Detection capability of the Medical Imaging Projection System for sentinel lymph node biopsy in patients with breast cancer with and without neoadjuvant chemotherapy: A retrospective study

Detection capability of the Medical Imaging Projection System for sentinel lymph node biopsy in patients with breast cancer with and without neoadjuvant chemotherapy: A retrospective study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Detection capability of the Medical Imaging Projection System for sentinel lymph node biopsy in patients with breast cancer with and without neoadjuvant chemotherapy: A retrospective study Marin Taguchi, Masahiro Takada, He Jiaxi, Yukiko Fukui, Hanako Shimizu, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5723931/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 May, 2025 Read the published version in Breast Cancer → Version 1 posted 5 You are reading this latest preprint version Abstract Background The Medical Imaging Projection System (MIPS) projects fluorescence ICG images on the surgical field. In this study, we aimed to assess sentinel lymph node (SLN) identification by the MIPS in patients with and without neoadjuvant chemotherapy (NAC) administration and compare the utility of the MIPS with the radioisotope (RI) method. Methods We retrospectively reviewed medical records of patients with primary breast cancer who underwent SLN biopsy using the MIPS at Kyoto University Hospital between April 2020 and December 2024 . The primary endpoint was the identification rate of SLNs. Secondary endpoints included the number of positive SLNs and SLNs detected per patient. Results The analysis included 470 procedures (448 patients), of which 56 (11.9%) were conducted after NAC. The identification rate of SLNs by the MIPS was 99.6% (95% confidence interval [CI], 98.5–99.9) in all procedures and 98.2% (95% CI, 90.6–99.7) after NAC. The median number of SLNs identified per patient was 3 (range, 2–4) by the MIPS and 2 (range, 1–3) by the RI method (P < 0.001). No significant difference was observed in the number of SLNs between patients who received NAC and those who did not (3 vs 3, P=0.84 ). Seventy-eight positive SLNs were excised, all of which were accurately identified by the MIPS. Conclusions This study suggested that the identification rate of SLNs by the MIPS was high regardless of the presence or absence of preceding systemic chemotherapy. breast cancer indocyanine green fluorescence method neoadjuvant chemotherapy projection mapping sentinel lymph node biopsy Introduction Breast cancer is the most commonly diagnosed cancer in the world. There were approximately 2.3 million new cases of breast cancer in women in 2020 [ 1 ], and it is presumed that its incidence rate will remain high for decades [ 2 ]. Multidisciplinary treatment, such as systemic therapy and radiotherapy, has improved the prognosis of patients with breast cancer. For patients with early breast cancer, the axillary nodal status is one of the important prognostic factors to make treatment decisions [ 3 ]. While axillary dissection has been a standard technique for axillary staging, sentinel lymph node (SLN) biopsy has become the standard of care for patients with early breast cancer [ 4 , 5 ]. Patients with negative-SLNs can avoid axillary dissection without compromising prognosis. Randomized controlled trials have shown that patients with limited number of metastatic nodes in the SLNs can also avoid axillary dissection [ 6 – 9 ]. Several studies have investigated the feasibility of SLN biopsy after neoadjuvant chemotherapy (NAC) for patients who initially presented with clinically positive axillary nodes. These studies showed that the false-negative rate was > 10% in intent-to-treat population, but it was suggested that use of dual tracer or removal of three or more SLNs may reduce the false-negative rate to an acceptable level [ 10 , 11 ]. Targeted