Avaliação da eficácia do uso do Verde Indocianina associada à fluorescência na biópsia do linfonodo sentinela
Data
2023-04-26
Autores
Sá, Rafael da Silva 
Orientadores
Nazário, Afonso Celso Pinto
Tipo
Tese de doutorado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Introdução: A biópsia do linfonodo sentinela é a técnica consagrada no estadiamento axilar das pacientes portadoras de câncer de mama inicial sem comprometimento clínico axilar. Embora já seja uma técnica amplamente difundida, seu histórico é relativamente recente. Três técnicas são muito utilizadas globalmente para deteção do linfonodo sentinela: o azul patente; o radiofármaco tecnécio 99 com uso do gamma probe; e a combinação dessas duas técnicas. Objetivos: Avaliar a taxa de detecção do linfonodo sentinela com uma técnica inovadora: o verde de indocianina associado à fluorescência em pacientes com câncer de mama, sua comparação com os demais métodos (azul patente e braço combinado azul patente + verde indocianina) e os custos destes procedimentos. Métodos: Foram avaliadas 99 pacientes com idade média de 58,4 ± 13,3 anos subdivididas em três braços com 33 pacientes, sendo que em um braço foi submetido à técnica do linfonodo sentinela utilizando azul patente, em outro o verde indocianina e no terceiro a combinação dos dois corantes. A verde indocianina, marcador fluorescente que consiste na iluminação do linfonodo sentinela no comprimento de onda de excitação (750 a 800 nm), foi aplicado na dose de 5mg na região periareolar, sendo visualizado através do aparelho image1S® acoplado à fonte de luz D-light P® e câmera de laparoscopia. Pesquisa realizada no Hospital de Esperança de Presidente Prudente -
SP em parceira com a Disciplina de Mastologia da Escola Paulista de Medicina da Universidade Federal de São Paulo no período de 02/08/2019 e 16/12/2021. Resultados:
Os principais subtipos histológico e imunohistoquímico foram o carcinoma invasivo do tipo não especial em 92,9% e luminal em 84,9% dos casos, respectivamente. A taxa de acurácia na identificação do linfonodo sentinela foi de 78,8% com a utilização do azul patente, 93,9% com o verde indocianina e 100% com o azul patente + verde indocianina. O grupo combinado identificou principalmente dois linfonodos sentinelas (48,5%), entretanto os demais grupos identificaram mais comumente um linfonodo sentinela apenas. O tempo médio de identificação do linfonodo sentinela foi de 20,6 minutos entre as pacientes submetidas ao corante tradicional, 8,6 minutos no braço do verde indocianina e 10 minutos na associação dos dois métodos (P<0,001). O tempo cirúrgico médio foi de 69,4 minutos com o azul patente, 55,1 minutos com o verde indocianina e 69,4 minutos no combinado (P<0,001). O custo total da internação hospitalar nas pacientes que foram submetidas ao verde indocianina foi menor que as do azul patente (P=0,026) e que as do braço combinado (P=0,007). Conclusões: A taxa de detecção do linfonodo sentinela através da fluorescência com o uso do verde indocianina foi considerada eficaz. A comparação da taxa de detecção do linfonodo sentinela entre o uso do azul patente, verde indocianina e azul patente + verde indocianina (combinado)
revelou diferenças estatisticamente significantes, sendo o método combinado o mais eficaz. O maior custo do corante verde indocianina não impactou na elevação do custo geral da internação hospitalar.
