Sentinel Lymph Node Detection Using Carbon Nanoparticles in Patients with Early Breast Cancer

Comparison of different tracers in sentinel lymph node detection for endometrial cancer: a systematic review and network meta-analysis

BACKGROUND

In the realm of endometrial cancer (EC) therapeutics and prognostic assessments, lymph nodes' status is paramount. The sentinel lymph node (SLN) detection, recognized for its reliability, has been progressively adopted as a standard procedure, posing a compelling alternative to conventional systematic lymphadenectomy. However, there remains a lack of agreement on the most effective choice of tracers for this procedure.

OBJECTIVE

This investigation was dedicated to a comparative analysis of various tracers to identify the most effective combination that achieves the highest detection rate. This endeavor sought to enhance the efficacy of SLN biopsy in the surgical management of EC.

METHODS

A systematic review was conducted across multiple databases, including the Cochrane Central Register of Controlled Trials, PubMed, Web of Science, Embase, and clinicaltrials.gov, to analyze studies employing different tracers for SLN biopsy during surgery in EC. Using Bayesian network meta-analysis, the authors compared the total and bilateral detection rates of various tracers.

RESULTS

After screening 1431 articles, 11 studies, including 2699 participants, were selected in this network meta-analysis. The combination of radioactive isotopes and indocyanine green (ICG) emerged as the most efficacious method in total and bilateral detection rates, with the Surface Under the Cumulative Ranking Curve (SUCRA) scores of 80.00 and 86.36%, respectively. Additionally, carbon nanoparticles (CNPs) demonstrated superior performance in the detection of para-aortic lymph nodes with an SUCRA score of 97.77%.

CONCLUSION

Network meta-analysis shows that the application of radioactive isotopes and ICG is the optimal tracer combination for SLN biopsy during surgery in EC.

Determining Accurate Dye Combinations for Sentinel Lymph Node Detection: A Systematic Review

Background

Lymphatic dyes are commonly used to map the drainage path from tumor to lymphatics, which are biopsied to determine if spread has occurred. A blue dye in combination with technetium-99 is considered the gold standard for mapping, although many other dyes and dye combinations are used. Not all of these substances have the same detection efficacy.

Methods

A systematic review of PubMed, SCOPUS, Web of Science, and Medline was performed. The predefined search terms were (indocyanine green OR isosulfan blue OR lymphazurin OR patent blue OR methylene blue OR fluorescein OR technetium-99) AND combination AND dye AND (sentinel lymph node biopsy OR lymphedema OR lymphatics OR lymph OR microsurgery OR cancer OR tumor OR melanoma OR carcinoma OR sarcoma).

Results

The initial search returned 4267 articles. From these studies, 37 were selected as candidates that met inclusion criteria. After a full-text review, 34 studies were selected for inclusion. Eighty-nine methods of sentinel lymph node (SLN) detection were trialed using 22 unique dyes, dye combinations, or other tracers. In total, 12,157 SLNs of 12,801 SLNs were identified. Dye accuracy ranged from 100% to 69.8% detection. Five dye combinations had 100% accuracy. Dye combinations were more accurate than single dyes.

Conclusions

Combining lymphatic dyes improves SLN detection results. Replacing technetium-99 with ICG may allow for increased access to SLN procedures with comparable results. The ideal SLN tracer is a low-cost molecule with a high affinity for lymphatic vessels due to size and chemical composition, visualization without specialized equipment, and no adverse effects.

Nano-tracers for sentinel lymph node detection: current trends in technique and application

Sentinel lymph node (SLN) detection and biopsy is a critical staging component for several cancers. Apart from established methods using dyes or radiolabeled colloids, newer techniques are emerging, like near-infrared fluorescent compounds, targeted molecular radiopharmaceuticals and magnetic nano-tracers. In the overview section of this review, we categorize SLN detection tracers based on their principle of use. We discuss the merits of existing tracers and provide a glimpse of in-development formulations. A subsequent clinical section explores the expanded role of SLN detection in management of various cancers, citing current medical guidelines and the leading conclusions of long-term clinical trials. The concluding section tries to provide a perspective of promising developments and the work required to bring them to clinical fruition.

New Opportunities and Old Challenges in the Clinical translation of Nanotheranostics

Nanoparticle-based systems imbued with both diagnostic and therapeutic functions, known as nanotheranostics, have enabled remarkable progress in guiding focal therapy, inducing active responses to endogenous and exogenous biophysical stimuli, and stratifying patients for optimal treatment. However, although in recent years more nanotechnological platforms and techniques have been implemented in the clinic, several important challenges remain that are specific to nanotheranostics. In this Review, we first discuss some of the many ways of 'constructing' nanotheranostics, focusing on the different imaging modalities and therapeutic strategies. We then outline nanotheranostics that are currently used in humans at different stages of clinical development, identifying specific advantages and opportunities. Finally, we define critical steps along the winding road of preclinical and clinical development and suggest actions to overcome technical, manufacturing, regulatory and economical challenges for the safe and effective clinical translation of nanotheranostics.

Use of Carbon Nanoparticles to Improve the Efficiency of Harvesting Lymph Nodes in Rectal Cancer

BACKGROUND

The accurate determination of lymph node status in patients with rectal cancer requires harvesting a certain number of lymph nodes. This study investigated whether using carbon nanoparticles (CNs) could improve the efficiency of harvesting lymph nodes in rectal cancer patients.

MATERIALS AND METHODS

Data from patients with rectal cancer treated with radical resection were collected from Nanfang Hospital between January 2014 and June 2021. Patients in the CN group received a CN suspension 1 day before surgery, which was endoscopically injected around the tumor. A 1:1 case-matched study was performed using the propensity score. The efficiency of harvesting lymph nodes was investigated by comparing the number of total nodes, total time, and percentage of nodes <5 mm in size between the CN and non-CN groups.

RESULTS

A total of 768 patients were included, with 246 patients who underwent CN injection and 522 patients who did not. After matching, 246 pairs of patients were analyzed. After matching, the number of total nodes of each sample was significantly higher in the CN group than in the non-CN group ( P <0.001). The total time for node detection ( P <0.001) was significantly shorter in the CN group. The percentage of nodes <5 mm in size was increased significantly in the CN group ( P <0.001). Among patients with clinical staging I/II, the difference in positive LNs was significant (21.79% vs. 11.95%, P =0.029).

CONCLUSIONS

The application of CNs improved the efficiency of harvesting lymph nodes during rectal cancer surgery.

Comparative observation of common tracers in sentinel lymph node biopsy of breast cancer and a study on simplifying its surgical procedure

Background

Many breast cancer patients have avoided axillary lymph node dissection after sentinel lymph node biopsy (SLNB). During the SLNB operation, the color of lymphatic vessels is sometimes poor and so finding them is difficult. This study observed the tracing effects of three tracer combinations and also reported our experience in simplifying the SLNB program.

Methods

In total, 123 breast cancer patients whose TNM stage was cT1-2N0M0 were retrospectively studied. According to the tracer used, the patients were divided into the carbon nanoparticle (CNP) group (38 cases), CNP combined with methylene blue (CNP + MB) group (41 cases), and indocyanine green combined with MB (ICG + MB) group (44 cases). All 123 breast cancer cases were also classified into the non-tracking group (53 cases) and tracking group (70 cases) according to the SLNB operation process. The non-tracking group looked for the stained sentinel lymph nodes directly, while the tracking group looked for the stained lymph nodes along the lymphatic vessels.