axillary dissection (TAD) is a technique for removing biopsy-proven positive axillary lymph nodes in addition to SLNs in patients who received NAC. TAD reportedly reduces the false-negative rate [ 12 – 14 ]. Conventionally, the radioisotope (RI) and blue dye methods have been used to identify SLNs [ 4 , 5 ]. In 2005, SLN identification with indocyanine green (ICG) fluorescence method was first reported [ 15 ], and since then, ICG fluorescence imaging has shown a high identification rate in several clinical studies [ 16 , 17 ]. Meta-analyses have shown that there was no significant difference in SLN identification between the ICG fluorescence and RI methods, and the ICG fluorescence method was superior to the blue dye method in terms of the identification rate. In addition, the ICG fluorescence method identified more SLNs per patient compared to the RI or blue dye methods, suggesting that the ICG fluorescence method may reduce the false-negative rate in SLN identification after NAC [ 18 , 19 ]. The Medical Imaging Projection System (MIPS) is an innovative near-infrared (NIR) fluorescence imaging system that projects ICG images directly onto the surgical field using projection mapping technology [ 20 ]. The MIPS-assisted ICG fluorescence method provides continuous real-time navigation for SLN biopsy, eliminating the need for surgeons to shift their visual focus from the surgical field. Previous studies have reported a high SLN identification rate with MIPS, comparable to the conventional ICG fluorescence and RI methods [ 20 , 21 ]. However, prior evaluations of the clinical utility of SLN biopsy using MIPS were limited by small sample sizes and a low proportion of patients with positive SLNs, particularly in post-NAC settings. In this study, we aimed to evaluate SLN identification using the MIPS both with and without NAC administration and to compare its utility with the RI method. Patients and methods Study design and patients We retrospectively reviewed medical records of patients with primary breast cancer who underwent SLN biopsy using the MIPS at Kyoto University Hospital between April 2020 and December 2024 . Eligibility criteria included histologically confirmed breast cancer and patients who underwent SLN biopsy using the MIPS. Patients with initially clinical node positive tumors who received NAC were also included. Exclusion criteria included patients with a previous history of axial surgery. We used the following methods when we performed SLN biopsies using MIPS and RI methods. The surgeon identified and excised the SLNs using MIPS, followed by the RI method to identify and excise any remaining SLNs. Each SLN removed was checked for fluorescence or RI signal and recorded. The study protocol was approved by the institutional review board of Kyoto University Hospital (approval no.: R4913). We collected data on age, sex, body mass index (BMI), tumor histology, subtype, administration of NAC, combined use of the RI method, number of SLNs identified, operating time of SLN biopsy, and pathology reports. A detailed description of the MIPS and its surgical procedure have been reported previously [ 22 ]. MIPS is approved in Japan as a class II medical device, and in this study period, commercially available MPIS was used in clinical practice. Statistical analysis The primary endpoint of this study was the SLN identification rate using the MIPS, defined as the proportion of patients in whom at least one SLN was detected with the system. Secondary endpoints included the number of positive SLNs, number of SLNs detected per patient using the MIPS, operating time for SLN biopsy, and number of patients with axillary recurrence after SLN biopsy. The SLN identification rate and number of positive SLNs were analyzed for all procedures and specifically for those performed after NAC. The number of SLNs detected was compared between patient groups