Application of carbon nanoparticles in laparoscopic sentinel lymph node detection in patients with early-stage cervical cancer

A Retrospective Study of Laparoscopic Distal Gastrectomy Guided by Carbon Nanoparticle Suspension Injection Lymphography for Gastric Cancer

BACKGROUND

The use of lymph node (LN) tracers can help obtain a complete dissection of the LNs and increase the detection rate of metastatic LNs. Carbon nanoparticle suspension injection (CNSI) has become increasingly used in radical gastrectomy procedures. This study is designed to evaluate the quality of LN dissection in gastric cancer patients with laparoscopic distal gastrectomy under the guidance of CNSI lymphography.

METHOD

This was a retrospective cohort study including patients with a pathological biopsy diagnosis of resectable gastric cancer who underwent laparoscopic distal gastrectomy. Data was focused on patients at [Renji Hospital of Shanghai Jiaotong University] from July 2023 to January 2024. Patients were divided into the CNSI group and control group after 1:1 propensity score matching analysis. The median number of LNs harvested was compared between groups. Perioperative status and any complications that arose within 30 days were also analyzed.

RESULT

After 1:1 propensity matching analysis, there were 49 patients each in the CNSI group and control group. The median number of harvested LNs was larger in the CNSI group than the control group (P = 0.01). A significant difference between 2 groups was observed in surgery time (P = 0.008). The morbidity of any short-term postoperative complications within 30 days after surgery revealed a similar outcome (P > 0.05).

DISCUSSION

CNSI-guided laparoscopic distal gastrectomy is less time-consuming and harvests more LNs. For laparoscopic distal gastrectomy, CNSI-guided lymphography can be an excellent adjuvant.

Targeted axillary dissection using carbon marking for patients with node-positive breast cancer following neoadjuvant therapy (TADCOM): study protocol for a prospective, multicenter, randomized controlled trial

BACKGROUND

Neoadjuvant chemotherapy (NAC) for breast cancer enables pathological complete response (pCR) in patients initially diagnosed with axillary lymph node metastases, potentially obviating the need for axillary lymph node dissection (ALND). Current targeted axillary dissection (TAD) techniques, guided by traditional tissue markers placed prior to NAC, face challenges such as marker loss and high costs. Carbon nanoparticle suspension injection (CNSI) offers a stable and reliable alternative for marking, which could enhance the TAD procedure. This study aims to evaluate the feasibility and accuracy of different TAD strategies using CNSIs and to explore their clinical utility in locally advanced breast cancer.

METHODS

This prospective, multicenter, randomized controlled trial will enroll 126 biopsy-proven breast cancer patients with suspicious axillary lymph node metastases (cN1-2a) who achieve ycN0 status following NAC. Participants will be randomized in a 1:1:1 ratio to undergo TAD guided by: [1] conventional tissue clips (CG-TAD); [2] CNSI lymph node marking (CN-LNM); or [3] peritumoral CNSI mapping (PCN-MAP). Primary endpoints include retrieval rate of marked lymph nodes, number of sentinel and marked lymph nodes, concordance rates, and complication rates. Secondary endpoints encompass regional and distant recurrence rates, survival outcomes, surgical duration, postoperative complications, quality of life scores, and margin status in breast-conserving surgery. Statistical analyses will adhere strictly to the CONSORT guidelines.

DISCUSSION

This study aims to evaluate the feasibility and accuracy of CNSI for targeted axillary dissection in breast cancer patients following neoadjuvant chemotherapy and to explore its clinical significance in reducing surgical complications and costs, as well as improving surgical precision.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04744506, Registered 27 December 2020, Updated 24 September 2024. Protocol Version Ver 1.2, 17/9/2024.

Neoadjuvant chemotherapy followed by surgery versus concurrent chemoradiotherapy in patients with stage IIB cervical squamous cell carcinoma: a retrospective cohort study

PURPOSE

This study aims to compare treatment outcomes between neoadjuvant chemotherapy (NACT) followed by surgery and concurrent chemoradiotherapy (CCRT) in patients with stage IIB cervical squamous cell carcinoma (CSCC).

MATERIALS AND METHODS

We conducted a retrospective cohort study involving patients with stage IIB CSCC treated at Guangxi Medical University Cancer Hospital between June 2012 and June 2019. We compared overall survival (OS), locoregional-free survival (LRFS), and distant metastasis-free survival (DMFS) between the NACT + surgery and CCRT groups.

