| BackgroundNowadays,procedure of breast cancer sentinel lymph node biopsy(SLNB)is mainly focus on traditional open surgery,which is easily affected by obesity etc.To reduce the false negative rate of sentinel lymph node(SLN),it is needed to remove more axillary tissue,similar to cleaning the first group of lymph nodes.In recent years,the endoscopic technology is gradually applied in breast cancer surgery,which owns the advantages of minimally invasive,better appearance and benefit in breast conservation.Injected the lipolysis liquid into the axilla at the superficial and deeper level,it provides the working space after liposuction,which is the common method in endoscopic sentinel lymph node biopsy(ESLNB).With the help of liposuction,clear network structures of lymphatics were shown under the view of endoscopy.But in the procedure of liposuction,leak detection of SLN and implantation metastasis would be happened.Methods without liposuction have been reported.It makes less damage of axilla,but the working space it provided is limited and the exposure of nerve and blood vessels is not equal to liposuction,which make higher requirement to surgeons.So,the accurate SLN localization should be apply,like dual-tracer of indocyanine green(ICG)and methylene blue.When methylene blue localization failed,SLNB with dual-tracer would ensure the detection rate.ESLNB is able to achieve the SLN with dual-tracer through a screen.The fluorescent-guided endoscopic navigation system is mainly used in liver and lung surgery,and it can provide real-time navigation to make up the above deficiencies.However,the fluorescent-guided endoscopic navigation system in breast cancer surgery still not be reportedObjective1.To summarize the experience of balloon dilation method in working space making of ESLNB,and provide new ideas of methods without liposuction.2.To review our previous breast cancer patients who using fluorescent-guided endoscopic navigation system in ESLNB,and the status of SLNs detection and perioperative features were collected to statistical analysis.To have a preliminary discussion on the safety and effectiveness in the ESLNB for fluorescent-guided endoscopic navigation system,comparing with the in vitro fluorescent localization method,and provide the clinical evidence in application of fluorescent-guided endoscopic navigation system in breast cancer surgery.Method1.125 cases of breast cancer diagnosed by needle biopsy were selected for further study,who received perioperative multi-mode SLN localization(preoperative CT lymphography and intraoperative ICG combined with methylene blue lymphoid tracing were performed).Marks of SLNs were made on the body surface of patients with the help of CT lymphography and the neighboring relationship of SLN and surrounding tissue were understood under three-dimensional reconstruction.During the operation,ICG combined with methylene blue was used for SLN localization,and near-infrared detector was used for in vitro fluorescence localization to guide working space construction.After localization,a self-made balloon was used to accurately construct the working space,by injecting 100-150ml normal saline into the balloon.Then ESLNB was performed and information was collected to evaluate the value of balloon dilation.2.45 cases of patients were selected,who underwent ESLNB or endoscopic axillary lymph node dissection(EALND).The characteristics of patients and tumor,SLNs detection rate of two tracers and patients’ perioperative features(operation time,intraoperative blood loss,drainage and postoperative hospital days)were retrospectively analyzed and statistical analysis were carried out.The advantages and disadvantages of in vivo fluorescence and in vitro fluorescence were analyzed,while Patients with in vitro fluorescence localization under near-infrared detector were used as control group.Using dual-tracer of ICG and methylene blue and balloon dilation to construct the working space after in vitro fluorescent localization,ESLNB was performed with the application of fluorescent-guided endoscopic navigation system.Appling the PINPOINT fluorescent-guided endoscopic system,images between HD-white mode and fluorescent mode may change freely,which makes the green and blue SLNs traceable.Result1.After balloon dilatation,125 patients underwent ESLNB with observation under endoscope,with the success rate 100%.After construction of the working space,blue lymph node or/and lymphatics were seen at the first detection.There were no obvious changes in axillary anatomical structure were observed.Lymph node and lymphatic vessel were complete in morphology,and adipose tissue received little injury.The detection rate and sensitivity of SLN in ESLNB were 100%,and no false-negative cases were found.No axillary vascular injury or nerve injury occurred during the operation,and no subcutaneous emphysema or incision infection occurred after the operation.One of the patients developed necrosis of the incisal edge resulting in increased drainage,which was not related to the method.2.In the fluorescence mode,lymph nodes with fluorescence could be detected in 45 patients,and the detection rate of SLN was 100%,while the detection rate of blue lymph nodes was 95.56%in the HD mode,with no significant statistical difference(p>0.05).In this study,a total of 544 lymph nodes were detected,of which 170 were SLN.Among the 21 patients receiving only ESLNB,115 SLN were detected,with an average of 5.5.In 9 patients with ALND,17 positive SLN and 133 lymph nodes were detected.Among the 15 patients who underwent ALND directly,296 lymph nodes were detected,with an average of 19.7.Although SLNB was not performed,fluorescent lymph nodes were observed in SLN exploration,and postoperative routine pathology indicated lymph node metastasis.There were no statistically significant differences in operation time,blood loss and postoperative hospital days among patients undergoing mastectomy.In vivo fluorescence navigation under ICG-guided endoscopic navigation system was superior to in vitro fluorescence localization alone in the number of SLN(p=0.002),but there was no significant difference in surgically related featuresConclusion1.Under the multi-modal SLN navigation,using balloon dilatation method(non-liposuction)to construct the working space of axillary helps surgeons reach the SLN area accurately,which reduces the damage of axillary and owns the practical importance of the precision removal of SLN.As a new method of non-liposuction axillary working space construction,it is safe and effective to become a new assistance in ESLNB,which is subject to further improvement and promotion.2.Fluorescent-guided endoscopic navigation system not only achieves real-time two-path SLN positioning navigation in ESLNB,but also has a high SLN detection rate in the auxiliary of HD amplified imaging.It provides new ideas for SLNB technology for safety,effect,convenience and non-pollution. |
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