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Cui RBJ, Hawes S, Azimi F, Chan B, Graham S, Mak C, Seah JL, Warrier S. Avoiding unnecessary sentinel lymph node biopsy with the use of superparamagnetic iron oxide mapping agents (Magtrace®) in breast surgery. ANZ J Surg 2024; 94:1090-1095. [PMID: 38456358 DOI: 10.1111/ans.18936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/24/2024] [Accepted: 02/27/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Superparamagnetic iron oxide (SPIO) (Magtrace®) is a non-radioactive liquid tracer that can stay in the sentinel lymph nodes for 30 days. Injection of SPIO at time of primary breast surgery where upfront sentinel lymph node biopsy (SLNB) is not immediately indicated allows for a return to theatre if pathology then identifies invasive disease. SLNB is associated with paraesthesia, pain, seroma formation and lymphoedema risk. Hence, our study aims to assess the use of SPIO to avoid upfront SLNB in breast surgery for ductal carcinoma in situ (DCIS) and prophylaxis. METHODS Retrospective single-centre study of consecutive patients who underwent injection of SPIO tracer at time of primary breast surgery to avoid upfront SLNB at Chris O'Brien Lifehouse, Sydney, NSW, Australia over a 10-month period. RESULTS SPIO was injected 38 times, with 34 at time of mastectomy and four cases at time of wide local excision. The indication for surgery was DCIS in 18 cases, risk reduction in 17 cases and other indications in three patients. Six cases (15.8%) required delayed SLNB (D-SLNB) due to the finding of invasive disease on post-operative histopathology. All patients who underwent D-SLNB had nodes successfully localized with SPIO. CONCLUSION In our cohort, 84.2% of cases were able to avoid upfront SLNB, and hence avoid the associated complications of SLNB. SPIO injection was successful in localizing the SLN in all cases at time of surgery for D-SLNB. This technique was safe with few associated complications.
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Affiliation(s)
- Rebecca Bei Jia Cui
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Susan Hawes
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Farhad Azimi
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Belinda Chan
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Susannah Graham
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Cindy Mak
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Jue Li Seah
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Sanjay Warrier
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
- Department of Surgery, The University of Sydney, Camperdown, New South Wales, Australia
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van Haaren ERM, Spiekerman van Weezelenburg MA, van Bastelaar J, Janssen A, van Nijnatten T, Bouwman LH, Vissers YLJ, Lobbes MBI. Impact of low dose superparamagnetic iron oxide tracer for sentinel node biopsy in breast conserving treatment on susceptibility artefacts on magnetic resonance imaging and contrast enhanced mammography. Surg Oncol 2024; 53:102045. [PMID: 38330805 DOI: 10.1016/j.suronc.2024.102045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/16/2024] [Accepted: 02/03/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Residual particles of superparamagnetic iron oxide (SPIO) tracer, used for sentinel node biopsy, cause susceptibility artefacts on breast Magnetic Resonance Imaging (MRI). We investigated the impact of these artefacts on the imaging quality of MRI and explored whether contrast-enhanced mammography (CEM) could be an alternative in the follow-up of breast cancer patients. MATERIALS AND METHODS Data on patients' characteristics, injection site, presence, size (mm) of artefacts on full-field digital mammography (FFDM)/CEM, MRI after 1 ml SPIO was recorded. Image quality scored by two breast radiologists using a 4-point Likert system: 0: no artefacts 1: good diagnostic quality 2: impaired but still readable 3: hampered clinical assessment. Continuous variables reported as means and standard deviations (SD), categorical variables as count and percentage. RESULTS On FFDM/CEM, performed 13 months postoperatively, no iron SPIO particles were detected, with a Likert score of 0. In all MRI (100%) images, executed at 16.6 months after SPIO injection, susceptibility artefacts at the injection sites i.e., retroareolair and lateral quadrant were observed with a mean size of 41.9 ± 9.8 mm (SD) by observer 1, and 44.8 ± 12.5 mm (SD) by observer 2, independent of the injection site. Both observers scored a Likert score of 2: locally impaired on all MRI images and sequences. CONCLUSIONS Even 1 ml SPIO tracer used for sentinel node procedure impairs the evaluation of breast MRI at the tracer injection site beyond one year of follow-up. No impairment was observed on FFDM/CEM, suggesting that CEM might be a reliable alternative to breast MRI if required.
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Affiliation(s)
| | | | - James van Bastelaar
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, the Netherlands.
| | - Alfred Janssen
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, the Netherlands.
| | - Thiemo van Nijnatten
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, the Netherlands; GROW School for Oncology and Reproduction, Maastricht University, the Netherlands.
| | - Lee H Bouwman
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, the Netherlands; Department of Clinical Engineering, Faculty of Science and Engineering, Maastricht University, Maastricht, the Netherlands.
| | - Yvonne L J Vissers
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, the Netherlands.
| | - Marc B I Lobbes
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, the Netherlands; Department of Medical Imaging, Zuyderland Medical Centre, Sittard-Geleen, the Netherlands; GROW School for Oncology and Reproduction, Maastricht University, the Netherlands.
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Meng YQ, Shi YN, Zhu YP, Liu YQ, Gu LW, Liu DD, Ma A, Xia F, Guo QY, Xu CC, Zhang JZ, Qiu C, Wang JG. Recent trends in preparation and biomedical applications of iron oxide nanoparticles. J Nanobiotechnology 2024; 22:24. [PMID: 38191388 PMCID: PMC10775472 DOI: 10.1186/s12951-023-02235-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/29/2023] [Indexed: 01/10/2024] Open
Abstract
The iron oxide nanoparticles (IONPs), possessing both magnetic behavior and semiconductor property, have been extensively used in multifunctional biomedical fields due to their biocompatible, biodegradable and low toxicity, such as anticancer, antibacterial, cell labelling activities. Nevertheless, there are few IONPs in clinical use at present. Some IONPs approved for clinical use have been withdrawn due to insufficient understanding of its biomedical applications. Therefore, a systematic summary of IONPs' preparation and biomedical applications is crucial for the next step of entering clinical practice from experimental stage. This review summarized the existing research in the past decade on the biological interaction of IONPs with animal/cells models, and their clinical applications in human. This review aims to provide cutting-edge knowledge involved with IONPs' biological effects in vivo and in vitro, and improve their smarter design and application in biomedical research and clinic trials.
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Affiliation(s)
- Yu Qing Meng
- State Key Laboratory for Quality Ensurance and Sustainable Use of Dao-di Herbs, Artemisinin Research Center, and Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Ya Nan Shi
- School of Pharmacy, Yantai University, No. 30, Qingquan Road, Laishan District, Yantai, Shandong, China
| | - Yong Ping Zhu
- State Key Laboratory for Quality Ensurance and Sustainable Use of Dao-di Herbs, Artemisinin Research Center, and Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Yan Qing Liu
- State Key Laboratory for Quality Ensurance and Sustainable Use of Dao-di Herbs, Artemisinin Research Center, and Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Li Wei Gu
- State Key Laboratory for Quality Ensurance and Sustainable Use of Dao-di Herbs, Artemisinin Research Center, and Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Dan Dan Liu
- State Key Laboratory for Quality Ensurance and Sustainable Use of Dao-di Herbs, Artemisinin Research Center, and Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Ang Ma
- State Key Laboratory for Quality Ensurance and Sustainable Use of Dao-di Herbs, Artemisinin Research Center, and Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Fei Xia
- State Key Laboratory for Quality Ensurance and Sustainable Use of Dao-di Herbs, Artemisinin Research Center, and Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Qiu Yan Guo
- State Key Laboratory for Quality Ensurance and Sustainable Use of Dao-di Herbs, Artemisinin Research Center, and Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Cheng Chao Xu
- State Key Laboratory for Quality Ensurance and Sustainable Use of Dao-di Herbs, Artemisinin Research Center, and Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Jun Zhe Zhang
- State Key Laboratory for Quality Ensurance and Sustainable Use of Dao-di Herbs, Artemisinin Research Center, and Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China.
| | - Chong Qiu
- State Key Laboratory for Quality Ensurance and Sustainable Use of Dao-di Herbs, Artemisinin Research Center, and Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China.
| | - Ji Gang Wang
- State Key Laboratory for Quality Ensurance and Sustainable Use of Dao-di Herbs, Artemisinin Research Center, and Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China.
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Abidi H, Bold RJ. Assessing the Sentimag system for guiding sentinel node biopsies in patients with breast cancer. Expert Rev Med Devices 2024; 21:1-9. [PMID: 37992402 DOI: 10.1080/17434440.2023.2284790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/14/2023] [Indexed: 11/24/2023]
Abstract
INTRODUCTION Sentinel lymph node biopsy for breast cancer is a method to localize and excise the first draining lymph node from an invasive cancer of the breast. The histopathologic evaluation of the sentinel lymph node is used for predicting recurrence and survival and thus, guiding oncologists for treatment-decision making to administer adjuvant therapies. The ability to identify the sentinel node depends on methods to map lymphatic drainage from the breast to the sentinel node and accurately discriminate that node from other non-sentinel lymph nodes of the axilla. AREAS COVERED This review covers the clinical demand for technologies to assist the surgeon in intraoperative lymphatic mapping to specifically identify the sentinel lymph node in patients with breast cancer. Performance characteristics are reviewed for superparamagnetic iron oxide tracers used in lymphatic mapping compared to other current available technologies for lymphatic mapping. EXPERT OPINION The Magtrace (superparamagnetic iron oxide tracer) Sentimag (handheld magnetic probe) system is an FDA-approved technology for intraoperative lymphatic mapping to facilitate sentinel lymph node biopsy in breast cancer with technologic performance characteristics that are equivalent to 99Technetium-sulfur colloid. Barriers to broader utilization primarily center around the need for nonmetallic devices to be used for the conduct of surgery, which would interfere with the paramagnetic method for tracer localization.
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Affiliation(s)
- Hira Abidi
- Division of Surgical Oncology, Department of Surgery, University of California, Davis, CA, USA
| | - Richard J Bold
- Division of Surgical Oncology, Department of Surgery, University of California, Davis, CA, USA
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Wärnberg F, Obondo C, Chin K. The Magnetic Technique-A Novel and Promising Method to Improve Axillary Staging Localisation from a Swedish Perspective. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1727. [PMID: 37893446 PMCID: PMC10608746 DOI: 10.3390/medicina59101727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/13/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023]
Abstract
The magnetic technique using superparamagnetic nanoparticles of iron oxide has been well established for sentinel lymph node detection. Its main advantage is in the context of logistics, with the possibility to inject several weeks before surgery and the possibility to give access to sentinel lymph node biopsy for women worldwide in places without nuclear medicine facilities. We have not yet seen the full potential of this technique, and new implications have been developed for breast tumour localisation with paramagnetic clips and axillary staging after neoadjuvant chemotherapy using paramagnetic clips inserted in lymph node metastases before chemotherapy. In this report, we have presented our experience of the magnetic technique starting in 2014, and we have highlighted our current and future research directions.
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Affiliation(s)
- Fredrik Wärnberg
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 41345 Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, 41345 Gothenburg, Sweden
| | | | - Kian Chin
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 41345 Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, 41345 Gothenburg, Sweden
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Rocco N, Velotti N, Pontillo M, Vitiello A, Berardi G, Accurso A, Masone S, Musella M. New techniques versus standard mapping for sentinel lymph node biopsy in breast cancer: a systematic review and meta-analysis. Updates Surg 2023; 75:1699-1710. [PMID: 37326934 PMCID: PMC10435404 DOI: 10.1007/s13304-023-01560-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/03/2023] [Indexed: 06/17/2023]
Abstract
New tracers for sentinel lymph node biopsy (SLNB), as indocyanine green (ICG), superparamagnetic iron oxide (SPIO) and micro bubbles, have been recently introduced in clinical practice showing promising but variable results. We reviewed the available evidence comparing these new techniques with the standard tracers to evaluate their safety. To identify all available studies, a systematic search was performed in all electronic databases. Data regarding sample size, mean number of SLN harvested for patient, number of metastatic SLN and SLN identification rate of all studies were extracted. No significant differences were found in terms of SLNs identification rates between SPIO, RI and BD but with a higher identification rate with the use of ICG. No significant differences were also found for the number of metastatic lymph nodes identified between SPIO, RI and BD and the mean number of SLNs identified between SPIO and ICG versus conventional tracers. A statistically significant differences in favor of ICG was reported for the comparison between ICG and conventional tracers for the number of metastatic lymph nodes identified. Our meta-analysis demonstrates that the use of both ICG and SPIO for the pre-operative mapping of sentinel lymph nodes in breast cancer treatment is adequately effective.