RESULTS

A total of 257 patients were enrolled: 165 underwent NACT + surgery and 92 received CCRT. Before propensity score matching, the NACT + surgery group exhibited lower 5-year OS (68.2% vs. 85.6%; hazard ratio [HR] = 2.50, 95% confidence interval [CI]: 1.26-4.96; P = 0.009), LRFS (85.2% vs. 96.9%; HR = 5.88, 95% CI: 1.33-25.94; P = 0.019), and DMFS (81.9% vs. 97.4%; HR = 6.65, 95% CI: 1.51-29.23; P = 0.012) compared to the CCRT group. After propensity score matching, OS, LRFS, and DMFS remained worse in the NACT + surgery group compared to the CCRT group.

CONCLUSION

NACT followed by surgery is associated with decreased OS, LRFS, and DMFS compared to CCRT among patients with stage IIB CSCC.

Recent status and trends of nanotechnology in cervical cancer: a systematic review and bibliometric analysis

Background

Cervical cancer is currently the second leading cause of cancer death among women from developing countries (1). However, there is a lack of effective treatment methods, and the existing treatments often result in significant adverse reactions and high chances of recurrence, which ultimately impact the prognosis of patients. As a result, the application of nanotechnology, specifically nanoparticle-based approaches, in the diagnosis and treatment of cervical cancer has gained significant attention. This study aims to examine the current research status and future development trends of nanotechnology in relation to cervical cancer using a bibliometric perspective.

Methods

A bibliometric analysis was performed to gather relevant research papers from the Web of Science database. VOSviewer and CiteSpace were utilized to conduct quantitative analysis and identify hot topics in the field, focusing on countries, institutions, journals, authors, and keywords.

Result

A total of 997 eligible literature were retrieved. From January 1, 2014 to September 20, 2023, the overall number of publications showed an upward trend. The paper mainly comes from China (n=414). The main institution is the Chinese Academy of Sciences (n=62), and 60% of the top 10 institutions in the number of documents issued are from China. First authors Ma, Rong (n=12) and Alifu, Nuernisha (n=12). The journal with the highest publication volume is ACS Applied Materials&INTERFACES (n=35), and the journal with the highest citation frequency is BIOMATERIALS (n=508). "Nanoparticles (n=295)", "cervical cancer (n=248)", and "drug delivery (n=218)" are the top three most frequently occurring keywords. In recent years, photothermal therapy and indocyanine green have become research hotspots.

Conclusion

The application of nanotechnology in the field of cervical cancer has garnered considerable attention. Nanoparticles-based methods for diagnosis, administration, and treatment have proven to be instrumental in enhancing the sensitivity of cervical cancer detection, improving the accuracy and efficiency of administration, and reducing drug toxicity. Enhancing treatment efficacy and improving patient prognosis have emerged as current research priorities and future directions.

[Application of methylene blue near-infrared fluorescence imaging for oral sentinel lymph node mapping in rats]

OBJECTIVE

To explore the concentration range and penetration depth of methylene blue near-infrared fluorescence imaging, and to clarify the role of methylene blue in oral lymphatic drainage and sentinel lymph node localization, so as to lay a foundation for the potential research and application of sentinel lymph node in oral cancer.

METHODS

10% (mass fraction) methylene blue injection was diluted into 29 different concentrations with 0.9% (mass fraction) normal saline, and the concentration range of methylene blue near-infrared fluorescence imaging was determined by near-infrared fluorescence imager. The maximum penetration depth of methylene blue near-infrared fluorescence was determined by covering pigskin with different thicknesses (1, 2, 3, 4 and 5 mm) in methylene blue solution. 0.2 mL methylene blue solution was injected into the submucosal 0.5 cm at the lateral margin of tongue on one side of the rats. The near-infrared fluorescence imager was used for continuously monitoring for 3 hours. The first near-infrared fluorescence hotspot was identified as sentinel lymph node and labeled by percutaneous observation. The rats were then sacrificed and dissected in the head and neck. Near-infrared fluorescence imaging was performed again to observe whether the fluorescent tissue was consistent with the labeled fluorescent hotspot in vitro, and the presence of lymphoid tissue was confirmed by pathological examination after resection.

RESULTS

Except that no fluorescence signals were detected in the blank control groups, the fluorescence intensity of methylene blue increased first and then decreased with its solution concentration decreased. When the concentration of methylene blue was diluted to the picomole level, the fluorescence signal could still be detected. The maximum penetration depth of methylene blue fluorescence was 4 mm. Methylene blue near-infrared fluorescence could be localized in oral lymphatic drainage and sentinel lymph node. The fluorescence was sustained for more than 3 hours after methylene blue injection. Methylene blue solution concentrations of 3.34 mmol/L, 6.68 mmol/L, 13.37 mmol/L and 26.74 mmol/L were selected in the rats to map sentinel lymph node by near-infrared fluorescence.

CONCLUSION

Methylene blue near-infrared fluorescence has a certain penetrating ability and can transcuta-neously map the sentinel lymph node and their associated lymphatic vessels in rats, which is expected to be further applied in the study of sentinel lymph node in oral cancer.