Results

The SLN identification rates in the CNP, CNP + MB, and ICG + MB groups were 97.4%, 97.6%, and 95.5% respectively (P > 0.05). The average number of SLNs detected was 4.92 ± 2.06, 5.12 ± 2.18, and 4.57 ± 1.90, respectively (P > 0.05). The ideal display rates of lymphatic vessels in the three groups were 86.8%, 87.8%, and 93.2%, respectively (P > 0.05). The SLN identification rates in the non-tracking and tracking groups were 96.2% and 97.1%, respectively (P > 0.05). The average number of SLNs detected were 5.73 ± 1.76 and 5.70 ± 1.93, respectively (P > 0.05), and the average operation time was 16.47 ± 5.78 and 27.53 ± 7.75 min, respectively (P < 0.05).

Conclusion

This is the first study to observe the application effect of CNP combined with MB and ICG combined with MB tracers in SLNB of breast cancer patients. No significant difference was observed among the patients in SLN identification and lymphatic vessel display. Omitting the step of searching for lymphatic vessels in SLNB surgery does not reduce the surgical effect, but the reduced operating steps can reduce the surgical time and theoretically reduce postoperative complications.

A narrative review on the role of carbon nanoparticles in oncology

The lymphatic system is the first site of metastasis for most tumors and is a common reason for the failure of cancer therapy. The lymphatic system's anatomical properties make it difficult to deliver chemotherapy agents at therapeutic concentrations while avoiding systemic toxicity. Carbon nanoparticles offer a promising alternative for identifying and transporting therapeutic molecules. The larger diameter of lymphatic vessels compared to the diameter of blood vessels, allows carbon nanoparticles to selectively enter the lymphatic system once administered subcutaneously. Carbon nanoparticles stain tumor-draining lymph nodes black following intratumoral injection, making them useful in sentinel lymph node mapping. Drug-loaded carbon nanoparticles allow higher concentrations of chemotherapeutics to accumulate in regional lymph nodes while decreasing plasma drug accumulation. The use of carbon nanoparticles for chemotherapy delivery has been associated with lower mortality, fewer histopathology changes in vital organs, and lower serum concentrations of hepatocellular enzymes. This review will focus on the ability of carbon nanoparticles to target the lymphatics as well as their current and potential applications in sentinel lymph node mapping and oncology treatment regimens. This article is categorized under: Implantable Materials and Surgical Technologies > Nanoscale Tools and Techniques in Surgery.

Sentinel lymph node mapping in patients with breast cancer using a photoacoustic/ultrasound dual-modality imaging system with carbon nanoparticles as the contrast agent: a pilot study

Assessing the metastatic status of axillary lymph nodes is a common clinical practice in the staging of early breast cancers. Yet sentinel lymph nodes (SLNs) are the regional lymph nodes believed to be the first stop along the lymphatic drainage path of the metastasizing cancer cells. Compared to axillary lymph node dissection, sentinel lymph node biopsy (SLNB) helps reduce morbidity and side effects. Current SLNB methods, however, still have suboptimum properties, such as restrictions due to nuclide accessibility and a relatively low therapeutic efficacy when only a single contrast agent is used. To overcome these limitations, researchers have been motivated to develop a non-radioactive SLN mapping method to replace or supplement radionuclide mapping. We proposed and demonstrated a clinical procedure using a dual-modality photoacoustic (PA)/ultrasound (US) imaging system to locate the SLNs to offer surgical guidance. In our work, the high contrast of PA imaging and its specificity to SLNs were based on the accumulation of carbon nanoparticles (CNPs) in the SLNs. A machine-learning model was also trained and validated to distinguish stained SLNs based on single-wavelength PA images. In the pilot study, we imaged 11 patients in vivo, and the specimens from 13 patients were studied ex vivo. PA/US imaging identified stained SLNs in vivo without a single false positive (23 SLNs), yielding 100% specificity and 52.6% sensitivity based on the current PA imaging system. Our machine-learning model can automatically detect SLNs in real time. In the new procedure, single-wavelength PA/US imaging uses CNPs as the contrast agent. The new system can, with that contrast agent, noninvasively image SLNs with high specificity in real time based on the unique features of the SLNs in the PA images. Ultimately, we aim to use our systems and approach to substitute or supplement nuclide tracers for a non-radioactive, less invasive SLN mapping method in SLNB for the axillary staging of breast cancer.

Characteristics of systematic lymph node dissection and influencing factors of sentinel lymph node biopsy using carbon nanoparticles in endometrial carcinoma: a single-center study

BACKGROUND

Carbon nanoparticles (CNPs) are a new tracer for lymph node mapping, which can quickly reach and develop lymph nodes through a lymphatic network. This research investigated the characteristics of systematic lymph node dissection and sentinel lymph node biopsy mapped with CNPs in endometrial carcinoma.

METHODS

We first applied CNPs to systematic lymph node dissection in 18 endometrial carcinoma patients as the study group and another 18 endometrial carcinoma patients who were not injected with anything served as the control group. Then, we applied CNPs to sentinel lymph nodes biopsy in 54 endometrial carcinoma patients. All 54 patients received systematic lymph node dissection after sentinel lymph node biopsy. The detection rate, sensitivity, specificity, and accuracy of systematic lymph node dissection and sentinel lymph node biopsy by CNPs were respectively analyzed. A nomogram model for predicting the success of sentinel lymph node mapping was established.

RESULTS

The average number of lymph nodes removed in the CNP-labeled study group was higher than that in the control group (p<0.001). CNPs improved the number of lymph nodes with a diameter ≤ 0.5cm. The detection rate, sensitivity, specificity, and accuracy of sentinel lymph nodes biopsy by CNPs for endometrial carcinoma were 70.4%, 100%, 100%, and 100%, respectively. The nomogram model included factors of long menopause time, cervical cyst, and hard cervical texture, and the area of ROC curve was 0.816.

CONCLUSIONS

CNPs improve the detection rate of small lymph nodes. CNPs can trace sentinel lymph nodes in evaluating lymph node metastasis in endometrial carcinoma.

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

Purpose

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

Aims and Objective

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

Methods

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

Results

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

Conclusion

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

The Role of Carbon Nanoparticles in Lymph Node Dissection and Parathyroid Gland Preservation during Surgery for Thyroid Cancer: A Systematic Review and Meta-Analysis

Thyroid cancer is the most common endocrine malignancy with an increasing incidence over the past few years. Surgery is considered the primary therapeutic option, which often involves lymph node dissection. The aim of this study was to assess the role of carbon nanoparticles, a novel agent, in thyroid cancer surgery. For that purpose, we conducted a systematic review of the literature on MEDLINE, EMBASE, Scopus, Cochrane and Google Scholar databases from 1 January 2002 to 31 January 2022. Ultimately, 20 articles with a total number of 2920 patients were included in the analysis. The outcome of the analysis showed that the use of carbon nanoparticles is associated with a higher number of harvested lymph nodes (WMD, 1.47, 95% CI, 1.13 to 1.82, p < 0.001) and a lower rate of accidental parathyroid gland removal (OR 0.34, CI 95% 0.24 to 0.50, p < 0.001). Based on these results, we suggest that carbon nanoparticles are applied in thyroid cancer surgery on a wider scale, so that these findings can be confirmed by future research on the subject.

