Green versus blue: Randomized controlled trial comparing indocyanine green with methylene blue for sentinel lymph node detection in endometrial cancer

Rozenholc, Alexandre; Samouëlian, Vanessa; Warkus, Thomas; Gauthier, Philippe; Provencher, Diane; Sauthier, Philippe; Gauthier, France; Drakopoulos, Panagiotis; Cormier, Béatrice

doi:10.1016/j.ygyno.2019.03.103

Cited by 71 publications

(48 citation statements)

References 18 publications

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“…The majority of published series report on cervical injection of tracers with a detection rate of 81%, bilateral detection rate of 50%, and aortic detection rate of 17% 5. Among the tracers used, indocyanine green (ICG) proved to be superior to blue dyes with a detection rate comparable to radiocolloid 8–10…”

Section: Introductionmentioning

confidence: 99%

Sentinel lymph node mapping in endometrial cancer: performance of hysteroscopic injection of tracers

Martinelli

Ditto

Bogani

et al. 2020

Int J Gynecol Cancer

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ObjectiveTo report on the performance of hysteroscopic injection of tracers (indocyanine green (ICG) and technetium-99m (Tc-99m)) for sentinel lymph node (SLN) mapping in endometrial cancer.MethodsSingle-center retrospective evaluation of consecutive patients who underwent SLN mapping following hysteroscopic peritumoral injection of tracer. Detection rate (overall/bilateral/aortic) diagnostic accuracy, and oncologic outcomes were evaluated.ResultsA total of 221 procedures met the inclusion criteria. Mean patient age was 60 (range 28–84) years and mean body mass index was 26.9 (range 15–47) kg/m2 . In 164 cases (70.9%) mapping was performed laparoscopically. The overall detection rate of the technique was 94.1% (208/221 patients). Bilateral pelvic mapping was found in 62.5% of cases with at least one SLN detected and was more frequent using ICG than with Tc-99m (73.8% vs 53.3%; p<0.001). In 47.6% of cases SLNs mapped in both pelvic and aortic nodes, and in five cases (2.4%) only in the aortic area. In eight patients (3.8%) SLNs were found in aberrant (parametrial/presacral) areas. Mean number of detected SLNs was 3.7 (range 1–8). In 51.9% of cases at least one node other than SLNs was removed. Twenty-six patients (12.5%) had nodal involvement: 12 (46.2%) macrometastases, six (23.1%) micrometastases, and eight (30.7%) isolated tumor cells. In 12 cases (46.8%) the aortic area was involved. Overall, 6/221 (2.7%) patients had isolated para-aortic nodes. Three false-negative results were found, all in the Tc-99m group. All had isolated aortic metastases. Overall sensitivity was 88.5% (95% CI 71.7 to 100.0) and overall negative predictive value was 96.5% (95% CI 86.8 to 100.0). There were 10 (4.8%) recurrences: five abdominal/distant, four vaginal, and one nodal (in the aortic area following a unilateral mapping plus side-specific pelvic lymphadenectomy). Most recurrences (9/10 cases) were patients in whom a completion lymphadenectomy was performed. No deaths were reported after a mean follow-up of 47.7 months.ConclusionsHysteroscopic injection of tracers for SLN mapping in endometrial cancer is as accurate as cervical injection with a higher detection rate in the aortic area. ICG improves the bilateral detection rate. Adding lymphadenectomy to SLN mapping does not reduce the risk of relapse.

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Section: Introductionmentioning

confidence: 99%

Sentinel lymph node mapping in endometrial cancer: performance of hysteroscopic injection of tracers

Martinelli

Ditto

Bogani

et al. 2020

Int J Gynecol Cancer

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“…In the literature before, a higher BMI is linked to lower detection rate of the SLN (13). However, in the study by Rozenholc et al there was no difference in the detection rate between surgeries that were robotic (mean BMI 44.6) and laparoscopic (mean BMI 29.4) (24). Moreover, when compared with open surgery, robotic-assisted surgery results in fewer blood transfusions and leads to a slightly shorter hospital stay (37).…”

Section: Discussionmentioning

confidence: 92%

“…In study of SLN mapping by Rossi et al there were only two patients with positive lymph nodes in those who had successful mapping and one of them showed negative SLN, leading to the lowest sensitivity of 50% (10). In other 10 studies with available data, 6 out of them showed the sensitivities of 100% and all of them were over 70% [(11–14, 17, 21–24, 26); Table 1]. In previous meta-analyses by Lin et al and Smith et al in uterine cancers with several tracers included, sensitivities were found 91% (95% Cl: 87–95) and 96% (95% CI: 93–98), respectively (28, 31).…”

Section: Discussionmentioning

confidence: 99%

Robotic-Assisted Sentinel Lymph Node Mapping With Indocyanine Green in Pelvic Malignancies: A Systematic Review and Meta-Analysis

Jing

Wang

et al. 2019

Front. Oncol.