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Affiliation(s)
- Nicola Rocco
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
| | - Nunzio Velotti
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy.
| | - Martina Pontillo
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
| | - Antonio Vitiello
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
| | - Giovanna Berardi
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
| | - Antonello Accurso
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
| | - Stefania Masone
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - Mario Musella
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
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Karakatsanis A, Eriksson S, Pistiolis L, Olofsson Bagge R, Nagy G, Man V, Kwong A, Wärnberg F. Delayed Sentinel Lymph Node Dissection in Patients with a Preoperative Diagnosis of Ductal Cancer In Situ by Preoperative Injection with Superparamagnetic Iron Oxide (SPIO) Nanoparticles: The SentiNot Study. Ann Surg Oncol 2023; 30:4064-4072. [PMID: 36719570 PMCID: PMC10250503 DOI: 10.1245/s10434-022-13064-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/22/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Difficulty in preoperatively assessing the risk for occult invasion or surgery that precludes future accurate axillary mapping in patients with ductal cancer in situ (DCIS) account for overutilization of SLND. METHODS Prospective, multicenter, cohort study, including women with any DCIS planned for mastectomy or DCIS grade 2 and > 20 mm, any DCIS grade 3, any mass-forming DCIS and any planned surgery. Patients received an interstitial SPIO injection during breast surgery, but no upfront SLND was performed. If invasion was identified on final pathology, delayed SLND (d-SLND) was performed separately with the coadministration of isotope ± blue dye (BD). Study outcomes were proportion of upfront SLNDs that were avoided, detection rates during d-SLND, and impact on healthcare costs. RESULTS In total, 78.7% of study participants (N = 254, mean age 60 years, mean DCIS size 37.8 mm) avoided upfront SLND. On d-SLND (median 28 days, range 9-46), SPIO outperformed Tc99 with (98.2% vs. 63.6%, p < 0.001) or without BD (92.7% vs. 50.9%, p < 0.001) and had higher nodal detection rate (86.9% vs. 32.3%, p < 0.001) and with BD (93.9% vs. 41.4%, p < 0.001). Only 27.9% of all SLNs retrieved were concordant for Tc99 and SPIO. Type of breast procedure (WLE vs. oncoplastic BCT vs. mastectomy) affected these outcomes and accounted for the low performance of Tc99 (p < 0.001). d-SLND resulted in a 28.1% total cost containment for women with pure DCIS on final pathology (4190 vs. 5828 USD, p < 0.001). CONCLUSIONS Marking the SLN with SPIO may avoid overtreatment and allow for accurate d-SLND in patients with DCIS.
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Affiliation(s)
- Andreas Karakatsanis
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
- Department of Surgery, Uppsala University Hospital, Uppsala, Sweden.
| | - Staffan Eriksson
- Centre for Clinical Research, Uppsala University, Västerås, Sweden
- Department of Surgery, Västmanland County Hospital, Västerås, Sweden
| | - Lida Pistiolis
- Department of Surgery, Sahlgrenska Center for Cancer Research, Institute of Clinical Sciences, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Roger Olofsson Bagge
- Department of Surgery, Sahlgrenska Center for Cancer Research, Institute of Clinical Sciences, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Gyula Nagy
- Breast Unit, Department of Surgery, Linköping University Hospital, Linköping, Sweden
| | - Vivian Man
- Department of Surgery, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Ava Kwong
- Department of Surgery, University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Surgery, The University of Hong, Kong-Shen Zhen Hospital, Shenzhen, China
- Department of Surgery, Hong Kong Sanatorium and Hospital, Hong Kong, Hong Kong SAR, China
| | - Fredrik Wärnberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Department of Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgery, Sahlgrenska Center for Cancer Research, Institute of Clinical Sciences, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
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Gante I, Maldonado JP, Figueiredo Dias M. Marking Techniques for Targeted Axillary Dissection Among Patients With Node-Positive Breast Cancer Treated With Neoadjuvant Chemotherapy. Breast Cancer (Auckl) 2023; 17:11782234231176159. [PMID: 37255883 PMCID: PMC10226338 DOI: 10.1177/11782234231176159] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 04/28/2023] [Indexed: 06/01/2023] Open
Abstract
Invasive breast cancer with axillary lymph node (LN) invasion is a continuing problem worldwide. The morbidity associated with axillary LN dissection along with the high rate of nodal downstaging after neoadjuvant chemotherapy (NACT) made the standard treatment shift towards less invasive surgery. Sentinel lymph node biopsy (SLNB) after NACT is associated with high false-negative rates (13%-14%). To overcome this problem, it was concluded that the positive nodes should first be indicated with image-detectable markers and then removed together with SLNB: targeted axillary dissection (TAD). This review aims to describe and evaluate the different marking techniques for TAD in patients with node-positive breast cancer treated with NACT, namely: clip placement and guidewire localization; clip placement and 125I-labelled radioactive seed localization; clip placement and skin mark; clip placement and intraoperative ultrasound; tattooing with a sterile black carbon suspension; magnetic seeds; radar and infrared light technology localization. Targeted axillary dissection techniques have shown false-negative rates below 9% and identification rates above 95%. The most studied technique is guidewire localization, as it is also the oldest one. However, according to data gathered from this review, some newer techniques have shown to be very promising due to their statistical results and management factors.
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Affiliation(s)
- Inês Gante
- Department of Gynecology, Coimbra
Hospital and Universitary Centre, Coimbra, Portugal
- Gynecologic University Clinic, Faculty
of Medicine, University of Coimbra, Coimbra, Portugal
- Area of Environment, Genetics and
Oncobiology (CIMAGO), Coimbra Institute for Clinical and Biomedical Research (iCBR),
Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - João Pedro Maldonado
- Gynecologic University Clinic, Faculty
of Medicine, University of Coimbra, Coimbra, Portugal
| | - Margarida Figueiredo Dias
- Department of Gynecology, Coimbra
Hospital and Universitary Centre, Coimbra, Portugal
- Gynecologic University Clinic, Faculty
of Medicine, University of Coimbra, Coimbra, Portugal
- Area of Environment, Genetics and
Oncobiology (CIMAGO), Coimbra Institute for Clinical and Biomedical Research (iCBR),
Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Axillary sentinel lymph node identification using superparamagnetic iron oxide versus radioisotope in early stage breast cancer: The UK SentiMag trial (SMART study). Surgeon 2023; 21:128-134. [PMID: 35551871 DOI: 10.1016/j.surge.2022.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/29/2022] [Accepted: 04/10/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND & OBJECTIVES Sentinel lymph node biopsy (SLNB) is an accurate and reliable method for staging the axilla in early breast cancer. The gold standard technique for localizing the sentinel lymph node (SLN) is the use of radioisotope with or without blue dye. However, this technique has its limitations. Various alternatives have been explored to overcome the disadvantages of the standard SLNB technique and superparamagnetic iron oxide mapping agents have garnered significant attention. The SMART study aims to compare the magnetic technique using the superparamagnetic iron oxide particles (SPIO, Sienna+®) to the radioisotope technique (Tc99) +/- blue dye, for SLN identification in patients with early breast cancer. METHODS A prospective, multicenter study was done that recruited 109 clinically node-negative early-stage breast cancer patients from five centres in the United Kingdom (UK). The patients received radioisotope ± blue dye injections, followed by intraoperative injection of magnetic tracer prior to SLNB. The sentinel node identification rate was compared between the magnetic and standard techniques to evaluate detection rate (per patient and per node), non-inferiority and concordance. RESULTS Data was analysed for 107 patients. The per patient detection rate was 98.13% (105/107) when using the magnetic tracer and 92.26% (103/107) when using the standard technique. The nodal detection rate was 93.07% (188/202 nodes) when using the magnetic tracer and 96.53% (195/202) when using the standard technique. Of the 31 patients with positive sentinel lymph nodes (SLNs), all 31 (100%) were detected by both techniques. CONCLUSION Our study demonstrates that the magnetic technique is a feasible method for SLNB, with an identification rate that is not inferior to the standard technique. The magnetic technique offers a suitable alternative to the standard technique thereby avoiding the need for the complexities of nuclear medicine, the hazards of radiation and the anaphylaxis risk of blue dye.
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10
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Yan X, Li S, Yan H, Yu C, Liu F. IONPs-Based Medical Imaging in Cancer Care: Moving Beyond Traditional Diagnosis and Therapeutic Assessment. Int J Nanomedicine 2023; 18:1741-1763. [PMID: 37034271 PMCID: PMC10075272 DOI: 10.2147/ijn.s399047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 03/14/2023] [Indexed: 04/03/2023] Open
Abstract
Cancer-related burden of morbidity and mortality is rapidly rising worldwide. Medical imaging plays an important role in every phase of cancer management, including diagnosis, staging, treatment planning and evaluation. Iron oxide nanoparticles (IONPs) could serve as contrast agents or labeling agents to enhance the identification and visualization of pathological tissues as well as target cells. Multimodal or multifunctional imaging can be easily acquired by modifying IONPs with other imaging agents or functional groups, allowing the accessibility of combined imaging techniques and providing more comprehensive information for cancer care. To date, IONPs-enhanced medical imaging has gained intensive application in early diagnosis, monitoring treatment as well as guiding radio-frequency ablation, sentinel lymph node dissection, radiotherapy and hyperthermia therapy. Besides, IONPs mediated imaging is also capable of promoting the development of anti-cancer nanomedicines through identifying patients potentially sensitive to nanotherapeutics. Based on versatile imaging modes and application fields, this review highlights and summarizes recent research advances of IONPs-based medical imaging in cancer management. Besides, currently existing challenges are also discussed to provide perspectives and advices for the future development of IONPs-based imaging in cancer management.
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Affiliation(s)
- Xiaolin Yan
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, Shandong Province, People’s Republic of China
| | - Shanshan Li
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, Shandong Province, People’s Republic of China
| | - Haiyin Yan
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, Shandong Province, People’s Republic of China
| | - Chungang Yu
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, Shandong Province, People’s Republic of China
| | - Fengxi Liu
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, Shandong Province, People’s Republic of China
- Correspondence: Fengxi Liu, Tel +86 0531-89269594, Email
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11
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Spiekerman van Weezelenburg MA, van Haaren ERM, Aldenhoven L, Frotscher CNA, Körver-Steeman R, van Bastelaar J, Bouwman LH, Vissers YLJ, Janssen A. An adapted protocol for magnetic localisation of nonpalpable breast cancer lesions and sentinel lymph nodes using a magnetic seed and superparamagnetic iron oxide tracer. J Surg Oncol 2023; 127:776-781. [PMID: 36598179 DOI: 10.1002/jso.27197] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/22/2022] [Accepted: 12/27/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Localisation techniques for nonpalpable breast cancer lesions and sentinel lymph node biopsy (SLNB) are associated with several drawbacks. A complete magnetic technique using magnetic seeds and superparamagnetic iron oxide tracer could be an interesting alternative. This study describes a clear protocol and the results of a combined magnetic approach. METHODS From August 2021 to February 2022 40 patients undergoing breast conserving surgery with SLNB were eligible for inclusion. Localisation was performed under ultrasound or stereotactic guidance, 1 week before surgery. Subsequently, 1 ml of tracer was injected at least 4 cm away from the tumour. Technetium-99m (99m Tc) was injected 1 day before surgery as control procedure. Outcomes were SLNB time, a number of nodes detected with magnetic tracer including comparison with 99m Tc, a success rate of malignant lesion detection and pathological margin assessment. RESULTS In total, 40 procedures were performed on 39 patients. A median of one node was retrieved. Sentinel nodes were retrieved using MagTrace® with a 92.5% detection rate compared to 99m Tc. Wide local excision under magnetic guidance was successful in 35 cases. CONCLUSIONS This paper describes a combined magnetic approach for breast-conserving surgery and SLNB. An adapted protocol is described and could be used for implementation.