The Application of Carbon Nanomaterials in Sensing, Imaging, Drug Delivery and Therapy for Gynecologic Cancers: An Overview

Gynecologic cancers are one of the main health concerns of women throughout the world, and the early diagnosis and effective therapy of gynecologic cancers will be particularly important for the survival of female patients. As a current hotspot, carbon nanomaterials have attracted tremendous interest in tumor theranostics, and their application in gynecologic cancers has also been developed rapidly with great achievements in recent years. This Overview Article summarizes the latest progress in the application of diverse carbon nanomaterials (e.g., graphenes, carbon nanotubes, mesoporous carbon, carbon dots, etc.) and their derivatives in the sensing, imaging, drug delivery, and therapy of different gynecologic cancers. Important research contributions are highlighted in terms of the relationships among the fabrication strategies, architectural features, and action mechanisms for the diagnosis and therapy of gynecologic cancers. The current challenges and future strategies are discussed from the viewpoint of the real clinical application of carbon-based nanomedicines in gynecologic cancers. It is anticipated that this review will attract more attention toward the development and application of carbon nanomaterials for the theranostics of gynecologic cancers.

Meta-Analysis of the Diagnostic Value of Tracer Staining Technology Based on Nanocarbon Suspension in Sentinel Lymph Node Biopsy of Breast Cancer

Objective. To evaluate the diagnostic value of the nanometer carbon suspension tracer staining technique in sentinel lymph node biopsy of breast cancer is the objective of this study. Methods. The PubMed, Embase, Cochrane Library (Central), and Web of Science (SCI Expanded), and Chinese databases (CNKI, VIP, Wan Fang, and CBM) were systematically searched for studies on the diagnostic value of nanocarbon suspension in sentinel lymph node biopsy of breast cancer. Two reviewers independently assessed the methodological quality of each study using the QUADAS-2 tool. The extracted valid data were calculated using Meta-Disc1.4 software and tested for heterogeneity. STATA14.0 software was selected for sensitivity analysis of the included studies, and publication bias was assessed using Deeks’ forest plot asymmetry test. Results. A total of 10 studies were obtained. The pooled data were as follows: sensitivity, 0.92 (0.88~0.95); specificity, 0.99 (0.98~1.00); positive likelihood ratio, 69.24 (30.34~158.02); negative likelihood ratio, 0.09 (0.06~0.13); and the combined diagnostic odds ratio, 747.40 (285.77~1954.76), $\text{AUC}=0.9881$ . Nanocarbon suspension tracers have an accuracy rate of 98.81% in the diagnosis of sentinel lymph nodes in breast cancer. Conclusion. Tracer staining technology based on nanocarbon suspension can accurately assess the status of lymph nodes in sentinel lymph node biopsy of breast cancer and has good stability and operability, which is worthy of clinical promotion.

Sentinel Lymph Node Biopsy Mapped With Carbon Nanoparticle Suspensions in Patients With Breast Cancer: A Systematic Review and Meta-Analysis

Background

The mapping method represents a crucial factor affecting the rate of sentinel lymph node detection in breast cancer. We carried out this meta-analysis to assess the clinical utility of carbon nanoparticle suspensions (CNSs) in guiding sentinel lymph node biopsy (SLNB) for breast cancer patients.

Methods

Electronic databases, which comprised the China National Knowledge Infrastructure, the Wanfang electronic database, the Cochrane Library, EMBASE, and PubMed, were explored to identify relevant studies from database inception to July 2021 that studied the detection rate of CNSs-guided SLNB. A meta-analysis was performed to generate pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), a summary receiver operator characteristic curve (SROC), and a diagnostic odds ratio (DOR).

Results

A total of 33 publications that enrolled 2,171 patients were analyzed. The pooled sensitivity, specificity, PLR, and NLR were 0.93 (95% CI: 0.91–0.95, I² = 0.0%), 0.99 (95% CI: 0.98–0.99, I² = 56.5%), 42.85 (95% CI: 29.73–61.77, I² = 47.0%), and 0.09 (95% CI: 0.07–0.11, I² = 0.0%), respectively. The area under the curve (AUC) of the SROC curve was 0.98. There were no significant differences when analyzed based on the dose and site of CNS injection. There was significant publication bias among the included publications based on Deeks’ funnel plot [Slope (Bias) = −7.35, P = 0.00]. Nonetheless, the sensitivity analysis identified the results to be reliable and stable.

Conclusion

This meta-analysis highlights the accuracy and feasibility of using CNSs for SLNB in patients with breast cancer. Clinically, the identification and predictive values of CNSs as an optimal tracer for SLNB remains undisputed.

Nanoparticle-assisted axillary staging: an alternative approach after neoadjuvant chemotherapy in patients with pretreatment node-positive breast cancers

PURPOSE

In order to achieve an optimized method of axillary staging after neoadjuvant chemotherapy (NAC) in breast cancer patients with pretreatment positive axillary lymph nodes, we evaluated the feasibility and accuracy of nanoparticle-assisted axillary staging (NAAS) which combines carbon nanoparticles with standard sentinel lymph node biopsy (SLNB) with radioisotope and blue dye.

METHODS

Invasive breast cancer patients with pre-NAC positive axillary lymph nodes who converted to ycN0 and received surgeries from November 2020 to March 2021 were included. All patients underwent ipsilateral NAAS followed by axillary lymph node dissection. Detection rate (DR), false-negative rate (FNR), negative predictive value (NPV) and accuracy of axillary staging were calculated.

RESULTS

Eighty of 136 (58.8%) breast cancer patients converted to ycN0 after NAC and received NAAS. The DR, NPV and accuracy was 95.0%, 93.3% and 97.4% for NAAS, respectively. And the FNR was 4.2% (2/48) for NAAS, which was lower than that of standard dual-tracer SLNB (SD-SLNB) (9.5%, 4/42). Pretreatment clinical T4 classification was a risk factor for detection failure in NAAS (p = 0.016). When patients with pretreatment inflammatory breast cancers were excluded from analysis, FNR dropped to 2.2% (1/45) for NAAS.

CONCLUSION

NAAS revealed great performance in invasive breast cancer patients with pre-NAC positive axillary lymph nodes who converted to ycN0. The application of NAAS reached a better balance between more accurate axillary evaluation and less intervention. Trial registration Chictr.org.cn (ChiCTR2000039814). Registered Nov 11, 2020.

Application of Carbon Nanoparticle Tracers in the Lateral Neck Lymph Nodes of CN1bx Patients with Papillary Thyroid Carcinoma

This study aimed to investigate the applicability of carbon nanoparticle tracers in the lateral neck lymph nodes of CN1bx patients with papillary thyroid carcinoma surgery. 73 patients with papillary thyroid carcinoma at our hospital between January 2019 to December 2019 were suspected metastasis in the lateral neck lymph node before surgical treatment. During the operation, carbon nanoparticle tracers were used as black staining tracers for the lateral neck lymph nodes to detect metastasis in each Compartment of the neck. The lateral Compartment is defined as level ll-V The black-stained lymph nodes, dyed by Carbon nanoparticle tracers, and non-dyed lymph nodes were compared. Post-surgery paraffin pathology was adopted as the gold standard to calculate the predictive performance of the carbon nanoparticle tracers in detecting lymph node biopsy metastasis. 59 of the patients (80.8%) had lateral neck metastasis. The black-stained lymph nodes, dyed by Carbon nanoparticle tracers, in Compartment IV exhibited the highest proportions in the case number submitted for detection and in lymph nodes metastasis, followed by Compartment III. The metastasis rate of the dyed lymph nodes in areas III and IV was significantly higher than that of non-dyed lymph nodes (P < 0.05). The sensitivity and accuracy of the dyed lymph node biopsy in Compartments III-IV were 90% and 93.2%, respectively. This predictive performance was similar to that Compartments ll-V combined. In conclusion, when carbon nanoparticle tracers are used for lymph node biopsy, high sensitivity and accuracy are obtained in lateral neck compartments III-IV, making these compartments ideal for lymph node biopsy.

