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    1 Comment for this article
    Radioisotope SLNB is the demonstrated safe standard
    John Aarsvold, PhD and Naomi P. Alazraki, MD | Department of Radiology & Imaging Sciences, Emory University
    Stoffels et al. (1) set out to assess, in melanoma, a new sentinel lymph node biopsy (SLNB) procedure, without radioactivity, based on use of indocyanine green (ICG) and multispectral optoacoustic tomography (MSOT). The standard against which they compare ICG-MSOT is the widely-accepted radioisotope-based SLNB with lymphoscintigraphy.

    Radioisotope-based SLNB is the standard:
    The data that established radioisotope-based SLNB with lymphoscintigraphy as accurate for SLN detection are from numerous studies, including many that are significant multicenter trials and many that demonstrated successful correlation with DFS (disease free survival) and OS (overall survival) using long-term follow-up after surgical/medical interventions.

    Radioisotope-based SLNB
    is safe:
    Radiopharmaceutical-based SLNBs are safe. There are no known negative events caused by radioactivity from the low radiopharmaceutical doses used in SLNBs: none to patients; none to healthcare professionals; none to the public. Reliable suitability of MSOT-based SLNB must be based on efficacy to identify SLNs and metastases and be demonstrated successful (efficacious) in multiple centers. Whether the technique uses radioactivity or not is not relevant.

    Single-center versus multi-center data:
    The report claims results obtained using the study’s MSOT-based SLNB are statistically concordant with their radiopharmaceutical-based SLNB results. However, the data lack absolute concordance [only 106 vs 112 basins (94.6%) and 159 of 165 SLNs (96.4%) were concordant]. These results don’t establish comparable reliability with radiotracer methods, which have been studied in several multicenter trials that have included significant multi-year patient follow-up (2).

    Flawed analysis:
    The last three sentences, second paragraph of Discussion, make extrapolations beyond the study data, contradictory to the study’s methods. The study’s standard, as defined by the investigators, is Tc99m-SLNB. In these sentences the authors discard their standard and speculate a conclusion with no data. Based on the data acquired, the standard concludes the 6 nodes in question are SLNs. If any were positive, the ICG-MSOT-SLNB failed on the node and failed on the patient as the technique failed to identify them as SLNs and thus failed to assess them.

    John N. Aarsvold, PhD (Applied Mathematics)
    Associate Professor

    Naomi P. Alazraki, MD
    Professor Emerita

    Department of Radiology and Imaging Sciences
    Emory University

    1) Stoffels I, Jansen P, Petri M, Goerdt L, Brinker TJ, Griewank KG, et al. Assessment of nonradioactive multispectral optoacoustic tomographic imaging with conventional lymphoscintigraphic imaging for sentinel lymph node biopsy in melanoma. JAMA Netw Open. 2019 Aug 2;2(8):e199020. doi: 10.1001/jamanetworkopen.2019.9020.
    2) Leiter U, Stadler R, Mauch C, Hohenberger W, Brockmeyer N, Berking C, et al., German Dermatologic Cooperative Oncology Group (DeCOG). Complete lymph node dissection versus no dissection in patients with sentinel lymph node biopsy positive melanoma (DeCOG-SLT): a multicentre, randomised, phase 3 trial. Lancet Oncol, 2016, 17(6):757-767.
    Original Investigation
    August 14, 2019

    Assessment of Nonradioactive Multispectral Optoacoustic Tomographic Imaging With Conventional Lymphoscintigraphic Imaging for Sentinel Lymph Node Biopsy in Melanoma

    Author Affiliations
    • 1Department of Dermatology, Venerology and Allergology, University Hospital-Essen, University of Duisburg-Essen, Essen, Germany
    • 2West German Cancer Center, University Duisburg-Essen, Essen, Germany
    • 3German Consortium for Translational Cancer Research, Partner Site, University Hospital-Essen, Essen, Germany
    • 4Department of Nuclear Medicine, University Essen-Duisburg, University of Duisburg, Essen, Germany
    JAMA Netw Open. 2019;2(8):e199020. doi:10.1001/jamanetworkopen.2019.9020
    Key Points español 中文 (chinese)

    Question  Is a nonradioactive imaging approach for sentinel lymph node detection a viable alternative to radioactive technetium?

    Findings  In this cross-sectional study of 83 patients with newly diagnosed melanoma, sentinel lymph node detection via indocyanine green and multispectral optoacoustic tomographic imaging was concordant with the detection frequency of conventional lymphoscintigraphic imaging with technetium Tc 99m.

    Meaning  Multispectral optoacoustic tomographic imaging may allow nonradioactive detection of sentinel lymph nodes at a frequency similar to the current radiotracer standard.


    Importance  The metastatic status of sentinel lymph nodes (SLNs) is the most relevant prognostic factor in breast cancer, melanoma, and other tumors. The conventional standard to label SLNs is lymphoscintigraphy with technetium Tc 99m. A worldwide shortage and known disadvantages of Tc 99m have intensified efforts to establish alternative, nonradioactive imaging techniques.

    Objective  To assess a new nonradioactive method using multispectral optoacoustic tomographic (MSOT) imaging in comparison with conventional lymphoscintigraphic imaging for SLN biopsy (SLNB) in melanoma.

    Design, Setting, and Participants  Analysis of a cross-sectional study was conducted at the University Hospital-Essen, Skin Cancer Center, Essen, Germany. Between June 2, 2014, and February 22, 2019, 83 patients underwent SLNB with an additional preoperative indocyanine green (ICG) application. Sentinel lymph node basins were preoperatively identified by MSOT imaging, and ICG-labeled SLNs were intraoperatively detected using a near-infrared camera. The surgeons were blinded to the lymphoscintigraphic imaging results in the beginning of the SLNB. Use of a γ probe was restricted until the SLNB procedure was attempted by the nonradioactive method.

    Main Outcomes and Measures  Concordance of SLN basins and SLNs identified by MSOT imaging plus near-infrared camera vs lymphoscintigraphic imaging plus single-photon emission computed tomographic or computed tomographic imaging was assessed.

    Results  Of the 83 patients (mean [SD] age, 54.61 [17.53] years), 47 (56.6%) were men. In 83 surgical procedures, 165 SLNs were excised. The concordance rate of ICG-labeled and Tc 99m–marked detected SLN basins was 94.6% (n = 106 of 112). Intraoperatively, 159 SLNs were detected using a near-infrared camera and 165 were detected by a γ probe, resulting in a concordance rate of 96.4%. Multispectral optoacoustic tomographic imaging visualized SLNs in all anatomic regions with high penetration depth (5 cm).

    Conclusions and Relevance  The findings of this study suggest that nonradioactive SLN detection via MSOT imaging allows identification of SLNs at a frequency equivalent to that of the current radiotracer conventional standard. Multispectral optoacoustic tomographic imaging appears to be a viable nonradioactive alternative to detect SLNs in malignant tumors.