Outcome of sentinel lymph node biopsy in breast cancer using dye alone: a single center review with a median follow-up of 5 years

Indocyanine Green and Methylene Blue Dye Guided Sentinel Lymph Node Biopsy in Early Breast Cancer: A Single-Center Retrospective Survival Study in 1574 Patients

BACKGROUND

Currently, the standard tracing method is to use blue dyes and radioisotope as the tracer for sentinel lymph node biopsy (SLNB). However, there are variations in the choice of tracer in different countries and regions. Some new tracers are also gradually applied in clinical practice, but there is still a lack of long-term follow-up data to confirm their clinical application value.

PATIENTS AND METHODS

Clinicopathological and postoperative treatment follow-up data were collected from patients with early-stage cTis-2N0M0 breast cancer who underwent SLNB using a dual-tracer method of ICG combined with MB. Statistical indicators including the identification rate, the number of sentinel lymph nodes (SLNs), regional lymph node recurrence, disease-free survival (DFS) and overall survival (OS) were analyzed.

RESULTS

Among the 1574 patients, SLNs were successfully detected during surgery in 1569 patients, with a detection rate of 99.7%; the median number of SLNs removed was 3. A total of 1531 patients were included in the survival analysis, with a median follow-up of 4.7 (0.5-7.9) years. In total, patients with positive SLNs had a 5-year DFS and OS of 90.6% and 94.7%, respectively. The 5-year DFS and OS of patients with negative SLNs were 95.6% and 97.3%, respectively. The postoperative regional lymph node recurrence rate was 0.7% in patients with negative SLNs.

CONCLUSION

Indocyanine green combined with methylene blue dual-tracer method is safe and effective in sentinel lymph node biopsy in patients with early breast cancer.

Sentinel node biopsy for axillary management after neoadjuvant therapy for breast cancer: a single-center retrospective analysis with long follow-up

PURPOSE

Sentinel node biopsy (SNB) after neoadjuvant therapy (NAT) for breast cancer remains controversial. We conducted a retrospective study of patients who underwent SNB after NAT to evaluate the effectiveness of this procedure.

METHODS

A consecutive 105 women with locally advanced breast cancer (cT1-4, cN0-3, M0) were treated with NAT between 2006 and 2015. The subjects were 80 of these patients who became or remained clinically node-negative after NAT, 53 of whom had axillary management determined by SNB (group A) and the other 27 underwent axillary lymph node dissection (ALND) without SNB (group B). SNB was performed using a modified dye method.

RESULTS

The sentinel node (SN) identification rate was 94.3% and the mean number of removed SNs was 2.4. ALND was avoided in 33 patients, who were confirmed as SN-negative. There was no difference in recurrence-free and overall survival rates between groups A and B (p = 0.71 and p = 0.46, respectively) during the median follow-up time of 63 months. Of the 33 patients who did not undergo ALND, 10 suffered recurrence (33%). One patient (3%) had recurrence in an axillary lymph node and four had recurrence in a supraclavicular lymph node.

CONCLUSION

Axillary SNB after NAT did not affect the axillary failure rate or the prognosis. SNB may be a reliable procedure, even after NAT.

Cost and Budget Impact Analysis of an Accurate Intraoperative Sentinel Lymph Node Diagnosis for Breast Cancer Metastasis

BACKGROUND

Conventional intraoperative sentinel lymph node biopsy (SLNB) in breast cancer (BC) has limitations in establishing a definitive diagnosis of metastasis intraoperatively, leading to an unnecessary second operation. The one-step nucleic amplification assay (OSNA) provides accurate intraoperative diagnosis and avoids further testing. Only five articles have researched the cost and cost effectiveness of this diagnostic tool, although many hospitals have adopted it, and economic evaluation is needed for budget holders.

OBJECTIVE

We aimed to measure the budget impact in Japanese BC patients after the introduction of OSNA, and assess the certainty of the results.

METHODS

Budget impact analysis of OSNA on Japanese healthcare expenditure from 2015 to 2020. Local governments, society-managed health insurers, and Japan health insurance associations were the budget holders. In order to assess the cost gap between the gold standard (GS) and OSNA in intraoperative SLNB, a two-scenario comparative model that was structured using the clinical pathway of a BC patient group who received SLNB was applied. Clinical practice guidelines for BC were cited for cost estimation.