Comparison of two different surgical strategies for breast cancer patients treated with mastectomy plus sentinel lymph node biopsy

Two separated incisions are generally adopted in breast cancer patients treated by mastectomy plus sentinel lymph node biopsy (SLNB). However, one-incision procedure is also applied in clinical practice. The outcomes of the two different surgical strategies remain unknown. This issue needs to be investigated. The medical records of breast cancer patients who underwent a mastectomy combined with an SLNB were reviewed retrospectively. Group A comprised patients who received a single incision for both the mastectomy and SLNB. Group B comprised patients who received a second incision for the SLNB. Demographics and outcomes were compared between the two groups. There were 280 female patients divided into Groups A (n = 130) and B (n = 150) included in this study. Preoperatively, the two groups were similar in demographics for age, tumor size, tumor location, body mass index, pathologic type, and cancer stage (P > 0.05). Group A showed shorter surgical times (129.5 ± 29.0 vs. 136.7 ± 21.9 min), less postoperative upper limb numbness (12.3% vs. 25.3%), and more harvested sentinel lymph nodes (3.2 ± 1.1 vs. 2.7 ± 1.0) than Group B (P < 0.05). There were no significant differences for intraoperative blood loss, total postoperative drainage amount, hospital stay, upper limb motility, upper limb pain, upper limb edema, number of metastatic sentinel lymph nodes, follow-up time, or recurrent cases (P > 0.05). The one-incision approach for a breast cancer mastectomy plus SLNB has several advantages over the two-incision approach, including a shorter surgical time, decreased upper limb numbness, and the harvesting of more sentinel lymph nodes. Further prospective randomized controlled clinical trials should be designed to verify the current findings.

Near-infrared laparoscopy with indocyanine green for axillary sentinel lymph node biopsy in early breast cancer: preliminary experience of a single unit

Background

A sentinel lymph node biopsy (SLNB) is a routine procedure for axillary staging in cN0 breast cancer (BC) patients. Indocyanine green (ICG) fluorescence can detect sentinel lymph nodes with higher sensitivity than carbon nanoparticle suspension (CNS). The present study investigated the availability and benefits of a near-infrared (NIR) laparoscopy-assisted SLNB using ICG and carbon nanoparticle suspension as tracers.

Methods

Forty patients with invasive BC, who had clinically negative axillary lymph nodes, participated in this observational study. ICG and CNS tracers were injected into the periareolar region simultaneously or sequentially. In the endoscopy-assisted group (n=20), the patients were given NIR laparoscopic SLNB based on ICG fluorescence and CNS staining. In the open-surgery group, the patients were given traditional SLNB using an open incision, and CNS tracers were injected into the same region as that in the endoscopy-assisted group.

Results

In the endoscopy-assisted group, lymphatic vessels and sentinel lymph nodes (SLNs) were successfully identified using ICG fluorescence imaging in most patients (19/20). The average number of SLNs removed was 2.85 (range, 1-4) in the endoscopy-assisted group, and 3.40 (range, 1-7) in the open-surgery group. There was no significant difference between the number of detected nodes (P=0.30). The patients who underwent endoscopy-assisted SLNBs had similar operating times, blood loss and hospital-stay lengths, but lower postoperative drainage volumes and higher satisfaction scores, as they did not have axillary incisions.

Conclusions

The NIR laparoscopy-assisted ICG-guided technique is a feasible and surgeon-friendly method for SLNB with good efficacy and acceptable safety. When combined with CNS, more SLNs can be detected and dissected.

Infiltration of nanocarbon suspension into the tracheal cavity during surgical treatment of papillary thyroid carcinoma: a case report

Cervical lymph node metastasis in patients with differentiated thyroid cancer affects postoperative recurrence and survival. Hypoparathyroidism is caused by parathyroid gland injury during thyroidectomy. Carbon nanoparticles can trace stained lymph nodes, aiding in thorough dissection of lymph nodes in the operation area. To reduce postoperative occurrence of hypoparathyroidism, the parathyroid glands and their functions (identified by negative imaging induced by carbon nanoparticles) are retained in situ. However, the safety and adverse effects of nanocarbon suspension in thyroid surgery have rarely been evaluated. In this report, we describe a patient with thyroid cancer who had carbon secretions in the trachea caused by nanocarbon suspension when tracheal intubation was performed under general anesthesia, and the inflatable balloon surface of the tracheal tube was covered with these secretions. The patient recovered without fever, cough, phlegm production, chest pain, hoarseness, or hypocalcemia-induced convulsions. No consensus has yet been reached on the most appropriate injection site, depth, dose, or waiting time for nanocarbons in thyroid cancer surgery. We believe that nanocarbon suspension is safe for use in thyroid cancer surgery, but the most appropriate injection depth should be based on the thickness of the thyroid gland tissue to avoid deep injection into the trachea.

Application of Carbon Nanoparticles in Tracing Lymph Nodes and Locating Tumors in Colorectal Cancer: A Concise Review

Background

Accurate lymph node (LN) staging has considerably prognostic and therapeutic value in patients with colorectal cancer (CRC). The purpose of this study is to evaluate the feasibility of applying carbon nanoparticles (CNPs) to track LN metastases in CRC.

Methods

Two researchers independently screened publications in PubMed, EMBASE, Cochrane and Ovid MEDLINE databases. The keywords were (carbon nanoparticles OR activated carbon nanoparticles) AND (colon cancer OR rectal cancer OR colorectal cancer). Titles and abstracts of the articles were meticulously read to rule out potential publications. Next, full texts of the ultimately obtained eligible publications were retrieved and analyzed in detail.

Results

The search produced 268 publications, and 140 abstracts were identified after a bibliographic review. Finally, 20 studies relevant to our subject were obtained; however, only 14 papers met our inclusion criteria and were included for final review. All studies included have compared the control group with carbon nanoparticles group (control group, defined as nontattooed group; and carbon nanoparticles group, defined as administering carbon nanoparticles during surgery) for their efficacy in intraoperative detecting and positioning. After analysis, appreciably less amount of bleeding (3/5 trials), shorter operation time (2/4 trials), and shorter time to detect lesions and dissect LNs (2/2 trials) were revealed in CNPs group compared to control group. Thirteen studies have recorded the numbers of the harvested LNs in both groups; meanwhile, CNPs group shows superiority to control group in LN retrieval as well (11/13 trials), which also could effectively aid in locating and harvesting more LNs with diameter below 5 mm.

Conclusion

The tracing technique for CNPs is a safe and useful strategy both in localizing tumor and tracing LNs in CRC surgery. But there is still a need for more randomized controlled trials to further establish its contribution to patient survival.

