNB procedure using technetium-99m radio-colloid, MB, and ICG. The detection rate of SLNs and positive SLNs and the number of SLNs were compared. The injection safety of ICG and MB was evaluated.

RESULTS

One hundred female patients with a median age of 52.3 years participated in the study. Sixty-eight percent had a body mass index < 25, 85% presented with a palpable lump, of which 59% were in the outer quadrant. SLNs were identified in all 100 cases. A total of 290 SLNs were removed (mean, 2.9; range, 1-6). The identification rate with dual dye was 94%, whereas with ICG alone, it was 96%. The SLNB sensitivity rate and false negative rate were 97.6% versus 93.2% and 3.1% versus 6.2% in the ICG and dual-dye combination, respectively. None of the patients had any local or systemic reaction with ICG; 3 patients with blue dye had tattooing and staining of skin.

CONCLUSION

ICG fluorescence imaging permits real time visualization of lymphatics and provides an additional dimension to SLN biopsy that is safe and effective. These results confirm high sensitivity for fluorescence localization with comparable performance to the gold standard. ICG can reliably replace dual dye and be employed as a sole tracer for SLNB in early breast cancer.

Deep learning radiomics can predict axillary lymph node status in early-stage breast cancer

Accurate identification of axillary lymph node (ALN) involvement in patients with early-stage breast cancer is important for determining appropriate axillary treatment options and therefore avoiding unnecessary axillary surgery and complications. Here, we report deep learning radiomics (DLR) of conventional ultrasound and shear wave elastography of breast cancer for predicting ALN status preoperatively in patients with early-stage breast cancer. Clinical parameter combined DLR yields the best diagnostic performance in predicting ALN status between disease-free axilla and any axillary metastasis with areas under the receiver operating characteristic curve (AUC) of 0.902 (95% confidence interval [CI]: 0.843, 0.961) in the test cohort. This clinical parameter combined DLR can also discriminate between low and heavy metastatic burden of axillary disease with AUC of 0.905 (95% CI: 0.814, 0.996) in the test cohort. Our study offers a noninvasive imaging biomarker to predict the metastatic extent of ALN for patients with early-stage breast cancer.

Breast cancer is frequently diagnosed using ultrasound. Here, the authors show that, in addition to ultrasound, shear wave elastography can be used to diagnose breast cancer and, in conjunction with deep learning and radiomics, can predict whether the disease has spread to axillary lymph nodes.

Indocyanine green fluorescence method for sentinel lymph node biopsy in breast cancer

BACKGROUND/OBJECTIVE

Breast biopsy and analysis of sentinel lymph nodes (SLNs) accurately predict tumor status in the affected basin and help in avoiding unnecessary axillary lymph node dissection, which is associated with remarkable morbidity risk. Blue dye and radioisotope are the most widely used mapping agents, but non-radioactive tracers of comparable accuracy warrant further investigation. This study aimed to investigate utilization of indocyanine green (ICG) fluorescence in sentinel node localization compared with blue dye and to assess the incremental value of ICG.

METHODS

A total of 39 consecutive patients underwent sentinel lymph node biopsy (SLNB) (40 cases: 38 unilateral and 1 bilateral) with combined blue dye and ICG for localization. The obtained fluorescence images of the lymphatic system were investigated.

RESULTS

All 84 lymph nodes removed in 40 procedures were identified by ICG, but only 37 were identified by blue dye. The ICG method identified an average of 2.1 SLNs in 39 of 40 cases with a detection rate of 97.5%, but only 0.93 SLN per case with blue dye. Subcutaneous lymphatic channel patterns were also detected by fluorescent imaging in 37 procedures, which all revealed lymphatic drainage toward the axilla except in one case with internal mammary pathway.

CONCLUSION

This study demonstrated the accuracy and safety of ICG for SLNB and its superiority to blue dye method in SLN localization. Therefore, ICG fluorescence method is safe and effective addition in breast clinical settings, wherein blue dye alone is used.

New Frontiers in Molecular Imaging with Superparamagnetic Iron Oxide Nanoparticles (SPIONs): Efficacy, Toxicity, and Future Applications

Supermagnetic Iron Oxide Nanoparticles (SPIONs) are nanoparticles that have an iron oxide core and a functionalized shell. SPIONs have recently raised much interest in the scientific community, given their exciting potential diagnostic and theragnostic applications. The possibility to modify their surface and the characteristics of their core make SPIONs a specific contrast agent for magnetic resonance imaging but also an intriguing family of tracer for nuclear medicine. An example is 68Ga-radiolabeled bombesin-conjugated to superparamagnetic nanoparticles coated with trimethyl chitosan that is selective for the gastrin-releasing peptide receptors. These receptors are expressed by several human cancer cells such as breast and prostate neoplasia. Since the coating does not interfere with the properties of the molecules bounded to the shell, it has been proposed to link SPIONs with antibodies. SPIONs can be used also to monitor the biodistribution of mesenchymal stromal cells and take place in various applications. The aim of this review of literature is to analyze the diagnostic aspect of SPIONs in magnetic resonance imaging and in nuclear medicine, with a particular focus on sentinel lymph node applications. Moreover, it is taken into account the possible toxicity and the effects on human physiology to determine the SPIONs' safety.

Use of indocyanine green fluorescence compared to radioisotope for sentinel lymph node biopsy in early-stage breast cancer: systematic review and meta-analysis

BACKGROUND

In early-stage breast cancer, indocyanine green (ICG)-fluorescence based sentinel lymph node (SLN) detection is being considered. This is a meta-analysis of SLN detection rates and sensitivity of ICG-fluorescence compared to radioisotope (RI), to evaluate its clinical applicability.

