The best of both worlds: a hybrid approach for optimal pre- and intraoperative identification of sentinel lymph nodes

There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

Abstract

Purpose

Hybrid image-guided surgery technologies such as combined radio- and fluorescence-guidance are increasingly gaining interest, but their added value still needs to be proven. In order to evaluate if and how fluorescence-guidance can help realize improvements beyond the current state-of-the-art in sentinel node (SN) biopsy procedures, use of the hybrid tracer indocyanine green (ICG)- ^99mTc-nancolloid was evaluated in a large cohort of patients.

Patients and methods

A prospective trial was conducted (n = 501 procedures) in a heterogeneous cohort of 495 patients with different malignancies (skin malignancies, oral cavity cancer, penile cancer, prostate cancer and vulva cancer). After injection of ICG- ^99mTc-nanocolloid, SNs were preoperatively identified based on lymphoscintigraphy and SPECT/CT. Intraoperatively, SNs were pursued via gamma tracing, visual identification (blue dye) and/or near-infrared fluorescence imaging during either open surgical procedures (head and neck, penile, vulvar cancer and melanoma) or robot assisted laparoscopic surgery (prostate cancer). As the patients acted as their own control, use of hybrid guidance could be compared to conventional radioguidance and the use of blue dye ( n = 300). This was based on reported surgical complications, overall survival, LN recurrence free survival, and false negative rates (FNR).

Results

A total of 1,327 SN-related hotspots were identified on 501 preoperative SPECT/CT scans. Intraoperatively, a total number of 1,643 SNs were identified based on the combination of gamma-tracing (>98%) and fluorescence-guidance (>95%). In patients wherein blue dye was used ( n = 300) fluorescence-based SN detection was superior over visual blue dye-based detection (22–78%). No adverse effects related to the use of the hybrid tracer or the fluorescence-guidance procedure were found and outcome values were not negatively influenced.

Conclusion

With ICG- ^99mTc-nanocolloid, the SN biopsy procedure has become more accurate and independent of the use of blue dye. With that, the procedure has evolved to be universal for different malignancies and anatomical locations.

Electronic supplementary material

The online version of this article (10.1007/s00259-018-4028-x) contains supplementary material, which is available to authorized users.

Related collections

Most cited references 28

Record: found
Abstract: found
Article: not found

A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer.

Umberto Veronesi, Giovanni Paganelli, Giuseppe Viale … (2003)

Although numerous studies have shown that the status of the sentinel node is an accurate predictor of the status of the axillary nodes in breast cancer, the efficacy and safety of sentinel-node biopsy require validation. From March 1998 to December 1999, we randomly assigned 516 patients with primary breast cancer in whom the tumor was less than or equal to 2 cm in diameter either to sentinel-node biopsy and total axillary dissection (the axillary-dissection group) or to sentinel-node biopsy followed by axillary dissection only if the sentinel node contained metastases (the sentinel-node group). The number of sentinel nodes found was the same in the two groups. A sentinel node was positive in 83 of the 257 patients in the axillary-dissection group (32.3 percent), and in 92 of the 259 patients in the sentinel-node group (35.5 percent). In the axillary-dissection group, the overall accuracy of the sentinel-node status was 96.9 percent, the sensitivity 91.2 percent, and the specificity 100 percent. There was less pain and better arm mobility in the patients who underwent sentinel-node biopsy only than in those who also underwent axillary dissection. There were 15 events associated with breast cancer in the axillary-dissection group and 10 such events in the sentinel-node group. Among the 167 patients who did not undergo axillary dissection, there were no cases of overt axillary metastasis during follow-up. Sentinel-node biopsy is a safe and accurate method of screening the axillary nodes for metastasis in women with a small breast cancer. Copyright 2003 Massachusetts Medical Society

0 comments Cited 338 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Sentinel-node biopsy or nodal observation in melanoma.