The Value of Contrast-Enhanced Ultrasound in the Detection of Sentinel Lymph Nodes in Malignant Melanoma

OBJECTIVE

To evaluate the location and characterization value of contrast-enhanced ultrasound (CEUS) in the detection of sentinel lymph nodes (SLNs) in malignant melanoma.

METHODS

SLNs and the lymph node network were tracked by subcutaneous injection of ultrasonic contrast agent around the tumor and preoperative localization, and qualitative analyses were performed. The SLNs were also detected by the intraoperative subcutaneous injection of carbon nanoparticles, and the findings were compared with lymph nodes located by CEUS. The accuracy of the preoperative lymph node identification was evaluated by the results of postoperative pathology, which served as the gold standard of detection.

RESULTS

In 47 patients with malignant melanoma, the mean number of SLNs detected by CEUS was 1.72 ± 0.10, while that by carbon nanoparticle administration it was 1.79 ± 1.07 (P = .371 > .05). Seven cases of lymph node metastasis were detected by CEUS, with a sensitivity of 70.0%, specificity of 97.3%, positive predictive value of 87.5%, negative predictive value of 92.3%, and accuracy of 91.5%. There was high consistency between the findings of CEUS and pathology in differentiating benign and malignant lymph nodes (kappa = 0.726, χ²  = 25.243, P < .001).

CONCLUSIONS

CEUS can localize and differentiate SLNs in malignant melanoma, and thus, may potentially guide clinical treatment in the future.

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.

The safety and efficacy of carbon nanoparticle suspension injection versus indocyanine green tracer-guided lymph node dissection during radical gastrectomy (FUTURE-01): A single-center randomized controlled trial protocol

Background

The use of lymph node (LN) tracers can help obtain a complete dissection of the lymph nodes and increase the detection rate of LNs and metastatic LNs. Carbon nanoparticle suspension injection (CNSI) and indocyanine green (ICG) have been widely used in radical gastrectomy in recent years. Nevertheless, the comparison of their clinical effects has not been studied.

Method/design

The FUTURE-01 trial will be the first randomized, open-label, single-center trial to compare CNSI and ICG. The study started in 2021 and enrolled 96 patients according to a prior sample size calculation. The primary outcome is the number of LNs retrieved. The secondary outcomes are LN staining rate, LN metastasis rate, stained LN metastasis rate, perioperative recovery and survival.

Conclusion

By comparing the safety and efficacy of CNSI and ICG tracer-guided LN dissection in patients with gastric cancer, we can determine the most appropriate LN tracer at present. With the help of LN tracers, the operation is simplified, and the prognosis of these patients is improved. Our study is a prospective exploration of the safety, efficacy, and prognosis of CNSI and ICG.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT05229874?cond=NCT05229874&draw=2&rank=1, identifier NCT05229874.

Feasibility of Sentinel Lymph Node Mapping With Carbon Nanoparticles in Cervical Cancer: A Retrospective Study

INTRODUCTION

This retrospective study aims to investigate the feasibility of using carbon nanoparticles to detect sentinel lymph nodes (SLNs) in cervical cancer.

METHODS

This study involved 174 patients with cervical cancer. Cervix tissues adjacent to the cancer were injected with 1 mL of carbon nanoparticles (CNPs) at the 3 and 9 o'clock positions according to the instructions. The pelvic lymph nodes were then dissected, and the black-stained sentinel lymph nodes were sectioned for pathological examination.

RESULTS

Of 174 cases, 88.5% of patients (154/174) had at least 1 sentinel lymph node, and 131 patients (75.29%) had bilateral pelvic sentinel lymph nodes. The left pelvic lymph node was the most common sentinel lymph node (34.16%). At least 1 sentinel lymph node was observed in 285 out of 348 hemipelvises, with a detection rate of a side-specific sentinel lymph node of 81.89%. In total, 47 hemipelvises had metastasis of the lymph node, and 33 involved the sentinel lymph node, with a sensitivity of 70.21% and a false-negative rate of 29.79%. There were 238 hemipelvises with no metastasis of the lymph node, as well as negative sentinel lymph nodes, with a specificity of 100% and a negative predictive value of 94.44%. The univariate analysis demonstrated that risk factors included tumor size (OR .598, 95% CI: .369-.970) and deep stromal invasion (OR .381, 95% CI: .187-.779). The deep stromal invasion was the only variable for the false-negative detection of a sentinel lymph node.

CONCLUSION

Sentinel lymph node mapping with carbon nanoparticles might be applied to predict the metastasis of pelvic lymph nodes in cervical cancer. However, tumor size and deep stromal invasion might negative influence the detection rate of SLN.

