Breast Cancer DOI 10.1007/s12282-015-0610-2
LETTER TO THE EDITOR
Use of indocyanine green alone for sentinel node biopsy in breast cancer D. Samorani1 • T. Fogacci1 • L. Dellachiesa2
Received: 20 March 2015 / Accepted: 31 March 2015 Ó The Japanese Breast Cancer Society 2015
Comment to: Inoue T et al.: Axillary lymph node recurrence after sentinel lymph node biopsy performed using a combination of indocyanine green fluorescence and the blue dye method in early breast cancer. Breast Cancer. 2014 Oct 28 [1]. The use of indocyanine green (ICG) to detect the sentinel lymph node (SLN) in breast cancer has been widely discussed in the literature. Some studies [2] pointed out that the SLN detected via ICG coincides with that detected via Technetium (Tc). Therefore, in our opinion, complete axillary dissection is not necessary to demonstrate false negatives, as we can refer to existing randomized studies in which Technetium was employed. After more than 300 surgeries during which we detected the SLN via ICG associated with Tc [3], thus refining our technique, in the last 3 months we have been using only ICG without combining it with any other tracers. So far, in 52 surgery cases, we have had 100 % detection of the SLN with a median of 2 lymph nodes per patient (range from 1 to 4). We inject a variable quantity of ICG that spans from 0.4 to 0.7 ml depending on the breast volume and on the distance between neoplasia and axilla or between areola and axilla. The time between the injection of the ICG and the incision varies from patient to patient This comment refers to the article available at doi:10.1007/s12282014-0573-8. & D. Samorani [email protected] 1
General Surgery Unit, Santarcangelo di Romagna Hospital, Rimini, AUSL Area Vasta Romagna, Rimini, Ospedale Santarcangelo di Romagna, UO Chirurgia Generalevia Pedrignone 7, Santarcangelo di Romagna (RN), Italy
2
General Surgery, Ferrara University, Ferrara, Italy
(from 2 to 8 min), with a median of 4 min. Therefore, it is necessary to follow the subcutaneous migration of the tracer using an infrared torch and make the incision only when the tracer has visibly reached the axilla, not before, otherwise, by interrupting the vessels too soon, the detection of SLNs becomes much more difficult. As we have already reported, ICG increases the average number of detected SLNs as compared to Tc, without increasing complications. This fact does not seem to be a limit, rather, in certain cases—and according to what Giuliano also stated [4]—it allows us to avoid axillary dissections when, out of three harvested lymph nodes, only a metastatic lymph node is detected. The advantages of ICG are well described in Dr. Inoue’s work and we fully agree with him on that. As per the conclusions of Dr. Inoue and his team, our experience in using only ICG to detect the SLN demonstrates there are no advantages in the association of ICG with Blue Dye, as the use of ICG only, once the technique is mastered, allows, always and in every case, the removal of the SLN. Conflict of interest We certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.
References 1. Inoue T, Nishi T, Nakano Y, Nishimae A, Sawai Y, Yamasaki M, et al.: Axillary lymph node recurrence after sentinel lymph node biopsy performed using a combination of indocyanine green fluorescence and the blue dye method in early breast cancer. Breast Cancer. 2014 Oct 28. 2. Ballardini B, Santoro L, Sangalli C, Gentilini O, Renne G, Lissidini G, et al. The indocyanine green method is equivalent to the 99 m Tc-labeled radiotracer method for identifying the sentinel
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Breast Cancer node in breast cancer: a concordance and validation study. Eur J Surg Oncol. 2013;39:1332–6. 3. Samorani D, Fogacci T, Panzini I, Frisoni G, Accardi FG, Ricci M, et al. The use of indocyanine green to detect sentinel nodes in breast cancer: a prospective study. Eur J Surg Oncol. 2015;41(1):64–70.
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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;305:569–75.
LETTER TO THE EDITOR
Use of indocyanine green alone for sentinel node biopsy in breast cancer D. Samorani1 • T. Fogacci1 • L. Dellachiesa2
Received: 20 March 2015 / Accepted: 31 March 2015 Ó The Japanese Breast Cancer Society 2015
Comment to: Inoue T et al.: Axillary lymph node recurrence after sentinel lymph node biopsy performed using a combination of indocyanine green fluorescence and the blue dye method in early breast cancer. Breast Cancer. 2014 Oct 28 [1]. The use of indocyanine green (ICG) to detect the sentinel lymph node (SLN) in breast cancer has been widely discussed in the literature. Some studies [2] pointed out that the SLN detected via ICG coincides with that detected via Technetium (Tc). Therefore, in our opinion, complete axillary dissection is not necessary to demonstrate false negatives, as we can refer to existing randomized studies in which Technetium was employed. After more than 300 surgeries during which we detected the SLN via ICG associated with Tc [3], thus refining our technique, in the last 3 months we have been using only ICG without combining it with any other tracers. So far, in 52 surgery cases, we have had 100 % detection of the SLN with a median of 2 lymph nodes per patient (range from 1 to 4). We inject a variable quantity of ICG that spans from 0.4 to 0.7 ml depending on the breast volume and on the distance between neoplasia and axilla or between areola and axilla. The time between the injection of the ICG and the incision varies from patient to patient This comment refers to the article available at doi:10.1007/s12282014-0573-8. & D. Samorani [email protected] 1
General Surgery Unit, Santarcangelo di Romagna Hospital, Rimini, AUSL Area Vasta Romagna, Rimini, Ospedale Santarcangelo di Romagna, UO Chirurgia Generalevia Pedrignone 7, Santarcangelo di Romagna (RN), Italy
2
General Surgery, Ferrara University, Ferrara, Italy
(from 2 to 8 min), with a median of 4 min. Therefore, it is necessary to follow the subcutaneous migration of the tracer using an infrared torch and make the incision only when the tracer has visibly reached the axilla, not before, otherwise, by interrupting the vessels too soon, the detection of SLNs becomes much more difficult. As we have already reported, ICG increases the average number of detected SLNs as compared to Tc, without increasing complications. This fact does not seem to be a limit, rather, in certain cases—and according to what Giuliano also stated [4]—it allows us to avoid axillary dissections when, out of three harvested lymph nodes, only a metastatic lymph node is detected. The advantages of ICG are well described in Dr. Inoue’s work and we fully agree with him on that. As per the conclusions of Dr. Inoue and his team, our experience in using only ICG to detect the SLN demonstrates there are no advantages in the association of ICG with Blue Dye, as the use of ICG only, once the technique is mastered, allows, always and in every case, the removal of the SLN. Conflict of interest We certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.
References 1. Inoue T, Nishi T, Nakano Y, Nishimae A, Sawai Y, Yamasaki M, et al.: Axillary lymph node recurrence after sentinel lymph node biopsy performed using a combination of indocyanine green fluorescence and the blue dye method in early breast cancer. Breast Cancer. 2014 Oct 28. 2. Ballardini B, Santoro L, Sangalli C, Gentilini O, Renne G, Lissidini G, et al. The indocyanine green method is equivalent to the 99 m Tc-labeled radiotracer method for identifying the sentinel
123
Breast Cancer node in breast cancer: a concordance and validation study. Eur J Surg Oncol. 2013;39:1332–6. 3. Samorani D, Fogacci T, Panzini I, Frisoni G, Accardi FG, Ricci M, et al. The use of indocyanine green to detect sentinel nodes in breast cancer: a prospective study. Eur J Surg Oncol. 2015;41(1):64–70.
123
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;305:569–75.