RESULTS

The total estimated cost of all BC patients diagnosed by GS was US$1,023,313,850. The budget impact of OSNA in total health expenditure was -US$24,413,153 (-US$346 per patient). Two-way sensitivity analysis between survival rate (SR) of the GS and OSNA was performed by illustrating a cost-saving threshold: y ≅ 1.14x - 0.16 in positive patients, and y ≅ 0.96x + 0.029 in negative patients (x = SR-GS, y = SR-OSNA). Base inputs of the variables in these formulas demonstrated a cost saving.

CONCLUSION

OSNA reduces healthcare costs, as confirmed by sensitivity analysis.

Clinical significance of breast cancer micrometastasis in the sentinel lymph node

The advantages of sentinel lymph node biopsy (SLNB) in breast cancer patients include an enhanced pathological examination of a small number of sentinel lymph nodes (SLNs), which permits more frequent detection of micrometastasis and isolated tumor cells (ITCs). At the same time, however, SLNB raises two new concerns: whether minimal SLN involvement has a significant impact on survival and whether patients with such minimal involvement should undergo further axillary dissections. Two large randomized studies, ACOSOG Z0011 and IBCSG 23-01, have demonstrated that axillary lymph node dissection (ALND) can be avoided for select SLN-positive patients. However, for patients with macrometastasis in SLN or who do not meet the inclusion criteria of the two studies, ALND is still the standard management. On the other hand, previous studies appear to disagree on the prognostic significance of minimal SLN involvement. One of the reasons for this discrepancy is the great variability among pathological examinations for SLN. The OSNA method, which is a fast molecular detection procedure targeting cytokeratin 19 (CK19) mRNA, has the advantage of reproducibility among institutions and the capability to examine a whole lymph node within 30-40 min. This novel method may thus be able to overcome the issue of variability among conventional pathological examinations.

Rate of sentinel lymph node identification using isosulfan blue dye in breast cancer patients at Charoenkrung Pracharak Hospital, Thailand

Background: The sentinel lymph node (SLN) is the first lymph node to receive lymphatic drainage from a primary breast tumor. If the SLN contains no metastatic tumor, then it is unlikely other lymph nodes will contain breast cancer metastasis. When the SLN does contains metastasis, an axillary lymph node dissection (ALND) is recommended to further stage the axilla and to maintain locoregional control. SLNs can be identified by using a dye, radioisotope, or combined techniques.

Objective: To determine the rate of SLN identification using isosulfan blue dye in breast cancer patients at Charoenkrung Pracharak Hospital, Thailand, and factors that affect it.

Methods: This prospective study of 106 consecutive cases breast cancer enrolled 105 women (1 bilateral breast cancer case) between October 2011 and October 2013 at Charoenkrung Pracharak Hospital. Clinical and pathological features were analyzed for the effectiveness of SLN identification using isosulfan blue dye.

Results: The rate of SLN identification using isosulfan blue dye in breast cancer patients at Charoenkrung Pracharak Hospital was 92%. The method was safe and well tolerated in early-stage breast cancer patients.

Conclusion: The effectiveness of sentinel node identification using isosulfan blue dye in breast cancer patients at Charoenkrung Pracharak Hospital is consistent with that shown in studies from other countries.

Use of indocyanine green for detecting the sentinel lymph node in breast cancer patients: from preclinical evaluation to clinical validation

Assessment of the sentinel lymph node (SLN) in patients with early stage breast cancer is vital in selecting the appropriate surgical approach. However, the existing methods, including methylene blue and nuclides, possess low efficiency and effectiveness in mapping SLNs, and to a certain extent exert side effects during application. Indocyanine green (ICG), as a fluorescent dye, has been proved reliable usage in SLN detection by several other groups. In this paper, we introduce a novel surgical navigation system to detect SLN with ICG. This system contains two charge-coupled devices (CCD) to simultaneously capture real-time color and fluorescent video images through two different bands. During surgery, surgeons only need to follow the fluorescence display. In addition, the system saves data automatically during surgery enabling surgeons to find the registration point easily according to image recognition algorithms. To test our system, 5 mice and 10 rabbits were used for the preclinical setting and 22 breast cancer patients were utilized for the clinical evaluation in our experiments. The detection rate was 100% and an average of 2.7 SLNs was found in 22 patients. Our results show that the usage of our surgical navigation system with ICG to detect SLNs in breast cancer patients is technically feasible.