[Carbon nanoparticle tracing of sentinel lymph nodes in diagnosis and treatment of cervical cancer and clinical value of lymph node ultrastaging detection]

OBJECTIVE

To evaluate the clinical value of sentinel lymph node (SLN) detection using carbon nanoparticles in the diagnosis and treatment of cervical cancer and the value of lymph node pathological ultrastaging detection.

METHODS

A total of 79 patients with cervical cancer in IA2, IB1, IB2, IIA1 and IIICp1 stages admitted to the Department of Gynecology and Obstetrics, Nanfang Hospital between June, 2018 and January, 2021 were included in this study. During the operation, the patients were injected with a total of 0.25 mL carbon nanoparticles at 3 and 9 o'clock of the normal cervix after general anesthesia. The first black-dyed lymph nodes were identified as SLNs and removed one by one. All the patients underwent pelvic lymph node dissection and radical hysterectomy with or without para-aortic lymphadenectomy. The black-dyed SLNs were removed for routine pathological examination. Thirty patients with negative SLNs were randomly selected for pathological ultrastaging.

RESULTS

In 67 of the 79 patients, a total of 417 SLNs were detected with a detection rate of 84.8%; in each patient, at least 1 SLN was detected with a mean SLN number of 5.28. After the operation, 5 patients were found to have positive SLNs; 1 patient was negative for SLN but positive for non-SLN. The sensitivity of SLN biopsy was 83.3% with a specificity of 100%, false negative rate of 16.7%, an accuracy of 98.5% and a negative predictive value of 98.4%. SLN was distributed mainly in the obturator region, the external iliac region, the internal iliac region and the total iliac region (15.11%). Univariate and multivariate analyses suggested that preoperative cervical coning (P=0.045 and 0.009) and tumor size (P=0.033 and 0.008) significantly affected the overall detection rate of SLN. Kappa test showed a high consistency between SLN and pelvic lymph node metastasis status (Kappa value=0.901, P < 0.001). In 30 patients with negative pathological results of SLN, pathological ultrastaging detection identified no micrometastases or isolated tumor cells.

CONCLUSION

Carbon nanoparticle tracing of the SLNs is safe and feasible in the diagnosis and treatment of cervical cancer, and SLN detection is safe in patients with primary lesion size below 2 cm or without cervical conization. SLN combined with pathological ultrastaging detection does not improve the detection rate of isolated tumor cells or micrometastases.

Sentinel node navigation surgery in cervical cancer: a systematic review and metaanalysis

Sentinel node navigation surgery (SNNS) is used in clinical practice for the treatment of cervical cancer. This study aimed to elucidate the appropriate sentinel lymph node (SLN) mapping method and assess the safety and benefits of SNNS. We searched the PubMed, Ichushi, and Cochrane Library databases for randomized controlled trials (RCT) and studies on SLN in cervical cancer from January 2012 to December 2020. Two authors independently assessed study quality and extracted data. We quantitatively analyzed the detection rate, sensitivity/specificity, and complications and reviewed information, including the survival data of SLN biopsy (SLNB) without pelvic lymphadenectomy (PLND). The detection rate of SLN mapping in the unilateral pelvis was median 95.7% and 100% and in the bilateral pelvis was median 80.4% and 90% for technetium-99 m (Tc) with/without blue dye (Tc w/wo BD) and indocyanine green (ICG) alone, respectively. The sensitivity and specificity of each tracer were high; the area under the curve of each tracer was 0.988 (Tc w/wo BD), 0.931 (BD w/wo Tc), 0.966 (ICG), and 0.977 (carbon nanoparticle). Morbidities including lymphedema, neurological symptoms and blood loss were associated with PLND. One RCT and five studies all showed SNNS without systematic PLND does not impair recurrence or survival in early-stage cervical cancer with a tumor size ≤ 2-4 cm. Both Tc w/wo BD and ICG are appropriate SLN tracers. SNNS can reduce the morbidities associated with PLND without affecting disease progression in early-stage cervical cancer.

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.

Assessment of Carbon Nanoparticle Suspension Lymphography-Guided Distal Gastrectomy for Gastric Cancer

IMPORTANCE

Carbon nanoparticle suspension injection (CNSI) can be used to visualize lymph node (LN) drainage in gastric cancer. The tracing and diagnostic value of carbon nanoparticle suspension lymphography-guided distal gastrectomy for gastric cancer has not been thoroughly reported.

OBJECTIVE

To compare the number of lymph nodes identified in patients with gastric cancer receiving a CNSI vs no injection.

