Indocyanine green utility in sentinel node detection for cervical cancer patients

Journal of Mind and Medical Sciences Volume 6 | Issue 2 Article 11 2019 Indocyanine green utility in sentinel node detection for cervical cancer patients Nicolae Bacalbașa Irina Balescu Cristian Balalau Mihaela Vilcu Iulian Brezean Follow this and additional works at: https://scholar.valpo.edu/jmms Part of the Oncology Commons, Preventive Medicine Commons, Primary Care Commons, and the Surgery Commons Recommended Citation Bacalbașa, Nicolae; Balescu, Irina; Balalau, Cristian; Vilcu, Mihaela; and Brezean, Iulian (2019) "Indocyanine green utility in sentinel node detection for cervical cancer patients," Journal of Mind and Medical Sciences: Vol. 6 : Iss. 2 , Article 11. DOI: 10.22543/7674.62.P248252 Available at: https://scholar.valpo.edu/jmms/vol6/iss2/11 This Review Article is brought to you for free and open access by ValpoScholar. It has been accepted for inclusion in Journal of Mind and Medical Sciences by an authorized administrator of ValpoScholar. For more information, please contact a ValpoScholar staff member at . https://scholar.valpo.edu/jmms/ https://proscholar.org/jmms/ ISSN: 2392-7674 J Mind Med Sci. 2019; 6(2): 248-252 doi: 10.22543/7674.62.P248252 Received for publication: April 22, 2019 Accepted: June 14, 2019 Review Indocyanine green utility in sentinel node detection for cervical cancer patients Nicolae Bacalbașa1,2,3, Irina Balescu4*, Cristian Balalau2,5, Mihaela Vilcu1,2, Iulian Brezean1,2 1 Ion Cantacuzino Clinical Hospital, Bucharest, Romania Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 3 Center of Excellence in Translational Institute, Fundeni Clinical Institute, Bucharest, Romania 4 Ponderas Academic Hospital, Bucharest, Romania 5 Pantelimon’ Clinical Hospital, Bucharest, Romania 2 Abstract With wide implementation of screening tests for the Human Papilloma Virus, the number of diagnosed cases of premalignant or early stages of cervical cancer has increased considerably. As a consequence, surgeons’ attention has focused on determining how best to limit the surgical procedure so the benefits of the procedure will not be surpassed by postoperative morbidity. In this respect, extended lymph node dissection, routinely associated so far with cervical cancer patients, has in the last decades been replaced with sentinel node detection and biopsy. Initially performed through radiocolloid injection, this method has undergone permanent changes in order to maximize its efficacy and safety. Although the laparoscopic approach had been widely used in the past, a new method has been proposed, i.e., the use of indocyanine green injection, which has yielded promising results for sentinel node detection in the early stages of cervical carcinoma. This paper reviews the literature of the most relevant studies conducted on this topic. Keywords  Highlights ✓ Sentinel lymph node detection by using indocyanine green injection seems to be a safe and effective method in cervical cancer patients. cervical cancer, sentinel lymph node detection, indocyanine green ✓ Attention should be paid to the method of dilution and injection of this product, in order to avoid the association of false positive results. To cite this article: Bacalbasa N, Balescu I, Balalau C, Vilcu M, Brezean I. Indocyanine green utility in sentinel node detection for cervical cancer patients. J Mind Med Sci. 2019; 6(2): 248-252. DOI: 10.22543/7674.62.P248252 *Corresponding author: Irina Balescu, Ponderas Academic Hospital, Bucharest, Romania Email: Bacalbașa N. et al. Introduction The benefits of detecting the sentinel node were demonstrated in cases of solid tumors almost a century ago. More recently, the method again proved safe and effective in treating other gynecologic malignancies such as breast cancer and vulvar cancer (1-4). Regarding cervical cancer, the technique of sentinel node biopsy has been implemented since 1996 and consisted of blue dye and/or radiocolloid injection. Although the method had encouraging results, it nevertheless failed in detecting bilateral sentinel lymph nodes in almost half the patients. As a consequence, a significant number of patients were further subjected to extended lymph node dissection even though the malignant process had been diagnosed in an early stage of the disease (5, 6). However, the failure to detect the sentinel nodes argued in favor of searching for a more specific tracer. Specifically, the administration of radioisotopes such as Technetium proved to be painful to the patient, expensive, challenging for the team, and even dangerous due to possible radioactive contamination after the injection (7, 8). Other tracers such as blue dye, although less costly, were associated with rapid clearance from the sentinel nodes, meaning they could no longer be detected after a period of time. Specifically, due to the reduced dimensions of the molecules, these dyes seemed to be associated with a rapid migration from the level of the sentinel nodes. Therefore, by the time of surgery, the true sentinel nodes might be missed, while the blue dye accumulates at the level of the next lymph node stations. As a result, the rates of false positives increase and the effectiveness of the method decreases (9, 10). Moreover, the injection of such dyes is sometimes associated with allergic reactions, including anaphylactic shock (9-11). For these reasons, there was need to identify other types of tracers that could provide a higher rate of detection, with lower rates of adverse reactions and better identification of the sentinel nodes bilaterally (12). Discussions The utility of indocyanine green for sentinel lymph node detection in gynecologic malignancies. This method uses an indocyanine green injection (approved by the FDA for many years) and the near infrared fluorescence imaging, due to the fluorescent properties of this substance in the 700-900 nm light spectrum (13). According to a study by Jewell and colleagues, the method consists in diluting a 25 mg vial in 20 cc of sterile water, thus obtaining a concentration of 1.25 mg/ml, and injecting one cc at 3 pm and 9 pm in the superficial and deep layer respectively at the level of the uterine cervix. The injection was done just after draping the patient, but before the insertion of the uterine manipulator and prior to laparoscopic surgery (12). Another site of injection is the endocervical or intrauterine cavity during hysteroscopy. The intracervical injection has been associated with the best results due to the presence of rich parametrial lymphatic drainage. However, when the surgeon decides to inject the indocyanine green, several points should be considered: the product contains up to 5% iodine-based excipients, so it cannot be used in patients with known allergies to iodine; the substance should be diluted in sterile water and not in other substances such as sodium chloride (due to the fact that it is not readily soluble in saline solution), and the fact that the produ (...truncated)