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Affiliation(s)
| | | | - Loeki Aldenhoven
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | | | | | - James van Bastelaar
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Lee H Bouwman
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands.,Department of Clinical Engineering, Faculty of Science and Engineering, Maastricht University, Maastricht, The Netherlands
| | - Yvonne L J Vissers
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Alfred Janssen
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
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12
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Man V, Suen D, Kwong A. Use of Superparamagnetic Iron Oxide (SPIO) Versus Conventional Technique in Sentinel Lymph Node Detection for Breast Cancer: A Randomised Controlled Trial. Ann Surg Oncol 2023; 30:3237-3244. [PMID: 36849573 DOI: 10.1245/s10434-023-13252-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 02/01/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND The objective of this study is to compare the efficacy of the superparamagnetic iron oxide (SPIO)-guided and standard techniques for sentinel lymph node (SLN) detection in early breast cancer. Multiple inferiority trials have concluded the non-inferiority of SPIO to the conventional radioisotope technique, with or without blue dye, in detecting SLNs. PATIENTS AND METHODS From July 2018 to August 2022, patients clinically diagnosed with node-negative invasive breast cancer were randomised into the study group (SPIO) and control group (radioisotope and blue dye). Patient data and disease characteristics were prospectively collected. SLN detection rates were compared between the two groups. RESULTS A total of 282 patients undergoing 288 sentinel lymph node biopsy (SLNB) procedures were recruited, and 144 SLNB procedures were randomised into each group. The baseline patient and disease characteristics were comparable. SLN localisation failed in one patient in each group; the success rate of SLNB was 99.3%. The SPIO group demonstrated a higher mean number of SLNs harvested (3.3 versus 2.8, p = 0.039) and longer mean procedure duration (33.1 min versus 22.3 min, p = 0.01) than the control group did. In the study group, the concordance rates per patient and node were 99.3% and 94.6%, respectively. Sixty-seven positive SLNs were detected in 37 patients. The concordance rates per malignant SLNB procedure and positive SLN were 97.3% and 96.8%, respectively. CONCLUSION Single-tracer SPIO-guided SLNB was non-inferior to the dual technique (radioisotope and blue dye) and could safely replace the gold standard for SLN mapping in early breast cancer.
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Affiliation(s)
- Vivian Man
- Division of Breast Surgery, Department of Surgery, Faculty of Medicine, Queen Mary Hospital, The University of Hong Kong Li Ka Shing, Hong Kong, Hong Kong SAR, China
| | - Dacita Suen
- Division of Breast Surgery, Department of Surgery, Faculty of Medicine, Queen Mary Hospital, The University of Hong Kong Li Ka Shing, Hong Kong, Hong Kong SAR, China
| | - Ava Kwong
- Division of Breast Surgery, Department of Surgery, Faculty of Medicine, Queen Mary Hospital, The University of Hong Kong Li Ka Shing, Hong Kong, Hong Kong SAR, China.
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13
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van Haaren ERM, Martens MH, Spiekerman van Weezelenburg MA, van Roozendaal LM, Frotscher CNA, Körver-Steeman RRM, Lobbes MBI, van Bastelaar J, Vissers YLJ, Janssen A. Combined use of magnetic seed and tracer in breast conserving surgery with sentinel lymph node biopsy for non-palpable breast lesions: A pilot study describing pitfalls and solutions. Surg Oncol 2023; 46:101905. [PMID: 36706578 DOI: 10.1016/j.suronc.2023.101905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 12/28/2022] [Accepted: 01/22/2023] [Indexed: 01/24/2023]
Abstract
BACKGROUNDS Traditionally, breast conserving surgery for non-palpable breast cancer is guided by wire or radioactive seed and radioactive tracer for sentinel lymph node biopsy (SLNB). Alternatively, a stain-less magnetic seed and superparamagnetic iron oxide tracer (SPIO) can be combined as a radioactive-free technique. The aim of this study was to define the pitfalls we encountered during implementation of this combined technique and provide solutions resulting in an instruction manual for a radio-active free procedure. METHODS Between January and March 2021, seventeen consecutive patients with cN0 non-palpable breast cancer were included. The magnetic seed was placed to localize the lesion and SPIO was used to identify the sentinel lymph node (SLN). A lymphoscintigraphy with Technetium-99m nano colloid was performed concomitantly in all patients as a control procedure for SPIO. Surgical outcomes are reported, including problems with placing and retrieval of the seed and SPIO and corresponding solutions. RESULTS Surgical excision was successful with invasive tumor-free margins in all patients. SLN detection was successful in 82% patients when compared to Technetium-99m. The most challenging issue was an overlapping magnetic signal of the seed and SPIO. Solutions are provided in detail. CONCLUSIONS Combined use of magnetic seed and SPIO for wide local excision and SLNB patients with non-palpable breast lesions appeared challenging due to overlapping magnetic signals. After multiple adaptations, the protocol proved to be feasible with an added advantage of eliminating the use of radioisotopes. We described the pitfalls and solutions resulting in an instruction manual for a totally radioactive-free procedure.
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Affiliation(s)
| | - Milou H Martens
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, the Netherlands
| | | | | | - Caroline N A Frotscher
- Department of Radiology and Nuclear Medicine Zuyderland Medical Centre, Sittard-Geleen, the Netherlands
| | - Rachel R M Körver-Steeman
- Department of Radiology and Nuclear Medicine Zuyderland Medical Centre, Sittard-Geleen, the Netherlands
| | - Marc B I Lobbes
- Department of Radiology and Nuclear Medicine Zuyderland Medical Centre, Sittard-Geleen, the Netherlands; Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, the Netherlands; GROW School for Oncology and Reproduction, Maastricht University, the Netherlands
| | - James van Bastelaar
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, the Netherlands
| | - Yvonne L J Vissers
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, the Netherlands
| | - Alfred Janssen
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, the Netherlands
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14
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Carpenter M, Le J. New Technology for the Breast Surgeon. Surg Clin North Am 2023; 103:107-119. [PMID: 36410344 DOI: 10.1016/j.suc.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
New innovations aid the breast surgeon with better ability to localize tumors using wireless techniques, reduce re-excision rates by intraoperative margin evaluation and perform aesthetically; pleasing, and safe surgeries. In addition to improving oncological outcomes, we can continue to improve the quality of life for our patients through evolving surgeries including nerve-sparing mastectomies, robotic mastectomies, and lymphovascular surgeries (LYMPHA). Our article reviews current and evolving techniques and technology that all breast surgeons should add to his or her armamentarium to provide optimal surgical care.
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Affiliation(s)
- Michele Carpenter
- Center for Cancer Prevention and Treatment, St. Joseph Hospital, 1010 W. LaVeta suite 475, Orange, CA 92868, USA; Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| | - Julie Le
- UC San Diego Comprehensive Breast Health, 9400 Campus Point Drive, La Jolla, CA 92037, USA
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15
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Donigiewicz UJ, Banks J, Saeed M, Green M, Knight H. Is the use of blue dye really necessary in axillary sentinel lymph node biopsy in staging of breast cancer? Breast Dis 2023; 42:23-26. [PMID: 36872761 DOI: 10.3233/bd-220036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Sentinel lymph node biopsy (SLNB) is the standard of care for staging the clinically node-negative axilla in early breast cancer. Evidence guiding current practice describes dual localization technique using Patent blue dye and radioisotope (99mTc). Adverse effects of blue dye include 1:1000 risk of anaphylaxis, skin staining and loss of plane visibility, which may increase operative time and reduce resectional accuracy. The risk to a patient posed by anaphylaxis may be greater when operating in a unit without on-site ITU support - a situation more common with recent restructuring during the COVID-19 pandemic. Aim is to quantify the benefit of blue dye above radioisotope alone in identifying nodal disease. This is a retrospective analysis of prospectively collected sentinel node data including all consecutive sentinel node biopsies in a single center during the period 2016-2019.In terms of results, 760 sentinel nodes were taken in 435 patients. 59 nodes (7.8%) were detected by blue dye alone; 120 (15.8%) 'hot' only, 581 (76.5%) hot and blue. 4 of the blue only nodes contained macrometastases but 3 of these patients had further hot nodes excised that also contained macrometastases. 1 out of 435 patients (0.2%) had macro metastatic disease identified as a result of blue dye alone which would have been missed had it not been used. In conclusion, the use of blue dye carries risk and offers little benefit in terms of staging in SLNB and its use may be unnecessary in the hands of the skilled surgeon. This study supports the omission of blue dye, which may be advisable if operating in units without ITU support. If larger studies support these figures, it may become as outdated.
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Affiliation(s)
- Urszula J Donigiewicz
- Department of Breast Surgery, Torbay and South Devon NHS Foundation Trust, Lowes Bridge, Torquay, UK
| | - Jenny Banks
- Department of Breast Surgery, Torbay and South Devon NHS Foundation Trust, Lowes Bridge, Torquay, UK
| | - Maira Saeed
- Department of Breast Surgery, Torbay and South Devon NHS Foundation Trust, Lowes Bridge, Torquay, UK
| | - Michael Green
- Department of Breast Surgery, Torbay and South Devon NHS Foundation Trust, Lowes Bridge, Torquay, UK
| | - Hannah Knight
- Department of Breast Surgery, Torbay and South Devon NHS Foundation Trust, Lowes Bridge, Torquay, UK
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16
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Pantiora E, Tasoulis MK, Valachis A, Eriksson S, Kühn T, Karakatsanis A, Rubio IT. Evolution and refinement of magnetically guided sentinel lymph node detection in breast cancer: meta-analysis. Br J Surg 2022; 110:410-419. [PMID: 36560842 PMCID: PMC10364535 DOI: 10.1093/bjs/znac426] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/29/2022] [Accepted: 11/08/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Superparamagnetic iron oxide nanoparticles (SPIO) have been used as a tracer for sentinel lymph node (SLN) localization in breast cancer, demonstrating comparable performance to the combination of radioisotope (RI) and blue dye (BD). METHODS A systematic literature search and meta-analysis with subgroup and meta-regression analysis were undertaken to update the available evidence, assess technique evolution, and define knowledge gaps. Recommendations were made using the GRADE approach. RESULTS In 20 comparative studies, the detection rate was 97.5 per cent for SPIO and 96.5 per cent for RI ± BD (risk ratio 1.006, 95 per cent c.i. 0.992 to 1.019; P = 0.376, high-certainty evidence). Neoadjuvant therapy, injection site, injection volume or nodal metastasis burden did not affect the detection rate, but injection over 24 h before surgery increased the detection rate on meta-regression. Concordance was 99.0 per cent and reverse concordance 97.1 per cent (rate difference 0.003, 95 per cent c.i. -0.009 to 0.015; P = 0.656, high-certainty evidence). Use of SPIO led to retrieval of slightly more SLNs (pooled mean 1.96 versus 1.89) with a higher nodal detection rate (94.1 versus 83.5 per cent; RR 1.098, 1.058 to 1.140; P < 0.001; low-certainty evidence). In meta-regression, injection over 24 h before surgery increased the SPIO nodal yield over that of RI ± BD. The skin-staining rate was 30.8 per cent (very low-certainty evidence), and possibly prevented with use of smaller doses and peritumoral injection. CONCLUSION The performance of SPIO is comparable to that of RI ± BD. Preoperative injection increases the detection rate and nodal yield, without affecting concordance. Whether skin staining and MRI artefacts are reduced by lower dose and peritumoral injection needs to be investigated.
