Sentinel lymph node detection using fluorescein and blue light-emitting diodes in patients with breast carcinoma: A single-center prospective study

Sentinel lymph node biopsy in early breast carcinoma using fluorescein sodium and methylene blue dye: A validation study

The availability of radioisotopes for sentinel lymph node biopsy (SLNB) in breast carcinoma is limited in low- and middle-income countries and thus the need for other reliable tracers exists. We aimed to validate the effectiveness of fluorescein sodium (FS) together with methylene blue dye (MBD) for patients with node-negative early breast carcinoma in a prospective cross-sectional study. Patients underwent SLNB using FS and MBD followed by axillary dissection to validate results. Sentinel lymph node (SLN) identification rate and false negative rate were assessed for all three tracers/combinations (MBD, FS, and MBD + FS). We concluded that SLNB using a combination of FS and MBD has an acceptable rate of SLN identification but the addition of FS provided no additional benefit.

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

BACKGROUND

Evaluation of axillary lymph nodes status in cN0 axilla is performed by sentinel lymph node biopsy (SLNB) utilizing a combination of radioactive isotope and blue dye or alternative to isotope like Indocyanine green (ICG). Both are very resource-intensive; which has prompted development of low-cost technique of Fluorescein Sodium (FS)-guided SLNB. This systematic review and meta-analysis evaluate the diagnostic performance of FS-guided SLNB in early breast cancer.

OBJECTIVES

The objective was to evaluate the diagnostic performance of FS for sentinel lymph node biopsy.

METHODS

Eligibility criteria: Studies where SLNB was performed using FS.

INFORMATION SOURCES

PubMed, EMBASE, Cochrane library and online clinical trial registers. Risk of bias: Articles were assessed for risk of bias using the QUADAS-2 tool.

SYNTHESIS OF RESULTS

The main summary measures were pooled Sentinel Lymph Node Identification Rate (SLN-IR) and pooled False Negative Rate (FNR) using random-effects model.

RESULTS

A total of 45 articles were retrieved by the initial systematic search. 7 out of the 45 studies comprising a total of 332 patients were included in the meta-analysis. The pooled SLN-IR was 93.2% (95% confidence interval [CI], 0.87-0.97; 87% to 97%). Five validation studies were included for pooling the false negative rate and included a total of 211 patients. The pooled FNR was 5.6% (95% confidence interval [CI], 2.9-9.07).

CONCLUSION

Fluorescein-guided SLNB is a viable option for detection of lymph node metastases in clinically node negative patients with early breast cancer. It achieves a high pooled Sentinel Lymph Node Identification Rate (SLN-IR) of 93% with a false negative rate of 5.6% for the detection of axillary lymph node metastasis.

Efficacy of Neonatal Porcine Bone Marrow-Derived Mesenchymal Stem Cell Xenotransplantation for the Therapy of Hind Limb Lymphedema in Mice

Lymphedema is an intractable disease with few effective therapeutic options. Autologous mesenchymal stem cell (MSC) transplantation is a promising therapy for this disease. However, its use is limited by the cost and time for preparation. Recently, xenotransplantation of porcine MSCs has emerged as an alternative to autologous MSC transplantation. In this study, we aimed to clarify the usefulness of neonatal porcine bone marrow-derived MSC (NpBM-MSC) xenotransplantation for the treatment of lymphedema. One million NpBM-MSCs were xenotransplanted into the hind limbs of mice with severe lymphedema (MSC transplantation group). The therapeutic effects were assessed by measuring the femoral circumference, the volume of the hind limb, the number and diameter of lymphatic vessels in the hind limb, and lymphatic flow using a near-infrared fluorescence (NIRF) imaging system. We compared the effects using mice with lymphedema that did not undergo NpBM-MSC transplantation (negative control group). The condition of the transplanted NpBM-MSCs was also evaluated histologically. The femoral circumference and volume of the hind limb had been normalized by postoperative day (POD) 14 in the MSC transplantation group, but not in the negative control group (P = 0.041). NIRF imaging revealed that lymphatic flow had recovered in the MSC transplantation group by POD 14, as shown by an increase in luminance in the hind limb. Histological assessment also showed that the xenotransplantation of NpBM-MSC increased the proliferation of lymphatic vessels, but they had been rejected by POD 14. The xenotransplantation of NpBM-MSCs is an effective treatment for lymphedema, and this is mediated through the promotion of lymphangiogenesis.

Laparoscopic fluorescence imaging technique for visualizing biliary structures using sodium fluorescein: the result of a preclinical study in a porcine model

Purpose

Near-infrared fluorescence imaging has been recently applied in the field of hepatobiliary surgery. Our objective was to apply blue-light fluorescence cholangiography during laparoscopic surgery. Therefore, we designed a preclinical study to evaluate the feasibility of using blue-light fluorescence for cholangiography in a porcine model.