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Objective: Newer technologies such as near-infrared (NIR) imaging of the fluorescent dye indocyanine green (ICG) and daVinci Xi Surgical System have become promising tools for sentinel lymph node (SLN) mapping. This meta-analysis was conducted to comprehensively evaluate the diagnostic value of SLN in assessing lymph nodal metastasis in pelvic malignancies, using ICG with NIR imaging in robotic-assisted surgery. Materials and Methods: A literature search was conducted using PubMed for studies in English before April 2019. The detection rate, sensitivity of SLN detection of metastatic disease, and factors associated with successful mapping (sample size, study design, mean age, mean body mass index, type of cancer) were synthesized for meta-analysis. Results: A total of 17 articles including 1,059 patients were finally included. The reported detection rates of SLN ranged from 76 to 100%, with a pooled average rate of 95% (95% CI: 93–97; 17 studies). The sensitivity of SLN detection of metastatic disease ranged from 50 to 100% and the pooled sensitivity was 86% (95% CI: 75–94; 8 studies). There were no complications related to ICG administration reported. Conclusions: NIR imaging system using ICG in robotic-assisted surgery is a feasible and safe method for SLN mapping. Due to its promising performance, it is considered to be an alternative to a complete pelvic lymph node dissection.

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“…However, the optimal technique for this procedure is yet to be defined. The superiority of ICG over blue dyes has been widely reported 20–22. In a recent prospective trial published by Backes et al, 204 patients were enrolled to receive either ICG or blue dye.…”

Section: Discussionmentioning

confidence: 99%

Technetium-99m-indocyanine green versus technetium-99m-methylene blue for sentinel lymph node biopsy in early-stage endometrial cancer

Cabrera

Bebia

Franco-Camps

et al. 2020

Int J Gynecol Cancer

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IntroductionThe low accuracy of pre-operative imaging techniques for prediction of nodal status strengthens the relevance of sentinel lymph node (SLN) biopsy in endometrial cancer, although the optimal method for its detection is still under investigation. The increasing use of indocyanine green (ICG) has aroused concern about its enhanced visualization of lymphatic channels, which could lead to a specimen that is thought to be nodal tissue not subsequently yielding a lymph node on pathologic analysis ('empty node packet'). Our main objective was to compare the overall and bilateral detection rates for SLN biopsy using two combined techniques: technetium-99m-ICG (Tc-99m-ICG) versus technetium-99m-methylene blue (Tc-99m-MB). Our secondary aim was to compare the ‘empty node packet’ rates between the two cohorts.MethodsA prospective, non-randomized, single-center trial including patients diagnosed with endometrial cancer (any grade or histology) in pre-operative early stage, and operated on between February 2017 and July 2019. All tracers were injected intracervically. Pelvic and aortic lymphadenectomy were performed on patients at intermediate or high risk of recurrence pre-operatively. All SLNs were sent for intra-operative frozen section and afterwards processed following an ultrastaging protocol.ResultsEighty-four patients were included, 58% (n=49) in the Tc-99m-MB group and 42% (n=35) in the Tc-99m-ICG group. Overall detection rate was 93% and was not statistically different between the two groups. A better bilateral detection rate was observed among Tc-99m-ICG patients (69% vs 41%, p=0.012). The 'empty node packet' rate was 4% in the Tc-99m-ICG cohort and 0% in the Tc-99m-MB cohort (p=0.032).DiscussionTc-99m-ICG is a feasible, safe technique for SLN biopsy in early-stage endometrial cancer, and appears to be superior in terms of bilateral detection to Tc-99m-MB. The addition of Tc-99m to ICG could decrease the rate of 'empty node packets' and better define the anatomic location of SLNs in patients with endometrial cancer.

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Green versus blue: Randomized controlled trial comparing indocyanine green with methylene blue for sentinel lymph node detection in endometrial cancer

Cited by 71 publications

References 18 publications

Sentinel lymph node mapping in endometrial cancer: performance of hysteroscopic injection of tracers

Sentinel lymph node mapping in endometrial cancer: performance of hysteroscopic injection of tracers

Robotic-Assisted Sentinel Lymph Node Mapping With Indocyanine Green in Pelvic Malignancies: A Systematic Review and Meta-Analysis

Technetium-99m-indocyanine green versus technetium-99m-methylene blue for sentinel lymph node biopsy in early-stage endometrial cancer

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