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Affiliation(s)
- Eirini Pantiora
- Department for Surgical Sciences, Uppsala University, Uppsala, Sweden
- Section for Breast Surgery, Department of Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Marios Konstantinos Tasoulis
- Breast Surgery Unit, Royal Marsden NHS Foundation Trust, London, UK
- Division of Breast Cancer Research, Institute of Cancer Research, London, UK
| | - Antonios Valachis
- Department of Oncology, Örebro University Hospital, School of Medicine, Örebro University, Örebro, Sweden
| | - Staffan Eriksson
- Section for Breast Surgery, Department of Surgery, Västmanland Hospital, Västerås, Sweden
- Centre for Clinical Research, Uppsala University, Västerås, Sweden
| | - Thorsten Kühn
- Department of Gynaecology and Obstetrics, Interdisciplinary Breast Centre, Hospital Esslingen, Esslingen, Germany
| | - Andreas Karakatsanis
- Department for Surgical Sciences, Uppsala University, Uppsala, Sweden
- Section for Breast Surgery, Department of Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Isabel T Rubio
- Breast Surgical Unit, Clinica Universidad de Navarra, Cancer Centre University of Navarra, Madrid, Spain
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17
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Aldenhoven L, Frotscher C, Körver-Steeman R, Martens MH, Kuburic D, Janssen A, Beets GL, van Bastelaar J. Sentinel lymph node mapping with superparamagnetic iron oxide for melanoma: a pilot study in healthy participants to establish an optimal MRI workflow protocol. BMC Cancer 2022; 22:1062. [PMID: 36241982 PMCID: PMC9563818 DOI: 10.1186/s12885-022-10146-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Current pre-operative Sentinel Lymph Node (SLN) mapping using dual tracing is associated with drawbacks (radiation exposure, logistic challenges). Superparamagnetic iron oxide (SPIO) is a non-inferior alternative for SLN mapping in breast cancer patients. Limited research has been performed on SPIO use and pre-operative MRI in melanoma patients to identify SLNs. METHODS: Healthy participants underwent MRI-scanning pre- and post SPIO-injection during 20 min. Workflow protocols varied in dosage, massage duration, route of administration and injection sites. The first lymph node showing a susceptibility artefact caused by SPIO accumulation was considered as SLN. RESULTS Artefacts were identified in 5/6 participants. Two participants received a 0.5 ml subcutaneous injection and 30-s massage, of which one showed an artefact after one hour. Four participants received a 1.0 ml intracutaneous injection and two-minute massage, leading to artefacts in all participants. All SLNs were observed within five minutes, except after lower limb injection (30 min). CONCLUSION SPIO and pre-operative MRI-scanning seems to be a promising alternative for SLN visualization in melanoma patients. An intracutaneous injection of 1.0 ml SPIO tracer, followed by a two-minute massage seems to be the most effective technique, simplifying the pre-operative pathway. Result will be used in a larger prospective study with melanoma patients. TRIAL REGISTRATION ClinicalTrials.gov (NCT05054062) - September 9, 2021.
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Affiliation(s)
- Loeki Aldenhoven
- Department of Surgery, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, 6262 BG, Sittard-Geleen, the Netherlands. .,Present address: Department of Surgery, Zuyderland Medical Center, Postbus 5500 , 6130 , MB, Sittard, the Netherlands. .,GROW - School for Oncology and Developmental Biology, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, the Netherlands.
| | - Caroline Frotscher
- Department of Radiology, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, 6262 BG, Sittard-Geleen, the Netherlands
| | - Rachelle Körver-Steeman
- Department of Radiology, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, 6262 BG, Sittard-Geleen, the Netherlands
| | - Milou H Martens
- Department of Surgery, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, 6262 BG, Sittard-Geleen, the Netherlands
| | - Damir Kuburic
- Department of Radiology, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, 6262 BG, Sittard-Geleen, the Netherlands
| | - Alfred Janssen
- Department of Surgery, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, 6262 BG, Sittard-Geleen, the Netherlands
| | - Geerard L Beets
- Present address: Department of Surgery, Zuyderland Medical Center, Postbus 5500 , 6130 , MB, Sittard, the Netherlands.,Department of Surgery, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - James van Bastelaar
- Department of Surgery, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, 6262 BG, Sittard-Geleen, the Netherlands
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18
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The Application of Magnetic Nanoparticles for Sentinel Lymph Node Detection in Clinically Node-Negative Breast Cancer Patients: A Systemic Review and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14205034. [PMID: 36291818 PMCID: PMC9599783 DOI: 10.3390/cancers14205034] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/03/2022] [Accepted: 10/04/2022] [Indexed: 11/30/2022] Open
Abstract
Superparamagnetic iron oxide (SPIO), an alternative mapping agent, can be used to identify sentinel lymph nodes in patients with clinically node-negative breast cancer. However, its performance in comparison with the standard method, using a radioisotope (technetium-99 m, Tc) alone or in combination with blue dye, remains controversial. Hence, a systematic review and meta-analysis were conducted to evaluate the diagnostic accuracy of SPIO and its clinical impact in the management of breast cancer. The PubMed, Embase, and Cochrane databases were comprehensively searched from inception to 1 May 2022. Cohort studies regarding the comparison of SPIO with standard methods for sentinel lymph node identification were included. A total of 19 prospective cohort studies, which collectively included 2298 clinically node-negative breast cancer patients undergoing sentinel lymph node identification through both the standard method and SPIO, were identified. The detection rate for sentinel lymph nodes (RR, 1.06; 95% CI, 1.05−1.08; p < 0.001) was considerably higher in the SPIO cohorts than in the standard method cohorts, although this difference was not significant in detected patients, patients with positive sentinel lymph nodes, or positive sentinel lymph nodes. Compared with the standard method, the SPIO method could be considered as an alternative standard of care for sentinel lymph node detection in patients with clinically node-negative breast cancer.
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19
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Krishnan G, Cousins A, Pham N, Milanova V, Nelson M, Krishnan S, Shetty A, van den Berg N, Rosenthal E, Krishnan S, Wormald PJ, Foreman A, Thierry B. Preclinical evaluation of a mannose-labeled magnetic tracer for enhanced sentinel lymph node retention in the head and neck. NANOMEDICINE : NANOTECHNOLOGY, BIOLOGY, AND MEDICINE 2022; 42:102546. [PMID: 35278683 DOI: 10.1016/j.nano.2022.102546] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/25/2022] [Accepted: 03/01/2022] [Indexed: 05/26/2023]
Abstract
Sentinel lymph node biopsy in cancers of the head and neck offers demonstrated clinical and diagnostic value, but adoption is limited by concerns about the detrimental consequence to survival of false negative results in a highly curable setting. The aim of this study was to demonstrate potential to overcome this via application of a novel mannose-labeled magnetic iron oxide tracer. In a large animal model, preoperative imaging and intraoperative magnetometer detection were used to identify magnetic lymph nodes. Iron quantification mapped the distribution of tracer within lymphatic levels. Over a 4-week test period, uptake of magnetic tracer in lymph nodes increased in a linear-like fashion, with a substantial percentage of accumulated iron (83%) being retained in the sentinel node. This result indicates a high affinity of mannose-labeled particles to the sentinel node, while providing a means for the magnetometer probe to indicate node status based on intraoperative signal.
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Affiliation(s)
- Giri Krishnan
- The Department of Otolaryngology, Head and Neck Surgery, The University of Adelaide, Adelaide, SA, Australia
| | - Aidan Cousins
- Future Industries Institute, University of South Australia, Mawson Lakes, SA, Australia.
| | - Nguyen Pham
- School of Chemistry, University of New South Wales, Sydney, NSW, Australia
| | - Valentina Milanova
- Future Industries Institute, University of South Australia, Mawson Lakes, SA, Australia
| | | | - Shridhar Krishnan
- The Department of Otolaryngology, Head and Neck Surgery, The University of Adelaide, Adelaide, SA, Australia
| | - Anil Shetty
- Ferronova Pty Ltd., Mawson Lakes, SA, Australia
| | - Nynke van den Berg
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - Eben Rosenthal
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - Suren Krishnan
- The Department of Otolaryngology, Head and Neck Surgery, The University of Adelaide, Adelaide, SA, Australia
| | - Peter-John Wormald
- The Department of Otolaryngology, Head and Neck Surgery, The University of Adelaide, Adelaide, SA, Australia
| | - Andrew Foreman
- The Department of Otolaryngology, Head and Neck Surgery, The University of Adelaide, Adelaide, SA, Australia
| | - Benjamin Thierry
- Future Industries Institute, University of South Australia, Mawson Lakes, SA, Australia.
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20
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Li P, Sun D. Advanced diagnostic imaging of sentinel lymph node in early stage breast cancer. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:415-421. [PMID: 35092313 PMCID: PMC9303781 DOI: 10.1002/jcu.23151] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 01/07/2022] [Accepted: 01/08/2022] [Indexed: 06/14/2023]
Abstract
Sentinel lymph node biopsy has been regarded as the standard procedure for early staging breast cancer. One of the key steps is to locate the sentinel lymph node (SLN). The recommended method is the joint use of blue dye and radioisotope. However, due to radionuclide radiation and high cost, it is urgent to develop more convenient and sensitive imaging methods to accurately locate SLN. This article discusses the advancement of accurately locating SLN by isotope tracer imaging, magnetic tracer method, computed tomographic lymphography, and trans-lymphatic contrast-enhanced ultrasound, as well as proposing new propose for clinical diagnosis.
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Affiliation(s)
- Ping Li
- Weifang Medical UniversityWeifangShandongChina
- Department of UltrasonographyPeking University Shenzhen HospitalShenzhenGuangdongChina
| | - Desheng Sun
- Department of UltrasonographyPeking University Shenzhen HospitalShenzhenGuangdongChina
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21
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A Propensity Score Matched Analysis of Superparamagnetic Iron Oxide versus Radioisotope Sentinel Node Biopsy in Breast Cancer Patients after Neoadjuvant Chemotherapy. Cancers (Basel) 2022. [PMID: 35158944 DOI: 10.3390/cancers14030676.pmid:35158944;pmcid:pmc8833727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
The standard method for nodal staging in breast cancer (BC) patients after neoadjuvant chemotherapy (NAC) is sentinel lymph node biopsy (SLNB) with a radioisotope (RI) injection. However, SLNB after NAC results in high false-negative rates (FNR), and the RI method is restricted by nuclear medicine unit dependency. These limitations resulted in the development of the superparamagnetic iron oxide (SPIO) method, reducing FNR and presenting a comparable detection rate. This bi-institutional cohort comparison study aimed to assess the efficacy of SPIO and radioisotope SNLB in BC patients after NAC using Propensity Score Matching (PSM) analysis. The study group comprised 508 patients who underwent SLNB after NAC for ycT1-4N0M0 BC between 2013 and 2021 in two high volume centers. Data were retrieved from prospectively conducted databases. In the SPIO group, the median of retrieved sentinel lymph nodes (SLNs) was significantly higher than in the RI group (3 vs. 2; p < 0.0001). The SPIO method was associated with a significantly higher chance of retrieving at least three lymph nodes when compared to the RI method (71% vs. 11.3%; p < 0.0001). None of the analyzed demographic and clinical variables had a statistically significant influence on the efficacy of SLNs retrieval in the RI group, while in the SPIO group, patients with ≥three harvested SLNs had lower weight and decreased BMI. Based on this PSM analysis, SPIO-guided SLNB allowed the efficient retrieval and detection of SLNs in BC patients after NAC compared to RI.
