A Prospective Self-Controlled Study of Indocyanine Green, Radioisotope, and Methylene Blue for Combined Imaging of Axillary Sentinel Lymph Nodes in Breast Cancer

Comparison of Indocyanine Green with conventional tracers for sentinel lymph node biopsy in breast cancer: A multidisciplinary evaluation of clinical effectiveness, safety, organizational and economic impact

BACKGROUND

Breast cancer is a global health problem, and sentinel lymph node biopsy (SLNB) is the standard procedure for early-stage breast cancer. Technetium-99 (TC-99), alone or combined with blue dye (BD) are conventional tracers for SLNB, but they have safety, availability, and cost limitations. Indocyanine green (ICG) is an alternative tracer that has been gaining acceptance among healthcare professionals. This study aimed at assessing the clinical and economic value of ICG in hospital settings, using the health technology assessment (HTA) framework.

METHODS

We conducted a comprehensive evaluation of ICG for SLNB, based on literature sources and data collected from two Italian hospitals that switched from TC-99 to ICG. We analyzed ICG's technical attributes through technology documentation and relevant databases. We performed a systematic literature review of 36 studies to assess the clinical effectiveness and safety of ICG. We obtained organizational insights from clinicians and the clinical engineer involved in the study. We applied Time-Driven Activity-Based Costing (TDABC) and Budget Impact Analysis (BIA) to estimate the economic impact of ICG. The ethical, legal, and social implications of ICG were considered through clinicians' inputs and technology documentation.

RESULTS

Our results showed that ICG had equivalent or superior clinical effectiveness compared to TC-99 and BD, with minimal adverse events. ICG simplified the surgical pathways, by streamlining procedures, reducing waiting times, and increasing flexibility in scheduling surgeries. Moreover, the TDABC analysis showed significant cost reductions by avoiding the need for pre-operative lymphoscintigraphy and hospitalization, with average savings per single care pathway of around 18% for ICG compared to TC-99. Finally, ICG improved patient experience, and proved regulatory compliance.

CONCLUSIONS

This study provided strong evidence for ICG's clinical and economic value for SLNB in breast cancer. It ascertained ICG as a valuable alternative to conventional tracers, ensuring clinical effectiveness along with economic and organizational benefits.

Fluorescent-guided surgery and the use of indocyanine green sentinel lymph node mapping in the pediatric and young adult oncology population

BACKGROUND

Technetium-99 (99m Tc) lymphoscintigraphy with blue dye injection is an accepted method for sentinel lymph node (SLN) mapping, but blue dye has known adverse effects, and injection of 99m Tc may increase time under anesthesia for pediatric patients. Indocyanine green (ICG) may serve as an adjunct to assist with visibility and identification of SLNs. We hypothesized that sensitivity of ICG was similar to blue dye in SLN biopsies.

METHODS

Thirty patients (36 procedures with 96 total specimens) underwent preoperative intradermal injection of 99m Tc, followed by intradermal injection of isosulfan blue and ICG. Test characteristics of blue dye, ICG, and 99m Tc included sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

ICG had a sensitivity of 87% and PPV of 83% for detection of 99m Tc-hot lymph nodes; blue dye had a sensitivity of 44% and PPV of 97%. For detection of pathologically confirmed lymph nodes, ICG had a sensitivity of 84% and a positive predictive value (PPV) of 91%. 99m Tc had a sensitivity of 82% and a PPV of 94%. ICG had no significant difference in odds of being positive in pathology-confirmed lymph nodes compared to 99m Tc (odds ratio [OR], 0.818; 95% confidence interval [CI], 0.3-2.172; p = .823) and had higher odds than isosulfan blue (OR, 0.025, 95% CI, 0.001-0.148; p < .001).

CONCLUSION

This study established the efficacy of ICG as an adjunct to SLNB in the pediatric and young adult population. ICG was safe, more efficacious than blue dye, and may obviate the need for lymphoscintigraphy in selected patients resulting in reduced time under anesthesia.

An Updated Review on the Emerging Role of Indocyanine Green (ICG) as a Sentinel Lymph Node Tracer in Breast Cancer

Sentinel lymph node biopsy (SLNB) has become the standard of care for clinically node-negative breast cancer and has recently been shown by clinical trials to be also feasible for clinically node-positive patients treated with primary systemic therapy. The dual technique using both radioisotope (RI) and blue dye (BD) as tracers for the identification of sentinel lymph nodes is considered the gold standard. However, allergic reactions to blue dye as well as logistics issues related to the use of radioactive agents, have led to research on new sentinel lymph node (SLN) tracers and to the development and introduction of novel techniques in the clinical practice. Indocyanine green (ICG) is a water-soluble dye with fluorescent properties in the near-infrared (NIR) spectrum. ICG has been shown to be safe and effective as a tracer during SLNB for breast cancer and accumulating evidence suggests that ICG is superior to BD and at least comparable to RI alone and to RI combined with BD. Thus, ICG was recently proposed as a reliable SLN tracer in some breast cancer clinical practice guidelines. Nevertheless, there is lack of consensus regarding the optimal role of ICG for SLN mapping. Specifically, it is yet to be determined whether ICG should be used in addition to BD and/or RI, or if ICG could potentially replace these long-established traditional SLN tracers. This article is an updated overview of somerecent studies that compared ICG with BD and/or RI regarding their accuracy and effectiveness during SLNB for breast cancer.

Indocyanine green combined with methylene blue versus methylene blue alone for sentinel lymph node biopsy in breast cancer: a retrospective study

BACKGROUND

Recent studies have shown that near-infrared (NIR) fluorescence imaging using Indocyanine green (ICG) may improve the efficiency of sentinel lymph node biopsy (SLNB). This study aimed to assess the effectiveness of the combination of ICG and methylene blue (MB) in breast cancer patients undergoing SLNB.

PATIENTS AND METHOD

We evaluated ICG plus MB (ICG + MB) identification effectiveness with MB alone using retrospective analysis. From 2016 to 2020, we collected data on 300 eligible breast cancer patients who got SLNB treatment in our institution by ICG + MB or MB alone. By comparing the distribution of clinicopathological characteristics, the detection rate of sentinel lymph nodes (SLNs) and metastatic SLNs, as well as the total number of SLNs in the two groups, we were able to assess the imaging efficiency.

RESULTS

Fluorescence imaging allowed 131 out of 136 patients in the ICG + MB group to find SLNs. ICG + MB group and MB group had detection rates of 98.5% and 91.5% (P = 0.007, χ² = 7.352), respectively. Besides, the ICG + MB approach was able to produce improved recognition outcomes. What's more, compared with the MB group, the ICG + MB group can identify more lymph nodes (LNs) (3.1 to 2.6, P = 0.000, t = 4.447). Additionally, in the ICG + MB group, ICG could identify more LNs than MB (3.1 vs 2.6, P = 0.004, t = 2.884).

CONCLUSION

ICG has high detection effectiveness for SLNs, and when paired with MB, the detection efficiency can be increased even further. Furthermore, the ICG + MB tracing mode does not involve radioisotopes, which has a lot of promise for clinical use and can take the place of conventional standard detection methods.