DESIGN, SETTING, AND PARTICIPANTS

This is a retrospective cohort study including patients with clinical T1 to T4 disease who underwent laparoscopic or robotic distal gastrectomy. Data from a cohort of 1225 patients at the Fourth Hospital of Hebei Medical University (Shijiazhuang, China) from November 2019 to February 2021 were analyzed. Patients were divided into the CNSI group and conventional group after 1:1 propensity matching analysis. The mean number of LNs detected was compared between groups, and the diagnostic role of CNSI was analyzed in the CNSI group. Statistical analysis was performed from May to July 2021.

EXPOSURE

CNSI was peritumorally injected under an endoscope 1 day before surgery in the CNSI group, and the conventional group did not receive any treatment before surgery.

MAIN OUTCOMES AND MEASURES

The main outcome was the number of LNs detected. Gastrectomy with systematic D1+ (ie, stations 1, 3, 4sb, 4d, 5, 6, and 7) or D2 (ie, all D1 stations, plus 8a, 9, 11p, and 12a) lymphadenectomy was performed. Black-stained LNs and nonblack-stained LNs were examined separately in the CNSI group.

RESULTS

A total of 312 consecutive patients (mean [SD] age, 56.7 [10.4] years; 216 [69.2%] men) who underwent distal gastrectomy were enrolled, including 78 patients in the CNSI group, and another 78 patients determined from 1:1 propensity score matching, making an overall cohort size of 156 patients. The mean (SD) number of LNs detected in the CNSI group was 59.6 (21.4), which was significantly higher than that in the conventional group (30.0 [11.3] LNs; P < .001). In the CNSI group, the mean (SD) number of LNs detected at black-stained LN stations was significantly higher than that at nonstained LN stations (9.2 [6.1] LNs per station vs 3.5 [3.2] LNs per station; P < .001). For black-stained LN stations, the sensitivity was 97.8% (95% CI, 91.6%-99.6%), specificity was 38.1% (95% CI, 34.2%-42.3%), positive predictive value was 20.1% (95% CI, 16.6%-24.2%), and negative predictive value was 99.1% (95% CI, 96.4%-99.8%); for the black-stained LNs, sensitivity was 97.6% (95% CI, 95.3%-98.8%), specificity was 35.4% (95% CI, 33.9%-36.8%), positive predictive value was 11.6% (95% CI, 10.5%-12.8%), and negative predictive value was 99.4% (95% CI, 98.8%-99.7%).

CONCLUSIONS AND RELEVANCE

These findings suggest that CNSI was associated with facilitating the dissection of all positive LNs, which could improve surgical quality. Carbon nanoparticle suspension-guided lymphography may be an alternative to conventional systematic lymphadenectomy for distal gastrectomy.

Safety and efficacy of carbon nanoparticle suspension injection and indocyanine green tracer-guided lymph node dissection during robotic distal gastrectomy in patients with gastric cancer

BACKGROUND

There is a lack of comparative analyses on the use of carbon nanoparticle suspension injection (CNSI) and indocyanine green (ICG) tracer technology for lymph node detection and their perioperative safety in robotic radical gastrectomy.

METHODS

A retrospective analysis was performed on patients who underwent robotic distal gastrectomy between November 2019 and November 2020. Patients were assigned to the CNSI group, the ICG group, or the control group. The number of lymph nodes detected, number of lymph nodes detected at each station, number of micro lymph nodes detected, rate of lymph node metastasis, and inoperative and postoperative recovery were compared.

RESULTS

Of the 93 patients analyzed, 34 were in the CNSI group, 27 were in the ICG group, and 32 were in the control group. The mean number of lymph nodes retrieved in the CNSI group (48.44) was higher than that in the ICG (39.19) and control (35.28) groups (P = 0.004; P < 0.001), and there was no difference between the ICG and control groups (P = 0.102). The mean number of micro lymph nodes retrieved in the CNSI group (13.24) was higher than that in the ICG (5.74) and control (5.66) groups (P < 0.001). The lymph node metastasis rates in the CNSI, ICG, and control groups were 5.03, 4.63, and 5.93%, respectively (P > 0.05).

CONCLUSION

The effect of CNSI on lymph node dissection and sorting was better than that of ICG, and CNSI improved the surgical quality and reduced lymph node staging deviation to a greater extent. CNSI was better than ICG in terms of improving the number of micro lymph nodes detected.

Carbon nanoparticles combined with indocyanine green for sentinel lymph node detection in endometrial carcinoma

OBJECTIVE

To evaluate the feasibility and clinical value of the combination of carbon nanoparticles (CNPs) and indocyanine green (ICG) for identifying sentinel lymph nodes (SLNs) in endometrial cancer.

MATERIALS AND METHODS

About 153 patients with endometrial cancer were recruited from July 2015 to May 2019. All patients underwent SLN biopsy according to the SLN algorithm for surgical staging with ICG and/or CNPs. The detection rate, factors associated with the detection rate, sensitivity, and negative predictive value (NPV) of SLNs were analyzed.