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22
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Nieuwenhuis ER, Kolenaar B, Hof JJ, van Baarlen J, van Bemmel AJM, Christenhusz A, Scheenen TWJ, ten Haken B, de Bree R, Alic L. A Comprehensive Grading System for a Magnetic Sentinel Lymph Node Biopsy Procedure in Head and Neck Cancer Patients. Cancers (Basel) 2022; 14:cancers14030678. [PMID: 35158946 PMCID: PMC8833366 DOI: 10.3390/cancers14030678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/22/2022] [Accepted: 01/26/2022] [Indexed: 02/05/2023] Open
Abstract
Simple Summary With 30% of clinically negative early-stage oral cancer patients harboring occult metastasis, an accurate staging of metastatic lymph nodes (LN) is of utmost importance for treatment planning. A magnetic sentinel lymph node biopsy (SLNB) procedure is offered as an alternative to conventional SLNB in oral oncology, however, a grading system is missing. A proper grading system is preferred to connect the different components of the magnetic SLNB: preoperative imaging, intraoperative detection, and histopathological examination of sentinel lymph nodes (SLNs). This study aims to provide a first grading system based on the distribution of a magnetic tracer, by means of preoperative magnetic resonance imaging (MRI), intraoperative estimation of iron content, and histopathological assessment of resected nodes. Pre- and post-operative MRI and harvested SLNs of eight tongue cancer patients with successful magnetic SLNB procedure were used for analyses. Abstract A magnetic sentinel lymph node biopsy ((SLN)B) procedure has recently been shown feasible in oral cancer patients. However, a grading system is absent for proper identification and classification, and thus for clinical reporting. Based on data from eight complete magnetic SLNB procedures, we propose a provisional grading system. This grading system includes: (1) a qualitative five-point grading scale for MRI evaluation to describe iron uptake by LNs; (2) an ex vivo count of resected SLN with a magnetic probe to quantify iron amount; and (3) a qualitative five-point grading scale for histopathologic examination of excised magnetic SLNs. Most SLNs with iron uptake were identified and detected in level II. In this level, most variance in grading was seen for MRI and histopathology; MRI and medullar sinus were especially highly graded, and cortical sinus was mainly low graded. On average 82 ± 58 µg iron accumulated in harvested SLNs, and there were no significant differences in injected tracer dose (22.4 mg or 11.2 mg iron). In conclusion, a first step was taken in defining a comprehensive grading system to gain more insight into the lymphatic draining system during a magnetic SLNB procedure.
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Affiliation(s)
- Eliane R. Nieuwenhuis
- Magnetic Detection and Imaging Group, Technical Medical Centre, University of Twente, 7522 NB Enschede, The Netherlands; (E.R.N.); (A.C.); (B.t.H.)
- Department of Maxillofacial Surgery—Head and Neck Surgical Oncology, Medisch Spectrum Twente, 7512 KZ Enschede, The Netherlands;
| | - Barry Kolenaar
- Department of Maxillofacial Surgery—Head and Neck Surgical Oncology, Medisch Spectrum Twente, 7512 KZ Enschede, The Netherlands;
| | - Jurrit J. Hof
- Department of Radiology, Medisch Spectrum Twente, 7512 KZ Enschede, The Netherlands;
| | - Joop van Baarlen
- Laboratorium Pathologie Oost Nederland, 7555 BB Hengelo, The Netherlands;
| | - Alexander J. M. van Bemmel
- Department of Otorhinolaryngology—Head and Neck Surgical Oncology, Medisch Spectrum Twente, 7512 KZ Enschede, The Netherlands;
| | - Anke Christenhusz
- Magnetic Detection and Imaging Group, Technical Medical Centre, University of Twente, 7522 NB Enschede, The Netherlands; (E.R.N.); (A.C.); (B.t.H.)
- Department of Surgery, Medisch Spectrum Twente, 7512 KZ Enschede, The Netherlands
| | - Tom W. J. Scheenen
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands;
| | - Bernard ten Haken
- Magnetic Detection and Imaging Group, Technical Medical Centre, University of Twente, 7522 NB Enschede, The Netherlands; (E.R.N.); (A.C.); (B.t.H.)
| | - Remco de Bree
- Department of Head and Neck Surgical Oncology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands;
| | - Lejla Alic
- Magnetic Detection and Imaging Group, Technical Medical Centre, University of Twente, 7522 NB Enschede, The Netherlands; (E.R.N.); (A.C.); (B.t.H.)
- Correspondence: ; Tel.: +31-534-898-731
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A Propensity Score Matched Analysis of Superparamagnetic Iron Oxide versus Radioisotope Sentinel Node Biopsy in Breast Cancer Patients after Neoadjuvant Chemotherapy. Cancers (Basel) 2022; 14:cancers14030676. [PMID: 35158944 PMCID: PMC8833727 DOI: 10.3390/cancers14030676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 12/13/2022] Open
Abstract
Simple Summary This Propensity Score Matched Analysis aimed to assess the efficacy of superparamagnetic iron oxide (SPIO) and radioisotope sentinel lymph node biopsy (SNLB) in breast cancer (BC) patients after neoadjuvant chemotherapy (NAC). One hundred and twenty-four patients were eligible for final analysis. In the SPIO group, the median of retrieved sentinel lymph nodes (SLNs) was significantly higher than in the RI group. The SPIO method was associated with a significantly higher chance of retrieving at least three SLNs when compared to the RI method. SPIO-guided SLNB allows efficient retrieval and detection of SLNs in BC patients after NAC when compared to RI. Abstract The standard method for nodal staging in breast cancer (BC) patients after neoadjuvant chemotherapy (NAC) is sentinel lymph node biopsy (SLNB) with a radioisotope (RI) injection. However, SLNB after NAC results in high false-negative rates (FNR), and the RI method is restricted by nuclear medicine unit dependency. These limitations resulted in the development of the superparamagnetic iron oxide (SPIO) method, reducing FNR and presenting a comparable detection rate. This bi-institutional cohort comparison study aimed to assess the efficacy of SPIO and radioisotope SNLB in BC patients after NAC using Propensity Score Matching (PSM) analysis. The study group comprised 508 patients who underwent SLNB after NAC for ycT1-4N0M0 BC between 2013 and 2021 in two high volume centers. Data were retrieved from prospectively conducted databases. In the SPIO group, the median of retrieved sentinel lymph nodes (SLNs) was significantly higher than in the RI group (3 vs. 2; p < 0.0001). The SPIO method was associated with a significantly higher chance of retrieving at least three lymph nodes when compared to the RI method (71% vs. 11.3%; p < 0.0001). None of the analyzed demographic and clinical variables had a statistically significant influence on the efficacy of SLNs retrieval in the RI group, while in the SPIO group, patients with ≥three harvested SLNs had lower weight and decreased BMI. Based on this PSM analysis, SPIO-guided SLNB allowed the efficient retrieval and detection of SLNs in BC patients after NAC compared to RI.
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Sugiyama S, Iwai T, Baba J, Oguri S, Izumi T, Kuwahata A, Sekino M, Kusakabe M, Mitsudo K. Sentinel lymph node biopsy with a handheld cordless magnetic probe following preoperative MR lymphography using superparamagnetic iron oxide for clinically N0 early oral cancer: A feasibility study. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2022; 123:521-526. [PMID: 35007780 DOI: 10.1016/j.jormas.2022.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/02/2022] [Accepted: 01/05/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Radioisotope (RI) tracers are generally used for preoperative mapping of sentinel lymph node (SLN) and intraoperative detection with a portable γ probe. However, the use of RI has several limitations. Therefore, a method without RI is required for the widespread application of SLN biopsy. The purpose of this study was to evaluate the feasibility of SLN biopsy with a handheld cordless magnetic probe following magnetic resonance lymphography (MRL) using superparamagnetic iron oxide (SPIO) and for clinically N0 early oral cancer. MATERIALS AND METHODS MRL using SPIO and SLNB with the handheld cordless magnetic probe were performed for 27 patients with clinically N0 early oral cancer. RESULTS In all 27 patients (100%), SLNs were detected by MRL, and the total and mean number of SLNs were 73 and 2.7, respectively. All SLNs identified by MRL were detectable using the magnetic probe in all patients. CONCLUSIONS SLNB with handheld cordless magnetic probe following preoperative SLN mapping by MRL using SPIO is feasible, without RI use, for neck management in cases of clinically N0 early oral cancer.
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Affiliation(s)
- Satomi Sugiyama
- Department of Oral and Maxillofacial Surgery/Orthodontics, Yokohama City University hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004, Japan
| | - Toshinori Iwai
- Department of Oral and Maxillofacial Surgery/Orthodontics, Yokohama City University hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004, Japan.
| | - Junichi Baba
- Department of Oral and Maxillofacial Surgery/Orthodontics, Yokohama City University hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004, Japan
| | - Senri Oguri
- Department of Oral and Maxillofacial Surgery/Orthodontics, Yokohama City University hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004, Japan
| | - Toshiharu Izumi
- Department of Radiology, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004, Japan
| | - Akihiro Kuwahata
- Department of Electrical Engineering, Tohoku University Graduate School of Engineering, Sendai, Miyagi 980-8579, Japan
| | - Masaki Sekino
- Department of Electrical Engineering and Information Systems, Graduate School of Engineering, The University of Tokyo, Tokyo 113-0032, Japan
| | - Moriaki Kusakabe
- Research Center for Food Safety, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo 113-0032, Japan; Department of Medical Device, Matrix Cell Research Institute Inc, Ushiku, Ibaraki 300-1232, Japan
| | - Kenji Mitsudo
- Department of Oral and Maxillofacial Surgery/Orthodontics, Yokohama City University hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004, Japan
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Mahdavi R, Yousefpour N, Abbasvandi F, Ataee H, Hoseinpour P, Akbari ME, Parniani M, Delshad B, Avatefi M, Nourinejad Z, Abdolhosseini S, Mehrvarz S, Hajighasemi F, Abdolahad M. Intraoperative pathologically-calibrated diagnosis of lymph nodes involved by breast cancer cells based on electrical impedance spectroscopy; a prospective diagnostic human model study. Int J Surg 2021; 96:106166. [PMID: 34768024 DOI: 10.1016/j.ijsu.2021.106166] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/19/2021] [Accepted: 11/03/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nodal status evaluation is a crucial step in determining prognostic factors and managing treatment strategies for breast cancer patients. Preoperative (CNB), intraoperative (SLNB), and even postoperative techniques (Formalin-Fixed Paraffin-Embedded sectioning, FFPE) have definite limitations of precision or sometimes are time-consuming for the result declaration. The primary purpose of this prospective study is to provide a precise complementary system for distinguishing lymph nodes (LNs) involved by cancerous cells in breast cancer patients intraoperatively. METHODS The proposed system, Electrical Lymph Scoring(ELS), is designed based on the dielectric properties of the under-test LNs. The system has a needle-shaped 2-electrode probe entered into SLNs or ALNs dissected from patients through standard surgical guidelines. Impedance magnitude in f = 1 kH (Z1kHz) and Impedance Phase Slope in frequency ranges of 100 kHz-500 kHz (IPS) were then extracted from the impedance spectroscopy data in a cohort study of 77 breast cancer patients(totally 282 dissected LNs) who had been undergone surgery before (n = 55) or after (n = 22) chemical therapies (non-neoadjuvant or neoadjuvant chemotherapy). A new admittance parameter(Yn') also proposed for LN detection in neoadjuvant chemotherapy patients. RESULTS Considering the permanent pathology result as the gold standard checked by two independent expert pathologists, a significant correlation was observed between the presence of cancerous cells in LNs and individual ranges of the ELS electrical responses. Compared with normal LNs containing fatty ambient and immune cells, LNs involved by cancerous clusters would reduce the Z1kHz and increase the IPS. These changes correlate with fat metabolism by cancer cells due to their Fatty Acid Oxidation (FAO) in LN, which results in different dielectric properties between high and low-fat content of normal and cancerous LNs, respectively. CONCLUSIONS By finding the best correlation between our defined impedimetric parameters and pathological states of tested LNs, a real-time intraoperative detection approach was developed for highly-sensitive (92%, P<0.001) diagnosis of involved sentinel or axillary LNs. The impact of real-time intraoperative scoring of SLNs would make a pre-estimation about the necessity of excising further LNs to help the surgeon for less invasive surgery, especially in the absence of frozen-section equipment.
