Occult lesion localization by indocyanine green fluorescence for nonpalpable breast cancer

Abstract

Funding informationMontpellier-Reine Breast Cancer Association.One third of operated breast cancers are clinically occult. 1 Nonpalpable breast cancers (NPBC) require accurate intraoperative guidance to achieve complete tumor removal. 1 Incomplete removal of lesions increases the rate of reexcision, worsening patient's discomfort, and cosmetic outcomes. 1 Localization techniques suffer from various limitations. Indocyanine green (ICG) fluorescence is commonly used for intraoperative identification of sentinel lymph nodes (SLN). 2 Its pertinence for NPBC is still underestimated.Darkness required in surgery room with available cameras has been a limitation for its use. We evaluated ICG method for NPBC localization, guided by a probe in ambient light, inspired by radioguided occult lesion localization (ROLL).We included ten patients scheduled for routine conserving surgery for NPBC, from October 2017 to July 2018 in our Breast Surgery Department. Nodular mass was assessed by mammography and ultra sound (US). Exclusion criteria were palpable tumor, advanced stage of disease requiring neo-adjuvant therapy, and hypersensitivity to iodine. Patients with bilateral tumor were randomized to evaluate this technique in one breast. Study was approved by Ethics Committee (NCT03313908). National Agency for Safety of Medicines (ANSM) authorized this clinical trial on medicinal product for human use (Reference: 170405A-13). Identifier on Clinical Trials. gov is NCT03313908. Written consent was signed after detailed written information. The day preceding surgery, injection of 0.2 mL (10 MBq) of 99mTc-labeled rhenium sulfide (Nanocis1, IBA molecular France) was performed by a radiologist as described in ROLL. 3 This injection is done the day before surgery to avoid delays in the operating room in case of difficulties in radiology or nuclear medicine departments. On the day of surgery, under general anesthesia, 0.2-0.8 mL (0.5-2 mg) of ICG was injected close to NPBC, by a radiologist under US guidance. Tumor was spotted by two methods: isotope and fluorescence. For isotope localization, common gamma probe (Gamma sud II/Clerad: GS 5002) with collimator was used, like classical ROLL. For fluorescence localization, we used new handheld dual-fluorescence probe (Europrobe 3, Eurorad SA) operating in ambient light, commercially available but mainly used for lymph node detection. Probes defined "hot spot'' in area of maximum radioactivity or fluorescence corresponding to the site of lesion. Localization of lesion was drawn on skin with marker pen for both methods (Figure 1). Distance between markers was measured. Surgeons performed conserving breast surgery following standard procedure, using ROLL. Primary end point was to determine reliability of ICG fluorescence in locating NPBC, estimated by distance between fluorescence hot spot and tumor localization on histologic specimen, compared to isotope hot spot, identified by wires (Figure 2). Secondary end points were distance between hot spot marks on skin, evaluation of technical feasibilit...

Efficacy of indocyanine green fluorescence for the identification of non-palpable breast tumours: systematic review

“…The most common reason for record exclusion was a focus on ICG fluorescence for SLN biopsies. A total of 11 articles met the inclusion criteria and were selected for inclusion 15–18 , 21–24 . A cross-reference check revealed no additional articles.…”

“…A cross-reference check revealed no additional articles. Additional and missing data were requested from the corresponding authors of three articles 17 , 21 , 22 .…”

“…All included studies were published between 2012 and 2023 ( Table 1 ); they included five comparative studies (two RCTs 16 , 20 , one non-randomized three-arm clinical trial 24 , one cohort study with a historical control group 17 , and one retrospective study with a control group 22 ), three single-arm clinical trials 21 , 23 , 26 , one single-arm retrospective cohort study 18 , and two case reports 15 , 25 . One study was conducted across four medical centres 20 , another study involved two medical institutions 24 , and all others were single-centre studies.…”

“…Five studies received funding for their research project 17 , 20 , 21 , 24 , 26 . The funding sources had no role in collection, analysis and interpretation of the data, or submission of the manuscript.…”

“…20 , successful visualization after localization of the excised specimen; Francini et al . 21 , occult lesion localization on the skin; Guo et al . 22 , retrieval of lesions as confirmed with imaging study to the breast specimen; Keating et al .…”