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. 2021 Dec 14;11(1):123.
doi: 10.1186/s13550-021-00863-x.

Detection of the sentinel lymph node with hybrid tracer (ICG-[99mTc]Tc-albumin nanocolloid) in intermediate- and high-risk endometrial cancer: a feasibility study

Nuria Sánchez-Izquierdo  1 , Sergi Vidal-Sicart  1   2 , Francisco Campos  1 , Aureli Torné  3   2   4 , Martina Aida Angeles  3   5 , Federico Migliorelli  6 , Meritxell Munmany  3 , Adela Saco  7   2   4 , Berta Diaz-Feijoo  3   2   4 , Ariel Glickman  3 , Jaume Ordi  7   4   8 , Andrés Perissinotti  1 , Marta Del Pino  3   2   4 , Pilar Paredes  9   10   11
Affiliations

Detection of the sentinel lymph node with hybrid tracer (ICG-[99mTc]Tc-albumin nanocolloid) in intermediate- and high-risk endometrial cancer: a feasibility study

Nuria Sánchez-Izquierdo et al. EJNMMI Res. .

Abstract

Purpose: Indocyanine green (ICG) is frequently used for the detection of the sentinel lymph node (SLN) in gynecology, but it carries the loss of the presurgical SLN mapping provided by [99mTc]-based colloids. Hybrid tracers such as ICG-[99mTc]Tc-albumin nanocolloid combine the benefits of both components. The aim of this study was to evaluate the feasibility and applicability of this hybrid tracer injected by transvaginal ultrasound-guided myometrial injection of radiotracer (TUMIR) approach in the detection of SLNs in patients with intermediate- and high-risk EC.

Methods: Fifty-two patients with intermediate- and high-risk EC underwent SLN biopsy after injection of a hybrid tracer using the TUMIR approach, followed by pelvic and paraaortic lymphadenectomy. SLNs were detected preoperatively by lymphoscintigraphic study and intraoperatively by gamma probe and near-infrared (NIR) optical laparoscopic camera.

Results: Preoperative lymphatic drainage was obtained in 69% and intraoperative detection in 71.4% of patients. A total of 146 SLNs (4.17 SLNs/patient) were biopsied. Pelvic bilateral detection was observed in 57% of the women and paraaortic drainage in 34% of the patients. The radioactive component allowed the detection of SLN in 97.1% of the patients, while the fluorescent component detected 80%. In more than 17% of the patients with intraoperative detection, SLNs were detected only by the radioactive signal. Lymph node metastasis was identified in 14.3% of patients submitted to SLNB. The sensitivity and negative predictive value for metastatic involvement were 100%.

Conclusion: TUMIR injection of a hybrid tracer in patients with intermediate- and high-risk EC combines the benefits of the radiotracer and the fluorescence methods with a single tracer. The method increases the paraaortic detection rate and allows a potential increase in SLN detection. Notwithstanding, based on our findings, the radioactive component of the hybrid tracer cannot be obviated.

Keywords: Endometrial cancer; Hybrid tracer (ICG-[99mTc]Tc-albumin nanocolloid); ICG; Lymphatic mapping; Radiotracer; Sentinel lymph node.

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Conflict of interest statement

The authors declared that they have no competing of interests.

Figures

Fig. 1
Fig. 1
Transvaginal ultrasound myometrial injection of the hybrid tracer (a). Hybrid tracer (ICG-[99mTc]Tc-nanocolloid) prepared for the injection (b). Tracer accumulation (green asterisk) in the anterior and posterior walls of the myometrium. Intermittent red line delimitates the uterus. Red double-headed arrow indicates the endometrium (c)
Fig. 2
Fig. 2
Planar and SPECT/CT lymphoscintigraphy performed 2 h after TUMIR injection of hybrid tracer (ICG-[99mTc]Tc-nanocolloid). Volumetric reconstruction of SPECT/CT (a) and planar lymphoscintigraphy (b) reveal drainage to the bilateral pelvic and paraaortic regions. Axial fused SPECT/CT images showing radioactive SLNs corresponding to a paraaortic node (green arrow) (c) and bilateral external iliac SLNs (red arrows) (d). SPECT/CT: single photon emission computed tomography; TUMIR: transvaginal ultrasound-guided myometrial injection of radiotracer; SLNs: sentinel lymph node
Fig. 3
Fig. 3
Intraoperative detection of SLNs by gamma probe and NIR optical camera: Combined laparoscopic sentinel node visualization with white light image (a) and multispectral fluorescence imaging (shown in blue) (b). Ex vivo images of the SLN biopsied with white light (c) and multispectral fluorescence (shown in blue) (d). SLNs: sentinel lymph node. NIR: near infrared
Fig. 4
Fig. 4
Flow chart of patients available for analysis and included in the study. SPECT/CT: single photon emission computed tomography. SLNB: sentinel lymph node biopsy; SLN: sentinel lymph node
Fig. 5
Fig. 5
Topographic distribution of SLNs identified in different anatomical areas on preoperative examination and surgery (a) and depending on the tracer detecting by gamma- and/or NIR-emission (b): radiotracer, indocyanine green and hybrid detection (radiotracer and indocyanine green). SLNs: sentinel lymph node. NIR: near infrared; SPECT/CT: single photon emission computed tomography; RT: radiotracer; ICG: indocyanine green
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