stratified by clinical factors, such as NAC administration or BMI, using the Wilcoxon rank-sum test. In cases where both the MIPS and RI methods were used, the number of SLNs identified and positive SLNs were compared between methods. Operating times were also compared between methods, with or without combination with the RI method, using the Wilcoxon rank-sum test. Statistical significance was assessed with a two-sided level of 0.05. All analyses were conducted using the JMP® Pro software (version 17.0.0; SAS Institute, Inc., Cary, NC, USA). Results A total of 452 patients (including 22 patients with bilateral breast cancer) underwent SLN biopsy using the MIPS between April 2020 and December 2024 . Four patients with unilateral breast cancer had a prior history of axial surgery. The analysis was based on a total of 470 procedures (448 patients) . The baseline characteristics of the patients and tumors are presented in Table 1 . The median age was 59 (range, 25 − 87) years and the median BMI was 21.7 (range, 15.6 − 43.0) kg/m 2 . Procedures performed for ductal carcinomas in situ accounted for 18.5% , and approximately 80% of procedures were performed for T1–T2 tumors. There were eight patients (1.7%) with clinically node-positive breast cancer, and six of them underwent NAC. Of the 470 procedures, 56 (11.9%) were conducted after NAC. Both the MIPS and RI methods were used in 327 (69.6%) procedures . Table 1 Patient and tumor characteristics Factors N % All procedures 470 Age (years) median (range) 59 (25–87) BMI median (range) 21.7 (15.6–43.0) Tumor stage Tis 87 18.5 T1mi 5 1.1 T1a 8 1.7 T1b 59 12.6 T1c 172 36.6 T2 131 27.9 T3 6 1.3 T4 2 0.4 Nodal stage N0 462 98.3 N1 8 1.7 Histology DCIS 87 18.5 IDC 326 69.4 ILC 28 6.0 others 29 6.2 Subtype HR+, HER2- 303 64.5 HR+, HER+ 30 6.4 HR-, HER2+ 13 2.8 Triple negative 37 7.9 unknown 87 18.5 Neoadjuvant chemotherapy Yes 56 11.9 No 414 88.1 Combined use of radioisotope method Yes 327 69.6 No 143 30.4 Operative procedure Bp 196 41.7 Bt 274 58.3 Axillary dissection Yes 30 6.4 No 440 93.6 BMI, body mass index; DCIS, ductal carcinomas in situ ; IDC, invasive ductal carcinoma; ILC, invasive lobular carcinoma The identification rate of SLNs by the MIPS was 99.6% (468/470: 95% confidence interval [CI], 98.5–99.9) in all procedures and 98.2% (55/56: 95% CI, 90.6–99.7) in procedures after NAC. Of 1480 SLNs excised among the patients who underwent SLN biopsy using by the MIPS, there were 114 positive SLNs . Of 180 SLNs excised among patients who have undergone NAC, four positive SLNs were detected. The median number of SLNs identified per patient was 3 (range, 2–4) by the MIPS and 2 (range, 1–3) by the RI method (P < 0.001) (Table 2 ). The median number of SLNs identified by the MIPS per patient who had received NAC was 3 (range, 2–4). This study showed no significant difference in the number of SLNs between patients who received NAC and those who did not (3 vs 3, P=0.84 ). There was no significant difference in the median number of SLNs detected by the MIPS between patients with a high BMI (≥ 22 kg/m 2 ) and those with a low BMI (< 22 kg/m 2 ) (3 vs 3, P = 0.41 ). Table 2 Number of SLNs identified by the MIPS Characteristics N Median IQR P-value BMI < 22 244 3 2–4 0.41 ≥ 22 226 3 2–4 NAC No 414 3 2–4 0.84 Yes 56 3 2–4 Breast surgery Bp 196 3 2–4 0.68 Bt 274 3 2–4 BMI, body mass index; NAC, neo adjuvant chemotherapy; IQR, interquartile range A total of 1062 SLNs were excised in 327 procedures , in which the MIPS and RI methods were used (Table 3 a). Among them, 657 (62%) SLNs were identified by both the MIPS and RI methods, 394 (37%) only by the MIPS, four (0.38%) only by the RI method, and seven (0.66%) by neither the MIPS nor RI method (palpation). A total of 78 positive SLNs were excised and all of them were identified by the MIPS. No positive SLNs were identified by the RI method alone. Among procedures