Methods

Five millimeters of sodium fluorescein (SF) solution was administered into the gallbladder of 20 male 3-way crossbred (Landrace × Yorkshire × Duroc) pigs in laparoscopic approach. The biliary tree was observed under blue light (a peak wavelength of 450 nm) emitted from a commercialized light-emitting diode (LED) light source (XLS1 extreme, Chammed).

Results

In 18 of 20 porcine models, immediately after SF solution was administered into the gallbladder, it was possible to visualize the biliary tree under blue light emitted from the LED light source.

Conclusion

This study provided a preclinical basis for using blue-light fluorescence cholangiography using SF in laparoscopic surgery. The clinical feasibility of blue-light fluorescence imaging techniques for laparoscopic cholecystectomy remained to be demonstrated.

Evaluation of New Tracers in the Identification of Sentinel Lymph Node in Patients with Early Breast Cancer

Purpose

Sentinel node mapping is the standard of care for evaluation of axilla for women with early node negative breast cancer. Validation of a new tracer for sentinel node biopsy requires full axillary lymph node dissection to establish its performance indicators. This exposes about 70% of women to unnecessary axillary dissection with its attendant morbidity.

Aims and Objective

To investigate the predictive value of identification of sentinel lymph nodes by a tracer for knowing its sensitivity and false-negative rates (FNR).

Methods

A linear regression on data from a network meta-analysis was carried out, and the correlation between identification and sensitivity and its predictive value were ascertained.

Results

A strong linear relationship was observed between identification and sensitivity of sentinel node biopsy (correlation coefficient r = 0.97). The sensitivity and false negativity can be predicted by the identification rate. An identification rate of 93% corresponds to sensitivity = 90.51% and a FNR = 9.49%. The current literature on newer tracers has been succinctly reviewed.

Conclusion

The linear regression demonstrated a very high predictive value of identification rate for ascertaining the sensitivity and FNRs of sentinel node biopsy. A new tracer for sentinel node biopsy can be introduced in clinical practice, if it achieves an identification rate of 93% or more.

Sentinel Node Mapping in Early Breast Cancer: A Randomized Comparison of Fluorescein Guided All India Institute of Medical Sciences, Anurag's Technique with Technetium-99 m Sulfur Colloid Plus Methylene Blue

Purpose

Evaluation of fluorescein along with blue dye as an affordable tracer for sentinel node biopsy in comparison with technetium + methylene blue. A randomized trial was conducted with the following objectives: (1) to demonstrate that the identification of sentinel lymph node by fluorescein + methylene blue is not inferior to the identification by Tc-99 m sulfur colloid + methylene blue and (2) to evaluate the cost-effectiveness of sentinel node biopsy by above two tracers.

Subjects and Methods

One-thirty patients above age 18 years presenting with early breast cancer T1, T2, N0 breast carcinoma were randomized to undergo sentinel node biopsy by either fluorescein + methylene blue or Tc-99 m sulfur colloid + methylene blue.

Results

The sentinel lymph nodes were identified in 89% in Fluorescein + methylene blue group and 90.9% with Tc-99 m sulfur colloid + methylene blue group. The trial demonstrated noninferiority of fluorescein + methylene blue as compared to isotope + methylene blue with effect size = 1; 95% confidence interval- 9.54 to + 11.54. The fluorescein + methylene blue was more cost-effective than isotope guided sentinel node biopsy.

Conclusion

Fluorescein-guided sentinel node biopsy is noninferior and more cost-effective than isotope-guided sentinel node biopsy.

Laparoscopic Liver Resection Enhanced by an Intervention-Guided Fluorescence Imaging Technique Using Sodium Fluorescein

BACKGROUND AND OBJECTIVES

In laparoscopic liver resections, tumor localization is a critical aspect of ensuring clear resection margins and preserving the hepatic parenchyma. In this study, we designed a fluorescence imaging technique using a new fluorophore for tumor localization.

MATERIALS AND METHODS

Immediately before laparoscopic or transthoracic liver resection, microcatheter was inserted through the hepatic artery and used to engrave the segment containing the tumor in the intervention room. Under blue light, the fluorescence of the lesion was visually confirmed, and the location was determined through intraoperative sonography. After tumor localization, liver resection was performed.

RESULTS

From February 2017 to March 2020, 24 patients underwent laparoscopic liver resection (LLR) or video-assisted transthoracic liver resection (VTLR) using intervention-guided fluorescence imaging technique (IFIT).

CONCLUSIONS

IFIT can provide some advantages in the field of LLR. In addition, in cases of VTLR for hepatocellular carcinoma in the superior posterior segment in patients with marginal liver function, IFIT is considered useful.

Techniques for sentinel node biopsy in breast cancer

INTRODUCTION

Sentinel node biopsy (SNB) is the standard of care in women with breast cancer (BC) and clinically non suspicious axillary lymph nodes (LNs), due to its high negative predictive value (NPV) in the assessment of nodal status. SNB has significantly reduced complications related to the axillary lymph node dissection, such as lymphedema and upper limb dysfunction.