RESULTS

The detection rates of SLNs with the combined method were the highest among the different methods. As calculated per hemipelvis, the sensitivity and NPV with ICG alone or with ICG plus CNPs were 100%. With CNP, tumor Grade 3 and laparoscopy were related to unsuccessful overall SLN mapping while tumor diameter greater than 2 cm and laparoscopy were statistically associated with failed bilateral mapping. With ICG, a higher body mass index was significantly associated with unsuccessful bilateral detection of SLN.

CONCLUSION

SLN assessment in endometrial cancer is feasible and safe with high sensitivity and high NPV when ICG and CNPs are combined and in low-risk patients. It is a superior option to use CNPs in laparotomy for patients with endometrial cancer.

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.

Controversies in Sentinel Lymph Node Biopsy for Gynecologic Malignancies

OBJECTIVE

Sentinel lymph node (SLN) biopsy represents an evolution in the advancement of minimally invasive surgical techniques for gynecologic cancers. Prospective and retrospective studies have consistently shown its accuracy in the detection of lymph node metastases for endometrial and cervical cancers. However, consistent with any emerging surgical technique in the early phases of adoption, new questions have arisen regarding its application and impact. This paper served as a scoping review to identify the key controversies that have arisen in the field of SLN biopsy for endometrial and cervical cancers.

DATA SOURCES

Several key controversies were identified, and PubMed, the Cochrane Library (cochranelibrary.com) advanced search function, and the National Comprehensive Cancer Network guidelines were searched for supporting evidence. These included search terms such as "the accuracy of SLN biopsy for high grade endometrial cancer or cervical cancers >2-cm," "cost effectiveness of SLN biopsy for gynecologic cancers," "clinical significance of low volume metastases in endometrial cancer," "morbidity of SLN biopsy for endometrial and cervical cancer," and "impact on cancer survival of SLN biopsy for endometrial and cervical cancer."

METHODS OF STUDY SELECTION

Studies were selected for review if they included significant numbers of patients, were level I evidence, or were prospective trials. Where this level of evidence failed to exist, seminal observational series that were published in high-quality journals were included.

TABULATION, INTEGRATION, AND RESULTS

Similar studies were listed and subcategorized and cross-compared, excluding those that included repeated analyses of the same patient populations. The relevant clinical trials or observational studies were clustered and reviewed for each chosen controversy. Adequate evidence supports the accuracy of SLN biopsy in the staging of high-grade endometrial cancer and cervical cancer, and it seems to be a cost-effective strategy for invasive endometrial cancer. Conclusive evidence was lacking with respect to the oncologic outcomes related to SLN biopsy, the impact on patient morbidity, and whether clinicians should treat isolated tumor cells in SLNs with adjuvant therapy.

CONCLUSION

SLN biopsy is an accepted staging strategy for cervical and endometrial cancer surgery; however, controversies remain in how it can be applied with the most safety and efficacy. These ultimately need to be resolved with further clinical trials and observations of larger series of patients.

Potential protection of indocyanine green on parathyroid gland function during near-infrared laparoscopic-assisted thyroidectomy: A case report and literature review

BACKGROUND

In recent decades, significant advances have been made in protecting the parathyroid glands and recurrent laryngeal nerves during thyro-idectomy. However, reliable and convenient technical means are still lacking. In this study, the reliability, safety and feasibility of near-infrared (NIR) laparoscopy-assisted thyroid lobectomy with isthmectomy and prophylactic central lymph node dissection (CLND) were reported.

CASE SUMMARY

A 63-year-old female patient with a free previous medical history, was admitted to our department due to multiple thyroid nodules. Ultrasonic examination suggested diffuse thyroid changes and one thyroid nodule in the right upper lobe with the largest diameter of 1.5 cm adjacent to the trachea and Breast Imaging Reporting and Data System grade 4B. Imaging examination of the neck showed no obvious enlarged lymph nodes. Fine needle aspiration biopsy suggested a papillary thyroid carcinoma. Combined with thyroid function examination, the patient was diagnosed with papillary thyroid carcinoma and Hashimoto's thyroiditis. Considering the risk of invading the capsule and the patient's extreme anxiety, a right thyroid lobectomy with isthmectomy and prophylactic CLND was planned. No significant abnormalities were found during preoperative examinations, except for an increased thyroid stimulating hormone level. The patient underwent NIR laparoscopy-assisted thyroid lobectomy with isthmectomy and prophylactic CLND. During the operation, two right parathyroid glands (PGs) adjacent to the thyroid gland capsule and the right recurrent laryngeal nerve (RLN) were examined by indocyanine green (ICG) fluorescence using a NIR fluorescence camera, and the PGs and RLN were reliably preserved. Considering the ICG-positive PG, prophylactic CLND was performed. The postoperative parathyroid hormone level was in the normal range and no significant hypocalcemia symptoms were observed.