which were conducted after NAC, 147 SLNs were identified in 44 procedures , in which both the MIPS and RI methods were used (Table 3 b). All SLNs were identified by the MIPS. There were four positive SLNs , which were identified by both the MIPS and RI methods. Table 3 Number of SLNs among cases using MIPS and RI a) Among all procedures (n = 327): SLN biopsy procedures Identified SLNs (total N = 1062) Positive SLNs (total N = 78) MIPS and RI 657 56 MIPS only 394 22 RI only 4 0 Neither MIPS nor RI 7 0 b) Among procedures following NAC (n = 44): The median operating time for SLN biopsy using only the MIPS was 26 (range, 19–39) min and using the MIPS and the RI method was 31 (range, 22–45) min (p < 0.01) (Table 4 ). At a median follow-up of 32 (range, 2–58) months , no patient experienced axillary recurrence following SLN biopsy. Table 4 Operating time using MIPS according to the combination of the RI method Method N Median IQR P-value MIPS and RI 326 31 22–45 < 0.01 MIPS only 142 26 19–39 IQR, interquartile range; MIPS, Medical Imaging Projection System; RI, radioisotope Discussion This study reinforces our previous findings demonstrating a high SLN identification rate using the ICG fluorescence method with MIPS [ 20 , 21 ]. Notably, even among patients who received NAC, the SLN identification rate with MIPS remained high. There was no significant difference in the median number of SLNs detected per patient by MIPS between those who received NAC and those who did not. In procedures utilizing both the MIPS and RI methods, all positive SLNs were identified by MIPS, with none identified solely by the RI method. A prior meta-analysis reported SLN identification rates of 88.6–100% with the ICG fluorescence method and 85–100% with the RI method [ 23 ]. A recent meta-analysis focusing on post-NAC SLN biopsies showed an identification rate of 90.6% (95% CI, 89.1–92.2) [ 24 ]. In this study, the SLN identification rate by MIPS was 99.6% (95% CI, 98.5–99.9) across all patients and 98.2% (95% CI, 90.6–99.7) in those who received NAC. These findings indicate that the SLN identification rate with MIPS is comparable to conventional methods, regardless of NAC status. The near-infrared camera equipped in MIPS is the same as the conventional one. Therefore, MIPS showed a high SLN identification rate similar to the conventional ICG fluorescence methods. Compared to conventional near-infrared camera systems, MIPS has the advantage of real-time visibility of the fluorescence signal in the operative field, allowing for a smoother surgical procedure. Accurate SLN biopsy is critical for early-stage breast cancer management, as the number of positive SLNs informs decisions regarding additional local axillary treatment and systemic adjuvant therapy. In this study, all positive SLNs excised were identified by MIPS, with none detected by the RI method alone. These results align with previous research [ 21 ], suggesting that the RI method may not provide additional value over MIPS in identifying positive SLNs. The results of the meta-analysis indicate that the ICG fluorescence method has a similar SLN identification rate as the RI method [ 18 , 19 ]. Sugie et al. also showed that the ICG fluorescence and RI combination had a significantly higher SLN identification rate than RI alone [ 17 ]. Because this study was a retrospective study, it was not possible to conclude whether the RI method should be used in addition to MIPS, and further studies are needed. The SLN identification rate is reportedly lower and the false-negative rate is higher in patients who received NAC compared to those who did not [ 11 , 25 ]. A recent meta-analysis indicated that removing at least three SLNs may reduce the false-negative rate in patients post-NAC [ 24 ]. In our study, the median number of SLNs identified per patient using the MIPS was 3 (95% CI, 2–4), consistent even among patients