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Application of Preoperative Computed Tomographic Lymphography For Wen et al. BMC Surg (2021) 21:187 https://doi.org/10.1186/s12893-021-01190-7 RESEARCH ARTICLE Open Access Application of preoperative computed tomographic lymphography for precise sentinel lymph node biopsy in breast cancer patients Shishuai Wen1,2,3†, Yiran Liang1†, Xiaoli Kong1, Baofeng Liu4, Tingting Ma1, Yeqing Zhou1, Liyu Jiang1, Xiaoyan Li1 and Qifeng Yang1,5,6* Abstract Background: In light of the extensive application of sentinel lymph node biopsy (SLNB) in clinically node-negative breast cancer patients and the recently investigated failure of SLNB after lumpectomy, it has become important to explore methods for preoperative mapping of sentinel lymph nodes (SLNs) and their lymphatics to direct precise SLNB and improve the identifcation rate of SLNs. Methods: Twenty-seven patients with suspected breast cancer based on the results of the clinical examination and imaging were enrolled in the study. Computed tomographic lymphography (CTLG) followed by CT three-dimensional reconstruction was performed to determine the localization of SLNs and lymphatics on the body surface preopera- tively. Intraoperatively combined staining with methylene blue and indocyanine green was used to evaluate the accuracy and feasibility of CTLG. Results: SLNs and lymphatics from the breast were identifed using CTLG in all patients, and preoperative SLNs and lymphatics localization on the body surface showed a signifcant role in the selection of operative incision and injec- tion points. The accuracy rate of SLN and lymphatic detection by CTLG was 92.6% compared with intraoperatively combined staining. Moreover, preoperative CTLG performed well in SLN number detection, and the accuracy rate was 95.2%. Conclusion: We evaluate the procedure and application of preoperative CTLG in the superfcial localization of SLNs and lymphatics, which may lead to a decreased incidence of cutting of the lymphatics of SLNs and consequently more rapid and accurate SLN detection. This method promotes personalized SLN mapping, providing detailed infor- mation about the number and anatomical location of SLNs and lymphatics for adequate surgical planning for breast cancer patients. Keywords: Sentinel lymph node biopsy, Preoperative SLNs and lymphatics localization, Computed tomographic lymphography, CT three-dimensional reconstruction Background Breast cancer is the predominant malignancy among women worldwide and accounts for approximately *Correspondence: [email protected] †Shishuai Wen and Yiran Liang contributed equally to this work. 15% of cancer-related deaths in women [1]. Te axillary 1 Department of Breast Surgery, General Surgery, Qilu Hospital lymph node (LN) status is essential for the prognosis and of Shandong University, Wenhua Xi Road No. 107, Jinan 250012, treatment of breast cancer patients. Indeed, the 5-year Shandong, China Full list of author information is available at the end of the article overall survival (OS) rate for breast cancer patients with © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Wen et al. BMC Surg (2021) 21:187 Page 2 of 8 LN metastasis is reduced by 40% compared to that of [23, 24]. Moreover, the waiting time for parafn pathol- patients with negative lymph nodes [2]. Terefore, it is ogy diagnosis after biopsies is too long, which restricts important to determine the lymph node status accu- its application to some extent. Terefore, excision biopsy rately. Mastectomy and axillary lymph node dissection might be performed when other percutaneous biopsies (ALND) have been widely accepted as the gold standard are not feasible. When excision biopsy was performed for treatment for patients with breast cancer for decades. the intraoperative pathological assessment before SLNB, Although ALND is a reliable procedure to identify nodal the lymphatic drainage of SLNs might be cut of, poten- metastasis and maintain locoregional disease control, it tially leading to identifcation failure of SLNs. Moreover, leads to notable postoperative complications, including lymph fow rerouting and fatty axilla could also reduce pain, numbness, loss of strength, loss of sensitivity, and the accumulation of radiocolloids and blue dye in SLNs edema [3, 4], which signifcantly afect the quality of life [25]. Terefore, preoperative mapping of SLNs and their of patients. lymph vessels (LVs) is helpful for avoiding inaccurate dis- Sentinel lymph nodes (SLNs) refer to the initial lymph section and consequently improving the identifcation nodes to receive lymphatic drainage from the primary rate of SLNB. tumor. SLN is reported to be a predictive factor of met- Recently, computed tomographic lymphography astatic spread to the respective regional nodal basins, (CTLG), a safe technique allowing preoperative SLN nav- and sentinel lymph node biopsy (SLNB) has gradually igation, has been proposed for SLN mapping in various substituted ALND as the standard surgical procedure cancers [26–28]. Tese high-resolution images could be for clinically node-negative patients with early-stage used for three-dimensional reconstruction and produce breast cancer due to signifcantly fewer complications favorable results for providing precise images of the SLNs and indiscrimination between ALND and SLNB in sur- and their aferent LVs with the surrounding anatomy [25]. vival and locoregional disease control [5–11]. With the Moreover, CTLG could be performed during routine development of dyes and tracers, various intraoperative CT scans to preoperatively screen distant metastasis for detection methods of SLNs have been revealed, including breast cancer patients, adding little costs or time to the methylene blue dye, indocyanine green fuorescence and procedure [29]. In this study, we performed CTLG to pre- radioactive colloid. Te combination of radioactive col- operatively localize SLNs and lymph vessels in patients loid and blue dye, which exhibits a higher SLN detection with early breast cancer and evaluated the usefulness and rate (> 90%) and a lower false negative rate (< 5–10%), accuracy of CTLG for the localization of SLNs. is the internationally recommended standard tracer method for SLNB [12]. However, given the risk of expo- Methods sure to radiation, training of doctors, legislative require- Patients ments, the need for professional equipment, and the cost, Between June 2017 and November 2017, 27 patients with the application of radioactive colloids in China is limited suspected breast cancer based on the results of clini- [13]. On the other hand, the dye method is simple and cal examination and imaging methods were included in easy to master after training and is the widely used trac- this study. Te median age of these patients was 51 years ing method for SLNB in China. (range 30–65 years). In 27 patients, the lymph nodes were For preoperative biopsy, fne needle aspiration cytol- clinically negative. Te axillary lymph nodes of patients ogy (FNAC) and core needle biopsy (CNB) are widely were negative as determined through clinical physical recommended for breast lesion diagnosis [14]. However, examination and imaging examination (mammography previous studies revealed that percutaneous biopsies may or ultrasound). No distant metastasis of these patients lead to spreading of malignant breast cells following the was detected. Patients with pregnancy, thyroid disease, needle tract or hematogenous spillage [15, 16], whereas contraindication to CT or allergy to the contrast agent other studies reported that displaced malignant cells were excluded. Te detailed patient characteristics are might not be viable due to the immune system [17, 18]. presented in Additional fle 1: Table S1. Informed con- Although several case studies reported the recurrence of sents were obtained from the patients before the tests. breast cancer in the needle tract [19], cohort studies have Te study was approved by the Ethical Committee of not found any association between local recurrence or Qilu Hospital of Shandong University (KYLL-2016-231). overall survival in breast cancer patients [20, 21]. How- ever, there seems to be a prevalent belief among patients Computed tomographic lymphography (CTLG) that percutaneous biopsies might promote the spread of CTLG is a safe technique allowing SLN navigation with cancer [22]. In addition, there exists a false negative rate satisfying results, which had been proved in several can- for FNAC and CNB due to the experience of surgeons cers. Radiation exposure to patients is negligible in SLNB and pathologists and the small volume of breast
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