МЕДИЧНІ ПЕРСПЕКТИВИ / MEDICNI PERSPEKTIVI UDC 618.19-006.6-089.168-06 https://doi.org/10.26641/2307-0404.2021.2.234516 1 J. Masia , INFLUENCE OF ICG-TECHNOLOGY ON THE O.Y. Savenkov 2 RESULTS OF SURGICAL TREATMENT OF EARLY FORMS OF BREAST CANCER Hospital de la Santa Creu i Sant Pau 1, Hospital str., 56, Barselona, 08001, Spain Dnipro State Medical University 2 V. Vernadsky str., 9, Dnipro, 49044, Ukraine Госпіталь Санта-Креу і Сан-Пау 1 Барселона, 08001, Іспанія Дніпровський державний медичний університет 2 кафедра хірургії 1 (зав. – д. мед.н., доц. Р.В. Дука) вул. В. Вернадського, 9, Дніпро, 49044, Україна e-mail: savenkovdr@gmail.com Цитування: Медичні перспективи. 2021. Т. 26, № 2. С. 67-72 Cited: Medicni perspektivi. 2021;26(2):67-72 Ключові слова: рак молочної залози, хірургічна тактика, інтраопераційна ICG-технологія Ключевые слова: рак молочной железы, хирургическая тактика, интраоперационная ICG-технология Kew word: breast cancer, surgical tactics, intraoperative ICG-technology Abstract. Influence of ICG-technology on the results of surgical treatment of early forms of breast cancer. Masia J., Savenkov O.Y. Breast cancer (BC) is one of the most common causes of death in women under 50 years old. For today the choice of adequate methods of surgical intervention and the need for an adequate surgical adjuvant therapy, quality of life of patients after surgery are important. The aim of our study was to select the volume of surgery for breast cancer using the technique of intraoperative identification of the sentinel lymph node (intraoperative ICG technology) and to evaluate the results of its urgent histological examination. It was shown that the most common method of surgery in patients who underwent intraoperative ICG technology was quadrantectomy, which was performed in 27 cases (54%), rarely subcutaneous mastectomy was performed (30%) and radical mastectomy (by Madden) – 16%. In the control group, priority was given to radical removal of the breast (63.2% of cases); partial resection (by U. Veronesi) was performed in 33.3% of patients, and subcutaneous mastectomy – in 3.5%. Pathomorphological examination of the sentinel lymph node during its intraoperative imaging using ICG-technology established metastatic lesion in 10 of 50 cases (20%) in the main group. The obtained results of the assessment of the regional lymph dissection size in the main group indicate its adequate nature to ensure the radicality of surgical treatment. In our opinion, it is one of the important preliminary conclusions of this study, as to assess the clinical significance of signal lymph node (SLN) analysis as a marker of regional tumor spread, firstly it is necessary to be sured that existing surgical techniques provide radical tumor removal. Реферат. Влияние ICG-технологии на результаты хирургического лечения ранних форм рака молочной железы. Масия Хайме, Савенков О.Ю. Рак молочной железы (РМЖ) входит в пятерку наиболее распространённых в мире онкологических заболеваний и лидирует среди причин смерти женщин в возрасте до 50 лет. На сегодня актуальными остаются вопросы выбора адекватного объема хирургического вмешательства, необходимости назначения послеоперационной адъювантной терапии и качества жизни пациенток после операции. Целью нашего исследования стали выбор обьема хирургической операции при раке молочной железы при применении методики интраоперационной идентификации сторожевого лимфоузла (интраоперационная ICG- технология) и оценка результатов срочного его гистологического исследования. Нами показано, что наиболее частым методом хирургического вмешательства у пациенток, у которых использовалась интраоперационная ICG- технология, была квадрантэктомия, которая была проведена в 27 случаев (54%), реже проводилась подкожная мастэктомия (30%) и у 16% радикальная мастэктомия (по Маддену). При этом в группе контроля приоритет отдавался радикальному удалению молочной железы (63,2% случаев); частичная резекция (по U. Veronesi) выпол- нена у 33,3% пациенток, а подкожная мастэктомия – у 3,5%. Патоморфологическими исследованиями сторо- жевого лимфоузла, во время его интраоперационной визуализации с использованием ICG-технологии, метастати- ческое поражение установлено в 10 из 50 случаев (20%) в основной группе. Полученные результаты оценки объема регионарной лимфодиссекции в основной группе указали на ее адекватный характер обеспечения радикальности хирургического лечения. Это, на наш взгляд, является одним из важных предварительных выводов данной работы, так как для оценки клинического значения анализа сигнального лимфоузла как маркера регионарного распространения опухоли необходимо в первую очередь удостовериться, что существующая хирургическая техника обеспечивает радикальное удаление опухоли. 