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Affiliation(s)
- Reihane Mahdavi
- Nano Bioelectronics Devices Lab, Cancer Electronics Research Group, School of Electrical and Computer Engineering, Faculty of Engineering, University of Tehran, Tehran, P.O. Box 14395/515, Iran Nano Electronic Center of Excellence, Nano Bio Electronics Devices Lab, School of Electrical and Computer Engineering, University of Tehran, Tehran, P.O. Box 14395/515, Iran ATMP Department, Breast Cancer Research Center, Motamed Cancer Institute, ACECR, P.O. BOX 15179/64311, Tehran, Iran School of Electrical and Computer Engineering, Faculty of Engineering, Amirkabir University of Technology, Tehran, P.O. BOX 1591634311, Iran SEPAS Pathology Laboratory, P.O.Box: 1991945391, Tehran, Iran Cancer Research Center, Shahid Beheshti University of Medical Sciences, P.O. BOX 15179/64311, Tehran, Iran Pathology Department, Breast Cancer Research Center, Motamed Cancer Institute, ACECR, P.O. BOX 15179/64311, Tehran, Iran Cancer Institute, Imam-Khomeini Hospital, Tehran University of Medical Sciences, P.O. BOX 13145-158, Tehran, Iran
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Abstract
The magnetic technique, consisting of a magnetic tracer and a handheld magnetometer, is a promising alternative technique for sentinel lymph node dissection (SLND) and was shown to be non-inferior to the standard technique in terms of identification rates. In this study, injection characteristics (iron dose, dilution, time course and massaging) were evaluated to optimize magnetic tracer uptake in the sentinel lymph nodes (SLN) in a rat hindleg model. 202 successful SLNDs were performed. Iron uptake in the SLN is proportional (10% utilization rate) to the injection dose between 20 and 200 μg, showing a plateau uptake of 80 μg in the SLN around 1000 μg injection. Linear regression showed that time had a higher impact than dilution, on the SLN iron uptake. Massaging showed no significant change in iron uptake. The amount of residual iron at the injection site was also proportional to the injection dose without any plateau. Time was a significant factor for wash-out of residual iron. From these results, preoperative injection may be advantageous for SLN detection as well as reduction in residual iron at the injection site by potential decrease in required injection dose.
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Optimization of SPIO Injection for Sentinel Lymph Node Dissection in a Rat Model. Cancers (Basel) 2021; 13:cancers13195031. [PMID: 34638516 PMCID: PMC8508039 DOI: 10.3390/cancers13195031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/15/2021] [Accepted: 10/05/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary In this study, the following injection characteristics were evaluated to optimize magnetic tracer uptake in the sentinel lymph nodes (SLN) in a rat hindleg model: (a) iron dose, (b) effect of dilution, (c) effect of injecting at different time courses and (d) effect of massaging the injection site. In conclusion, injection dose and time were primary factors for the SLN iron uptake. The result from this study will provide a background for magnetic procedures. Abstract The magnetic technique, consisting of a magnetic tracer and a handheld magnetometer, is a promising alternative technique for sentinel lymph node dissection (SLND) and was shown to be non-inferior to the standard technique in terms of identification rates. In this study, injection characteristics (iron dose, dilution, time course and massaging) were evaluated to optimize magnetic tracer uptake in the sentinel lymph nodes (SLN) in a rat hindleg model. 202 successful SLNDs were performed. Iron uptake in the SLN is proportional (10% utilization rate) to the injection dose between 20 and 200 μg, showing a plateau uptake of 80 μg in the SLN around 1000 μg injection. Linear regression showed that time had a higher impact than dilution, on the SLN iron uptake. Massaging showed no significant change in iron uptake. The amount of residual iron at the injection site was also proportional to the injection dose without any plateau. Time was a significant factor for wash-out of residual iron. From these results, preoperative injection may be advantageous for SLN detection as well as reduction in residual iron at the injection site by potential decrease in required injection dose.
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Sentinel lymph node biopsy in breast cancer after neoadjuvant therapy using a magnetic tracer versus standard technique: A multicentre comparative non-inferiority study (IMAGINE-II). INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100404] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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29
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Bove S, Fragomeni SM, Romito A, DI Giorgio D, Rinaldi P, Pagliara D, Verri D, Romito I, Paris I, Tagliaferri L, Marazzi F, Visconti G, Franceschini G, Masetti R, Garganese G. Techniques for sentinel node biopsy in breast cancer. Minerva Surg 2021; 76:550-563. [PMID: 34338468 DOI: 10.23736/s2724-5691.21.09002-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Sonia Bove
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy
| | - Simona M Fragomeni
- Unità di Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessia Romito
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy -
| | | | - Pierluigi Rinaldi
- Radiology and Interventional Radiology Unit, Mater Olbia Hospital, Olbia, Italy.,Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Domenico Pagliara
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy
| | - Debora Verri
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy
| | - Ilaria Romito
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy
| | - Ida Paris
- Unità di Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luca Tagliaferri
- Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia - Gemelli ART (Advanced Radiation Therapy), Interventional Oncology Center (IOC), Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Fabio Marazzi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, UOC di Radioterapia Oncologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giuseppe Visconti
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, UOC Chirurgia Plastica, Università Cattolica del Sacro Cuore - Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
| | - Gianluca Franceschini
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Multidisciplinary Breast Center, Università Cattolica del Sacro Cuore - Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
| | - Riccardo Masetti
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Multidisciplinary Breast Center, Università Cattolica del Sacro Cuore - Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
| | - Giorgia Garganese
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy.,Dipartimento Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
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Superparamagnetic Iron Oxide for Identifying Sentinel Lymph Node in Breast Cancer after Neoadjuvant Chemotherapy: Feasibility Study. J Clin Med 2021; 10:jcm10143149. [PMID: 34300315 PMCID: PMC8305632 DOI: 10.3390/jcm10143149] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/02/2021] [Accepted: 07/15/2021] [Indexed: 12/23/2022] Open
Abstract
Sentinel lymph node biopsy (SLNB) is a well-established procedure for staging clinically node-negative early breast cancer (BC). Superparamagnetic iron oxide (SPIO) demonstrated efficacy for nodal identification using a magnetic probe after local retroaeroal interstitial injection. Its benefits lie in its flexibility, which is an essential property in the global setting, where access to the isotope is difficult. To the best of our knowledge, this is the first study to evaluate the feasibility and safety of the SPIO for SLNB in BC patients treated with neoadjuvant chemotherapy (NAC). Seventy-four female patients were included. The median time of lymph node retrieval was 20 min. The median number of resected sentinel nodes (SNs) was 4. SN was detected in all patients. No serious adverse event was observed. SPIO in identifying SN in BC patients after NAC is feasible and oncologically safe.
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Kurylcio A, Pelc Z, Skórzewska M, Rawicz-Pruszyński K, Mlak R, Gęca K, Sędłak K, Kurylcio P, Małecka-Massalska T, Polkowski W. Superparamagnetic Iron Oxide for Identifying Sentinel Lymph Node in Breast Cancer after Neoadjuvant Chemotherapy: Feasibility Study. J Clin Med 2021. [PMID: 34300315 DOI: 10.3390/jcm10143149.pmid:34300315;pmcid:pmc8305632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
Sentinel lymph node biopsy (SLNB) is a well-established procedure for staging clinically node-negative early breast cancer (BC). Superparamagnetic iron oxide (SPIO) demonstrated efficacy for nodal identification using a magnetic probe after local retroaeroal interstitial injection. Its benefits lie in its flexibility, which is an essential property in the global setting, where access to the isotope is difficult. To the best of our knowledge, this is the first study to evaluate the feasibility and safety of the SPIO for SLNB in BC patients treated with neoadjuvant chemotherapy (NAC). Seventy-four female patients were included. The median time of lymph node retrieval was 20 min. The median number of resected sentinel nodes (SNs) was 4. SN was detected in all patients. No serious adverse event was observed. SPIO in identifying SN in BC patients after NAC is feasible and oncologically safe.
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Affiliation(s)
- Andrzej Kurylcio
- Department of Surgical Oncology, Medical University of Lublin, Radziwiłłowska 13 St., 20-080 Lublin, Poland
| | - Zuzanna Pelc
- Department of Surgical Oncology, Medical University of Lublin, Radziwiłłowska 13 St., 20-080 Lublin, Poland
| | - Magdalena Skórzewska
- Department of Surgical Oncology, Medical University of Lublin, Radziwiłłowska 13 St., 20-080 Lublin, Poland
| | - Karol Rawicz-Pruszyński
- Department of Surgical Oncology, Medical University of Lublin, Radziwiłłowska 13 St., 20-080 Lublin, Poland
| | - Radosław Mlak
- Department of Human Physiology, Medical University of Lublin, Radziwiłłowska 11 St., 20-080 Lublin, Poland
| | - Katarzyna Gęca
- Department of Surgical Oncology, Medical University of Lublin, Radziwiłłowska 13 St., 20-080 Lublin, Poland
| | - Katarzyna Sędłak
- Department of Surgical Oncology, Medical University of Lublin, Radziwiłłowska 13 St., 20-080 Lublin, Poland
| | - Piotr Kurylcio
- Department of Surgical Oncology, Medical University of Lublin, Radziwiłłowska 13 St., 20-080 Lublin, Poland
| | - Teresa Małecka-Massalska
- Department of Human Physiology, Medical University of Lublin, Radziwiłłowska 11 St., 20-080 Lublin, Poland
| | - Wojciech Polkowski
- Department of Surgical Oncology, Medical University of Lublin, Radziwiłłowska 13 St., 20-080 Lublin, Poland
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Kedrzycki MS, Leiloglou M, Ashrafian H, Jiwa N, Thiruchelvam PTR, Elson DS, Leff DR. Meta-analysis Comparing Fluorescence Imaging with Radioisotope and Blue Dye-Guided Sentinel Node Identification for Breast Cancer Surgery. Ann Surg Oncol 2021; 28:3738-3748. [PMID: 33156466 PMCID: PMC8184731 DOI: 10.1245/s10434-020-09288-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/27/2020] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Conventional methods for axillary sentinel lymph node biopsy (SLNB) are fraught with complications such as allergic reactions, skin tattooing, radiation, and limitations on infrastructure. A novel technique has been developed for lymphatic mapping utilizing fluorescence imaging. This meta-analysis aims to compare the gold standard blue dye and radioisotope (BD-RI) technique with fluorescence-guided SLNB using indocyanine green (ICG). METHODS This study was registered with PROSPERO (CRD42019129224). The MEDLINE, EMBASE, Scopus, and Web of Science databases were searched using the Medical Subject Heading (MESH) terms 'Surgery' AND 'Lymph node' AND 'Near infrared fluorescence' AND 'Indocyanine green'. Studies containing raw data on the sentinel node identification rate in breast cancer surgery were included. A heterogeneity test (using Cochran's Q) determined the use of fixed- or random-effects models for pooled odds ratios (OR). RESULTS Overall, 1748 studies were screened, of which 10 met the inclusion criteria for meta-analysis. ICG was equivalent to radioisotope (RI) at sentinel node identification (OR 2.58, 95% confidence interval [CI] 0.35-19.08, p < 0.05) but superior to blue dye (BD) (OR 9.07, 95% CI 6.73-12.23, p < 0.05). Furthermore, ICG was superior to the gold standard BD-RI technique (OR 4.22, 95% CI 2.17-8.20, p < 0.001). CONCLUSION Fluorescence imaging for axillary sentinel node identification with ICG is equivalent to the single technique using RI, and superior to the dual technique (RI-BD) and single technique with BD. Hospitals using RI and/or BD could consider changing their practice to ICG given the comparable efficacy and improved safety profile, as well as the lesser burden on hospital infrastructure.