Carbon nanoparticles suspension injection for photothermal therapy of xenografted human thyroid carcinoma in vivo

Due to the unique structure, carbon nanomaterials could convert near‐infrared (NIR) light into heat efficiently in tumor ablation using photothermal therapy (PTT). Carbon nanoparticles suspension injection (CNSI) is a commercial imaging reagent for lymph node mapping. CNSI has similar structural characteristics to other carbon nanomaterials, and thus, might be applied as photothermal agent. Herein, we evaluated the photothermal conversion ability and therapeutic effects of CNSI on thyroid carcinoma. CNSI was composed by carbon nanoparticle cores and polyvinylpyrrolidone K30 as the dispersion reagent. CNSI absorbed NIR light efficiently following the Lambert‐Beer law. The temperature of CNSI dispersion increased quickly under the NIR irradiation. CNSI killed the TCP‐1 thyroid carcinoma cells under 808 nm laser irradiation at 0.5 W/cm², while CNSI or NIR irradiation treatment alone did not demonstrate this effect. Temperature increases were observed in tumor injected with CNSI under NIR irradiation. After three irradiation treatments, the tumor growth was completely blocked and the disruption of cellular structure was observed. When the tumor temperatures reached 53^°C during treatment, the tumors did not recur within the observation period of 3 months. Our results suggested that CNSI might be used for PTT through “off label” use to benefit the patients immediately.

Novel technique to manage refractory chylous ascites with carbon nanoparticle suspension in infants

OBJECTIVE

Chylous ascites (CA) is a rare form of ascites that results from the leakage of lipid-rich lymph into the peritoneal cavity. In infants, CA is mostly caused by lymphatic malformation or unknown reasons. The creation of a shunt for the lymphorrhea is the last option for patients unresponsive to all other conservative treatments. Localization of the leakage is a critical problem during surgery. We applied a carbon nanoparticle suspension (CNS) in CA patients to locate the external lymphatic leakage and evaluated its utility during surgery.

PATIENTS AND METHODS

Twelve infants with CA were treated in our center recently. Ten patients received laparotomy, one refused therapy, and one was cured after undergoing conservative treatment. Recently, two infants with CA received CNS in the visceral peritoneum during laparotomy. The results of the traditional procedure were compared to our innovative technique for CA to evaluate the use of CNS in treating CA.

RESULTS

The features of the baseline data did not differ substantially. Location of the leakage with CNS was employed in 2 of the 10 patients whose lymphatic leakages were identified with the resolution of the refractory CA. Overall, in 5 patients, ascites was resolved successfully. The refractory CA was resolved more effectively in patients in whom the leakage site was identified with CNS than in patients in whom the leakage site could not be identified under conventional surgery.

CONCLUSIONS

Injecting CNS improved the accuracy of lymphorrhagia leakage site identification and the outcomes of infants who underwent surgical treatment for refractory CA.

LEVEL OF EVIDENCE

II-III.

Combination diagnosis with elastography strain ratio and molecular markers effectively improves the diagnosis rate of small breast cancer and lymph node metastasis

Background

To evaluate the strain ratio (SR) combined with molecular pathological and serum markers for the diagnosis of breast masses.

Methods

SR and 7-point scale elasticity scores were used with real-time tissue elastography and 2-dimensional color-Doppler ultrasound (US) to diagnose breast lesions in 311 hospitalized patients. Immunohistochemical staining and enzyme-linked immunosorbent assays (ELISAs) were used to examine pathological and serum tumor markers and their correlations with SR findings.

Results

SR had a higher diagnostic value compared to the 7-point scale elasticity score, displaying an obvious low-to-high distribution from benign to malignant lesions with an optimal cutoff point at 3.88, which yielded an area under the curve (AUC) of 0.896 with 89.1% sensitivity, 85.6% specificity, and positive and negative predictive values of 91.0% and 82.8%, respectively. The differences of SR values between small (≤1.5 cm), large (>3 cm) (P=0.010), and moderate (>1.5 cm and ≤3 cm) sizes (P=0.038) in distinguishing benign from malignant breast masses were statistically significant, with SR being most specific and sensitive for diagnosing small lesions. Expression of 3 molecular pathological indicators (p75NTR, p63, and CK5/6), and 5 serum mastocarcinoma markers (uPA, PAI-I, CA27-29, CEA, and CA15-3) showed statistical significance (P<0.05) in distinguishing between benign and malignant breast lesions. Furthermore, SR combined with CA15-3 and CK5/6 positivity showed 94.2% sensitivity and 89.2% specificity as combined markers for triple-negative (TN) breast cancer, whereas SR combined with D2-40 and CK19 were good diagnostic markers for breast cancer lymph node metastasis.

Conclusions

SR, together with a molecular and serological marker, may serve as an additional tool for the diagnosis of small breast cancer tumors.

Novel Multifunctional Nanoagent for Visual Chemo/Photothermal Therapy of Metastatic Lymph Nodes via Lymphatic Delivery

Breast cancer is one of the major diseases that threaten women's health. Lymph node (LN) metastasis is the most common metastatic path of breast cancer. Finding a simple, effective, and safe strategy to eliminate metastatic tumors in LNs is highly desired for clinical use. Carbon nanoparticles (CNs), as an LN tracer, have been widely used in the clinical setting. In addition, previous experiments have confirmed that CNs have good photoacoustic imaging and photothermal effects. In this study, we used CNs as a photothermal conversion material and drug carrier, poly(lactic-co-glycolic acid) (PLGA) as a film-forming material, and docetaxel as a chemotherapy drug to prepare multifunctional nanoparticles (DOC-CNPs). The prepared DOC-CNPs present as a black solution, which shows smooth spherical particles under light microscopy and transmission electron microscopy (TEM), and they have a good ability for liquid-gas phase transition, good dispersibility, high drug-loading capacity, and low cytotoxicity. In vitro, they can release drugs and inhibit tumor cells after laser irradiation. The photoacoustic (PA) signal intensity and the photothermal conversion efficiency increased with an increase in the concentration of DOC-CNPs. In vivo, after administration, the DOC-CNPs reached the LNs. After laser irradiation, the DOC-CNPs absorbed laser energy, and the temperature of the LNs increased high enough to achieve photothermal therapy under PA and ultrasound monitoring. Fracture of the DOC-CNPs was caused by the liquid-gas phase transition with the increased temperature, and the ruptured DOC-CNPs released docetaxel to achieve targeted chemotherapy. These findings suggested that DOC-CNPs can achieve precise treatment for metastatic LNs of breast cancer with PA and ultrasound visualization.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

SIGNIFICANCE

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

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

Purpose

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

Methods

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

Results

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

Conclusion

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

A case-control study of using carbon nanoparticles to trace decision-making lymph nodes around inferior mesenteric artery in rectal cancer

BACKGROUND

Accurate identification of lymph nodes localized around inferior mesenteric artery (IMA), with or without metastasis, is of crucial importance for surgeons when dissecting D2 or D3 lymph nodes in patients with rectal cancer (RC). The following study evaluates whether carbon nanoparticles can be used for detection of decision-making lymph nodes (DLNs) in station 253 lymph nodes found around IMA during RC surgery.

METHODS

A total of 66 patients with rectal adenocarcinomas were recruited between January 2014 and August 2017. Patients were divided into carbon nanoparticle (CN) group and control (CL) group; for the CN group, 1 ml nanoparticles were endoscopically injected into submucosal layer of primary tumor 1 day before surgery. DLNs were defined as black-dyed nodes in CN group or macroscopic lymph nodes in CL group localized along the IMA, proximal to the origin of the left colic artery. D3 lymph nodes were dissected using laparoscopic radical resection, and then examined using pathological approach. Intra-operative and post-operative data were compared between the two groups.