21/ Vol. XXVI / 2 67 CLINICAL MEDICINE Breast cancer (BC) is one of the main medical The mean age of the observed patients was and social problems of modern oncology, which is 56.5±1.9 years (from 27 to 83 years). explained by the prevalence of this pathology and Criteria for inclusion of patients in this study psychological aspects associated with the problems were: of social adaptation of patients after surgery [3, 6, - early forms of breast cancer (tumor size – T1, 7]. This form of cancer belongs to those malignant T2); neoplasms, the characteristic features of which are - morphological (histological, immunohistoche- high growth rate, territorial and geographical uneven mical) verification of the diagnosis of breast cancer; distribution of morbidity levels [1, 4, 10], which is - absence of clinical, radiological and morpho- primarily mediated by a variety of socio-demo- logical signs of metastatic lesions of regional lymph graphic, ethnic and individual risk factors [5, 9]. nodes (N0); Breast cancer is one of the five most common - absence of preoperative treatment (neoadjuvant cancers in the world and the leading cause of death therapy) and previous breast surgery. for women under the age of 50. In 25% of cases, it is Patients excluded from the study: diagnosed during the reproductive period. Every - previous treatment of breast cancer (neo- year, more than 1 million new cases of breast cancer adjuvant radiation or polychemotherapy) was are registered in the world: the highest incidence is performed; in the United States, Canada, France, Israel, - multicentric tumor growth; Switzerland, Spain, Finland, the Baltic States, - diagnosis of edematous breast cancer; Australia and Hawaii. Low rates of breast cancer are - presence of scars on the breast and/or axillary observed in Japan, China, Mexico and Venezuela. area due to surgeries, injuries, inflammatory pro- According to the World Health Organization, the cesses; occurrence and development of malignant neo- - comorbidities in the stage of decompensation plasms in the population are largely due to the state [7]. of anti-cancer measures, as evidenced by the wide The results were processed by the methods of range of fluctuations in morbidity in different variation statistics (M.Yu. Antomonov, 2018) [2] countries, especially in breast cancer. using the licensed statistical program STATISTICA Currently, the widespread introduction of modern v.6.1 (Statsoft Inc., USA), (serial number diagnostic techniques and a fuller coverage of the AGAR909E415822FA). female population with preventive examinations RESULTS AND DISCUSSION contribute to the effective and timely detection of According to the results, the maximum pro- minimal forms of breast cancer. However, the issues portion of patients in the group of those after of choosing an adequate amount of surgery and the radical surgery with full regional lymph dissection need for postoperative adjuvant treatment remain and in patients who underwent intraoperative relevant, primarily to prevent the development of ICG-technology, were middle-aged and at the age local recurrences and complications and improve the of maturity in conditions for compliance of quality of life of this group of patients. . the observed sample with the normal The aim of our study was to substantiate the use general population (Shapiro-Wilk's W test: of the method of intraoperative identification of SW-W=0.9883; p=0.2365) (Table 1). sentinel lymph nodes (intraoperative ICG-techno- The average body mass index (BMI, Kettle logy) in the surgical treatment of breast cancer. index) in the examined patients of the main group MATERIALS AND METHODS OF RESEARCH was 25.7±1.8, the control group – 27.9±1.2: the Our study is based on the analysis of data from a number and percentage of women taking into comprehensive examination and treatment of 107 account BMI (W=0.9829; p=0.1058). patients with early resectable forms of infiltrative The results of the distribution of patients in the breast cancer (T1-2aN0M0). The work was per- main and control groups depending on the volume of formed during 2016-2020 on the basis of Dni- surgery are shown in table 2. propetrovsk Regional Oncology Center and MC It was shown that the most common method of Clinic "Garvis" (Dnipro). The planning and imple- surgery in patients who underwent intraoperative mentation of the work took into account the practical ICG technology was quadrantectomy, which was recommendations of the European Society of performed in 27 cases (54%), subcutaneous mas- Medical Oncologists (ESMO) and the International tectomy (30%) and radical mastectomy (according Practical Recommendations (NCCN) 2016-2019. to Madden) (16%) were performed rarely. In the 68 Licensed under CC BY 4.0 МЕДИЧНІ ПЕРСПЕКТИВИ / MEDICNI PERSPEKTIVI control group, priority was given to radical removal (according to U. Veronesi) was performed in 33.3% of the breast (63.2% of cases); partial resection of patients and subcutaneous mastectomy – in 3.5%. Table 1 Distribution of patients by age in the main and control group Number of patients Age, years main group control group 27 – 45 13 10 46 – 60 27 28 61 – 75 8 14 76 – 83 2 5 Total 50 57 We noted that neither in the main nor in the the control