CONCLUSION

During NIR laparoscopy-assisted thyroidectomy, ICG fluorescence may aid PG identification and protection.

Role of carbon nanoparticle suspension in sentinel lymph node biopsy for early-stage cervical cancer: a prospective study

OBJECTIVE

To evaluate the clinical diagnostic validity of carbon nanoparticle suspension (CNS) in sentinel lymph node biopsy (SLNB) for assessing lymphatic spread of early-stage cervical cancer.

DESIGN

A prospective study.

SETTING AND POPULATION

356 cases.

METHODS

We enrolled 356 stage Ia2-IIa2 cervical cancer patients to undergo SLNB using CNS, followed by systematic pelvic lymphadenectomy. All lymph node specimens were assessed using conventional histopathologic ± pathologic ultrastaging analyses.

MAIN OUTCOME MEASURES

Sentinel lymph node detection rate (DR), clinical diagnostic validity and various related factors were analysed.

RESULTS

CNS identified 1456 SLNs in 325 patients. The overall SLN DR was 91.29%. A significantly higher DR was found for patients with tumours <20 mm (97.75% versus 71.91%; P < 0.001). Two patients had false-negative results. SLNB with CNS had sensitivity of 96.65%, false-negative rate (FNR) of 4.35% and negative predictive value (NPV) of 99.29%. Importantly, sensitivity (100%), NPV (100%) and FNR (0%) were improved when testing the subgroup of patients with tumours <20 mm (267 cases). There were no observed differences in DR based on pathological type or grade, stage, depth of stromal invasion, surgical approach, menopausal status or prior treatment with chemotherapy (P > 0.05).

CONCLUSIONS

Sentinel lymph node biopsy with CNS results in favourable DR, sensitivity and NPV for women with early-stage cervical cancer with small tumour sizes. SLNB with CNS is safe, feasible and relatively effective for guiding precise surgical treatment of early-stage cervical cancer.

TWEETABLE ABSTRACT

Sentinel lymph node biopsy with carbon nanoparticle suspension is safe and feasible for early-stage cervical cancer.

Image-guided tumor surgery: The emerging role of nanotechnology

Surgical resection is a mainstay treatment for solid tumors. Yet, methods to distinguish malignant from healthy tissue are primarily limited to tactile and visual cues as well as the surgeon's experience. As a result, there is a possibility that a positive surgical margin (PSM) or the presence of residual tumor left behind after resection may occur. It is well-documented that PSMs can negatively impact treatment outcomes and survival, as well as pose an economic burden. Therefore, surgical tumor imaging techniques have emerged as a promising method to decrease PSM rates. Nanoparticles (NPs) have unique characteristics to serve as optical contrast agents during image-guided surgery (IGS). Recently, there has been tremendous growth in the volume and types of NPs used for IGS, including clinical trials. Herein, we describe the most recent contributions of nanotechnology for surgical tumor identification. This article is categorized under: Therapeutic Approaches and Drug Discovery > Nanomedicine for Oncologic Disease Implantable Materials and Surgical Technologies > Nanoscale Tools and Techniques in Surgery Diagnostic Tools > in vivo Nanodiagnostics and Imaging.

Detection of high-risk human papillomavirus DNA in sentinel lymph nodes of patients with cervical cancer

The aim of the present study was to investigate the expression of human papillomavirus (HPV) DNA in sentinel lymph nodes (SLN) in patients with early-stage cervical cancer (CC). In addition, the present study compared the positive rate of SLNs metastasis detected by routine pathological examination, and investigated the value of HPV-DNA in the detection of early CC lymph node micrometastasis. Reverse transcription-quantitative PCR (RT-qPCR) was used in order to evaluate the HPV DNA detection in all CC samples [International Federation of Gynecology and Obstetrics (FIGO) stage IA2-IIA2]. The consistency of HPV-DNA was compared between primary lesions and SLNs. The positive rates of HPV-DNA were compared with pathological diagnosis of SLN metastasis, and the association between the positive expression of HPV-DNA in SLNs and the clinical and pathological parameters of patients with cervical cancer were analyzed. A total of 345 sentinel lymph nodes were detected in 100 patients with IA2-IIA2 CC. The positive rates of RT-qPCR and conventional histopathological detection of SLNs metastasis were 31.6% (109/345) and 12.8% (44/345), respectively (P<0.001). The positive expression of HPV-DNA in SLNs was associated with the clinical stage and tumor diameter (P<0.05), but not with patients' age, depth of cervical invasion, histological grade, lymphatic and vascular space invasion (LVSI), squamous cell carcinoma antigen (SCCAg) (P>0.05). The detection of HPV-DNA expression in pelvic lymph nodes of early CC may be used to improve the detection rate of micrometastasis, guide the postoperative adjuvant therapy more accurately and improve prognosis. Patients with positive HPV-DNA would require closer surveillance than those with negative HPV-DNA.

