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Pinelli M, Gerardi C, Lettieri E, Maioru M, Marone L, Bertoldi L, Navanteri G, Costantini M, Botti C, Pellini F. 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. PLoS One 2024; 19:e0309336. [PMID: 39208241 PMCID: PMC11361597 DOI: 10.1371/journal.pone.0309336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 08/08/2024] [Indexed: 09/04/2024] Open
Abstract
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.
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Affiliation(s)
- Maria Pinelli
- Department of Management, Economics and Industrial Engineering, Politecnico di Milano, Milan, Italy
| | - Chiara Gerardi
- Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Emanuele Lettieri
- Department of Management, Economics and Industrial Engineering, Politecnico di Milano, Milan, Italy
| | - Madalina Maioru
- Department of Management, Economics and Industrial Engineering, Politecnico di Milano, Milan, Italy
| | - Laura Marone
- Department of Management, Economics and Industrial Engineering, Politecnico di Milano, Milan, Italy
| | - Lorenzo Bertoldi
- Oncology Department Azienda Ospedaliera Universitaria Integrata (AOUI) Verona, Complex Operative Unit (UOC) Breast Surgery, Breast Unit, Verona, Italy
| | - Giuseppe Navanteri
- Clinical Engineering (IRCCS Istituto Nazionale Tumori Regina Elena—Roma, Italy), Roma, Italy
| | - Maurizio Costantini
- Department Breast Surgery (IRCCS Istituto Nazionale Tumori Regina Elena—Roma, Italy), Roma, Italy
| | - Claudio Botti
- Department Breast Surgery (IRCCS Istituto Nazionale Tumori Regina Elena—Roma, Italy), Roma, Italy
| | - Francesca Pellini
- Oncology Department Azienda Ospedaliera Universitaria Integrata (AOUI) Verona, Complex Operative Unit (UOC) Breast Surgery, Breast Unit, Verona, Italy
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Anichkina KA, Pasternak AV, Arslanov KS, Kvetenadze GE, Shivilov EV, Klimashevich AV. [Domestic system for fluorescent diagnostics in breast cancer: pros and cons]. Khirurgiia (Mosk) 2024:55-60. [PMID: 38380465 DOI: 10.17116/hirurgia202402255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
OBJECTIVE To analyze the effectiveness of identifying the sentinel lymph node in breast cancer using the «MARS» system for fluorescent diagnostics in near infrared light. MATERIAL AND METHODS There were 51 patients with breast cancer cT0-2N0M0 between July 2023 and October 2023. Mean age of patients was 52.3 years. Invasive ductal carcinoma was diagnosed in 39 (76.5%) patients, invasive lobular carcinoma - in 8 (15.7%) patients, other forms of breast cancer - in 4 (7.8%) patients. RESULTS Sentinel lymph node was successfully identified in all cases (n=51). A total of 122 sentinel lymph nodes were detected and mapped (2.4 nodes per a patient). CONCLUSION The MARS system for intraoperative fluorescence diagnostics in near-infrared light is effective for identifying the sentinel lymph node in breast cancer.
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Affiliation(s)
- K A Anichkina
- Loginov Moscow Clinical Research Center, Moscow, Russia
| | - A V Pasternak
- Loginov Moscow Clinical Research Center, Moscow, Russia
| | - Kh S Arslanov
- Loginov Moscow Clinical Research Center, Moscow, Russia
| | | | - E V Shivilov
- Loginov Moscow Clinical Research Center, Moscow, Russia
- Federal State Budgetary Educational Institution of Higher Education Russian University of Medicine of the Ministry of Health of Russia, Moscow, Russia
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Johnston ME, Farooqui ZA, Nagarajan R, Pressey JG, Turpin B, Dasgupta R. Fluorescent-guided surgery and the use of indocyanine green sentinel lymph node mapping in the pediatric and young adult oncology population. Cancer 2023; 129:3962-3970. [PMID: 37740680 DOI: 10.1002/cncr.35023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 07/16/2023] [Accepted: 08/03/2023] [Indexed: 09/25/2023]
Abstract
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.
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Affiliation(s)
- Michael E Johnston
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Zishaan A Farooqui
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rajaram Nagarajan
- Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Joseph G Pressey
- Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Brian Turpin
- Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Roshni Dasgupta
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Akrida I, Michalopoulos NV, Lagadinou M, Papadoliopoulou M, Maroulis I, Mulita F. An Updated Review on the Emerging Role of Indocyanine Green (ICG) as a Sentinel Lymph Node Tracer in Breast Cancer. Cancers (Basel) 2023; 15:5755. [PMID: 38136301 PMCID: PMC10742210 DOI: 10.3390/cancers15245755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
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.