RESULTS

In CN group, black-dyed DLNs were easily found under laparoscopy; the median number of DLNs was 3 (range 1-9). In CL group, the median number of DLNs was 0 (range 0-3). Consistency between intra-operative DLNs and post-operative station 253 nodes were confirmed by pathological examination. Significant higher number of DLNs in station 253 nodes (2.91 ± 2.47 vs 0.58 ± 0.75, p < 0.001), number of station 251 nodes (12.85 ± 8.99 vs 8.09 ± 5.85, p = 0.014), number of station 253 nodes (5.21 ± 5.26 vs 3.15 ± 2.32, p = 0.045), and the number of total lymph nodes (24.06 ± 13.20 vs 16.21 ± 9.09, p = 0.007) were found in the CN group compared to CL group.

CONCLUSIONS

Carbon nanoparticles are useful for identifying DLNs in station 253 LNs around IMA in RC. It is not necessary to perform D3 lymph node dissection if there are no intra-operative DLNs metastases in RC.

Short and Long-Term Potential Role of Carbon Nanoparticles in Total Thyroidectomy with Central Lymph Node Dissection

Whether we should use carbon nanoparticle (CN) routinely in thyroid surgery is still controversial. 406 papillary thyroid cancer (PTC) patients who underwent total thyroidectomy (TT) with bilateral central lymph node dissection (CLND) from January 2010 to December 2012 were retrospectively analyzed. The incidence of transient hypoparathyroidism and hypocalcemia in CN group was significantly lower than the control group at second, fifth day after surgery (P = 0.004, 0.042, 0.002 and 0.045 respectively). However, no significant difference existed between the two groups about the permanent hypoparathyroidism and hypocalcemia (P = 1.000). Total number of central lymph nodes and metastatic lymph nodes in CN group were more than those in control group (P = 0.031 and 0.038 respectively). However, recurrence was not significantly different between the two groups after at least 5-year follow up (P = 0.7917). In the subgroup of prophylactic and therapeutic CLND study, no significant difference existed between the two groups (P = 0.5295 and 0.8459 respectively). CN significantly help in identifying the parathyroid glands in surgery and increased the number of lymph nodes in central compartment. However, we should not exaggerate the function of CN since it couldn’t improve the permanent hypoparathyroidism and recurrence in PTC patients who underwent TT with bilateral CLND.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of sentinel lymph node biopsy in newly diagnosed invasive breast cancer patients with suspicious node: a comparative accuracy survey of fine-needle aspiration biopsy versus core-needle biopsy

Comparing diagnostic accuracy study between ultrasonography (US) guided fine-needle aspiration biopsy (FNAB) and core-needle biopsy (CNB) of the Sentinel lymph nodes (SLNs) in newly diagnosed invasive breast cancer patients. We selected 289 newly diagnosed invasive breast cancer patients from June 2015 to July 2017. Ultrasound (US) guided fine-needle aspiration cytology (FNA) and core-needle biopsy (CNB) was performed to identify patients with suspicious sentinel lymph node (SLN). Patients with a cortical thickness > 2 mm or atypical morphological characteristics were recommended FNA and CNB. Axillary lymph node dissection (ALND) was applied to patients with biopsy-proven metastasis, and sentinel lymph node biopsy (SLNB) was applied to FNA or CNB negative patients. ALND was also performed when SNB is positive. Out of 289 patients, only 131 patients met final study criteria. Lymph node status was evaluated by FNA, CNB, SLND, and ALND. Among 131 patients, 45 were deemed positive for metastasis and 86 were determined to be negative with CNB, whereas 38 were deemed positive for metastasis and 93 were determined to be negative by using FNAB. CNB was used to correctly identify seven axillae as positive for metastasis that were deemed negative by using FNAB. There were no positive FNAB results in axillae that were negative for metastasis with CNB. All patients underwent SLNB and those with biopsy-proved axillary metastases were assigned directly to ALND as the primary staging procedure. The final histopathologic assessment indicated that 50 (38.2%) of the 131 axillae studied had axillary LN metastases. Axillary US-guided CNB was used to correctly identify 45 (90.0%) of the 50 LN-positive axillae, whereas axillary US-guided FNAB was used to correctly identify 38 (76.0%, P < 0. 001). There were no false-positive results. CNB netted 5 false-negative results, and FNAB resulted in 12. There was significantly different accuracy between different diagnostic tools. In our study, we demonstrated that CNB is a more reliable approach than FNA for the preoperative diagnosis of SLN metastasis.

Analysis of 246 sentinel lymph node biopsies of patients with clinical primary breast cancer by application of carbon nanoparticle suspension

AIM

This study aims to explore the accuracy, specificity and laws of axillary lymph node metastasis predicted by sentinel lymph node biopsy (SLNB) by comparing axillary lymph node status via SLNB and axillary lymph node dissection (ALND) with nanocarbon as the tracer.

METHODS

Forty six patients were retrospectively analyzed. These patients underwent SLNB with nanocarbon as the tracer from March 2013 to April 2014.

RESULTS

Two hundred and forty six patients of sentinel lymph node (SLN) were successfully detected. Among these patients, 8 patients had 1 SLN (3.25%), 33 patients had 2 SLN (13.41%), 46 patients had 3 SLN (18.70%), 51 patients had 4 SLN (20.73%), 40 patients had 5 SLN (16.26%), 24 patients had 6 SLN (9.76%) and 24 patients had 7 or more SLN (9.76%). The SLNB success rate of nanocarbon staining in the 246 cases was 99.59%, accuracy rate was 97.06% and sensitivity was 93.22%. Furthermore, false negatives were found in four patients, and the false-negative rate was 6.78%. The number of lymph node metastasis in the SLNB and ALND of early-stage breast cancer was analyzed. When the number of SLN dissection was 1, 2, 3, 4, 5, 6 or 7, the coincidence rate of lymph node metastasis for SLNB and ALND was 80.00, 84.36, 78.57, 88.89, 90.48, 80.00, 73.68 and 78.36, respectively.

CONCLUSION

Sentinel lymph node biopsy performed using the nanocarbon staining method is simple, easy and reliable, and it can be used to predict the axillary status of breast cancer in the early stage.

Nanomedicine applications in women's health: state of the art

State-of-the-art applications of nanomedicine have the potential to revolutionize the diagnosis, prevention, and treatment of a range of conditions and diseases affecting women’s health. In this review, we provide a synopsis of potential applications of nanomedicine in some of the most dominant fields of women’s health: mental health, sexual health, reproductive medicine, oncology, menopause-related conditions and dementia. We explore published studies arising from in vitro and in vivo experiments, and clinical trials where available, to reveal novel and highly promising therapeutic applications of nanomedicine in these fields. For the first time, we summarize the growing body of evidence relating to the use of nanomaterials as experimental tools for the detection, prevention, and treatment of significant diseases and conditions across the life course of a cisgender woman, from puberty to menopause; revealing the far-reaching and desirable theoretical impact of nanomedicine across different medical disciplines. We also present an overview of potential concerns regarding the therapeutic applications of nanomedicine and the factors currently restricting the growth of applied nanomedicine.

Big Potential from Small Agents: Nanoparticles for Imaging-Based Companion Diagnostics

The importance of medical imaging in the diagnosis and monitoring of cancer cannot be overstated. As personalized cancer treatments are gaining popularity, a need for more advanced imaging techniques has grown significantly. Nanoparticles are uniquely suited to fill this void, not only as imaging contrast agents but also as companion diagnostics. This review provides an overview of many ways nanoparticle imaging agents have contributed to cancer imaging, both preclinically and in the clinic, as well as charting future directions in companion diagnostics. We conclude that, while nanoparticle-based imaging agents are not without considerable scientific and developmental challenges, they enable enhanced imaging in nearly every modality, hold potential as in vivo companion diagnostics, and offer precise cancer treatment and maximize intervention efficacy.