Pathologic Protocols for Sentinel Lymph Nodes Ultrastaging in Cervical Cancer

CONTEXT.—

Ultrastaging of sentinel lymph nodes (SLNs) is a crucial aspect in the approach to SLN processing. No consensual protocol for pathologic ultrastaging has been approved by international societies to date.

OBJECTIVE.—

To provide a review of the ultrastaging protocol and all its aspects related to the processing of SLNs in patients with cervical cancer.

DATA SOURCES.—

In total, 127 publications reporting data from 9085 cases were identified in the literature. In 24% of studies, the information about SLN processing is entirely missing. No ultrastaging protocol was used in 7% of publications. When described, the differences in all aspects of SLN processing among the studies and institutions are substantial. This includes grossing of the SLN, which is not completely sliced and processed in almost 20% of studies. The reported protocols varied in all aspects of SLN processing, including the thickness of slices (range, 1-5 mm), the number of levels (range, 0-cut out until no tissue left), distance between the levels (range, 40-1000 μm), and number of sections per level (range, 1-5).

CONCLUSIONS.—

We found substantial differences in protocols used for SLN pathologic ultrastaging, which can impact sensitivity for detection of micrometastases and even small macrometastases. Since the involvement of pelvic lymph nodes is the most important negative prognostic factor, such profound discrepancies influence the referral of patients to adjuvant radiotherapy and could potentially cause treatment failure. It is urgent that international societies agree on a consensual protocol before SLN biopsy without pelvic lymphadenectomy is introduced into routine clinical practice.

Dendritic cell engineering for selective targeting of female reproductive tract cancers

Female reproductive tract cancers (FRCs) are considered as one of the most frequently occurring malignancies and a foremost cause of death among women. The late-stage diagnosis and limited clinical effectiveness of currently available mainstay therapies, primarily due to the developed drug resistance properties of tumour cells, further increase disease severity. In the past decade, dendritic cell (DC)-based immunotherapy has shown remarkable success and appeared as a feasible therapeutic alternative to treat several malignancies, including FRCs. Importantly, the clinical efficacy of this therapy is shown to be restricted by the established immunosuppressive tumour microenvironment. However, combining nanoengineered approaches can significantly assist DCs to overcome this tumour-induced immune tolerance. The prolonged release of nanoencapsulated tumour antigens helps improve the ability of DC-based therapeutics to selectively target and remove residual tumour cells. Incorporation of surface ligands and co-adjuvants may further aid DC targeting (in vivo) to overcome the issues associated with the short DC lifespan, immunosuppression and imprecise uptake. We herein briefly discuss the necessity and progress of DC-based therapeutics in FRCs. The review also sheds lights on the future challenges to design and develop clinically effective nanoparticles-DC combinations that can induce efficient anti-tumour immune responses and prolong patients’ survival.

The potential role of carbon nanoparticles-assisted biopsy for sentinel lymph nodes of incidental thyroid carcinoma

Background

Some thyroid cancers are found after thyroidectomy for benign lesions, implying additional surgery and treatments. This work aimed to investigate the role of intraoperative sentinel lymph node biopsy (SLNB) for diagnosis of incidental thyroid carcinoma.

Methods

This was a retrospective study of 541 consecutive patients who underwent thyroid surgery between 02/2012 and 02/2014 at the Hunan Provincial People's Hospital. All patients were diagnosed with thyroid benign lesions preoperatively and intraoperatively. Among them, 375 underwent successful intraoperative SLNB using carbon nanoparticles (CNs).

Results

The preoperative diagnoses were nodular goiter (n=472), Hashimoto's disease with nodules (n=24), hyperthyroidism with nodules (n=16), and thyroid cysts with obstructive symptoms (n=29). In the SLNB group, SLN metastasis of thyroid microcarcinoma was confirmed in 21/392 cases (5.4%). These 21 patients received radical surgical treatment for thyroid carcinoma during the initial operation. In the no-SLNB group (n=149), seven patients (4.7%) were finally diagnosed with thyroid microcarcinoma. Six patients had to undergo a second surgery.

Conclusions

Intraoperative SLNB could help diagnose differentiated thyroid microcarcinoma that may be missed preoperatively and intraoperatively. This could prevent the need for a second surgery since the intraoperative frozen section examination of the SLNs can reveal metastasis from thyroid cancer.