Introduction. Sentinel lymph node (SLN) biopsy is a vital component of staging and management of multiple cancers. The current gold standard utilizes technetium 99 (tech99) and a blue dye to detect regional nodes. While the success rate is typically over 90%, these two methods can be inconclusive or inconvenient for both patient and surgeon. We evaluated a new technique using laser-assisted ICG dye lymphangiography to identify SLN. Methods. In this retrospective analysis, we identified patients with melanoma who were candidates for SLN biopsy. In addition to tech99 and methylene blue, patients received a dermal injection of indocyanine green (ICG). The infrared signal was detected with the SPY machine (Novadaq), and nodes positive by any method were excised. Results. A total of 15 patients were evaluated, with 40 SLNs removed. Four patients were found to have nodal metastases on final pathology. 100% of these 4 nodes were identified by ICG, while only 75% (3/4) were positive for tech99 and/or methylene blue. Furthermore, none of the nodes missed by ICG (4/40) had malignant cells. Conclusion. ICG dye lymphangiography is a reasonable alternative for locating SLNs in patients with melanoma. Prospective studies are needed to better ascertain the full functionality of this technique. 1. Introduction Sentinel lymph node biopsy has become a standard method of staging lymph node basins for multiple cancers, including melanoma. The status of the lymph node provides valuable prognostic information and helps patients and physicians make decisions about further treatment. The current method uses an injection of technetium99 (tech99) in the cancerous area, with imaging an hour later. This is usually done the day prior to surgery but can be done on the same day. Following induction of anesthesia, the patient is injected with blue dye (methylene blue in our institution, MB), again in the cancerous area. The radioactive signal from the sentinel node is localized with a probe, and the blue dye is a visual aid. With these two methods, sentinel node localization has a reported success rate of 96–99% [1]. Despite this high reported success rate, both tech99 and blue dye have drawbacks. The tech99 often requires an additional visit to the hospital and is a radioactive substance, and the injection is often painful. MB dye stains surrounding tissues, which can obscure tissue planes, and may be toxic to skin grafts. For these reasons we sought an alternative method of sentinel node localization. Indocyanine green (ICG) is a green dye with near-infrared fluorescent properties.
References
[1]
J. E. Gershenwald, C.-H. Tseng, W. Thompson et al., “Improved sentinel lymph node localization in patients with primary melanoma with the use of radiolabeled colloid,” Surgery, vol. 124, no. 2, pp. 203–210, 1998.
[2]
N. Tagaya, R. Yamazaki, A. Nakagawa et al., “Intraoperative identification of sentinel lymph nodes by near-infrared fluorescence imaging in patients with breast cancer,” American Journal of Surgery, vol. 195, no. 6, pp. 850–853, 2008.
[3]
A. Hirano, M. Kamimura, K. Ogura, et al., “A comparison of indocyanine green fluorescence imaging plus blue dye and blue dye alone for sentinel node navigation surgery in breast cancer patients,” Annals of Surgical Oncology, vol. 19, no. 13, pp. 4112–4116, 2012.
[4]
G. A. M. Govaert, R. J. Oostenbroek, and P. W. Plaisier, “Prolonged skin staining after intradermal use of patent blue in sentinel lymph node biopsy for breast cancer,” European Journal of Surgical Oncology, vol. 31, no. 4, pp. 373–375, 2005.
[5]
C. R. Scoggins, R. C. G. Martin, M. I. Ross et al., “Factors associated with false-negative sentinel lymph node biopsy in melanoma patients,” Annals of Surgical Oncology, vol. 17, no. 3, pp. 709–717, 2010.
[6]
C. Hirche, D. Murawa, Z. Mohr, S. Kneif, and M. Hünerbein, “ICG fluorescence-guided sentinel node biopsy for axillary nodal staging in breast cancer,” Breast Cancer Research and Treatment, vol. 121, no. 2, pp. 373–378, 2010.
[7]
M. Fujiwara, T. Mizukami, A. Suzuki, and H. Fukamizu, “Sentinel lymph node detection in skin cancer patients using real-time fluorescence navigation with indocyanine green: preliminary experience,” Journal of Plastic, Reconstructive and Aesthetic Surgery, vol. 62, no. 10, pp. e373–e378, 2009.
[8]
K. Motomura, H. Inaji, Y. Komoike, T. Kasugai, S. Noguchi, and H. Koyama, “Sentinel node biopsy guided by indocyanin green dye in breast cancer patients,” Japanese Journal of Clinical Oncology, vol. 29, no. 12, pp. 604–607, 1999.
[9]
H. Uhara, N. Yamazaki, M. Takata et al., “Applicability of radiocolloids, blue dyes and fluorescent indocyanine green to sentinel node biopsy in melanoma,” Journal of Dermatology, vol. 39, no. 4, pp. 336–338, 2012.
[10]
O. R. Brouwer, W. M. Klop, T. Buckle, et al., “Feasibility of sentinel node biopsy in head and neck melanoma using a hybrid radioactive and fluorescent tracer,” Annals of Surgical Oncology, vol. 19, no. 6, pp. 1988–1994, 2012.
[11]
Y. Fujisawa, Y. Nakamura, Y. Kawachi, and F. Otsuka, “Indocyanine green fluorescence-navigated sentinel node biopsy showed higher sensitivity than the radioisotope or blue dye method, which may help to reduce false-negative cases in skin cancer,” Journal of Surgical Oncology, vol. 106, no. 1, pp. 41–45, 2012.
[12]
K. Namikawa and N. Yamazaki, “Sentinel lymph node biopsy guided by indocyanine green fluorescence for cutaneous melanoma,” European Journal of Dermatology, vol. 21, no. 2, pp. 184–190, 2011.
[13]
K. Polom, D. Murawa, Y. S. Rho, A. Spychala, and P. Murawa, “Skin melanoma sentinel lymph node biopsy using real-time fluorescence navigation with indocyanine green and indocyanine green with human serum albumin,” British Journal of Dermatology, vol. 166, no. 3, pp. 682–683, 2012.
[14]
S. L. Troyan, V. Kianzad, S. L. Gibbs-Strauss et al., “The FLARE？ intraoperative near-infrared fluorescence imaging system: a first-in-human clinical trial in breast cancer sentinel lymph node mapping,” Annals of Surgical Oncology, vol. 16, no. 10, pp. 2943–2952, 2009.
[15]
M. E. Valsecchi, D. Silbermins, N. De Rosa, S. L. Wong, and G. H. Lyman, “Lymphatic mapping and sentinel lymph node biopsy in patients with melanoma: a meta-analysis,” Journal of Clinical Oncology, vol. 29, no. 11, pp. 1479–1487, 2011.