Donald L. Morton, John F Thompson, Alistair J. Cochran … (2006)

We evaluated the contribution of sentinel-node biopsy to outcomes in patients with newly diagnosed melanoma. Patients with a primary cutaneous melanoma were randomly assigned to wide excision and postoperative observation of regional lymph nodes with lymphadenectomy if nodal relapse occurred, or to wide excision and sentinel-node biopsy with immediate lymphadenectomy if nodal micrometastases were detected on biopsy. Among 1269 patients with an intermediate-thickness primary melanoma, the mean (+/-SE) estimated 5-year disease-free survival rate for the population was 78.3+/-1.6% in the biopsy group and 73.1+/-2.1% in the observation group (hazard ratio for recurrence[corrected], 0.74; 95% confidence interval [CI], 0.59 to 0.93; P=0.009). Five-year melanoma-specific survival rates were similar in the two groups (87.1+/-1.3% and 86.6+/-1.6%, respectively). In the biopsy group, the presence of metastases in the sentinel node was the most important prognostic factor; the 5-year survival rate was 72.3+/-4.6% among patients with tumor-positive sentinel nodes and 90.2+/-1.3% among those with tumor-negative sentinel nodes (hazard ratio for death, 2.48; 95% CI, 1.54 to 3.98; P<0.001). The incidence of sentinel-node micrometastases was 16.0% (122 of 764 patients), and the rate of nodal relapse in the observation group was 15.6% (78 of 500 patients). The corresponding mean number of tumor-involved nodes was 1.4 in the biopsy group and 3.3 in the observation group (P<0.001), indicating disease progression during observation. Among patients with nodal metastases, the 5-year survival rate was higher among those who underwent immediate lymphadenectomy than among those in whom lymphadenectomy was delayed (72.3+/-4.6% vs. 52.4+/-5.9%; hazard ratio for death, 0.51; 95% CI, 0.32 to 0.81; P=0.004). The staging of intermediate-thickness (1.2 to 3.5 mm) primary melanomas according to the results of sentinel-node biopsy provides important prognostic information and identifies patients with nodal metastases whose survival can be prolonged by immediate lymphadenectomy. (ClinicalTrials.gov number, NCT00275496 [ClinicalTrials.gov].). Copyright 2006 Massachusetts Medical Society.

0 comments Cited 245 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Sentinel node biopsy for early-stage melanoma: accuracy and morbidity in MSLT-I, an international multicenter trial.

O. Nieweg, Nicola Mozzillo, Robert Elashoff … (2005)

The objective of this study was to evaluate, in an international multicenter phase III trial, the accuracy, use, and morbidity of intraoperative lymphatic mapping and sentinel node biopsy (LM/SNB) for staging the regional nodal basin of patients with early-stage melanoma. Since our introduction of LM/SNB in 1990, this technique has been widely adopted and has become part of the American Joint Committee on Cancer (AJCC) staging system. Eleven years ago, the authors began the international Multicenter Selective Lymphadenectomy Trial (MSLT-I) to compare 2 treatment approaches: wide excision (WE) plus LM/SNB with immediate complete lymphadenectomy (CLND) for sentinel node (SN) metastases, and WE plus postoperative observation with CLND delayed until the subsequent development of clinically evident nodal metastases. After each center achieved 85% accuracy of SN identification during a 30-case learning phase, patients with primary cutaneous melanoma (> or =1 mm with Clark level > or =III, or any thickness with Clark level > or =IV) were randomly assigned in a 4:6 ratio to WE plus observation (WEO) with delayed CLND for nodal recurrence, or to WE plus LM/SNB with immediate CLND for SN metastasis. The accuracy of LM/SNB was determined by comparing the rates of SN identification and the incidence of SN metastases in the LM/SNB group versus the subsequent development of nodal metastases in the regional nodal basin of those patients with tumor-negative SNs. Early morbidity of LM/SNB was evaluated by comparing complication rates between the 2 treatment groups. Trial accrual was completed on March 31, 2002, after enrollment of 2001 patients. Initial SN identification rate was 95.3% overall: 99.3% for the groin, 95.3% for the axilla, and 84.5% for the neck basins. The rate of false-negative LM/SNB during the trial phase, as measured by nodal recurrence in a tumor-negative dissected SN basin, decreased with increasing case volume at each center: 10.3% for the first 25 cases versus 5.2% after 25 cases. There were no operative mortalities. The low (10.1%) complication rate after LM/SNB increased to 37.2% with the addition of CLND; CLND also increased the severity of complications. LM/SNB is a safe, low-morbidity procedure for staging the regional nodal basin in early melanoma. Even after a 30-case learning phase and 25 additional LM/SNB cases, the accuracy of LM/SNB continues to increase with a center's experience. LM/SNB should become standard care for staging the regional lymph nodes of patients with primary cutaneous melanoma.

