Preoperative Contrast-Enhanced Ultrasound (CEUS) Combined with 125I Seeds Localization in Sentinel Lymph Node Biopsy for Breast Cancer

Pengpeng Zhou,1,2,* Weizhen Zheng,3,* Yanbing Liu,2 Yongsheng Wang2 1Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, 250000, Shandong, People’s Republic of China; 2Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250000, Shandong, People’s Republic of China; 3Shandong Provincial Hospital, Jinan, 250000, Shandong, People’s Republic of China*These authors contributed equally to this workCorrespondence: Yongsheng WangShandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Ji Yan Road 440, Jinan, 250000, Shandong, People’s Republic of ChinaEmail wangysh2008@aliyun.comObjective: To assess the clinical value of contrast-enhanced ultrasound (CEUS) technology in predicting axillary lymph nodes status before surgery, and to explore the feasibility of sentinel lymph nodes (SLNs) localization guided by CEUS combined with 125I implantation for breast cancer.Methods: From August 2017 to February 2019, 115 patients were included in this prospective study. Before surgery, a microbubble (SonoVue) was injected intradermally next to the areola. The enhancement patterns of SLNs were recorded and 125I seeds were deployed into the enhanced nodes. Then, all patients underwent standard sentinel lymph node biopsy (SLNB) and all 125I seeds were found out guided by a gamma detector in surgery. The localization was considered successful if 125I seeds were implanted in/beside the nodes.Results: SLNs in 103 cases were successfully identified, the success rate was 89.6% (103/115), 118 SLNs were detected in total. 125I seeds were deployed successfully in 99 cases, and all of the 125I-labeled SLNs were then successfully detected by combined method (radionuclides and blue dye). The accuracy of 125I seeds localization was 96.1% (99/103). Based on the enhancement patterns recorded, 34 cases were predicted to have SLNs metastasis (metastasis in 27 cases and no metastasis in 7 cases confirmed by postoperative pathology) and 65 cases were predicted to have no SLNs metastasis (metastasis in 5 cases and no metastasis in 60 cases by pathology). The positive predictive value and negtive predictive valueof CEUS in assessing axillary status were 79.4% (27/34) and 92.3% (60/65), respectively. The axillary metastasis rate in CEUS combined with 125I seeds localization was 27.3% (27/99), while the metastasis rate in the combined method of SLNB was 32.3% (32/99). The sensitivity of 125I seeds localization was 84.4% (27/32), the false-negative rate was 15.6% (5/32), and the consistency evaluation was excellent (Kappa value=0.880, P< 0.001).Conclusion: CEUS combined with 125I seeds implantation can locate SLNs accurately and has excellent consistency with the combined method. The enhancement patterns can provide helpful predicting information of axillary status preoperatively. However, more studies are needed to be carried out to verify our outcomes and explore the feasibility of applying CEUS technology in clinical work.Keywords: breast cancer, contrast-enhanced ultrasonography, CEUS, sentinel lymph node biopsy, SLNB