Chirappapha Prakasit, Chatmongkonwat Tanet, Lertsithichai Panuwat, Pipatsakulroj Wiriya, Sritara Chanika, Sukarayothin Thongchai
Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
Ann Med Surg (Lond). 2020 Sep 22;59:156-160. doi: 10.1016/j.amsu.2020.09.030. eCollection 2020 Nov.
The breast cancer treatment paradigm has shifted to neoadjuvant treatment. There are many advantages to neoadjuvant treatment, such as tumor downsizing, tumor biology testing, treating micrometastasis, and achieving complete pathological response (a surrogate marker for overall survival). However, in the post neoadjuvant settings, sentinel lymph node biopsy can be done using a dual staining technique to decrease the false-negative rate (FNR) and increase the detection rate. However, many hospitals are not equipped to use radioisotopes. Here we investigate the detection rate and accuracy of sentinel lymph node biopsy in post neoadjuvant treatment breast cancer, comparing radioisotope, isosulfan blue, and indocyanine green (ICG) approaches.
This prospective study includes breast cancer patients (T2-4, N1-2) who had received neoadjuvant treatment. Carcinomas were confirmed by tissue pathology. Patients who had previous surgical biopsy or surgery involving the axillary regions, and those with a history of allergy to ICG, isosulfan blue, or radioisotope were excluded from the study.
The study was done between July 1, 2019 to March 31, 2020. The mean age of participants was 53 years. Fourteen (60.87%) were post-menopause, two (8.7%) were perimenopause, and seven (30.43%) were premenopause. The clinical-stage distribution of the participants was: 2A (8.7%), 2B (34.78%), 3A (43.48%), and 3B (13.04%). The primary tumor size was 4.82 ± 2.73 cm. The lymph node size was 1.8 ± 0.96 cm. The detection rates at the individual level were 95.23% with ICG, 85.71% with isosulfan blue, and 85.71% with a radioisotope. The detection rate increased up to 100% when the ICG and blue dye methods were combined. The FNRs of sentinel lymph node biopsy at the individual level were: 10% using ICG, 30% using isosulfan blue, and 40% using radioisotope. At the lymph node level, the detection rates were 93.22% using ICG, 81.78% using isosulfan blue, and 53.87% using a radioisotope. The FNRs of sentinel lymph node biopsy at the lymph node level were 19.05% with ICG, 21.43% with isosulfan blue, and 18.03% with a radioisotope. However, the FNR was less than 10% when ICG, isosulfan blue, and a radioisotope were combined.
We can perform sentinel lymph node biopsy by combining blue dye with ICG as an optional modality and achieve a comparable outcome with combine radioisotope in locally advanced breast cancer after neoadjuvant treatment.
乳腺癌治疗模式已转向新辅助治疗。新辅助治疗有诸多优势，如肿瘤缩小、肿瘤生物学检测、治疗微转移以及实现完全病理缓解（总体生存的替代标志物）。然而，在新辅助治疗后，前哨淋巴结活检可采用双重染色技术以降低假阴性率（FNR）并提高检出率。然而，许多医院没有配备使用放射性同位素的条件。在此，我们比较放射性同位素、异硫蓝和吲哚菁绿（ICG）方法，研究新辅助治疗后乳腺癌前哨淋巴结活检的检出率和准确性。
这项前瞻性研究纳入接受新辅助治疗的乳腺癌患者（T2 - 4，N1 - 2）。通过组织病理学确诊癌症。既往有腋窝区域手术活检或手术史以及对ICG、异硫蓝或放射性同位素有过敏史的患者被排除在研究之外。
该研究于2019年7月1日至2020年3月31日进行。参与者的平均年龄为53岁。14名（60.87%）处于绝经后，2名（8.7%）处于围绝经期，7名（30.43%）处于绝经前。参与者的临床分期分布为：2A期（8.7%），2B期（34.78%），3A期（43.48%）和3B期（13.04%）。原发肿瘤大小为4.82 ± 2.73厘米。淋巴结大小为1.8 ± 0.96厘米。个体水平的检出率分别为：ICG法95.23%，异硫蓝法85.71%，放射性同位素法85.71%。ICG和蓝色染料方法联合使用时检出率提高至100%。个体水平前哨淋巴结活检的FNR分别为：ICG法10%，异硫蓝法30%，放射性同位素法40%。在淋巴结水平，检出率分别为：ICG法93.22%，异硫蓝法81.78%，放射性同位素法53.87%。淋巴结水平前哨淋巴结活检的FNR分别为：ICG法19.05%，异硫蓝法21.43%，放射性同位素法18.03%。然而，ICG、异硫蓝和放射性同位素联合使用时FNR小于10%。
在新辅助治疗后的局部晚期乳腺癌中，我们可以将蓝色染料与ICG联合作为一种可选方式进行前哨淋巴结活检，并获得与联合放射性同位素相当的结果。
