J Breast Cancer.  2014 Sep;17(3):250-255. 10.4048/jbc.2014.17.3.250.

Use of Fluorescence Imaging in Combination with Patent Blue Dye versus Patent Blue Dye Alone in Sentinel Lymph Node Biopsy in Breast Cancer

• Tong M
• Guo W
• Gao W

• KMID: 2286352
• DOI: http://doi.org/10.4048/jbc.2014.17.3.250

Abstract

PURPOSE
Near-infrared fluorescence imaging with indocyanine green (ICG) has the potential to improve sentinel lymph node (SLN) mapping in breast cancer. In this clinical trial, we compared the potential value of ICG combined with blue dye with that of blue dye alone for detecting SLNs.
METHODS
Patients undergoing SLN biopsy (SLNB) between November 2010 and November 2013 were included. Up to December 2011, SLNs were detected by using patent blue (PB) alone, and since January 2012, by using PB in combination with ICG. The patients were divided into the following two groups: group A (ICG-PB; n=96) and group B (PB; n=73), and SLN detection parameters were compared between the groups. All patients underwent level I and II axillary dissections after SLNB.
RESULTS
In group A, the SLN detection rate was 96.9% (93/96), the accuracy of detection was 98.9% (92/93), and the false-negative rate (FNR) was 3.4% (1/29). In group B, the SLN detection rate was 84.9% (62/73), the accuracy of detection was 96.8% (60/62), and the FNR was 11.1% (2/18). The ICG-PB group showed significantly superior results compared to the PB group for SLN detection (p=0.005) and a greatly improved FNR.
CONCLUSION
The combined fluorescence and blue dye-based tracer technique was superior to the use of blue dye alone for identifying SLNs, and for predicting axillary lymph node status in patients with breast cancer; in addition, the combined technique had reduced false-negative results.

Keyword

Breast neoplasms; Indocyanine green; Optical imaging; Patent blue dye; Sentinel lymph node biopsy

MeSH Terms

Biopsy
Breast Neoplasms*
Fluorescence
Humans
Indocyanine Green
Lymph Nodes
Optical Imaging*
Sentinel Lymph Node Biopsy*
Indocyanine Green

Figure

• 

  Figure 1 Near-infrared fluorescence imaging during sentinel lymph node (SLN) mapping. (A) The periareolar injection site and afferent lymphatic duct are clearly observed. (B) A skin incision made at the point where the fluorescence disappeared, and a strong fluorescence is seen clearly after incision. (C) Lymphatic flow in the axilla is identified. (D) A resected SLN with fluorescence imaging reconfirmed by photodynamic eye.

Reference

1. Mansel RE, Fallowfield L, Kissin M, Goyal A, Newcombe RG, Dixon JM, et al. Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC Trial. J Natl Cancer Inst. 2006; 98:599–609.

2. Straver ME, Meijnen P, van Tienhoven G, van de Velde CJ, Mansel RE, Bogaerts J, et al. Sentinel node identification rate and nodal involvement in the EORTC 10981-22023 AMAROS trial. Ann Surg Oncol. 2010; 17:1854–1861.

3. Erb KM, Julian TB. Completion of axillary dissection for a positive sentinel node: necessary or not? Curr Oncol Rep. 2009; 11:15–20.

4. Giuliano AE, Hunt KK, Ballman KV, Beitsch PD, Whitworth PW, Blumencranz PW, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011; 305:569–575.

5. Julian TB, Krag D, Brown A, Anderson S, Harlow S, Ashikaga T, et al. Preliminary technical results of NSABP B-32, a randomized phase III clinical trial to compare sentinel node resection to conventional axillary dissection in clinical node negative breast cancer patients. Breast Cancer Res Treat. 2004; 88:Suppl. S511–S512.

6. Wang L, Yu JM, Wang YS, Zuo WS, Gao Y, Fan J, et al. Preoperative lymphoscintigraphy predicts the successful identification but is not necessary in sentinel lymph nodes biopsy in breast cancer. Ann Surg Oncol. 2007; 14:2215–2220.

7. Noguchi M, Inokuchi M, Zen Y. Complement of peritumoral and subareolar injection in breast cancer sentinel lymph node biopsy. J Surg Oncol. 2009; 100:100–105.

8. Teal CB, Slocum JP, Akin EA. Evaluation of the benefit of using blue dye in addition to radioisotope for sentinel lymph node biopsy in patients with breast cancer. Breast J. 2005; 11:391–393.

9. Sandrucci S, Casalegno PS, Percivale P, Mistrangelo M, Bombardieri E, Bertoglio S. Sentinel lymph node mapping and biopsy for breast cancer: a review of the literature relative to 4,791 procedures. Tumori. 1999; 85:425–434.