Reassembly of 89 Zr-Labeled Cancer Cell Membranes into Multicompartment Membrane-Derived Liposomes for PET-Trackable Tumor-Targeted Theranostics

Nanoengineering of cell membranes holds great potential to revolutionize tumor-targeted theranostics, owing to their innate biocompatibility and ability to escape from the immune and reticuloendothelial systems. However, tailoring and integrating cell membranes with drug and imaging agents into one versatile nanoparticle are still challenging. Here, multicompartment membrane-derived liposomes (MCLs) are developed by reassembling cancer cell membranes with Tween-80, and are used to conjugate 89 Zr via deferoxamine chelator and load tetrakis(4-carboxyphenyl) porphyrin for in vivo noninvasive quantitative tracing by positron emission tomography imaging and photodynamic therapy (PDT), respectively. Radiolabeled constructs, 89 Zr-Df-MCLs, demonstrate excellent radiochemical stability in vivo, target 4T1 tumors by the enhanced permeability and retention effect, and are retained long-term for efficient and effective PDT while clearing gradually from the reticuloendothelial system via hepatobiliary excretion. Toxicity evaluation confirms that the MCLs do not impose acute or chronic toxicity in intravenously injected mice. Additionally, 89 Zr-labeled MCLs can execute rapid and highly sensitive lymph node mapping, even for deep-seated sentinel lymph nodes. The as-developed cell membrane reassembling route to MCLs could be extended to other cell types, providing a versatile platform for disease theranostics by facilely and efficiently integrating various multifunctional agents.

Bioaccumulation and Toxicity of Carbon Nanoparticles Suspension Injection in Intravenously Exposed Mice

Carbon nanoparticles suspension injection (CNSI) has been widely used in tumor drainage lymph node mapping, and its new applications in drug delivery, photothermal therapy, and so on have been extensively investigated. To develop new clinical applications, the toxicity of CNSI after intravenous exposure should be thoroughly investigated to ensure its safe use. Herein, we studied the bioaccumulation of CNSI in reticuloendothelial system (RES) organs and the corresponding toxicity to mice. After the intravenous injection of CNSI, no abnormal behavior of mice was observed during the 28-day observation period. The body weight increases were similar among the exposed groups and the control group. The parameters of hematology and serum biochemistry remained nearly unchanged, with very few of them showing significant changes. The low toxicity of CNSI was also reflected by the unchanged histopathological characteristics of these organs. The injection of CNSI did not induce higher apoptosis levels either. The slight oxidative stress was observed in RES organs at high dosages at day 7 post-exposure. The implication to the clinical applications and toxicological evaluations of carbon nanomaterials is discussed.

Retrospective observational study about reducing the false negative rate of the sentinel lymph node biopsy: Never underestimate the effect of subjective factors

Reducing the false negative rate of sentinel lymph node biopsy (SLNB) for breast cancer patients has always been a focus of clinical research. We aimed to map the sentinel lymph nodes (SLNs) in detail, and analyze the factors related to SLNs located at locations that are often ignored by surgeons, to reduce the rate of false negatives from SLNB. A retrospective analysis involving 545 breast cancer patients who underwent SLNB in west China hospital between August 2010 and February 2016 was performed. Blue dye, radioisotope, or combined methods were used for tracing SLNs. Using blue dye, radioisotope, and a combination of blue dye and radioisotope successfully traced SLNs in 479, 507, and 525 patients, the detection rate was 88.2%, 93.9%, and 97.4%, respectively. Among the 1559 detected SLNs, 139 (9.6%) were located at the latissimus dorsi lateral margin, and 108 (6.9%) were located at level 2. Subcutaneous injection of radioisotope (P = .004) and intradermal injection of blue dye (P = .002) were independent factors associated with SLNs distributed at level 2 and the latissimus dorsi lateral margin, respectively. It was noteworthy that 2 of 7 patients had skipping metastasis in level 2, so subcutaneous injection of the isotope is strongly recommended for tracing SLNs distributed in level 2 because of the possibility of skipping metastasis. Though intradermal injection of blue dye was superior methods for tracing SLNs located at the latissimus dorsi lateral margin, we surprisingly found those patients with metastasis to the latissimus dorsi lateral margin nodes also could have metastasis to level 1 (expect for the latissimus dorsi lateral margin) nodes, it seemed that maybe there is no need to excise SLNs at the latissimus dorsi lateral margin in SLNB, whether such nodes should be regarded as useful for SLNB still needs to be determined by further large, multicenter clinical studies.

Skeleton labeled 13C-carbon nanoparticles for the imaging and quantification in tumor drainage lymph nodes

Carbon nanoparticles (CNPs) have been widely used in tumor drainage lymph node (TDLN) imaging, drug delivery, photothermal therapy, and so on. However, during the theranostic applications, the accumulation efficiency of CNPs in target organs is unknown yet, which largely hinders the extension of CNPs into clinical uses. Herein, we prepared skeleton-labeled 13C-CNPs that had identical properties to commercial CNPs suspension injection (CNSI) for the imaging and quantification in TDLN. 13C-CNPs were prepared by arc discharge method, followed by homogenization with polyvinylpyrrolidone. The size distribution and morphology of 13C-CNPs were nearly the same as those of CNSI under transmission electron microscope. The hydrodynamic radii of both 13C-CNPs and CNSI were similar, too. According to X-ray photoelectron spectroscopy and infrared spectroscopy analyses, the chemical compositions and chemical states of elements were also nearly identical for both labeled and commercial forms. The skeleton labeling of 13C was reflected by the shift of G-band toward lower frequency in Raman spectra. 13C-CNPs showed competitive performance in TDLN imaging, where the three lymph nodes (popliteal lymph node, common iliac artery lymph node, and paraaortic lymph node) were stained black upon the injection into the hind extremity of mice. The direct quantification of 13C-CNPs indicated that 877 μg/g of 13C-CNPs accumulated in the first station of TDLN (popliteal lymph node). The second station of TDLN (common iliac artery lymph node) had even higher accumulation level (1,062 μg/g), suggesting that 13C-CNPs migrated efficiently along lymphatic vessel. The value decreased to 405 μg/g in the third station of TDLN (paraaortic lymph node). Therefore, the 13C-CNPs provided quantitative approach to image and quantify CNSI in biological systems. The implication in biomedical applications and biosafety evaluations of CNSI is discussed.

In-Situ Formation of Holmium Oxide in Pores of Mesoporous Carbon Nanoparticles as Substrates for Neutron-Activatable Radiotherapeutics

Radionuclide therapy with nano-sized carriers is a very promising approach to treat various types of cancer. The preparation of radioactive nanocarriers can be achieved with minimum handling using a neutron-activation approach. However, the nanocarrier material must possess certain characteristics such as low density, heat-resistance, high metal adsorption, easy surface modification and low toxicity in order to be useful. Mesoporous Carbon Nanoparticles (MCNs) in which holmium oxide is formed in their pores by a wet-impregnation process are investigated as a suitable material for this application. Holmium (¹⁶⁵Ho) has a natural abundance of 100% and possesses a large cross-section for capturing thermal neutrons. After irradiation of Ho-containing MCNs in a neutron flux, ¹⁶⁶Ho, which emits therapeutic high energy beta particles as well as diagnostic low energy gamma photons that can be imaged externally, is produced. The wet impregnation process (16 w/w% Ho loading) is shown to completely prevent the leaching of radioactive holmium from the MCNs without compromising their structural integrity. In vitro studies showed that the MCNs containing non-radioactive holmium do not exhibit toxicity and the same formulation with radioactive holmium (¹⁶⁶Ho) demonstrated a tumoricidal effect. Post-irradiation PEGylation of the MCN surfaces endows dispersibility and biocompatibility.