DATA SOURCES

Systematic review of full-text articles from PubMed and Scopus, of women with early breast cancer who underwent SLN mapping using ICG and RI concurrently was performed. The meta-analysis was performed using the Mantel-Haenszel method.

RESULTS

2301 patients from 19 studies were included. No significant difference was observed between ICG and RI for SLN detection (OR0.90,95%CI0.66-1.24) or sensitivity (OR1.23,95%CI0.73-2.05) with heterogeneity between studies (I² = 58%,P = 0.003). Sensitivity of dual mapping (ICG + RI) was significantly better compared to single mapping with RI (OR3.69,95%CI1.79-7.62) or ICG (OR3.32,95%CI1.52-7.24) alone with no heterogeneity between studies (I² = 0%,P = 0.004).

CONCLUSION

ICG-fluorescence could complement RI method or provide alternative in centers with poor accessibility to RI lymphoscintigraphy.

Development of Magnetic Probe for Sentinel Lymph Node Detection in Laparoscopic Navigation for Gastric Cancer Patients

New laparoscopic sentinel lymph node navigation using a dedicated magnetic probe and magnetic nanoparticle tracer for gastric cancer patients allows minimally invasive surgeries. By identifying the sentinel lymph nodes containing magnetic nanoparticles, patients can avoid excessive lymph node extraction without nuclear facilities and radiation exposure. This paper describes the development of the laparoscopic magnetic probe, ACDC-probe, for laparoscopic sentinel lymph node identification utilizing the nonlinear response of the magnetic nanoparticles magnetized by an alternating magnetic field with a static magnetic field. For highly sensitive detection, the ratio of static to alternating magnetic fields was optimized to approximately 5. The longitudinal detection length was approximately 10 mm for 140 μg of iron, and the detectable amount of iron was approximately 280 ng at a distance of 1 mm. To demonstrate the feasibility of laparoscopic detection using the ACDC-probe and magnetic tracers, an experiment was performed on a wild swine. The gastric sentinel lymph node was clearly identified during laparoscopic navigation. These results suggest that the newly developed ACDC-probe is useful for laparoscopic sentinel lymph node detection and this magnetic technique appears to be a promising method for future sentinel lymph node navigation of gastric cancer patients.

Advanced Nanotechnology Leading the Way to Multimodal Imaging-Guided Precision Surgical Therapy

Surgical resection is the primary and most effective treatment for most patients with solid tumors. However, patients suffer from postoperative recurrence and metastasis. In the past years, emerging nanotechnology has led the way to minimally invasive, precision and intelligent oncological surgery after the rapid development of minimally invasive surgical technology. Advanced nanotechnology in the construction of nanomaterials (NMs) for precision imaging-guided surgery (IGS) as well as surgery-assisted synergistic therapy is summarized, thereby unlocking the advantages of nanotechnology in multimodal IGS-assisted precision synergistic cancer therapy. First, mechanisms and principles of NMs to surgical targets are briefly introduced. Multimodal imaging based on molecular imaging technologies provides a practical method to achieve intraoperative visualization with high resolution and deep tissue penetration. Moreover, multifunctional NMs synergize surgery with adjuvant therapy (e.g., chemotherapy, immunotherapy, phototherapy) to eliminate residual lesions. Finally, key issues in the development of ideal theranostic NMs associated with surgical applications and challenges of clinical transformation are discussed to push forward further development of NMs for multimodal IGS-assisted precision synergistic cancer therapy.

In Vivo Photoacoustic Sentinel Lymph Node Imaging Using Clinically-Approved Carbon Nanoparticles

OBJECTIVE

Breast cancer is the most common type of invasive cancer and one of the leading causes of cancer death in women worldwide. Correct staging of breast cancer is critical to the survival rate of the patients. Sentinel lymph node (SLN) biopsy (SLNB), currently the gold standard technique for breast cancer staging, requires preoperative and intraoperative image guidance for noninvasive SLN identification and minimal surgical invasion. However, existing image guidance techniques suffer from a variety of limitations, such as ionizing radiation, high cost, and poor imaging depth. To address the clinical challenges, new methodology has to be developed.

METHODS

We developed a photoacoustic (PA) imaging procedure for noninvasive and nonradioactive SLN identification and biopsy guidance enhanced with a clinically-approved lymphatic tracer, i.e., carbon nanoparticles (CNPs) suspension injection.

RESULTS

In vivo experiments show that the proposed procedure could sensitively identify the SLN and provide high-contrast image guidance for fine-needle aspiration simulation. In addition, we demonstrated that CNPs have significantly better performance than other commonly-used contrast agents, such as methylene blue and indocyanine green.

CONCLUSION

PA imaging technique using clinically-approved CNPs as the contrast agent is capable for noninvasive and nonradioactive SLN identification and high-contrast biopsy guidance, and should be considered as a new tool for assisting SLNB in breast cancer staging.

SIGNIFICANCE

The proposed CNPs-enhanced PA imaging technique provides a practical way for SLN identification and biopsy guidance for breast cancer patients and paves the way for clinical translation of PA SLN imaging.

Use of New Technologies in Implant-Based Breast Reconstruction

Outcomes after mastectomy and prosthetic-based breast reconstruction have improved immensely since the development of the first tissue expander and breast implant in the 1960s. One major factor contributing to our improved outcomes over the past two decades is the increasing availability and improvement of perfusion assessment technology. Instrumental methods now exist which allow surgeons to assess tissue viability intraoperatively, and provide actionable, objective data that augments clinical assessment. In this article, the authors detail two commercially available, state-of-the-art technologies that surgeons may use to assist in mastectomy flap assessment and facilitate the reconstructive process.