group – 54.4% and 45), 6% respectively). control group patterns of tumor localization in the In the main group, in most cases (42%) the tumor left or right breast (p=0.805) were found. Thus, in was localized in the upper outer quadrant, less often the group where intraoperative ICG technology was – in the lower outer (18%), inner quadrants (4%) and used, in 26 out of 50 cases (52%) the tumor was central sector (24%) (Table 3). found in the right breast, in 24 (48%) – in the left (in Table 2 Distribution of patients by volume of surgical treatment in the main and the control group Number of patients, n (%) The nature of the intervention Statistical indicators main group control group 2=28.8; Quadrantectomy 27 (54%) 19 (33.3%) р<0.001 Radical mastectomy (according to Madden) 8 (16%) 36 (63.2%) Subcutaneous mastectomy 15 (30%) 2 (3.5%) Total 50 (100%) 57 (100%) Note. p – level of statistical significance of differences between groups (according to Pearson's criterion 2. It was found that in patients who underwent wall, as well as edematous infiltrative forms of the intraoperative ICG technology, the size of the tumor were excluded from the study. primary tumor averaged 20.8±1.3 mm (T2). In It is important to note that in patients who general, in the main group in 27 patients (54%) the showed signs of metastatic lesions of regional lymph size of the tumor ranged from 5 to 20 mm, in 23 nodes at the preoperative stage and the presence of (46%) - from 21 to 50 mm (in the control group – metastases confirmed by histological analysis were 54.4% and 45.6%, respectively) (Table 3). Patients excluded from this study. with tumor growth in the skin or anterior thoracic 21/ Vol. XXVI / 2 69 CLINICAL MEDICINE Table 3 Distribution of patients by tumor location and size in the main and the control group Number of patients, n (%) Parameters Statistical indicators main group control group Side of lesion Left (S) 24 (48%) 26 (45.6%) 2=0.061; p>0.05 Rights (D) 26 (52%) 31 (54.4%) Tumor Upper outer 22 (44%) 26 (45.6%) 2=2.15; localization p>0.05 (quadrant) Lower outer 10 (20%) 8 (14.0%) Upper inner 3 (6%) 4 (7.0%) Lower inner 0 2 (3.6%) Central 12 (24%) 11 (19.3%) Multifocal 3 (6%) 6 (10.5%) Tumor size T1 (less than 20 mm) 27 (54%) 23 (40.4%) 2=1.99; p>0.05 T2 (20 - 50 mm) 23 (46%) 34 (59.6%) Average, mm, M ± m 20.8±1.3 22.6±1.7 t=0.831; p>0.05 Note. p – level of statistical significance of differences between groups (according to Pearson's criterion 2 and Student's t-test for unrelated samples). Pathomorphological examination of the sentinel patients, complete regional lymph dissection (LD) lymph node during its intraoperative imaging using must be performed simultaneously with breast ICG technology showed metastatic lesions in 10 out surgery; in 80% of cases the patient's lymphatic of 50 cases (20%) in the main group. In such collector was preserved (Fig.). 100 90 Monitoring frequency, % Частота спостережень, % 80 70 60 50 40 * ** 30 20 10 0 Основна група Main group Control group Контроль Metastatic lymph node involvement Radical axillary lymph dissection Метастатичне ураження лімфовузлів (в т.ч. сигнальних) Радикальна аксилярна лімфодисекція (including signal) Note. * – p<0.05 (differences are statistically significant for control), ** – p <0.001 (differences are statistically significant for control). Distribution of patients by metastatic lymph node involvement in the main and control group 70 Licensed under CC BY 4.0 МЕДИЧНІ ПЕРСПЕКТИВИ / MEDICNI PERSPEKTIVI According to the Unified Clinical Protocol of the important conclusions of this work, because to primary, secondary (Specialized), tertiary (highly assess the clinical significance of signal lymph node specialized) medical care "Breast Cancer", in the (SLN) as a marker of regional tumor spread, first it control group, which consisted of 57 patients with is necessary to make sure that existing surgical early forms of breast cancer, along with radical techniques provide radical removal of tumors. surgery a compete volume of regional lymph CONCLUSIONS dissection of I-III level was performed. According to 1. Intraoperative use of ICG technology proved the results of the pathomorphological study, its effectiveness in removal of sentinel lymph node metastases in the axillary lymph nodes were absent in surgical treatment of BC in 53 patients (93.0%), and metastatic lesions of 2. Evaluation of clinical and pathomorphological regional lymph nodes were found in 4 patients importance of signaling lymph node as a marker of (7.0%) of the control group. The absence of signs of the regional spread of the tumor is necessary metastatic lesions of regional lymph nodes in these primarily for the confidence that the existing patients at the stage of examination is probably due surgical technique provides a radical excretion of the to the presence of micrometastases in the affected tumor. lymph nodes, single tumor cells and the small size of 3. 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