0 comments Cited 58 times – based on 0 reviews      Review now

Bookmark

All references

Author and article information

Contributors

F. W. B. van Leeuwen: F.W.B.van_Leeuwen@lumc.nl

Journal

Journal ID (nlm-ta): Eur J Nucl Med Mol Imaging

Journal ID (iso-abbrev): Eur. J. Nucl. Med. Mol. Imaging

Title: European Journal of Nuclear Medicine and Molecular Imaging

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 1619-7070

ISSN (Electronic): 1619-7089

Publication date (Electronic): 25 April 2018

Publication date PMC-release: 25 April 2018

Publication date (Print): 2018

Volume: 45

Issue: 11

Pages: 1915-1925

Affiliations

[1 ]ISNI 0000000089452978, GRID grid.10419.3d, Interventional Molecular Imaging Laboratory, Department of Radiology, , Leiden University Medical Center, ; Albinusdreef 2 (C2-S zone), PO BOX 9600, 2300 RC Leiden, The Netherlands

[2 ]GRID grid.430814.a, Department of Nuclear Medicine, , The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, ; Amsterdam, The Netherlands

[3 ]GRID grid.430814.a, Department of Urology, , The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, ; Amsterdam, The Netherlands

[4 ]GRID grid.430814.a, Department of Biostatistics, , The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, ; Amsterdam, The Netherlands

[5 ]GRID grid.430814.a, Department of Head and Neck Surgery and Oncology, , The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, ; Amsterdam, The Netherlands

[6 ]GRID grid.430814.a, Department of Gynecology, , The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, ; Amsterdam, The Netherlands

[7 ]GRID grid.430814.a, Department of Surgery, , The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, ; Amsterdam, The Netherlands

[8 ]GRID grid.430814.a, Department of Pathology, , The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, ; Amsterdam, The Netherlands

Article

Publisher ID: 4028

DOI: 10.1007/s00259-018-4028-x

PMC ID: 6132545

PubMed ID: 29696442

SO-VID: dc255643-f909-4faa-a534-b0ad0ae038c4

License:

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

History

Date received : 11 February 2018

Date accepted : 16 April 2018

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100004622, KWF Kankerbestrijding;

Award ID: PGF 2009-4344

Funded by: FundRef http://dx.doi.org/10.13039/501100003958, Stichting voor de Technische Wetenschappen;

Award ID: STW BGT11272

Funded by: FundRef http://dx.doi.org/10.13039/501100000781, European Research Council;

Award ID: 2012-306890

Custom metadata

ScienceOpen disciplines: Radiology & Imaging

Keywords: hybrid,fluorescence imaging,nuclear medicine,sentinel lymph node biopsy,image-guided surgery

Data availability:

ScienceOpen disciplines: Radiology & Imaging

Keywords: hybrid, fluorescence imaging, nuclear medicine, sentinel lymph node biopsy, image-guided surgery

The best of both worlds: a hybrid approach for optimal pre- and intraoperative identification of sentinel lymph nodes

Read this article at

Abstract

Purpose

Patients and methods

Results

Conclusion

Electronic supplementary material

Related collections

Radiology and Natural Language Processing

Most cited references 28

A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer.

Sentinel-node biopsy or nodal observation in melanoma.

Sentinel node biopsy for early-stage melanoma: accuracy and morbidity in MSLT-I, an international multicenter trial.

Author and article information

Contributors

Journal

Affiliations

Article

History

Funding

Categories

Custom metadata

Comments

Comment on this article

Similar content 16

Cited by 36

Most referenced authors 389