Guardian lymph node (FL) defined as the first lymph node to receive the lymphatic drainage of a tumour. That is, the FL is the first lymph node to which cancer cells are directed from the original tumour (1st station of lymphatic spread of the disease). If the FL is negative, then the other lymph nodes involved in the spread of the cancer in question are considered negative and do not need to be removed, significantly reducing the morbidity of surgery.
Biopsy of the FL 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 lymph node cleansing, radiotherapy, chemotherapy).
Until recently, only radioactive technetium and cyan dye, usually patent blue, were used for the detection of FL. In fact, it has become standard practice to use them in combination in large breast centres to increase the detection rate of FL. Thus, the established technique is the so-called dual technique (radioactive technetium and cyan dye).
In recent years, the technique of biopsy of the FL using ICG, i.e. the fluorescence method, has been used internationally with great success. ICG has been approved by the FDA for its use in FL biopsy. ICG detection is achieved by using a special near infrared (NIR) imaging technique with a special PDE or FLARE camera.
The new technique of sentinel lymph node biopsy in breast cancer with the use of ICG was used for the first time in Northern Greece in October 2019. In order to reduce the cost of the procedure, the endoscopic ICG camera of Storz (video-assisted ICG guided technique), which the Clinic already has for gynecological oncological procedures, was used.
Technical
In the biopsy of the FL in breast cancer, ICG is injected locally. Various concentrations and amounts of the drug, as well as techniques (perithecal or hypothelial, subcutaneous or intradermal injection) have been described in the literature. Personally, I prefer intradermal injection into the nipple alveolus of 2 ml of ICG at a concentration of 5 mg/ml.
Fluorescence is caused by the stimulation of ICG by high-intensity radiation (760 nm wavelength).
Advantages of sentinel lymph node biopsy using ICG:
- High detection rate of FL, same as the double technique
- The surgeon and the hospital are not dependent on a nuclear medicine department for the injection of the radioactive artificially-induced radiation. Therefore, patients do not have to go to the Nuclear Medicine department and the use of radiation, however small, is avoided.
- Real time drainage from the breast to the armpit is visualized a few minutes after the injection of ICG into the nipple. That is, we see the lymphatic vessels flowing from the injection site in the breast to the axilla and finally to the FL! So the incision in the armpit is also made more accurately
- Cheap technique
- Avoids the staining (tatoo) caused by the cyan pigment and remains for several months or years
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