Lymph node guard (FL) the first lymph node to receive lymphatic drainage of a tumor was defined. That is, FL is the first lymph node to which cancer cells are directed from the original tumor (1st lymphogenous dissemination station of the disease). If the FL is negative, then the remaining lymph nodes involved in the spread of the cancer are considered negative and do not need to be removed, significantly reducing the morbidity of the operation.
PL biopsy is part of the staging of breast cancer in the axillary lymph nodes. If the FL is found to be negative or positive, it affects the further course of treatment (removal of all axillary lymph nodes or axillary lymphatic cleansing, radiation therapy, chemotherapy).
Until now, only radioactive technetium and the blue pigment, usually patent blue, were used to detect FL. In fact, their use has been established to be done in large breast centers in combination, to increase the detection rate of FL. Thus, the established technique is the so-called double technique (radioactive technetium and cyan pigment).
In recent years, the technique of biopsy of FL with the use of ICG, that is, by the method of fluorescence, has been used with great success internationally. ICG has been approved by the FDA for its use in the biopsy of FL. Detection of ICG is achieved using a special near infrared (NIR) imaging technique with a special PDE or FLARE camera.
The new technique of guarding lymph node biopsy in breast cancer using ICG was used for the first time in Northern Greece at the Clinic “AGIOS LOUKAS” in October 2019. To reduce the cost of the operation, the endoscopic ICG camera of Storz (video-assisted ICG guided technique), already available at the Clinic for Gynecological Oncological Operations, was used.
Technique
In the biopsy of FL in breast cancer, the injection of ICG is done locally. Various concentrations and quantities of the drug have been described in the literature, as well as techniques (perithelial or hypodermic injection, subcutaneously or intradermally). Personally, I prefer an intradermal injection in the breast to take 2ml ICG with a concentration of 5 mg/ml.
The fluorescence is caused by the excitation of the ICG by high-intensity radiation (wavelength 760 nm).
Advantages of biopsy of the guard lymph node using ICG:
- High detection rate of FL,Same as the double technique
- The surgeon and the hospital do not depend on the department of Nuclear Medicine for the injection of radioactive technetium. Therefore, patients do not need to go to the Department of Nuclear Medicine and avoid the use of radioactivity, however small it may be
- Real-time visualization of the lymph flow (real tim drainage) from the breast to the armpit, a few minutes after the injection of ICG into the areola mammary gland. That is, we see the lymphatic vessels that fluoresce from the injection site in the breast to the armpit and finally to the FL! Thus and the incision in the armpit is made more accurately
- Inexpensive technique
- Avoiding staining (tatoo) which causes the blue pigment and persists for several months or years
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