A Prospective Validation Cohort Study of a Prediction Model on Non-sentinel Lymph Node Involvement in Early Breast Cancer

BACKGROUND

Early breast cancer with one or two sentinel lymph nodes (SLNs) may omit axillary lymph node dissection (ALND) if followed by radiotherapy. However, only less than one-third of the patients have positive non-SLNs and can truly benefit from radiotherapy. Before any regional treatment decision, the risk of non-SLN metastasis must be identified. The authors previously developed a predictive model for non-SLN involvement using CK19 mRNA and contrast-enhanced ultrasound (CEUS) score in a training set. They designed a further study to evaluate the predictive effect using the model prospectively in a validation set of one or two involved SLNs.

METHODS

This study identified early breast cancer patients at Zhejiang Cancer Hospital from July 2017 to June 2018. The CK19 mRNA tested by quantitative real-time polymerase chain reaction and CEUS scores were collected before surgery. Patients with one or two involved SLNs were enrolled and underwent ALND. The estimated percentage of non-SLN involvement was calculated by the authors' model formula and the Memorial Sloan Kettering Cancer Center (MSKCC) nomogram. The false-negative rates, predictive accuracy, and area under curve (AUC) were compared between two predictive models.

RESULTS

The study enrolled 235 patients, and 35.36% (83/235) of them had non-SLN involvement. The authors' model had a false-negative rate of 6% and an accuracy of 94.9%. The AUC was 0.952 (95% confidence interval [CI] 0.922-0.982), which was significantly higher than that of the MSKCC model at all three cutoff value levels.

CONCLUSION

The authors' model, using CK19 mRNA and the CEUS score, showed the potential predictive value of non-SLNs before surgery for early breast cancer patients.

CLINICALTRIALS REGISTRY

NCT02992067, NCT03280134.

Preliminary study of contrast-enhanced ultrasound in combination with blue dye vs. indocyanine green fluorescence, in combination with blue dye for sentinel lymph node biopsy in breast cancer

Background

This preliminary study aimed to examine the feasibility of sentinel lymph node biopsy (SLNB) using contrast-enhanced ultrasound (CEUS) vs. indocyanine green fluorescence (ICG), combined with blue dye in patients with breast cancer.

Methods

This was a retrospective study of consecutive female patients with invasive stage I-III (based on pre-operative physical examination and imaging) primary breast cancer at the Peking Union Medical College Hospital between 01/2013 and 01/2015 who underwent preoperative SLNB by ICG + blue dye or CEUS + blue dye. The numbers of detected SLNs, detection rates, and recurrence-free survival (RFS) rates were compared between the two groups.

Results

A total of 443 patients were included. The detection rates of SLNs in the CEUS + blue dye and ICG + blue dye groups were 98.4 and 98.1%, respectively (P = 0.814). The average numbers of SLNs detected per patient showed no significant difference between the two groups (3.06 ± 1.33 and 3.12 ± 1.31 in the CEUS + blue dye and ICG + blue dye groups, respectively; P = 0.659). After a median follow-up of 46 months, five patients in the CEUS + blue dye group and 15 in the ICG + blue dye group had recurrence. RFS rates showed no significant difference (P = 0.55).

Conclusion

This preliminary study suggests that CEUS + blue dye and ICG + blue dye are both feasible for SLN detection in breast cancer.

Perinodal fibrosis developed after ultrasonography-guided core-needle biopsy of a contrast-enhanced ultrasound-detected sentinel axillary node interferes with subsequent surgical sentinel node dissection

OBJECTIVE

To evaluate perinodal fibrosis after 14-gauge staging core-needle biopsy (CNB) of the axillary sentinel lymph node (SLN) identified using contrast-enhanced ultrasonography (CEUS) and its interference with subsequent surgical SLN dissection in breast cancer patients.

METHODS

Frequencies or means of main clinical, sonographic, pathological, and surgical characteristics were calculated. We also compared patient groups with and without perinodal pathological fibrosis.

RESULTS

Forty-eight patients who underwent CEUS + CNB and axillary surgery were eligible for this cross-sectional study. Axillary surgical specimens showed perinodal fibrosis in 9/48 (18.7%) patients. Interference with SLN dissection was reported in 4/48 (8.3%) patients (two hematomas, three abnormal palpation findings, and four difficult dissections). The overall surgical detection rate of SLN was 43/48 (89.6%). In the majority of cases, perinodal fibrosis was described as moderate (4/9 [44.4%]) or severe (4/9 [44.4%]). The mean time elapsed between CEUS + CNB and axillary dissection was shorter in patients with perinodal fibrosis (P = .04). Interference with SLN dissection was only reported in patients with perinodal fibrosis (P < .001). Surgical SLN detection was successful in all nine cases in which perinodal pathological fibrosis or interference with SLN dissection was reported.

CONCLUSION

Perinodal fibrosis may impair the surgical SLN dissection in early stage breast cancer patients who were staged using CEUS + CNB using a14-gauge needle.

Folate-Targeted and Oxygen/Indocyanine Green-Loaded Lipid Nanoparticles for Dual-Mode Imaging and Photo-sonodynamic/Photothermal Therapy of Ovarian Cancer in Vitro and in Vivo