post-NAC, where 3 (range, 2–4) SLNs were identified. As previous studies have shown, the use of dual tracers for SLN detection may further reduce the false-negative rate [ 10 , 11 , 24 ]. Our study included eight patients with clinically node-positive breast cancer and six of them underwent NAC. All procedures were conducted both by the MIPS and the RI method, and all SLNs including metastatic SLNs excised were identified by the MIPS. Among six procedures conducted after NAC, there were no metastatic nodes in five procedures leading to avoiding axillary dissection. Although TAD was not routinely conducted in our facility, considering that there was no patient who experienced axillary recurrence following SLN biopsy, use of dual tracer and detecting stable number of SLNs could improve the feasibility of SLN biopsy. Our study found significant difference in SLN biopsy operating time between procedures conducted solely with MIPS and those combining MIPS and RI methods. Although the addition of the RI method may lead to longer operating time than only by the MIPS, it was suggested that use of dual tracer may reduce the false-negative rate [ 10 , 11 ]. The MIPS-assisted ICG fluorescence method enables real-time navigation during SLN biopsy, potentially streamlining the procedure. In this study, the median operating time for SLN biopsy was 26 (range, 19–39) min using MIPS alone and 31 (range, 22–45) min with MIPS and RI methods combined. These durations are comparable to SLN biopsy times using conventional methods [ 26 , 27 ]. Operating times can be influenced by various factors, such as surgeon skill level or patient BMI. Although we did not collect specific data on SLN biopsy times with conventional NIR devices, these findings suggest that MIPS does not prolong surgery compared to conventional methods. A systematic review reported an axillary recurrence rate of 0.3% in clinically node-negative patients with breast cancer and SLN-negative findings [ 28 ]. For patients who initially presented with clinically positive axillary nodes but became node-negative after NAC, the reported axillary recurrence rate was < 1% [ 29 , 30 ]. Consistent with these findings, no axillary recurrences have been observed in our cohort following SLN biopsy to date. The current study had some limitations. First, as this study was conducted at a single center, the generalizability of the findings may have been limited. Further multi-institutional studies are necessary to validate the efficacy and utility of MIPS. Second, procedures conducted after NAC accounted for only 12% of the total cohort, and the sample size of patients with clinical node-positive breast cancer was small. Although the results demonstrated high SLN identification rates with MIPS in patients who have undergone NAC, larger studies are required to confirm these findings and establish broader applicability. Third, the follow-up duration at the time of this investigation was insufficient to thoroughly evaluate the recurrence rate. Additionally, safety assessments of the procedures were not included in this study. Extended follow-up and more comprehensive analyses are needed to address these gaps. Despite these limitations, MIPS achieved an SLN identification rate of 99.6% and 98.2% overall and in patients who received NAC, respectively, showcasing its robustness across varied clinical scenarios. The MIPS method can serve as a reliable approach to identifying positive SLNs and consistently removing a stable number of SLNs, regardless of whether systemic chemotherapy was administered. Furthermore, it holds potential to reduce the false-negative rate, supporting its utility in SLN biopsies. Declarations Acknowledgements We would like to thank all investigators and patients who participated in this study for their contributions. We would like to thank Editage (www.editage.jp) for English language editing. Compliance