Nanoparticles as Theranostic Vehicles in Experimental and Clinical Applications-Focus on Prostate and Breast Cancer

Prostate and breast cancer are the second most and most commonly diagnosed cancer in men and women worldwide, respectively. The American Cancer Society estimates that during 2016 in the USA around 430,000 individuals were diagnosed with one of these two types of cancers, and approximately 15% of them will die from the disease. In Europe, the rate of incidences and deaths are similar to those in the USA. Several different more or less successful diagnostic and therapeutic approaches have been developed and evaluated in order to tackle this issue and thereby decrease the death rates. By using nanoparticles as vehicles carrying both diagnostic and therapeutic molecular entities, individualized targeted theranostic nanomedicine has emerged as a promising option to increase the sensitivity and the specificity during diagnosis, as well as the likelihood of survival or prolonged survival after therapy. This article presents and discusses important and promising different kinds of nanoparticles, as well as imaging and therapy options, suitable for theranostic applications. The presentation of different nanoparticles and theranostic applications is quite general, but there is a special focus on prostate cancer. Some references and aspects regarding breast cancer are however also presented and discussed. Finally, the prostate cancer case is presented in more detail regarding diagnosis, staging, recurrence, metastases, and treatment options available today, followed by possible ways to move forward applying theranostics for both prostate and breast cancer based on promising experiments performed until today.

[Application of carbon nanoparticles as lymph node tracers in patients with cN0 lingual squamous cell carcinoma un-dergoing neck dissection]

OBJECTIVE

This study aimed to investigate the value of carbon nanoparticles as lymph node tracers in neck dissection for cN0 lingual squamous cell carcinoma patients.

METHODS

Ninety-six patients with cN0 lingual squamous cell carcinoma were recruited to undergo surgical treatment were randomly divided into two groups, namely, the carbon nanoparticle-labeled group (the experimental group, 50 cases) and the control group (46 cases). Carbon nanoparticle suspension was injected into the submucosal layer around the site of the primary tumor at three or four points (0.1 mL for each point) 12 h before surgery. Supraomohyoid neck dissection (SOHND, Levels Ⅰ to Ⅲ) or comprehensive neck dissection (CND, Levels Ⅰto Ⅴ) were performed based on the size and location of the primary tumor. All the lymph nodes were dissected and separated from the ex vivo surgical specimens for histopathological evaluation. The number, size, location, and pathological result of all the lymph nodes were compared between the two groups. Statistical analyses were conducted by SPSS 19.0 software.

RESULTS

A total of 1 137 lymph nodes were detected in 31 SOHND patients. The average number of lymph nodes detected in the experimental group was (43.79±19.23) /case, which was significantly higher than that in the control group [(30.82±8.77) /case] (P=0.019). Level Ⅲ covered the largest number of lymph nodes in the two groups. However, the number and proportion of lymph nodes found in Level Ⅱ of the experimental group were significantly higher than those of the control group (P=0.000). A total of 3 938 lymph nodes were detected in 65 CND patients. The average number of lymph nodes detected in the experimental group [(66.67±20.02) /case] was larger than that in the control group [(53.03±20.98) /case] (P=0.026). The difference in the lymph node location between the two groups was not statistically significant (P=0.354). In the two neck dissection methods, both the proportion of minute lymph nodes and the accuracy of the detected lymph nodes in the experimental group were significantly larger than those in the control groups (P=0.000). Compared with the control group, more metastases were proven by the carbon nanoparticle-labeled lymph nodes (P=0.000) in the experimental group.

CONCLUSIONS

Carbon nanoparticles as lymph node tracers in patients with cN0 lingual squamous cell carcinoma undergoing neck dissection can increase the number of detected lymph nodes, especially the minute nodes. Such nanoparticles can further ensure the thoroughness of neck dissection and the accuracy of clinicopathological stage.

Lymphatic metastasis of gallbladder cancer: Present and future

Lymphatic metastasis is the most common way of metastasis in gallbladder cancer (GBC), and it is also one of the important factors influencing prognosis. Therefore, it is important to elucidate the lymphatic drainage pathways, group the metastatic lymph nodes, assess the extent of lymphadenectomy, and identify relevant predictors of lymphatic metastasis. The development of lymph node tracer technique has greatly improved the surgical procedure, and exploration of the molecular mechanisms of lymphatic metastases may provide new therapeutic targets. In the current review, we discuss the lymphatic drainage pathways as well as the substation, predictors, tracers and mechanisms of lymphatic metastasis of GBC.

Preoperative endoscopic localization of colorectal cancer and tracing lymph nodes by using carbon nanoparticles in laparoscopy

Background

The objective of this study is to evaluate the effectiveness of preoperative endoscopic localization of colorectal cancer and tracing lymph nodes by carbon nanoparticle tattooing in laparoscopic colorectal cancer surgery.

Methods

From January 2013 to December 2014, 54 patients with colorectal cancer were recruited and divided into experimental (n = 27) and control (n = 27) groups. The patients in the experimental group were localized preoperatively by endoscopic carbon nanoparticle tattooing, whereas patients in the control group were not tattooed.

Results

All injection sites in the experimental group were visible to surgeons. No abdominal pain, fever, diarrhea, and other symptoms of infection were found in the experimental group. The time for detecting the tumor (2.71 ± 2.13 min versus 6.91 ± 5.16 min, p < 0.001), operation time (151.22 ± 30.66 min versus 170.26 ± 33.13 min, p = 0.033), and blood loss during the operation (125.04 ± 29.48 mL versus 147.52 ± 34.35 mL, p = 0.013) were lower in the experimental group than in the control group. Average numbers of dissected lymph nodes in the experimental group exceeded those in the control group (14.41 ± 3.32 versus 8.96 ± 2.90, p < 0.001), and the rate of dissected lymph nodes ≥12 was higher in the experimental group than in the control group (70.37 versus 37.04 %, p < 0.001). Moreover, no difference in postoperative complications was found between the two groups.

Conclusions

Tattooing colorectal cancer with carbon nanoparticles in laparoscopic colorectal cancer surgery is safe and useful both in localization and lymph node tracing.

A mini-review on factors and countermeasures associated with false-negative sentinel lymph node biopsies in breast cancer

Sentinel lymph node biopsy (SLNB) is a new surgical technique for local axillary lymph nodes (ALNs) of breast cancer. Large-scale clinical trials have confirmed that undergoing SLNB and ALN dissection (ALND) showed no significant difference for sentinel lymph node (SLN)-negative patients in terms of disease-free survival, overall survival and recurrence-free survival. However, false-negative results are still the main concern of physicians as well as patients who undergo SLNB instead of ALND. The American Society of Breast Surgeons established a task force to suggest acceptable standards for SLNB. In 2000, the task force recommended that the identification rate for SLNB be 85% or higher and the false-negative rate be 5% or lower. This review focuses on clinical factors (tumor volume, multifocal/multi-center cancers, neoadjuvant chemotherapy and skip metastasis), tracer techniques and pathological factors affecting SLNB and explores methods for reducing the false-negative rate.