We have successfully fabricated versatile folate-targeted and oxygen/indocyanine green-loaded lipid nanoparticles (FA-OINPs) for dual-mode imaging-guided therapy in ovarian cancer cells and subcutaneous xenograft models. FA-OINPs were demonstrated to have great potential as superb contrast agents to enhance ultrasound and photoacoustic (US/PA) imaging We have successfully fabricated versatile folate-targeted and oxygen/indocyanine green-loaded lipid nanoparticles (FA-OINPs) for dual-mode imaging-guided therapy in ovarian cancer cells and subcutaneous xenograft models. FA-OINPs were demonstrated to have great potential as superb contrast agents to enhance ultrasound and photoacoustic (US/PA) imaging in vitro and in vivo. Confocal laser scanning microscopy and flow cytometry analysis verified that FA-OINPs could specifically target SKOV3 ovarian cancer cells and be endocytosed with a remarkable efficiency. Compared with other therapeutic options, FA-OINPs exhibited an excellent therapeutic outcome after exposure to laser and ultrasound. The MTT assay and flow cytometry analysis confirmed that cytotoxicity effects and apoptosis/necrosis rates were significantly increased. The fluorescence microscopy and fluorescence microplate reader detection validated that the generation of intracellular reactive oxygen species (ROS) was dramatically improved. Immunohistochemical analyses of tumor tissues demonstrated the enhanced tumor apoptosis, the decreased vascular endothelial growth factor (VEGF) and microvascular density (MVD) expression, and the decreased expression of CD68 after treatment. The presented results suggest that photo-sonodynamic/photothermal mediated FA-OINPs could provide a promising strategy for synergistic therapy in ovarian cancer with the guidance of US/PA dual-mode imaging.

In Vivo Imaging of Exogenous Progenitor Cells in Tendon Regeneration via Superparamagnetic Iron Oxide Particles

BACKGROUND

Although tendon injuries and repairs are common, treatment of these injuries has limitations. The application of mesenchymal progenitor cells (MPCs) is increasingly used to optimize the biological process of tendon repair healing. However, clinically relevant technologies that effectively assess the localization of exogenous MPCs in vivo are lacking.

HYPOTHESIS

Exogenous MPCs labeled with superparamagnetic iron oxide (SPIO) particles would allow monitoring of the localization and retention of cells within the site of implantation via magnetic resonance imaging (MRI) without negatively affecting cell survival or differentiation.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Genetically modified C3H10T1/2 MPCs engineered to express luciferase (Luc+) reporter gene were implanted into surgically created Achilles tendon defects of 10 athymic nude rats (Hsd:RH-Foxn1^rnu). Of these animals, 5 animals received Luc+ C3H10T1/2 MPCs colabeled with SPIO nanoparticles (+SPIO). These 2 groups of animals then underwent optical imaging with quantification of bioluminescence and MRI at 7, 14, and 28 days after surgery. Statistical analysis was conducted by use of 2-way analysis of variance. At 28 days after surgery, animals were euthanized and the treated limbs underwent histologic analysis.

RESULTS

Optical imaging demonstrated that the implanted cells not only survived but also proliferated in vivo, and these cells remained viable for at least 4 weeks after implantation. In addition, SPIO labeling did not appear to affect MPC survival or proliferation, as assessed by quantitative bioluminescence imaging (P > .05, n = 5). MRI demonstrated that SPIO labeling was an effective method to monitor cell localization, retention, and viability for at least 4 weeks after implantation. Histologic and immunofluorescence analyses of the repaired tendon defect sites demonstrated tenocyte-like labeled cells, suggesting that cell differentiation was not affected by labeling the cells with the SPIO nanoparticles.

CONCLUSION

MRI of exogenous MPCs labeled with SPIO particles allows for effective in vivo assessments of cell localization and retention in the setting of tendon regeneration for at least 4 weeks after implantation. This SPIO labeling does not appear to impair cell survival, transgene expression, or differentiation.

CLINICAL RELEVANCE

SPIO labeling of MPCs appears to be safe for in vivo assessments of MPCs in tendon regeneration therapies and may be used for future clinical investigations of musculoskeletal regenerative medicine.

Clinical feasibility of imaging with indocyanine green combined with carbon nanoparticles for sentinel lymph node identification in papillary thyroid microcarcinoma

BACKGROUND

Although several previous studies demonstrated the feasibility and efficacy of indocyanine green (ICG) for thyroid cancer surgery, ICG was administered through venous injection and focused on parathyroid gland protection. We thus aimed to study the feasibility of imaging using ICG combined with carbon nanoparticles (CNs) in the identification of sentinel lymph nodes (SLNs) in patients diagnosed with papillary thyroid microcarcinoma (PTMC).

METHODS

Two approaches were applied to detect lymph nodes in PTMC surgery. Patients were randomized into 2 groups. ICG and CNs were injected into the thyroid in Group A. In Group B, only CNs was injected. Black-stained or fluorescent nodes observed using near-infrared fluorescence imaging systems were defined as SLNs. SLN and central lymph node (CLN) dissection was completed in both groups. The pathological and postoperative outcomes were compared between 2 groups.

RESULTS

There were 40 patients in Group A and 60 in Group B. A total of 138 SLNs were identified; 72 and 66 SLNs were detected and dissected in Groups A and B, respectively. The number of SLNs identified (per patient) in Group A was higher than that in Group B (P = .027). The number of harvested CLNs was 161 and 192 in Groups A and B, respectively, out of which 45 and 48 lymph nodes with metastasis were confirmed by permanent pathology. The CLN metastatic rate in Group A was higher than that in Group B (P = .048).

CONCLUSION

Imaging using ICG combined CNs is feasible and safe for SLN identification in PTMC patients. Compared with using only CNs, more SLNs can be removed and more metastatic lymph nodes can be confirmed when using the combined method. Although the combined method appears to accurately stage tumors, further research is needed.

SentimagIC: A Non-inferiority Trial Comparing Superparamagnetic Iron Oxide Versus Technetium-99m and Blue Dye in the Detection of Axillary Sentinel Nodes in Patients with Early-Stage Breast Cancer

BACKGROUND

Sentinel lymph node biopsy (SLNB) is a highly accurate method for staging the axilla in early breast cancer. Superparamagnetic iron oxide mapping agents have been explored to overcome the disadvantages of the standard SLNB technique, which uses a radioisotope tracer with or without blue dye. One such agent, Sienna+, was shown to be non-inferior to the standard technique for SLNB in a number of studies. The SentimagIC trial was designed to establish the non-inferiority of a new formulation of this magnetic tracer, Magtrace (formerly SiennaXP).

