Sentinel Lymph Node Detection Using A Dual-Dedector Gamma Probe Device and Simultaneous Indocyanine Green and Colloid Substance: First Experience in Turkey

Abstract

Aim: Fluorescence detection using indocyanine green (ICG) in sentinel lymph node (SLN) biopsy in breast cancer is a newly described method. In this study, we wanted to show the usefulness of the combination of ICG and radiocolloid material in the determination of SLN for axillary staging of early breast cancer and to share our initial experiences. Material and Methods: Our study included 15 patients with early stage breast cancer. Intraoperative Surgical Gamma Probe device designed for the detection of Gamma and Fluorescent rays was used for SLN detection. The patients were given radiocolloid material in the nuclear medicine department before surgery and ICG after general anesthesia. Then, lymph nodes with ICG and then radiocolloid uptake were excised with a double-detector gamma probe. The numbers of ICG alone, radiocolloid alone and SLN with both involvement were recorded. Axillary lymph node dissection was performed in cases with metastatic SLN frozen examination removed during the operation. Results: The mean age was 57±25. ICG and radiocolloid were detected in 14 patients, and SLN was detected in 1 patient with only radiocolloid. The median number of excised SLNs was calculated as 4 with ICG and 3 with radiocolloid. The detection rate of SLN was 93.3% with ICG and 100% with radiocolloid. Metastasis was detected in the SLN in 26.6% of the patients. Metastatic lymph node detection rate was 28.5% with ICG and 26.6% with radiocolloid. Axillary dissection was performed in 4 patients with lymph node metastasis and no metastases were observed in lymph nodes other than sentinel. There were no complications related to the methods during and after the operation. Conclusion: According to our limited experience, sentinel lymph node biopsy performed under the guidance of indocyanine green and radiocolloid substance, which has the advantage of being detected simultaneously with the dual-detector gamma probe device, which was first used in our clinic in our country, seems to be technically feasible and useful.

Keywords

• Fluorescent light
• indocyanine green
• sentinel lymph node biopsy

Çift Dedektörlü Gama Prob Cihazı ile Eş Zamanlı İndosiyanin Yeşili ve Radyokolloid Madde Kullanılarak Sentinel Lenf Nodu Belirlenmesi: Türkiye’de İlk Deneyimimiz

Abstract

Amaç: Meme kanserinde sentinel lenf nodu(SLN) biyopsisisinde indosiyanin yeşili(ICG) ile yapılan floresan tespiti yeni uygulanan bir yöntemdir. Bu çalışmada erken evre meme kanserinin aksiller evrelemesi için SLN’nin belirlenmesinde, ICG ve radyokolloid maddenin birlikteliğinin yararlılığını göstermek ve ilk deneyimlerimizi paylaşmak istedik. Gereç ve Yöntemler: Çalışmamızda erken evre meme kanserli 15 hasta yer aldı. SLN tespitinde, Gama ve Floresan ışınlarının dedeksiyonu için tasarlanmış İntraoperatif Cerrahi Gama Prob cihazı kullanıldı. Hastalara cerrahi öncesi nükleer tıp bölümünde radyokolloid madde ve genel anestezi sonrası ICG verildi. Sonra çift dedektörlü gama probla önce ICG, ardından radyokolloid tutulumu izlenen lenf nodları eksize edildi. Tek başına ICG, tek başına radyokolloid ve ikisinin birlikte tutulumu olan SLN sayıları kayıt altına alındı. Ameliyat esnasında çıkarılan SLN frozen incelemesi metastatik olarak bildirilen olgularda aksiller lenf nodu diseksiyonu yapıldı. Bulgular: Hastaların yaş ortalaması 56 (32-82) idi. 14 hastada ICG ve radyokolloid, 1 hastada ise sadece radyokolloidle SLN tespiti yapıldı. Eksize edilen ortanca SLN sayısı ICG ile 4, radyokolloidle ise 3 hesaplandı. SLN tespit etme oranı ICG ile %93.3, radyokolloid ile %100 olarak bulundu. Hastaların %26.6 da SLN’de metastaz saptandı. Metastatik lenf nodu tespit etme oranı ICG ile %28.5, radyokolloid ile %26.6 bulundu. Lenf nodu metastazı olan 4 hastaya aksiller diseksiyon yapıldı ve sentinel dışındaki lenf nodlarında metastaz görülmedi. Ameliyat sırasında ve sonrasında yöntemlere bağlı komplikasyon görülmedi. Sonuç: Sınırlı tecrübemize göre ülkemizde ilk olarak kliniğimizde kullanılmaya başlanan çift dedektörlü gama prob ile eş zamanlı tespit edilme avantajına sahip olan ICG ve radyokolloid madde rehberliğinde yapılan SLN biyopsisi teknik olarak uygulanabilir ve metastatik sentinel lenf nodunun doğru olarak tespitinde yararlı görülmektedir.