with Ethical Standards Disclosure of potential conflicts of interest Masahiro Takada received a research grant from Yakult Honsha, Guardant Health Japan and Medbis, and received lecture fees from Daiichi Sankyo, AstraZeneca, Taiho, Eli-Lilly, MSD, Pfizer, Eisai, Chugai, Devicor Medical Japan, Kyowa Kirin, and Mitaka Kohki; Masahiro Kawashima received a research grant from Nippon Kayaku, Kyowa Kirin and Advalife Science. He received lecture fees from Guardant Health AMEA, Chugai, Daiichi-Sankyo, Pfizer, Eisai, Taiho and Devicor Medical Japan; Nobuko Kawaguchi-Sakita received personal fees from Chugai, Kyowa Kirin, Eisai, Zene, Daiichi-Sankyo, Taiho, Astra Zeneca, Yakult, PRiME-R, HUG, IHC, NTT, CANNON Medical and Meiji Seika Pharma; Masakazu Toi received a research grant from Chugai, Takeda, Pfizer, Taiho, JBCRG assoc., KBCRN assoc., Eisai, Eli-Lilly and companies, Daiichi-Sankyo, AstraZeneca, Astellas, Shimadzu, Yakult, Nippon Kayaku, AFI technology, Luxonus, Shionogi, GL Science and Sanwa Shurui. He has funding from Chugai, Takeda, Pfizer, Kyowa-Kirin, Taiho, Eisai, Daiichi-Sankyo, AstraZeneca, Eli Lilly and companies, MSD, Exact Science, Novartis, Shimadzu, Yakult, Nippon Kayaku, Devicore Medical Japan and Sysmex as compensation for Lecture honoraria or lecture chairs. He has funding from Daiichi-Sankyo, Eli Lilly and companies, BMS, Athenex Oncology, Bertis, Terumo, Kansai Medical Net for Advisory board. He has funding from British Journal of Cancer, Scientific Reports, Breast Cancer Research and Treatment, Cancer Science, Asian Journal of Surgery, and Asian Journal of Breast Surgery for Associate editor; Marin Taguchi, He Jiaxi, Yukiko Fukui, Hanako Shimizu, Ayane Yamaguchi and Kosuke Kawaguchi have no conflict of interest. Research involving Human Participants All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study protocol was approved by the institutional review board of Kyoto University Hospital (approval no.: R4913). Informed consent Formal consent was not required owing to the retrospective nature of the study. References Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71:209–49. https://doi.org/10.3322/caac.21660 . Arnold M, Morgan E, Rumgay H, Mafra A, Singh D, Laversanne M, et al. Current and future burden of breast cancer: Global statistics for 2020 and 2040. Breast. 2022;66:15–23. https://doi.org/10.1016/j.breast.2022.08.010 . Burstein HJ, Curigliano G, Thurlimann B, Weber WP, Poortmans P, Regan MM, et al. Customizing local and systemic therapies for women with early breast cancer: the St. Gallen International Consensus Guidelines for treatment of early breast cancer 2021. Ann Oncol. 2021;32:1216–35. https://doi.org/10.1016/j.annonc.2021.06.023 . Veronesi U, Paganelli G, Viale G, Luini A, Zurrida S, Galimberti V, et al. Sentinel-lymph-node biopsy as a staging procedure in breast cancer: update of a randomised controlled study. Lancet Oncol. 2006;7:983–90. https://doi.org/10.1016/s1470-2045(06)70947-0 . Krag DN, Anderson SJ, Julian TB, Brown AM, Harlow SP, Costantino JP, et al. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol. 2010;11:927–33. https://doi.org/10.1016/s1470-2045(10)70207-2 . Giuliano AE, Ballman KV, McCall L, Beitsch PD, Brennan MB, Kelemen PR, et al. Effect of Axillary Dissection vs No Axillary Dissection on 10-Year Overall Survival Among Women With Invasive Breast Cancer and Sentinel Node Metastasis: The ACOSOG Z0011 (Alliance) Randomized Clinical Trial. JAMA. 2017;318:918–26. https://doi.org/10.1001/jama.2017.11470 . Bartels SAL, Donker M, Poncet C, Sauvé N, Straver ME, van de Velde CJH, et al. Radiotherapy or Surgery of the Axilla After a Positive Sentinel Node in Breast Cancer: 10-Year Results of the Randomized Controlled EORTC 10981–22023 AMAROS Trial. J Clin Oncol. 