METHODS

Patients with clinically node-negative early-stage breast cancer were recruited from six centers in the US. Patients received radioisotope and isosulfan blue dye injections, followed by an intraoperative injection of magnetic tracer, prior to SLNB. The sentinel node identification rate was compared between the magnetic and standard techniques to evaluate non-inferiority and concordance.

RESULTS

Data were collected for 146 procedures in 146 patients. The per patient detection rate was 99.3% (145/146) when using the magnetic tracer and 98.6% (144/146) when using the standard technique, while the nodal detection rate was 94.3% (348/369 nodes) when using the magnetic tracer and 93.5% (345/369) when using the standard technique (difference 0.8%, 95% binomial confidence interval lower bound - 2.1%). Of the 22 patients with positive sentinel lymph nodes (SLNs), 21 (95.4%) were detected by both the magnetic tracer and the standard technique. All malignant nodes detected by standard technique were also identified by the magnetic technique.

CONCLUSION

The magnetic technique is non-inferior to the standard technique of radioisotope and blue dye for axillary SLN detection in early-stage breast cancer. The magnetic technique is therefore a viable alternative.

Murine Model Study of a New Receptor-Targeted Tracer for Sentinel Lymph Node in Breast Cancer

Purpose

Sentinel lymph node biopsy (SLNB), a critical staging and treatment step, has replaced axillary lymph node (LN) dissection as the standard staging procedure for early stage breast cancer patients with clinically negative axillary LNs. Hence, using a murine sentinel lymph node (SLN) model, we investigated the localization effect of the new receptor-targeted tracer, indocyanine green (ICG)-rituximab, on breast cancer SLNB.

Methods

After establishing the murine SLN model, different doses of ICG-rituximab were subcutaneously injected into the hind insteps of BALB/c mice to determine the optimal dose and imaging time using continuous (> 3 hours) MDM-I fluorescence vasculature imaging. To explore the capacity of ICG-rituximab for sustained SLN localization with the optimal dose, MDM-I imaging was monitored at 6, 12, and 24 hours.

Results

The popliteal LN was defined as the SLN for hindlimb lymphatic drainage, the iliac LN as the secondary, and the para-aortic or renal LN as the tertiary LNs. The SLN initial imaging and optimal imaging times were shortened with increased ICG-rituximab doses, and the imaging rates of the secondary and tertiary LNs increased accordingly. The optimal ICG dose was 0.12 μg, and its optimal imaging time was 34 minutes. After 24 hours, the SLN imaging rate remained 100%, while those of the secondary and the tertiary LNs increased from 0% (6 hours) and 0% (6 hours) to 10% (12 hours) and 10% (12 hours) to 20% (24 hours) and 10% (24 hours), respectively.

Conclusion

ICG-rituximab localized to the SLN without imaging from the secondary or tertiary LNs within 6 hours. The optimal ICG dose was 0.12 μg, and the optimal interval for SLN detection was 34 minutes to 6 hours post-injection. This novel receptor-targeted tracer is of great value to clinical research and application.

Comparative study of indocyanine green combined with blue dye with methylene blue only and carbon nanoparticles only for sentinel lymph node biopsy in breast cancer

Purpose

The combination of indocyanine green and methylene blue (ICG + MB) was reported to be an efficient tracer method in sentinel lymph node biopsy (SLNB). However, whether this method is superior to MB only or carbon nanoparticles (CN) is controversial. This study was to evaluate the efficacy of the three methods in SLNB for breast cancer, and to analyze its influencing factors.

Methods

One hundred eighty patients with early breast cancer were recruited and randomly divided into 3 groups. Each group comprising of 60 patients with SLNB using ICG + MB, MB, and CN, respectively. Then the 3 groups were compared in detection rate, mean number of SLNs, and the detection rates and number of metastatic sentinel lymph nodes (SLNs).

Results

The detection rate of SLNs was 100% (60 of 60) in ICG + MB group, 96.7% (58 of 60), and 98.3% (59 of 60) in MB and CN group, respectively, with no significant difference (P = 0.362). Totally, 204 SLNs (mean ± standard deviation [SD] [range], 3.4 ± 1.4 [2–8]) were detected in ICG + MB group, 102 (1.7 ± 0.7 [0–3]) and 145 (2.4 ± 0.7 [0–6]) in MB and CN group, indicating significant difference (P < 0.001). The detection rate of metastatic SLN was 23.3% (14 of 60) in ICG + MB group, which was higher than 18.3% (11 of 60) and 20% (11 of 60) in MB and CN group, respectively, but showed no statistical significance (P = 0.788).

Conclusion

ICG + MB method was superior to MB only and CN only methods in the mean number of SLNs, thus predicting axillary lymph node metastasis more accurately. Therefore, in areas where the standard method is not available, ICG + MB may be more suitable as an alternative tracer for SLNB.

The Sentinel Lymph Node Biopsy Using Indocyanine Green Fluorescence Plus Radioisotope Method Compared With the Radioisotope-Only Method for Breast Cancer Patients After Neoadjuvant Chemotherapy: A Prospective, Randomized, Open-Label, Single-Center Phase 2 Trial

BACKGROUND

This study aimed to compare the sentinel lymph node (SLN) identification rates for breast cancer patients after neoadjuvant chemotherapy (NAC) between the dual method (DM) of indocyanine green fluorescence (ICG-F) plus a radioisotope (RI) and RI alone.

METHODS

This randomized study enrolled 130 patients who received NAC for breast cancer and 122 patients who received SLN biopsy (SLNB) using either DM (n = 58) or RI only (n = 64). The study compared the identification rate, number of SLNs, and detection time of SLNB.