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Affiliation(s)
- Martha S Kedrzycki
- Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, London, UK. .,Department of Surgery and Cancer, Imperial College London, London, UK. .,Department of Breast Surgery, Imperial Healthcare Trust, London, UK.
| | - Maria Leiloglou
- Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - Hutan Ashrafian
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Natasha Jiwa
- Department of Surgery and Cancer, Imperial College London, London, UK.,Department of Breast Surgery, Imperial Healthcare Trust, London, UK
| | - Paul T R Thiruchelvam
- Department of Surgery and Cancer, Imperial College London, London, UK.,Department of Breast Surgery, Imperial Healthcare Trust, London, UK
| | - Daniel S Elson
- Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - Daniel R Leff
- Department of Surgery and Cancer, Imperial College London, London, UK.,Department of Breast Surgery, Imperial Healthcare Trust, London, UK
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33
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Sentinel lymph node assessment in breast cancer-an update on current recommendations. Virchows Arch 2021; 480:95-107. [PMID: 34164706 DOI: 10.1007/s00428-021-03128-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/16/2021] [Accepted: 05/27/2021] [Indexed: 02/06/2023]
Abstract
Sentinel lymph node biopsy (SLNB) has become the preferred method of surgical pathological nodal staging of early breast cancer by the end of the nineties. As the most likely sites of metastasis, the SLNs allow a more precise staging, and indeed gross sectioning, step sectioning, immunohistochemistry, and molecular staging methods have been used to disclose metastatic involvement of these lymph nodes. This review summarizes the backgrounds of SLNB, trends in related surgery and pathology. It also gives an insight into European National recommendations related to SLN and divergent daily practices in European pathology departments, on the basis of replies to questionnaires from 84 pathologists from 38 European countries. The questionnaires revealed the post-neoadjuvant setting as an area where a significant minority of pathologists report less confidence in classifying residual nodal involvement into TNM categories. The review also summarizes the neoadjuvant therapy-related aspects of SLNB.
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Boland MR, Al-Hilli Z. Management of the axilla after neoadjuvant chemotherapy in breast cancer patients. Br J Surg 2021; 108:748-749. [PMID: 33993211 PMCID: PMC10364851 DOI: 10.1093/bjs/znab137] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 04/03/2021] [Indexed: 11/13/2022]
Affiliation(s)
- M R Boland
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Z Al-Hilli
- Department of General Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Sugiyama S, Iwai T, Baba J, Oguri S, Izumi T, Sekino M, Kusakabe M, Mitsudo K. MR lymphography with superparamagnetic iron oxide for sentinel lymph node mapping of N0 early oral cancer: A pilot study. Dentomaxillofac Radiol 2021; 50:20200333. [PMID: 33180632 DOI: 10.1259/dmfr.20200333] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES The purpose of this pilot study was to evaluate the usefulness of magnetic resonance lymphography (MRL) with superparamagnetic iron oxide (SPIO) in sentinel lymph node (SLN) mapping of clinically N0 early oral cancer, and to conduct a comparative study of this MRL with CT lymphography (CTL). METHODS CTL and MRL were performed for SLN mapping before surgery for 20 patients with clinically N0 early oral cancer. The detection rate, number, and location of SLNs in CTL and MRL were evaluated. Furthermore, optimal scanning/imaging timing in MRL was examined. RESULTS SLNs were detected by CTL in 18 (90%) patients, and the total and mean number of SLN were 35 and 1.8, respectively. All SLNs could be detected 2 min and 3.5-5 min after contrast medium injection. In all patients, SLNs were detected by MRL at 10 min after SPIO injection, and the total and mean number of SLN was 53 and 2.7, respectively. MRL at 30 min after the injection showed additional 18 secondary lymph nodes. CONCLUSION MRL with SPIO is safe and useful imaging for the detection of SLNs in clinically N0 early oral cancer, and the optimal imaging timing is 10 min after SPIO injection.
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Affiliation(s)
- Satomi Sugiyama
- Department of Oral and Maxillofacial Surgery/Orthodontics, Yokohama City University hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, Japan
| | - Toshinori Iwai
- Department of Oral and Maxillofacial Surgery/Orthodontics, Yokohama City University hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, Japan
| | - Junichi Baba
- Department of Oral and Maxillofacial Surgery/Orthodontics, Yokohama City University hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, Japan
| | - Senri Oguri
- Department of Oral and Maxillofacial Surgery/Orthodontics, Yokohama City University hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, Japan
| | - Toshiharu Izumi
- Department of Radiology, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, Japan
| | - Masaki Sekino
- Department of Electrical Engineering and Information Systems, Graduate School of Engineering, The University of Tokyo, Tokyo, Japan
| | - Moriaki Kusakabe
- Research Center for Food Safety, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan.,Department of Medical Device, Matrix Cell Research Institute Inc, Ushiku, Ibaraki, Japan
| | - Kenji Mitsudo
- Department of Oral and Maxillofacial Surgery/Orthodontics, Yokohama City University hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, Japan
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Hersi AF, Pistiolis L, Dussan Luberth C, Vikhe-Patil E, Nilsson F, Mohammed I, Olofsson Bagge R, Wärnberg F, Eriksson S, Karakatsanis A. Optimizing Dose and Timing in Magnetic Tracer Techniques for Sentinel Lymph Node Detection in Early Breast Cancers: The Prospective Multicenter SentiDose Trial. Cancers (Basel) 2021; 13:cancers13040693. [PMID: 33572114 PMCID: PMC7914636 DOI: 10.3390/cancers13040693] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/02/2021] [Accepted: 02/05/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Superparamagnetic iron oxide (SPIO) nanoparticles have comparable performance to the combination of radioisotope and blue dye (RI + BD) for sentinel lymph node (SLN) biopsy in breast cancer. In this multicenter prospective study, lower SPIO doses (undiluted 1.5 vs. 1.0 mL) in different timeframes (perioperative vs. 1–7 days preoperative) and injection sites (subareolar vs. peritumoral) were compared to the previous standard (diluted 2.0 mL perioperatively) from the earlier Nordic trial. RI + BD were co-administered as background. In total, 534 patients were analyzed. SPIO SLN detection rates were similar (97.5% vs. 100% vs. 97.6%, p = 0.11) and respectively non-inferior to the dual technique. Significantly more SLNs were retrieved in the preoperative 1.0 mL cohort compared with 1.5 mL and the Nordic cohorts (2.18 vs. 1.85 vs. 1.83, p = 0.003). Thus, SPIO at 1.5 and 1.0 mL was non-inferior to both Sienna+® and the dual technique for SLN detection. Abstract Superparamagnetic iron oxide nanoparticles (SPIO) are non-inferior to radioisotope and blue dye (RI + BD) for sentinel lymph node (SLN) detection. Previously, 2 mL SPIO (Sienna+®) in 3 mL NaCl was used. In this dose-optimizing study, lower doses of a new refined SPIO solution (Magtrace®) (1.5 vs. 1.0 mL) were tested in different timeframes (0–24 h perioperative vs. 1–7 days preoperative) and injections sites (subareolar vs. peritumoral). Two consecutive breast cancer cohorts (n = 328) scheduled for SLN-biopsy were included from 2017 to 2019. All patients received isotope ± blue dye as back-up. SLNs were identified primarily with the SentiMag® probe and thereafter a gamma-probe. The primary endpoint was SLN detection rate with SPIO. Analyses were performed as a one-step individual patient-level meta-analysis using patient-level data from the previously published Nordic Trial (n = 206) as a third, reference cohort. In 534 patients, the SPIO SLN detection rates were similar (97.5% vs. 100% vs. 97.6%, p = 0.11) and non-inferior to the dual technique. Significantly more SLNs were retrieved in the preoperative 1.0 mL cohort compared with 1.5 and the 2.0 mL cohorts (2.18 vs. 1.85 vs. 1.83, p = 0.003). Lower SPIO volumes injected up to 7 days before the operation have comparable efficacy to standard SPIO dose and RI + BD for SLN detection.
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Affiliation(s)
- Abdi-Fatah Hersi
- Centre for Clinical Research, Region Västmanland—Uppsala University, Sigtunagatan, 72189 Västerås, Sweden;
- Department of Surgery, Västmanlands Hospital, Sigtunagatan, 72189 Västerås, Sweden
- Correspondence:
| | - Lida Pistiolis
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden; (L.P.); (R.O.B.); (F.W.)
| | - Carlos Dussan Luberth
- Department of Surgery, Linköping University Hospital, 58185 Linköping, Sweden; (C.D.L.); (E.V.-P.)
| | - Eva Vikhe-Patil
- Department of Surgery, Linköping University Hospital, 58185 Linköping, Sweden; (C.D.L.); (E.V.-P.)
| | - Fredrik Nilsson
- Department of Surgery and Perioperative Sciences, Umeå University Hospital, 90187 Umeå, Sweden;
| | - Imad Mohammed
- Department of Surgery, Kalmar County Hospital, 39185 Kalmar, Sweden;
| | - Roger Olofsson Bagge
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden; (L.P.); (R.O.B.); (F.W.)
| | - Fredrik Wärnberg
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden; (L.P.); (R.O.B.); (F.W.)
- Department of Surgical Sciences, Uppsala University, Akademiska Sjukhuset, 75185 Uppsala, Sweden;
| | - Staffan Eriksson
- Centre for Clinical Research, Region Västmanland—Uppsala University, Sigtunagatan, 72189 Västerås, Sweden;
- Department of Surgery, Västmanlands Hospital, Sigtunagatan, 72189 Västerås, Sweden
| | - Andreas Karakatsanis
- Department of Surgical Sciences, Uppsala University, Akademiska Sjukhuset, 75185 Uppsala, Sweden;
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Optimizing Dose and Timing in Magnetic Tracer Techniques for Sentinel Lymph Node Detection in Early Breast Cancers: The Prospective Multicenter SentiDose Trial. Cancers (Basel) 2021. [PMID: 33572114 DOI: 10.3390/cancers13040693.pmid:33572114;pmcid:pmc7914636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
Superparamagnetic iron oxide nanoparticles (SPIO) are non-inferior to radioisotope and blue dye (RI + BD) for sentinel lymph node (SLN) detection. Previously, 2 mL SPIO (Sienna+®) in 3 mL NaCl was used. In this dose-optimizing study, lower doses of a new refined SPIO solution (Magtrace®) (1.5 vs. 1.0 mL) were tested in different timeframes (0-24 h perioperative vs. 1-7 days preoperative) and injections sites (subareolar vs. peritumoral). Two consecutive breast cancer cohorts (n = 328) scheduled for SLN-biopsy were included from 2017 to 2019. All patients received isotope ± blue dye as back-up. SLNs were identified primarily with the SentiMag® probe and thereafter a gamma-probe. The primary endpoint was SLN detection rate with SPIO. Analyses were performed as a one-step individual patient-level meta-analysis using patient-level data from the previously published Nordic Trial (n = 206) as a third, reference cohort. In 534 patients, the SPIO SLN detection rates were similar (97.5% vs. 100% vs. 97.6%, p = 0.11) and non-inferior to the dual technique. Significantly more SLNs were retrieved in the preoperative 1.0 mL cohort compared with 1.5 and the 2.0 mL cohorts (2.18 vs. 1.85 vs. 1.83, p = 0.003). Lower SPIO volumes injected up to 7 days before the operation have comparable efficacy to standard SPIO dose and RI + BD for SLN detection.