EVIDENCE ACQUISITION

The gold standard technique for SNB is the blue dye (BD) and technetium labelled nanocolloid (Tc-99m) double technique. However, nuclear medicine is not available in all Institutions and several new tracers and devices have been proposed, such as indocyanine green (ICG) and superparamagnetic iron oxides (SPIO). All these techniques show an accuracy and detection rate not inferior to that of the standard technique, with different specific pros and cons. The choice of how to perform a SNB primarily depends on the surgeon's confidence with the procedure, the availability of nuclear medicine and the economic resources of the Institutions. In this setting, new tracers, hybrid tracers and imaging techniques are being evaluated in order to improve the detection rate of sentinel lymph nodes (SNs) and minimize the number of unnecessary axillary surgeries through an accurate preoperative assessment of nodal status and to guide new minimally invasive diagnostic procedures of SNs. In particular, the contrast-enhanced ultrasound (CEUS) is an active field of research but cannot be recommended for clinical use at this time.

EVIDENCE SYNTHESIS

The ICG fluorescence technique was superior in terms of DR, as well as having the lowest FNR. The DR descending order was SPIO, Tc, dual modality (Tc/BD), CEUS and BD.

CONCLUSIONS

This paper is a narrative review of the most common SNB techniques in BC with a focus on recent innovations.

Low-cost Fluorescein as an Alternative to Radio-colloid for Sentinel Lymph Node Biopsy-a Prospective Validation Study in Early Breast Cancer

BACKGROUND

Sentinel lymph node biopsy (SLNB) using radio-pharmaceutical (RP) and a blue dye is gold standard for axillary staging in clinically node-negative early breast cancer. High costs and limited availability of RP and/or gamma probe are major deterrents in performing SLNB in developing countries. Fluorescence-guided SLNB can obviate the need for RP and gamma probe. Fluorescein is an inexpensive fluorescent lymphatic tracer. In this study, we compared SLN identification rate (SLN-IR) and false negative rates (FNR) of fluorescein-guided SLNB and radio-guided SLNB using ^99mTc-Sulfur-colloid, in isolation, or in combination with methylene blue dye (MBD).

METHODS

Sixty-five cN0 early and large operable breast cancer patients underwent validation SLNB using fluorescein (and blue LED light), ^99mTc-Sulfur-colloid (and gamma probe) and MBD. Inj Fluorescein 4% was injected, 1 ml each peri-tumoral and sub-areolar five minutes before axillary incision. Axillary dissection was performed irrespective of SLNB histology. The SLN-IR and FNR with various tracers and their combinations were compared.

RESULTS

The mean number of SLNs identified was 3.5 ± 1.8 (range 1-6). The SLN-IR using RP alone was 94%, fluorescein alone was 92%, and MBD alone was 82%. The SLN-IR using fluorescein plus MBD combination was 95.4%, compared to 97% using MBD plus RP combination. FNR was 6.3% using fluorescein plus MBD, as well as RP plus MBD combinations.

CONCLUSIONS

SLN-IR of > 90% and SLN-FNR of < 10% using fluorescein plus MBD combination are in acceptable range, and are comparable to that of RP plus MBD combination. Fluorescein can replace RP for performing SLNB, in combination with MBD.

Indocyanine Green Fluorescence Versus Blue Dye or Radioisotope Regarding Detection Rate of Sentinel Lymph Node Biopsy and Nodes Removed in Breast Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Either blue dye (BD) or radioisotope (RI) is mainly used for sentinel lymph node biopsy (SLNB) in breast cancer patients. Unlike the BD, RI has lower false-negative rate of SLNB. However, its lymphoscintigraphy, difficulty in preoperative injection, and undetected sentinel lymph nodes in some cases cause surgeons to rely only on BD. Currently, indocyanine green (ICG) fluorescence method (ICG-SLNB) is increasingly used as an alternative to the conventional mapping methods in many centers. This systematic review compared ICG with the conventional method of BD or RI in terms of detection rate of SLNB and the number of sentinel lymph nodes (SLNs) removed in.

METHODS

  We searched all relevant studies published between January 2000 and October 2019. All data on for evaluation of SLN detection rate, number of SLNs removed per patient, and tumor positive rate of SLNB were extracted.

RESULTS

A total of 30 studies, including 4,216 SLN procedures were retrieved. There was a statistically significant difference between ICG and BD method in terms of SLN detection rate (OR, 6.73; 95% CI, 4.20-10.78). However, there was no significant difference between ICG and RI in this regard (OR, 0.90; 95% CI, 0.40-2.03). The number of SLNs removed per patient were 2.35 (1.46-5.4), 1.92 (1.0-3.64), and 1.72 (1.35-2.08) for ICG, BD, and RI, respectively. Only in 8 studies, the tumor positive rates in SLNB could be analyzed (ICG, 8.5-20.7%; BD, 12.7-21.4%; RI, 11.3-16%).

CONCLUSION

ICG-SLNB could be an additional or an alternative method for axillary node mapping in breast cancer.<br />.