RESULTS

Among the 122 patients, 113 (92.6%) were clinically node-positive before NAC. The SLN identification rate was 98.3% in the DM group and 93.8% in the RI group (p = 0.14). The DM group and the RI group were similar in the average number of SLNs (2.2 ± 1.13 vs. 1.9 ± 1.33; p = 0.26) and the time to detection of the first SLN (8.7 ± 4.98 vs. 8.3 ± 4.31 min; p = 0.30). In the DM group, transcutaneous lymphatic drainage was visualized by fluorescence imaging for 65.5% (38 of 58) of the patients. The SLN identification rate was 94.7% using ICG-F and 93% using RI (p = 0.79). During and after the operation, no complications, including allergic reactions or skin necrosis, occurred.

CONCLUSIONS

This study is the first randomized trial to use ICG-F for SLNB in breast cancer patients after NAC. The DM including ICG-F could be a feasible and safe method for SLNB in initially node-positive breast cancer patients with NAC.

Detection of Sentinel Lymph Nodes with Near-Infrared Imaging in Malignancies

Optical molecular imaging, a highly sensitive and noninvasive technique which is simple to operate, inexpensive, and has the real-time capability, is increasingly being used in the diagnosis and treatment of carcinomas. The near-infrared fluorescence dye indocyanine green (ICG) is widely used in optical imaging for the dynamic detection of sentinel lymph nodes (SLNs) in real time improving the detection rate and accuracy. ICG has the advantages of low scattering in tissue absorbance, low auto-fluorescence, and high signal-to-background ratio. The detection rate of axillary sentinel lymph nodes biopsy (SLNB) in breast cancers with ICG was more than 95 %, the false-negative rate was lower than 10 %, and the average detected number ranged from 1.75 to 3.8. The combined use of ICG with nuclein or blue dye resulted in a lower false-negative rate. ICG is also being used for the sentinel node detection in other malignant cancers such as head and neck, gastrointestinal, and gynecological carcinomas. In this article, we provide an overview of numerous studies that used the near-infrared fluorescence imaging to detect the sentinel lymph nodes in breast carcinoma and other malignant cancers. It is expected that with improvements in the optical imaging systems together with the use of a combination of multiple dyes and verification in large clinical trials, optical molecular imaging will become an essential tool for SLN detection and image-guided precise resection.

Network meta-analysis of novel and conventional sentinel lymph node biopsy techniques in breast cancer

Background

The aim of this network meta‐analysis was to compare the performance of blue dye alone or in combination with radioisotope (technetium‐99m, Tc) with three novel techniques for sentinel lymph node detection in breast cancer: indocyanine green fluorescence (ICG), superparamagnetic iron oxide (SPIO) nanoparticles and contrast‐enhanced ultrasound imaging (CEUS).

Methods

PubMed, Embase, the Cochrane Library, China Knowledge Research Integrated Database, ClinicalTrials.gov and OpenGrey databases were searched up to 31 November 2017, without language restriction. Studies that compared the detection performance of at least one of the novel methods (ICG, SPIO and CEUS) with that of traditional methods (blue dye and/or radioisotope) were included in network meta‐analysis.

Results

Thirty‐five studies were included. Pooled risk ratios (RRs) for Tc (1·09, 95 per cent c.i. 1·04 to 1·15), ICG (1·12, 1·07 to 1·16) and SPIO (1·09, 1·01 to 1·18) showed statistically better performance in detecting sentinel lymph nodes than blue dye alone. ICG had the lowest false‐negative rate, with a RR of 0·29 (0·16 to 0·54), followed by Tc (RR 0·44, 0·20 to 0·96) and SPIO (RR 0·45, 0·14 to 1·45), with blue dye alone as the reference group.

Conclusion

SPIO or ICG alone are superior to blue dye alone and comparable to the standard dual‐modality technique of blue dye with Tc.

A retrospective validation study of sentinel lymph node mapping for high-risk endometrial cancer

OBJECTIVES

To determine the feasibility and performance of sentinel lymph-node (SLN) mapping among women with high-risk endometrial cancer (EC).

MATERIALS AND METHODS

Ninety-eight patients at high-risk EC were enrolled in this retrospective surgical trial from August 2016 to August 2018. All patients underwent intraoperative SLN biopsy, with ICG injection for laparoscopic staging; this was followed by pelvic and paraaortic lymphadenectomy (LAD). Outcomes included SLN detection rate, false-negative SLN algorithm rate, and the negative predictive value (NPV) of the SLN algorithm. The Chi-square test was used to analyze the relationship between SLN mapping and the risk factors. Then, we performed Kappa consistency check (P < 0.05 with Meaning), to estimate the consistency of SLN and lymph-node metastasis.

RESULTS

Successful biopsy occurred in 94 patients (170 sides) among 98 patients (196 sides). At least 1 SLN was identified in 86.7% (170/196). Overall, the false-negative rate (FNR) was 11.8% (2/17), NPV was 97.3% (72/74), and sensitivity was 88.2% (15/17). 22/98 patients (22.4%) with high-risk EC had at least one metastatic lymph node identified. When the SLN algorithm was retrospectively applied, the FNR was 9.1% (2/22) and sensitivity was 90.9% (20/22). Considering the surgeon's experience, 68 cases of EC (except for 30 patients), the detection rate was 89.7% (122/136), NPV was 98.1% (50/51), and the FNR was 5.6% (1/18). The factor significantly affecting the detection rate of SLNs was lymphovascular space invasion (LVSI) (P = 0.016). SLN metastasis of EC was associated with depth of myometrial invasion (P = 0.034). The analysis result of SLN and the consistency of pelvic lymph-node metastasis status. As detected by Kappa coefficient was 0.939 (P < 0.001), suggests highly consistency.

