Evaluation of sentinel node biopsy by combined fluorescent and dye method and lymph flow for breast cancer.
BACKGROUND
Conservative breast resection with subsequent sentinel lymph node biopsy (SNB) is an increasingly popular initial approach for the treatment of breast cancer due to decreased invasiveness. SNB is a shorter procedure with fewer side effects than more substantial surgical procedures, but it sometimes fails to identify metastatic disease. Therefore, a highly sensitive and convenient method is needed to identify sentinel lymph nodes (SLN) with a high probability of containing disease in SNB. We compared the combination of radioisotope or dye with a fluorescence compound to analyze lymph flow to identify targets for SNB.


METHODS
We examined patients with breast cancer lacking metastases in the axillary lymph node (ALN). Two methods for targeted SNB were developed: (1) Indocyanine Green (ICG) and Patent blue were injected into the skin overlying the tumor and sub-areolar region just before the surgical procedure. (2) ICG and radiocolloid were injected into the skin overlying the tumor and sub-areolar region. The draining fluorescent lymphatic duct was visualized using a Photodynamic Eye (PDE). We removed the SLNs that were identified by the dye and fluorescence imaging methods. Method 1 was applied to 113 patients undergoing SNB, and 29 patients were treated with Method 2. In our study, patients were grouped by lymph flow into two types: Type C demonstrated convergence to one lymph duct. Type S demonstrated separate lymph ducts.


RESULTS
Using the fluorescence imaging method, 99.3% of SLNs were identified, and 3.8 SLNs per patient were seen. The SLN identification rates for Patent blue dye and radiocolloid were 92.9% and 100%, respectively, while 1.9 and 2.0 SLNs per patient, respectively, were seen with these methods. We classified two types of lymph flow based on the pattern of lymphatic drainage. Type C converged to a single lymph duct, while Type S drained to separate ducts. Type S lymph drainage was seen in 29/142 patients (20.4%), and Type C drainage was found in 113/141 patients (79.6%). Of the patients with Type S drainage, there were 4.1 SLNs per patient, but only 3.4 SLNs per patient were seen in individuals with Type C drainage. Forty cases had metastases found in the ALNs, and five of these cases were dye-negative and fluorescence-positive. Among these cases, the average number of SLNs identified was one.


CONCLUSIONS
The combination of fluorescence with a visible dye is a highly sensitive method for SLN identification. When SNB is guided by only the dye method, there is a risk of missing appropriate SLNs in patients with Type S lymph drainage or weak dye staining. The use of a fluorescence method together with dye could increase sensitivity of detection in these cases. Furthermore, fluorescent methods are ideal for hospitals that cannot use conventional radioactive measures.
National Cancer Center Hospital, Department of Surgery and Division of Breast Cancer, 5-1-1 Tsukiji Chuo-ku, Tokyo, Japan. tahojo@ncc.go.jp
Takashi
T
Hojo
Tomoya
T
Nagao
Mizuho
M
Kikuyama
Sadako
S
Akashi
Takayuki
T
Kinoshita
D000328:Adult; D000368:Aged; D001365:Axilla; D001943:Breast Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology*; D004396:Coloring Agents; D005260:Female; D006801:Humans; D007208:Indocyanine Green; D008196:Lymph; D008220:Lymphography / Q000379:methods*; D008875:Middle Aged; D019275:Radiopharmaceuticals; D012394:Rosaniline Dyes; D021701:Sentinel Lymph Node Biopsy / Q000379:methods*; D013667:Technetium
D004396:Coloring Agents; D019275:Radiopharmaceuticals; D012394:Rosaniline Dyes; D013667:Technetium; C008769:sulfan blue; D007208:Indocyanine Green