10. Stratmann SL, McCarty TM, Kuhn JA. Radiation safety with breast sentinel node biopsy. Am J Surg. 1999; 178:454–457.

11. Sardi A, Spiegler E, Colandrea J, Frishberg D, Sing H, Regan P, et al. The benefit of using two techniques for sentinel lymph node mapping in breast cancer. Am Surg. 2002; 68:24–28.

12. Ueno H, Hihara J, Shimizu K, Osaki A, Yamashita Y, Yoshida K, et al. Experimental study on fluorescent microspheres as a tracer for sentinel node detection. Anticancer Res. 2005; 25(2A):821–825.

13. Murawa D, Hirche C, Dresel S, Hünerbein M. Sentinel lymph node biopsy in breast cancer guided by indocyanine green fluorescence. Br J Surg. 2009; 96:1289–1294.

14. Doubrovsky A, De Wilt JH, Scolyer RA, McCarthy WH, Thompson JF. Sentinel node biopsy provides more accurate staging than elective lymph node dissection in patients with cutaneous melanoma. Ann Surg Oncol. 2004; 11:829–836.

15. Xing Y, Foy M, Cox DD, Kuerer HM, Hunt KK, Cormier JN. Meta-analysis of sentinel lymph node biopsy after preoperative chemotherapy in patients with breast cancer. Br J Surg. 2006; 93:539–546.

16. Derossis AM, Fey J, Yeung H, Yeh SD, Heerdt AS, Petrek J, et al. A trend analysis of the relative value of blue dye and isotope localization in 2,000 consecutive cases of sentinel node biopsy for breast cancer. J Am Coll Surg. 2001; 193:473–478.

17. McMasters KM, Wong SL, Martin RC 2nd, Chao C, Tuttle TM, Noyes RD, et al. Dermal injection of radioactive colloid is superior to peritumoral injection for breast cancer sentinel lymph node biopsy: results of a multiinstitutional study. Ann Surg. 2001; 233:676–687.

18. Hung WK, Chan CM, Ying M, Chong SF, Mak KL, Yip AW. Randomized clinical trial comparing blue dye with combined dye and isotope for sentinel lymph node biopsy in breast cancer. Br J Surg. 2005; 92:1494–1497.

19. Kang SW, Chung SE, Shin WJ, Lee JH. Polypoidal choroidal vasculopathy and late geographic hyperfluorescence on indocyanine green angiography. Br J Ophthalmol. 2009; 93:759–764.

20. Schneider PD. Preoperative assessment of liver function. Surg Clin North Am. 2004; 84:355–373.

21. Kitai T, Inomoto T, Miwa M, Shikayama T. Fluorescence navigation with indocyanine green for detecting sentinel lymph nodes in breast cancer. Breast Cancer. 2005; 12:211–215.

22. Cox CE, Pendas S, Cox JM, Joseph E, Shons AR, Yeatman T, et al. Guidelines for sentinel node biopsy and lymphatic mapping of patients with breast cancer. Ann Surg. 1998; 227:645–651.

23. Hirche C, Murawa D, Mohr Z, Kneif S, Hünerbein M. ICG fluorescence-guided sentinel node biopsy for axillary nodal staging in breast cancer. Breast Cancer Res Treat. 2010; 121:373–378.

24. Hojo T, Nagao T, Kikuyama M, Akashi S, Kinoshita T. Evaluation of sentinel node biopsy by combined fluorescent and dye method and lymph flow for breast cancer. Breast. 2010; 19:210–213.

25. Cox CE, Kiluk JV, Riker AI, Cox JM, Allred N, Ramos DC, et al. Significance of sentinel lymph node micrometastases in human breast cancer. J Am Coll Surg. 2008; 206:261–268.

26. Christiansen P, Friis E, Balslev E, Jensen D, Møller S. Danish Breast Cancer Cooperative Group. Sentinel node biopsy in breast cancer: five years experience from Denmark. Acta Oncol. 2008; 47:561–568.

27. Bass SS, Cox CE, Reintgen DS. Learning curves and certification for breast cancer lymphatic mapping. Surg Oncol Clin N Am. 1999; 8:497–509.

28. Dupont E, Cox C, Shivers S, Salud C, Nguyen K, Cantor A, et al. Learning curves and breast cancer lymphatic mapping: institutional volume index. J Surg Res. 2001; 97:92–96.

29. Sanidas EE, de Bree E, Tsiftsis DD. How many cases are enough for accreditation in sentinel lymph node biopsy in breast cancer? Am J Surg. 2003; 185:202–210.