CONCLUSIONS

Our SLN detection rate for high-risk EC was the same as previously reported. When SLN is not detected, better after 30 patients' experience, is a reasonable alternative to complete LAD in high-risk EC. In addition, SLN shows high co-occurrence with pelvic lymph nodes. Therefore, SLN biopsy can be used to diagnose high-risk EC.

A novel characterization technique for superparamagnetic iron oxide nanoparticles: The superparamagnetic quantifier, compared with magnetic particle spectroscopy

Superparamagnetic iron oxide nanoparticles (SPIONs) are used as a tracer material in sentinel node biopsies. The latter is a procedure to analyze if cancer cells have spread to lymph nodes, helping to personalize patient care. To predict SPION behavior in vivo, it is important to analyze their magnetic properties in biological environments. The superparamagnetic quantifier (SPaQ) is a new device to measure the dynamic magnetization curve of SPIONs. The magnetization curve was measured for two types of SPIONs: Resovist and SHP-25. We used three techniques: Vibrating Sample Magnetometry (VSM), Magnetic Particle Spectroscopy (MPS), and our new SPaQ. Furthermore, AC susceptibility (ACS) measurements were performed as part of the evaluation of the three techniques. SPaQ and VSM results were found to be similar. Measurement results were nearly identical in both directions, indicating minor hysteresis. However, in MPS measurements, a clear hysteresis loop was observed. Furthermore, the ACS measurements showed a pronounced Brownian maximum, indicating an optimal response for an AC frequency below 10 kHz for both particle systems. Both the SPaQ and MPS were found to be superior to VSM since measurements are faster, can be performed at room temperature, and are particularly sensitive to particle dynamics. The main difference between the SPaQ and MPS lies in the excitation sequence. The SPaQ combines an alternating magnetic field that has a low amplitude with a gradual DC offset, whereas MPS uses only an alternating field that has a large amplitude. In conclusion, both the SPaQ and MPS are highly suited to improve understanding SPION behavior, which will lead to the radical improvement of sentinel node biopsy accuracy.

Targeted delivery of paclitaxel by functionalized selenium nanoparticles for anticancer therapy through ROS-mediated signaling pathways

As a therapeutic anticancer agent, the clinical use of paclitaxel (PTX) is limited by its poor water solubility and serious adverse side effects. The targeted-specific intracellular delivery of an anticancer drug as a new therapeutic modality is promising for cancer treatment. The anticancer activity of selenium nanoparticles (SeNPs) with low toxicity and excellent activity has attracted increasing attention for use in biomedical intervention in recent years. In this study, β-cyclodextrin (β-CD)-folate (FA)-modified selenium nanoparticles (SeNPs) loaded with paclitaxel (PTX) (Se@β-CD-FA@PTX) were successfully fabricated through a layer-by-layer method. The nanosystem is able to enter cancer cells through FA receptor-mediated endocytosis to achieve targeted-specific intracellular delivery. Se@β-CD-FA@PTX was found to increase the selectivity between normal and cancer cells. The viability in MCF-7 cells was remarkably lower than in MCF 10A cells, which may promote the specific targeted delivery of Se@β-CD-FA@PTX into MCF-7 cells. Moreover, Se@β-CD-FA@PTX was found to enhance the cytotoxic effect on MCF-7 cells via the induction of apoptosis activation of ROS-mediated p53 and AKT signaling pathways. The results demonstrate that Se@β-CD-FA@PTX nanoparticles provide a strategy for the design of cancer-targeted nanosystems for use in cancer therapy.

A Novel Indocyanine Green Fluorescence-Guided Video-Assisted Technique for Sentinel Node Biopsy in Breast Cancer

BACKGROUND

The equipment to detect indocyanine green (ICG) fluorescence for sentinel lymph node (SLN) biopsy in breast cancer is not widely accessible nor optimal. The fluorescence appears as a poorly defined white shine on a black background, and dimmed lighting is required. The aim of this study was to assess the feasibility, accuracy and healthcare costs of a novel approach for SLN biopsy by a video-assisted ICG-guided technique.

METHODS

The technique for detecting SLN was radioisotope (RI) in 194 cases, video-assisted ICG-guided in 70 cases and a combined method in 71 cases. In the video-assisted ICG group, a full HD laparoscopic system equipped with xenon lamps was used for a laser-free detection of ICG within a colored and magnified high-resolution image.

RESULTS

Detection of ICG fluorescence using a laparoscope with a near-infrared filter provided a highly defined and colored image during SLN biopsy. SLN was identified in 100% of patients in all groups. Multiple SLNs were identified in 0.5% of RI patients, in 12.9% of ICG patients and in 14.1% of ICG + RI patients (p < 0.0001). In ICG + RI group, 95.1% of lymph nodes were radioactive and 92.7% were fluorescent. Operative times and healthcare costs were equivalent between groups.

CONCLUSIONS

Video-assisted ICG-guided technique is a feasible and surgeon-friendly method for SLN biopsy, with equivalent efficacy compared to RI, providing an accurate staging of the axilla.

Indocyanine green can stand alone in detecting sentinel lymph nodes in cervical cancer

OBJECTIVES

The effectiveness of indocyanine green (ICG) dye for detecting sentinel lymph nodes (SLNs) in cervical cancer compared with other tracers is unknown. This study aimed to assess the validity of ICG dye in detecting SLNs in cervical cancer preoperatively.

METHODS

We performed a literature search for identifying eligible articles from PubMed database using the search terms "cervical cancer", "sentinel lymph node", "indocyanine green", "blue dyes", "human serum albumin", and "technetium-99 radiocolloid". We performed a meta-analysis. Comparison of the overall, bilateral, and unilateral detection rates of the different tracers was the primary goal. Comparison of the false-negative rate among the tracers was the secondary goal.