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38
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Sun X, Zhang Q, Niu L, Huang T, Wang Y, Zhang S. Establishing a prediction model of axillary nodal burden based on the combination of CT and ultrasound findings and the clinicopathological features in patients with early-stage breast cancer. Gland Surg 2021; 10:751-760. [PMID: 33708557 DOI: 10.21037/gs-20-899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Axillary lymph node (ALN) management in early-stage breast cancer (ESBC) patients has become less invasive during the past decades. Here, we tried to explore whether high nodal burden (HNB) in ESBC patients could be predicted preoperatively, so as to avoid unnecessary sentinel lymph node biopsy (SLNB). Methods The clinicopathological and imaging data of patients with early invasive breast cancer (cT1-2N0M0) were analyzed retrospectively. Univariate and multivariate analyses were performed for the risk factors of axillary HNB in ESBC patients, and a risk prediction model of HNB was established. Results HNB was identified in 105 (8.0%) of 1,300 ESBC patients. Multivariate analysis showed that estrogen receptors (ER) status, human epidermal growth factor receptor 2 (HER2) status, number of abnormal lymph nodes (LNs) on computed tomography (CT), and axillary score on ultrasound (US) were the risk factors of HNB (all P<0.05). The area under the receiver operating characteristic (ROC) curve in the prediction model was 0.914, with the sensitivity being 85.7% and the specificity being 82.4%. The calibration curve showed that the prediction model had good performance. Conclusions As a valuable tool for predicting HNB in ESBC patients, this newly established model helps clinicians to make reasonable axillary surgery decisions and thus avoid unnecessary SLNB.
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Affiliation(s)
- Xianfu Sun
- Department of Breast Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Qiang Zhang
- Department of Breast Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Lianjie Niu
- Department of Breast Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Tao Huang
- Department of Breast Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Yingjie Wang
- Department of Oncology, Affiliated Zhengzhou Cancer Hospital of Henan University, Zhengzhou Cancer Hospital, Zhengzhou, China
| | - Shengze Zhang
- Department of Thyroid and Breast III, Cangzhou Central Hospital, Cangzhou, China
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van de Loosdrecht MM, Abelmann L, Ten Haken B. Experimental comparison of four nonlinear magnetic detection methods and considerations on clinical usability. Biomed Phys Eng Express 2020; 7. [PMID: 34037534 DOI: 10.1088/2057-1976/abce90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/27/2020] [Indexed: 11/12/2022]
Abstract
Superparamagnetic iron oxide nanoparticles (SPIONs) are promising for clinical applications, because they have a characteristic nonlinear magnetic response when an external magnetic field is applied. This nonlinearity enables the distinct detection of SPIONs and makes measurements less sensitive to the human body and surgical steel instruments. In clinical applications, only a limited field strength for the magnetic detection is allowed. The signal to noise ratios (SNRs) of four nonlinear magnetic detection methods are compared. These methods include differential magnetometry and three variations of magnetic particle spectroscopy: frequency mixing, second harmonic detection and third harmonic detection. All methods were implemented on the same hardware and experimentally compared for various field strengths. To make the comparison fair, the same power was supplied to the excitation coil each time. In general, the SNR increases with increasing field strength. The SNR per drive field of all methods stabilizes or even decreases for field strengths above 6 mT. The second harmonic detection has the best SNR and the most room for improvement.
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Affiliation(s)
- M M van de Loosdrecht
- Magnetic Detection and Imaging, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | | | - B Ten Haken
- Magnetic Detection and Imaging, Technical Medical Centre, University of Twente, Enschede, The Netherlands
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40
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Chapman MC, Lee AY, Hayward JH, Joe BN, Price ER. Superparamagnetic Iron Oxide Sentinel Node Tracer Injection: Effects on Breast MRI Quality. JOURNAL OF BREAST IMAGING 2020; 2:577-582. [PMID: 38424862 DOI: 10.1093/jbi/wbaa083] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Indexed: 03/02/2024]
Abstract
OBJECTIVE To evaluate the MRI artifact rendered by the typical injection of a ferromagnetic tracer now being intermittently used for intraoperative sentinel node (SN) identification at our institution, and to explore its impact on postoperative imaging and management. METHODS This study was Institutional Review Board-approved and granted a waiver of consent. A database search tool was used to identify MRI exams performed on patients who had previously undergone breast-conserving surgery with use of a superparamagnetic iron oxide (SPIO) SN tracer between January 1, 2015, and May 1, 2020. MRI reports, images, and relevant demographic, oncologic, and surgical history were collected. The presence or absence of SPIO residue on breast MRI, as well as its impact on image quality, were extracted from the prospective reports. RESULTS A total of 21 MRI exams were identified in 16 patients who had undergone breast-conservation therapy for cancer with use of SPIO SN tracer. Mean time from particle injection to baseline postoperative MRI exam was 10.8 months. All reports (21/21) noted evidence of SPIO residue. Of these, 5/21 were assessed as non-diagnostic; the remainder were assessed as limited. CONCLUSION Radiologists should be aware of the use of superparamagnetic tracers for SN identification and the impact on the quality of future MRI examinations. Alternative injection approaches are being developed and sequence parameters adjusted to minimize artifact.
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Affiliation(s)
- Molly C Chapman
- University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, CA
| | - Amie Y Lee
- University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, CA
| | - Jessica H Hayward
- University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, CA
| | - Bonnie N Joe
- University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, CA
| | - Elissa R Price
- University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, CA
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New technologies in breast cancer sentinel lymph node biopsy; from the current gold standard to artificial intelligence. Surg Oncol 2020; 34:324-335. [DOI: 10.1016/j.suronc.2020.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 05/28/2020] [Accepted: 06/18/2020] [Indexed: 01/14/2023]
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Kempson I. Mechanisms of nanoparticle radiosensitization. WILEY INTERDISCIPLINARY REVIEWS-NANOMEDICINE AND NANOBIOTECHNOLOGY 2020; 13:e1656. [PMID: 32686321 DOI: 10.1002/wnan.1656] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 06/04/2020] [Accepted: 06/04/2020] [Indexed: 02/06/2023]
Abstract
Metal-based nanoparticles applied to potentiating the effects of radiotherapy have drawn significant attention from the research community and are now available clinically. By improving our mechanistic understanding, nanoparticles are likely to evolve to provide very significant improvements in radiotherapy outcomes with only incremental increase in cost. This review critically assesses the inconsistent observations surrounding physical, physicochemical, chemical and biological mechanisms of radiosensitization. In doing so, a number of needs are identified for continuing research and are highlighted. The large degree of variability from one nanoparticle to another emphasizes that it is a mistake to generalize nanoparticle radiosensitizer mechanisms. Nanoparticle formulations should be considered in an analogous way as pharmacological agents and as a broad class of therapeutic agents, needing to be considered with a high degree of individuality with respect to their interactions and ultimate impact on radiobiological response. In the same way that no universal anti-cancer drug exists, it is unlikely that a single nanoparticle formulation will lead to the best therapeutic outcomes for all cancers. The high degree of complexity and variability in mechanistic action provides notable opportunities for nanoparticle formulations to be optimized for specific indications. This article is categorized under: Therapeutic Approaches and Drug Discovery > Emerging Technologies Nanotechnology Approaches to Biology > Nanoscale Systems in Biology.
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Affiliation(s)
- Ivan Kempson
- Future Industries Institute, University of South Australia, Mawson Lakes, SA, Australia
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Rubio IT, Rodriguez-Revuelto R, Espinosa-Bravo M, Siso C, Rivero J, Esgueva A. A randomized study comparing different doses of superparamagnetic iron oxide tracer for sentinel lymph node biopsy in breast cancer: The SUNRISE study. Eur J Surg Oncol 2020; 46:2195-2201. [PMID: 32631710 DOI: 10.1016/j.ejso.2020.06.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/10/2020] [Accepted: 06/11/2020] [Indexed: 12/22/2022] Open
Abstract
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.
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MESH Headings
- Axilla
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/surgery
- Female
- Humans
- Magnetic Iron Oxide Nanoparticles/administration & dosage
- Middle Aged
- Postoperative Complications
- Sentinel Lymph Node/pathology
- Sentinel Lymph Node Biopsy/methods
- Skin Pigmentation
- Technetium Tc 99m Aggregated Albumin
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Affiliation(s)
- Isabel T Rubio
- Breast Surgical Oncology, Clinica Universidad de Navarra, Madrid, Spain; Universidad de Navarra, Spain.
| | | | - Martin Espinosa-Bravo
- Breast Surgical Oncology, Hospital Universitario Vall d'Hebron, Barcelona, Spain; Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Christian Siso
- Breast Surgical Oncology, Hospital Universitario Vall d'Hebron, Barcelona, Spain; Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Joaquin Rivero
- Breast Surgical Oncology, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Antonio Esgueva
- Breast Surgical Oncology, Clinica Universidad de Navarra, Madrid, Spain; Universidad de Navarra, Spain
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Moukarzel LA, Feinberg J, Levy EJ, Leitao MM. Current and novel mapping substances in gynecologic cancer care. Int J Gynecol Cancer 2020; 30:387-393. [PMID: 31953349 PMCID: PMC7375198 DOI: 10.1136/ijgc-2019-001078] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/02/2020] [Accepted: 01/06/2020] [Indexed: 01/01/2023] Open
Abstract
Many tracers have been introduced into current medical practice with the purpose of improving lymphatic mapping techniques, anatomic visualization, and organ/tissue perfusion assessment. Among them, three tracers have dominated the field: indocyanine green, technetium-99m radiocolloid (Tc99m), and blue dye. Tc99m and blue dye are used individually or in combination; however, given particular challenges with these tracers, such as the need for a preoperative procedure by nuclear medicine and cost, other options have been sought. Indocyanine green has proven to be a promising alternative for certain procedures, as it is easy to use and has quick uptake. Its use in the management of gynecologic cancers was first described for sentinel lymph node mapping in cervical cancer, and later for endometrial and vulvar cancers. This review provides an in-depth look at these mapping substances, their uses, and the potential for new discoveries.
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Affiliation(s)
- Lea A Moukarzel
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jacqueline Feinberg
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Evan J Levy
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mario M Leitao
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, United States
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Talluri S, Malla RR. Superparamagnetic Iron Oxide Nanoparticles (SPIONs) for Diagnosis and Treatment of Breast, Ovarian and Cervical Cancers. Curr Drug Metab 2020; 20:942-945. [DOI: 10.2174/1389200220666191016124958] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 09/09/2019] [Accepted: 09/15/2019] [Indexed: 12/15/2022]
Abstract
Background:
The potential of Super Paramagnetic Iron Oxide Nanoparticles (SPIONs) as theranostic
agents for cancer has been investigated extensively. SPIONS can be utilized for diagnostic imaging, drug delivery as
well as for therapeutic applications. SPIONS are of particular interest because of their potential for non-invasive
diagnosis and non-invasive therapeutic applications. This article is a review of in vivo and clinical studies of SPIONs
for diagnosis and treatment of breast, ovarian and cervical cancer. The current limitations of this technology with
relation to clinical therapeutic applications and the potential to overcome these limitations are also discussed.
Methods:
NCBI Pubmed was searched for relevant documents by using keyword and MESH based search. The following
keyword combinations were used: ‘breast cancer’ and SPION, ‘ovarian cancer’ and SPION, and ‘cervical
cancer’ and SPION. The resulting list was manually scanned for the studies involving clinical and in vivo studies.
Results:
The 29 most relevant publications were identified and reviewed.
Conclusion:
Although numerous in vitro and in vivo studies have demonstrated the safety and effectiveness of the
use of SPIONs for both diagnostic and therapeutic applications, there is relatively little progress towards translation
to clinical applications involving breast, ovarian and cervical cancer.
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Affiliation(s)
- Sekhar Talluri
- Department of Biotechnology, Institute of Technology, GITAM (Deemed to be University), Visakhapatnam, India
| | - Rama R. Malla
- Cancer Biology Lab, Department of Biochemistry and Bioinformatics, Institute of Science, GITAM (Deemed to be University), Visakhapatnam, India
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