Introduction: Sentinel lymph node biopsy is the established technique in the axillary staging of patients with early breast cancer without clinical axillary involvement. Although it is already a widespread technique, its history is relatively recent. Three techniques are widely used globally for the detection of sentinel lymph nodes: patent blue; the radiopharmaceutical technetium 99 with the use of the gamma probe; and the combination of these two techniques. Objectives: To evaluate the sentinel lymph node detection rate with an innovative technique: indocyanine green associated with fluorescence in breast cancer patients, its comparison with the other methods (patent blue and combined patent blue + indocyanine green arm) and costs of these procedures. Methods: Ninety-nine patients with a mean age of 58.4 ± 13.3 years were evaluated, divided into three arms with 33 patients, with one arm undergoing the sentinel lymph node technique using patent blue, the other indocyanine green, and the third the combination of the two dyes. Indocyanine green, a fluorescent marker that consists of lighting the sentinel lymph node at the excitation wavelength (750 to 800 nm), was applied at a dose of 5mg in the periareolar region, being visualized through the image1S® device coupled to the D-light source. light P® and laparoscopy camera. Research carried out at Hospital de Esperança de Presidente Prudente - SP in partnership with the Discipline of Mastology at Escola Paulista de Medicina, Universidade Federal de São Paulo, between 08/02/2019 and 12/16/2021. Results: The main histological and immunohistochemical subtypes were non-special invasive carcinoma in 92.9% and luminal in 84.9% of cases, respectively. The accuracy rate in the identification of sentinel lymph nodes was 78.8% with the use of patent blue, 93.9% with indocyanine green and 100% with patent blue + indocyanine green. The combined group identified mainly two sentinel nodes (48.5%), however the other groups more commonly identified only one sentinel node. The mean time of sentinel lymph node identification was 20.6 minutes among patients submitted to the traditional dye, 8.6 minutes in the indocyanine green arm and 10 minutes in the combination of the two methods (P<0.001). x The mean surgical time was 69.4 minutes with patent blue, 55.1 minutes with indocyanine green and 69.4 minutes with combined (P<0.001). The total cost of hospital stay in patients who underwent indocyanine green was lower than that of patent blue (P=0.026) and that of the combined arm (P=0.007). Conclusions: The sentinel lymph node detection rate by fluorescence with the use of indocyanine green was considered effective. The comparison of the sentinel lymph node detection rate between the use of patent blue, indocyanine green and patent blue + indocyanine green (combined) revealed statistically significant differences, with the combined method being the most effective. The higher cost of the indocyanine green dye did not impact the increase in the overall cost of hospital admission.
Introduction: Sentinel lymph node biopsy is the established technique in the axillary staging of patients with early breast cancer without clinical axillary involvement. Although it is already a widespread technique, its history is relatively recent. Three techniques are widely used globally for the detection of sentinel lymph nodes: patent blue; the radiopharmaceutical technetium 99 with the use of the gamma probe; and the combination of these two techniques. Objectives: To evaluate the sentinel lymph node detection rate with an innovative technique: indocyanine green associated with fluorescence in breast cancer patients, its comparison with the other methods (patent blue and combined patent blue + indocyanine green arm) and costs of these procedures. Methods: Ninety-nine patients with a mean age of 58.4 ± 13.3 years were evaluated, divided into three arms with 33 patients, with one arm undergoing the sentinel lymph node technique using patent blue, the other indocyanine green, and the third the combination of the two dyes. Indocyanine green, a fluorescent marker that consists of lighting the sentinel lymph node at the excitation wavelength (750 to 800 nm), was applied at a dose of 5mg in the periareolar region, being visualized through the image1S® device coupled to the D-light source. light P® and laparoscopy camera. Research carried out at Hospital de Esperança de Presidente Prudente - SP in partnership with the Discipline of Mastology at Escola Paulista de Medicina, Universidade Federal de São Paulo, between 08/02/2019 and 12/16/2021. Results: The main histological and immunohistochemical subtypes were non-special invasive carcinoma in 92.9% and luminal in 84.9% of cases, respectively. The accuracy rate in the identification of sentinel lymph nodes was 78.8% with the use of patent blue, 93.9% with indocyanine green and 100% with patent blue + indocyanine green. The combined group identified mainly two sentinel nodes (48.5%), however the other groups more commonly identified only one sentinel node. The mean time of sentinel lymph node identification was 20.6 minutes among patients submitted to the traditional dye, 8.6 minutes in the indocyanine green arm and 10 minutes in the combination of the two methods (P<0.001). x The mean surgical time was 69.4 minutes with patent blue, 55.1 minutes with indocyanine green and 69.4 minutes with combined (P<0.001). The total cost of hospital stay in patients who underwent indocyanine green was lower than that of patent blue (P=0.026) and that of the combined arm (P=0.007). Conclusions: The sentinel lymph node detection rate by fluorescence with the use of indocyanine green was considered effective. The comparison of the sentinel lymph node detection rate between the use of patent blue, indocyanine green and patent blue + indocyanine green (combined) revealed statistically significant differences, with the combined method being the most effective. The higher cost of the indocyanine green dye did not impact the increase in the overall cost of hospital admission.
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Citação
SÁ, Rafael da Silva. Avaliação da eficácia do uso do Verde Indocianina associada à fluorescência na biópsia do linfonodo sentinela. 2023. 72 f. Tese (Doutorado em Ginecologia) - Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP). São Paulo, 2023.