ICG Fluorescence Technique for the Detection of Sentinel Lymph Nodes

Objectives of Clinical Trial

The main objective of this clinical trial is to show the efficacy of fluorescence lymphangiography with indocyanine green (ICG) for the detection of sentinel lymph nodes.

Considering the high diagnostic accuracy and less vulnerable staging and therapy procedures, SLNB has rapidly become the state of the art diagnostic for axillary staging in early breast cancer.

Prior surgery, the so called sentinel lymph nodes are detected, harvested and histopathologically examined. The histopathologic status of the sentinel node thereby accurately reflects the status of the remaining axillary nodes. The sentinel lymph node biopsy allows minimizing risks and burdens for patients who very likely have no metastasis in the axillary lymph nodes sparing the ALND and reducing the risk of surgery and postoperative lymph oedema for instance. Contrarily to former procedure where an axillary lymph node dissection (ALND) was done each time, an ALND now only follows if the detected sentinel lymph node is metastatic.

Routinely sentinel lymph nodes are mapped using radiocolloid tracers such as technetium, sometimes combined with a blue dye.

However the infrastructure for a radioactive tracing is complex and not available easily: special techniques and equipment for the manufacturing of the radiocolloid as well as training in the use with radioisotopes are needed. For example, the application of radioactive markers needs a ready access to a nuclear medicine department, a pre-operative visit and an effective coordination between the involved disciplinesis. As these radioisotopes are formed by specialised, rare industry facilities availability is heavenly dependend and lack of radioisotopes with shortages in diagnostic procedures has already been reported. Furthermore radiocolloid mapping is associated with radioactive exposure of the concerned patients and health workers and imposes problems with surgical waste disposal.

Novel methods for detecting sentinel lymph nodes which waive the pre-operative injection of the radioactive marker are currently investigated. One of these new methods is the application of a fluorescence marker for SLN detection.

In this clinical trial a novel method for detecting the sentinel lymph node using indocyanine green, a fluorescent molecule shall by investigated.

Inclusion Criteria:

• Early breast cancer: histopathologically confirmed diagnosis, maximum tumour stage T1 and T2, therefore diameter < 5 cm, unifocal tumour or multifocal tumour Grading G1-G3, invasive ductal and / or invasive lobar carcinoma ≤ 5 cm diameter
• Indicated sentinel lymph node biopsy as part of the patient's routine management for breast cancer
• Age: 18 - 80 years, inclusive
• Gender: male and female
• BMI: ≤ 30
• Non-smoker (for at least the previous 3 months)
• General operability
• Intact site-specific anatomy at the concerned breast and /or axilla for ensuring an adequate lymphangiography
• Performance of investigations with radioactive traced iodide at least 1 week before and 1 week after ICG application
• No clinically significant findings in the routine blood examinations
• Female subjects with childbearing potential must have a negative pregnancy test prior Tc application and must be either at least two years postmenopausal or using a highly effective mean of birth control (birth control that, alone or in combination, result in a low failure rate of less than 1 percent per year when used consistently and correctly):
• hormonal method of contraception,
• surgical sterility,
• double barrier methods,
• intrauterine contraceptive device,
• lifestyle with a personal choice of abstinence,
• bilateral vasectomy of sexual partner at least 3 months prior to enrolment in combination with barrier methods
• Willing and able to complete screening and study procedures, as described in the protocol
• Signed written informed consent to participate in this clinical trial

Exclusion Criteria:

• Breast cancer: stage T3 or T4 carcinoma, inflammatory or exulcerated mamma carcinoma
• Former operation in axilla
• Any previous radiotherapy at the concerned breast and / or axilla and / or chestwall
• Definite lymph node metastases (ultrasound and / or fine-needle aspiration) (definite nodal positive patients in fine-needle aspiration)
• Contraindication for technetium imaging
• History of allergy or hypersensitivity against the investigational medicinal products (its active substance or ingredients)
• History of intolerability to ICG-Pulsion during a previous injection, as this may lead to serious anaphylactic reactions
• History of allergic diseases / hypersensitivities, unless the investigator considers the allergic disease as clinically irrelevant for the purpose of this clinical trial
• Allergy to iodine or to shellfish
• Any other contraindication to one of the investigational medicinal products as described in their Summary of Product Characteristics
• Apparent hyperthyroidism, autonomous thyroid adenoma, unifocal, multifocal or disseminated autonomies of the thyroid gland
• Advanced renal impairment (creatinine > 1,5mg/dl)
• Complete lymphatic obstruction
• All clinically relevant internal medicinal diseases, cardiac or renal that could impair the outcome of the clinical trial or that in the investigator's mind are not compatible with participation for medical reasons
• Acute inflammatory or febrile illness
• Evidence of local inflammation at the site of surgery
• Concurrent medication or any medication during the 2 weeks preceeding the enrolment which reduce or increase the extinction of ICG (i.e. anticonvulsants, haloperidol)
• Current or recent history of illicit drug or alcohol abuse, or dependence as defined as the continued use of alcohol or drugs despite the development of social, legal, or health problems
• Psychiatric or cognitive impairment that, in the opinion of the investigator, would interfere with the subject's ability to comply with the study requirements (e.g. Alzheimer's disease)
• Pregnancy, breastfeeding
• Inability to understand the nature and the extent of the trial and the procedures required
• Missing signed written informed consent to participate in the clinical trial
• Participation in a drug trial during the whole clinical trial