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Affiliation(s)
- Ioanna Akrida
- Department of Surgery, General University Hospital of Patras, 26504 Rio, Greece; (I.A.); (I.M.)
| | - Nikolaos V. Michalopoulos
- 4th Department of Surgery, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 1 Rimini Street, Chaidari, 12462 Athens, Greece; (N.V.M.); (M.P.)
| | - Maria Lagadinou
- Department of Internal Medicine, General University Hospital of Patras, 26504 Rio, Greece;
| | - Maria Papadoliopoulou
- 4th Department of Surgery, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 1 Rimini Street, Chaidari, 12462 Athens, Greece; (N.V.M.); (M.P.)
| | - Ioannis Maroulis
- Department of Surgery, General University Hospital of Patras, 26504 Rio, Greece; (I.A.); (I.M.)
| | - Francesk Mulita
- Department of Surgery, General University Hospital of Patras, 26504 Rio, Greece; (I.A.); (I.M.)
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Gao Y. Invited Commentary: Evaluation of Dual Dye Technique for Sentinel Lymph Node Biopsy in Breast Cancer: Two Arm Open Label Parallel Design Non-inferiority Randomized Controlled Trial. World J Surg 2023; 47:2186-2187. [PMID: 37271763 DOI: 10.1007/s00268-023-07052-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2023] [Indexed: 06/06/2023]
Affiliation(s)
- Yinguang Gao
- Beijing Friendship Hospital, Capital Medical University, 95 Yong-an Road, Xicheng District, Beijing, 100050, China.
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Zhang-Yin J. State of the Art in 2022 PET/CT in Breast Cancer: A Review. J Clin Med 2023; 12:jcm12030968. [PMID: 36769616 PMCID: PMC9917740 DOI: 10.3390/jcm12030968] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/18/2023] [Accepted: 01/24/2023] [Indexed: 02/01/2023] Open
Abstract
Molecular imaging with positron emission tomography is a powerful and well-established tool in breast cancer management. In this review, we aim to address the current place of the main PET radiopharmaceuticals in breast cancer care and offer perspectives on potential future radiopharmaceutical and technological advancements. A special focus is given to the following: the role of 18F-fluorodeoxyglucose positron emission tomography in the clinical management of breast cancer patients, especially during staging; detection of recurrence and evaluation of treatment response; the role of 16α-18Ffluoro-17β-oestradiol positron emission tomography in oestrogen receptors positive breast cancer; the promising radiopharmaceuticals, such as 89Zr-trastuzumab and 68Ga- or 18F-labeled fibroblast activation protein inhibitor; and the application of artificial intelligence.
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Affiliation(s)
- Jules Zhang-Yin
- Department of Nuclear Medicine, Clinique Sud Luxembourg, Vivalia, B-6700 Arlon, Belgium
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Zikiryakhodzhaev AD, Starkov MV, Timoshkin VO. [Indocyanine green in diagnostics and reconstructive surgery for breast cancer]. Khirurgiia (Mosk) 2023:20-24. [PMID: 37682543 DOI: 10.17116/hirurgia202309220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVE To analyze the efficacy of sentinel lymph node detection using indocyanine green (ICG) in breast cancer. MATERIAL AND METHODS The study included 153 breast cancer patients (stage 0-I-II-III, cN0 or cN1-ycN0) between October 2022 and April 2023. All patients underwent sentinel lymph node biopsy using ICG. RESULTS Sentinel lymph node was successfully detected in 150 cases out of 153 ICG injections. Optimal period between ICG injection and its accumulation in regional lymph nodes was 10-12 min. Sensitivity of sentinel lymph node detection was 98.0% that exceeds the approximate value of radioisotope method adopted as a standard (96.9-97.2%), as well as sensitivity of proprietary blue dye (90.6-95.0%). Specificity of this method was 100%. CONCLUSION The authors' experience regarding application of indocyanine green is consistent with numerous world statistics and proves the possibility of its effective use for sentinel lymph node biopsy. It is necessary to introduce this diagnostic method as a leading or alternative method for analysis of sentinel lymph node in national clinical guidelines.
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Affiliation(s)
- A D Zikiryakhodzhaev
- Herzen Moscow Oncology Research Institute, Moscow, Russia
- People's Friendship University of Russia, Moscow, Russia
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - M V Starkov
- Herzen Moscow Oncology Research Institute, Moscow, Russia
| | - V O Timoshkin
- Herzen Moscow Oncology Research Institute, Moscow, Russia
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