RESULTS

Only eight retrospective studies including 661 patients were included. ICG versus combinations of three other tracers showed significantly higher bilateral and unilateral detection rates, but no difference in the overall rate of detecting SLNs. ICG had a higher bilateral detection rate than blue dye and technetium-99. Absorbing human serum albumin into ICG as a lymphatic tracer did not show a difference in detection rate compared with ICG alone.

CONCLUSIONS

ICG is superior and better than other tracers, and absorbing human serum albumin as a lymphatic tracer is not required in patients with cervical cancer.

New Technologies for Sentinel Lymph Node Detection

The 'standard of care' method for sentinel node mapping is the combination technique using radioisotope and blue dye although some centres use radioisotope or blue dye alone. Radioisotope usage requires licensing, has regulatory issues around handling and disposal of waste, and logistically may be unavailable or difficult to implement in some centres or less developed country. This has led to the development of alternative methods such as superparamagnetic iron oxide (SPIO), fluorescence techniques using indocyanine green (ICG) or fluorescein, computed tomography lymphography, and contrast-enhanced ultrasound scan (CEUS) using microbubbles. The newer techniques will potentially enable a more widespread adoption of this procedure; however, a common barrier for these techniques is the lack of standardisation and no randomised trials to evaluate their effectiveness against the current standard of care. Furthermore, many of these techniques are more costly and may become redundant in node-negative patients with small tumours if ongoing trials show that sentinel node biopsy offers no additional benefit to grey-scale axillary ultrasound. This review discusses the new techniques for sentinel node mapping that have emerged including their pros and cons.

Noninvasive detection of cancer spread to lymph nodes: A review of molecular imaging principles and protocols

Identification of cancer spread to tumor-draining lymph nodes offers critical information for guiding treatment in many cancer types. Current clinical methods of nodal staging are invasive and can have substantial negative side effects. Molecular imaging protocols have long been proposed as a less invasive means of nodal staging, having the potential to enable highly sensitive and specific evaluations. This review article summarizes the current status and future perspectives for molecular targeted nodal staging.

Contrast-Enhanced Ultrasound-Guided Fine-Needle Aspiration for Sentinel Lymph Node Biopsy in Early-Stage Breast Cancer

The purpose of this study was to assess whether translymphatic contrast-enhanced ultrasound (CEUS) combined with fine-needle aspiration (FNA) can be used pre-operatively to assess the status of axillary lymph nodes in early-stage breast cancer patients. Furthermore, we wanted to determine whether this less invasive method could potentially be a pre-operative surgical strategy. One hundred sixty-four sentinel lymph nodes (SLNs) were detected by CEUS after intradermal injection of microbubbles in 126 cases. One hundred twenty of 126 cases (95.24%) were accurately diagnosed with the SLN-FNA method. All 6 false-negative cases were due to micrometastasis or macrometastasis. There were no false-positive results after CEUS-guided FNA biopsy based on post-operative histopathological results. In conclusion, translymphatic CEUS combined with SLN-FNA is a less traumatic approach that has high accuracy in the pre-operative evaluation of axillary lymph node status. It might have the potential to be as reliable an indicator for axillary lymph node dissection as SLN biopsy.

Application of a carbon nanoparticle suspension for sentinel lymph node mapping in patients with early breast cancer: a retrospective cohort study

BACKGROUND

To stage axillary lymph nodes in women with early-stage breast cancer, sentinel lymph node biopsy (SLNB), rather than axillary lymph node dissection (ALND), has been employed. Moreover, different tracer methods have various advantages and disadvantages. In recent years, carbon nanoparticle suspensions (CNSs) have been used as lymph node tracers during surgeries for thyroid cancer, gastric cancer, and colorectal cancer. The study retrospectively analyzed the feasibility and accuracy of CNS for sentinel lymph node (SLN) mapping in patients with early breast cancer.

METHODS

This single-center, retrospective study included breast cancer patients who underwent SLNB from January 1, 2016, to December 31, 2017, in the Department of Breast Cancer, Guangdong General Hospital. All patients received standard SLNB surgery using a CNS tracer.

RESULTS

A total of 332 cases were included in this study. The SLN identification rate was 99.1% (329/332), and the mean number of SLNs was 2.6 (range, 1-6). SLN metastasis was found in 62 (18.8%) cases, of which 90.3% were found to be macrometastases. The sensitivity of SLNB was 95.9% (47/49), with a specificity of 100% (42/42), a positive predictive value of 100% (47/47), a negative predictive value of 95.5% (42/44), and a false-negative rate of 4.1% (2/49).

CONCLUSION

The identification and predictive values of a CNS tracer for SLNB were satisfactory.

Comparison of sentinel lymph node biopsy guided by blue dye with or without indocyanine green in early breast cancer

BACKGROUND

There were limited data available for a head-to-head comparison of the identification rate and survival between the combined method of indocyanine green fluorescence and blue dye versus the traditional blue dye alone method for sentinel lymph node (SLN) biopsy.

METHODS

From January 2013 to December 2015, 523 eligible breast cancer patients were included in this nonrandomized prospective analysis. The identification rates, the number of SLNs identified, and the disease-free survival (DFS) between the two mapping methods were compared.

RESULTS

The identification rate of SLNs was significantly higher with the combined method than that with the blue dye alone method (99.2% vs 93.3%, respectively; P < 0.001). The average number of SLNs identified per patient in the combined method group was 3.7 ± 2.4, which was more than that in the blue dye alone group (3.2 ± 1.6; P = 0.004). With a median follow-up of 29 months, 0.5% patients in the combined group, and 1.3% patients in the blue dye group had axillary recurrences. The DFS between the two groups showed no significant difference (P = 0.161).

CONCLUSION

The combined method achieved a higher identification rate and lower rate of axillary recurrence compared to the blue dye alone method.