Keywords

• Floresan ışık
• indosiyanin yeşili
• sentinel lenf nodu biyopsisi

References

1. 1. Eser M, Kaptanoğlu L ve ark. Erken evre meme kanserinde sadece mavi boya klavuzluğunda yapılan sentinel lenf nodu biyopsisinin yeri: Dr. Lütfi Kırdar Kartal Eğitim ve Araştırma Hastanesi 3. Cerrahi Kliniği'nin Geçerlik Çalışması. Meme Sağlığı Dergisi 2007; 3: 3.
2. 2. Giammarile F, Alazraki N, et al. The EANM and SNMMI practice guideline for lymphoscintigraphy and sentinel node localization in breast cancer. Eur J Nucl Med Mol Imaging 2013;40:1932-1947.
3. 3. Lyman GH, Somerfield MR, et al. Sentinel Lymph Node Biopsy for Patients With Early-Stage Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 2017;35:561-564.
4. 4. Aydogan F, Salihoglu Z, et al. Intraparenchymal methylene blue injection for sentinel lymph node biopsy in breast cancer patients does not interfere with the pulse oximetry readings. J Breast Cancer 2009; 12: 32-35.
5. 5. Parvaiz MA, Isgar B. Anaphylaxis and blue urticaria associated with Patent Blue V injection. Anaesthesia 2012; 67: 1275-1276.
6. 6. Hayashida T, Jinno H, et al. Superiority of radioisotope over blue dye for sentinel lymph node detection in breast cancer. Eur Surg Res 2010; 44: 111-116.
7. 7. Meyer-Rochow GY, Martin RC, et al. Sentinel node biopsy in breast cancer: validation study and comparison of blue dye alone with triple modality localization. ANZ J Surg 2003; 73: 815-818.
8. 8. Radovanovic Z, Golubovic A, et al. Blue dye versus combined blue dye-radioactive tracer technique in detection of sentinel lymph node in breast cancer. Eur J Surg Oncol 2004; 30: 913-917.

9. 9. Alander JT, Kaartinen I, et al. A review of indocyanine green fluorescent imaging in surgery. Int J Biomed Imaging 2012; 2012: 94058.
10. 10. Murawa D, Hirche C, et al. Sentinel lymph node biopsy in breast cancer guided by indocyanine green fluorescence. Br J Surg 2009; 96: 1289-1294.
11. 11. Bonnema J, van de Velde CJ. Sentinel lymph node biopsy in breast cancer. Ann Oncol 2002; 13: 1531-1537.
12. 12. Cox CE, Pendas S, et al. Guidelines for sentinel node biopsy and lymphatic mapping of patients with breast cancer. Ann Surg 1998; 227: 645-53.
13. 13. Carter CL, Allen C, et al. Relation of tumor size, lymph node status, and survival in 24,740 breast cancer cases. Cancer 1989;63: 181-187.
14. 14. Özbaş S, Koçak S. Meme kanserinin cerrahi tedavisinde aksiller lenf nodu disseksiyonu. Meme Sağlığı Dergisi 2006; 2: 2.
15. 15. Barry W. Feig, David H. Berger, et al. M. D. Anderson Cerrahi Onkoloji 4. Baskı Lippincot Williams and Wilkins. 2005; 241: 319-25.
16. 16. Bergqvist l, Strand SE, et al. Particle sizing and biokinetics of interstitial lymphoscintigraphic agents. Semin Nucl Med 1983;13:9-19.
17. 17. Hawley AE, Davis SS, et al. Targeting of colloids to lymph nodes: influence of lymphatic physiology and colloidal characteristics, Adv Drug Deliv Rev 1995;17:129-148.
18. 18. Moghimi SM, Bonnemain B. Subcutaneous and intravenous delivery of diagnostic agents to the lymphatic system: applications in lymphoscintigraphy and indirect lymphography. Adv Drug Deliv Rev 1999;37:295-312.
19. 19. Uren RF, Howman-Giles RB, et al. Regarding sentinel lymph node localization in early breast cancer, J Nucl Med 1999;40:1403-1406.
20. 20. McCarter MD, Yeung H, et al, Cody HS 3rd. Localization of the sentinel node in breast cancer: identical results with same-day and day-before isotope injection. Ann Surg Oncol 2001;8:682-686.
21. 21. Krag DN, Anderson SJ, et al. Technical outcomes of sentinel-lymph-node resection and conventional axillary-lymph-node dissection in patients with clinically node-negative breast cancer: results from the NSABP B-32 randomised phase III trial. Lancet Oncol 2007;8:881-888.
22. 22. Dauphine CE, Khalkhali I, et al. Intraoperative injection of technetium-99m sulfur colloid is effective in the detection of sentinel lymph nodes in breast cancer.Am J Surg 2006; 192: 423-426.
23. 23. Aydogan F, Celik V, et al. A comparison of the adverse reactions associated with isosulfan blue versus methylene blue dye in sentinel lymph node biopsy for breast cancer. Am J Surg 2008; 195: 277-278.
24. 24. Murawa D, Hirche C, et al. Sentinel lymph node biopsy in breast cancer guided by indocyanine green fluorescence. Br J Surg 2009; 96: 1289-1294.
25. 25. Sugie T, Sawada T, et al. Comparison of the indocyanine green fluorescence and blue dye methods in detection of sentinel lymph nodes in early-stage breast cancer. Ann Surg Oncol 2013; 20: 2213-2218.
26. 26. Van den Berg NS, Brouwer OR, et al. Concomitant radio- and fluorescence-guided sentinel lymph node biopsy in squamous cell carcinoma of the oral cavity using ICG-(99m) Tcnanocolloid. Eur J Nucl Med Mol Imaging 2012;39:1128- 1136. 22.
27. 27. Van der Vorst JR, Schaafsma BE, et al. Randomized comparison of near-infrared fluorescence imaging using indocyanine green and 99(m) technetium with or without patent blue for the sentinel lymph node procedure in breast cancer patients. Ann Surg Oncol 2012;19:4104- 4111.
28. 28. Pleijhuis RG, Langhout GC, et al. Near-infrared fluorescence (NIRF) imaging in breast-conserving surgery: assessing intraoperative techniques in tissue-simulating breast phantoms. Eur J Surg Oncol 2011; 37: 32-39.
29. 29. Kitai T, Kawashima M. Transcutaneous detection and direct approach to the sentinel node using axillary compression technique in ICG fluorescence-navigated sentinel node biopsy for breast cancer. Breast Cancer 2012; 19: 343-348.