2023;41:2159–65. https://doi.org/10.1200/jco.22.01565 . Sávolt Á, Péley G, Polgár C, Udvarhelyi N, Rubovszky G, Kovács E, et al. Eight-year follow up result of the OTOASOR trial: The Optimal Treatment Of the Axilla - Surgery Or Radiotherapy after positive sentinel lymph node biopsy in early-stage breast cancer: A randomized, single centre, phase III, non-inferiority trial. Eur J Surg Oncol. 2017;43:672–9. https://doi.org/10.1016/j.ejso.2016.12.011 . Tinterri C, Gentile D, Gatzemeier W, Sagona A, Barbieri E, Testori A, et al. Preservation of Axillary Lymph Nodes Compared with Complete Dissection in T1-2 Breast Cancer Patients Presenting One or Two Metastatic Sentinel Lymph Nodes: The SINODAR-ONE Multicenter Randomized Clinical Trial. Ann Surg Oncol. 2022;29:5732–44. https://doi.org/10.1245/s10434-022-11866-w . Boughey JC, Suman VJ, Mittendorf EA, Ahrendt GM, Wilke LG, Taback B, et al. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA. 2013;310:1455–61. https://doi.org/10.1001/jama.2013.278932 . Kuehn T, Bauerfeind I, Fehm T, Fleige B, Hausschild M, Helms G, et al. Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicentre cohort study. Lancet Oncol. 2013;14:609–18. https://doi.org/10.1016/S1470-2045(13)70166-9 . Caudle AS, Yang WT, Krishnamurthy S, Mittendorf EA, Black DM, Gilcrease MZ, et al. Improved Axillary Evaluation Following Neoadjuvant Therapy for Patients With Node-Positive Breast Cancer Using Selective Evaluation of Clipped Nodes: Implementation of Targeted Axillary Dissection. J Clin Oncol. 2016;34:1072–8. https://doi.org/10.1200/JCO.2015.64.0094 . Siso C, de Torres J, Esgueva-Colmenarejo A, Espinosa-Bravo M, Rus N, Cordoba O, et al. Intraoperative Ultrasound-Guided Excision of Axillary Clip in Patients with Node-Positive Breast Cancer Treated with Neoadjuvant Therapy (ILINA Trial): A New Tool to Guide the Excision of the Clipped Node After Neoadjuvant Treatment. Ann Surg Oncol. 2018;25:784–91. https://doi.org/10.1245/s10434-017-6270-z . García-Novoa A, Acea-Nebril B, Díaz Carballada C, Bouzón Alejandro A, Conde C, Cereijo Garea C, et al. Combining Wire Localization of Clipped Nodes with Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy in Node-Positive Breast Cancer: Preliminary Results from a Prospective Study. Ann Surg Oncol. 2021;28:958–67. https://doi.org/10.1245/s10434-020-08925-5 . Kitai T, Inomoto T, Miwa M, Shikayama T. Fluorescence navigation with indocyanine green for detecting sentinel lymph nodes in breast cancer. Breast Cancer. 2005;12:211–5. https://doi.org/10.2325/jbcs.12.211 . Sugie T, Sawada T, Tagaya N, Kinoshita T, Yamagami K, Suwa H, et al. Comparison of the indocyanine green fluorescence and blue dye methods in detection of sentinel lymph nodes in early-stage breast cancer. Ann Surg Oncol. 2013;20:2213–8. https://doi.org/10.1245/s10434-013-2890-0 . Sugie T, Kinoshita T, Masuda N, Sawada T, Yamauchi A, Kuroi K, et al. Evaluation of the Clinical Utility of the ICG Fluorescence Method Compared with the Radioisotope Method for Sentinel Lymph Node Biopsy in Breast Cancer. Ann Surg Oncol. 2016;23:44–50. https://doi.org/10.1245/s10434-015-4809-4 . Goonawardena J, Yong C, Law M. Use of indocyanine green fluorescence compared to radioisotope for sentinel lymph node biopsy in early-stage breast cancer: systematic review and meta-analysis. Am J Surg. 2020;220:665–76. https://doi.org/10.1016/j.amjsurg.2020.02.001 . Kedrzycki MS, Leiloglou M, Ashrafian H, Jiwa N, Thiruchelvam PTR, Elson DS, et al. Meta-analysis Comparing Fluorescence Imaging with Radioisotope and Blue Dye-Guided Sentinel Node Identification for Breast Cancer Surgery. Ann Surg Oncol. 2021;28:3738–48. https://doi.org/10.1245/s10434-020-09288-7 . Takada M, Takeuchi M, Suzuki E, Sato F, Matsumoto Y, Torii M, et al. Real-time navigation system for sentinel lymph node biopsy in breast cancer patients using projection mapping with indocyanine green fluorescence. Breast Cancer. 2018;25:650–5. https://doi.org/10.1007/s12282-018-0868-2 . Nakamura Y, Takada M, Imamura M, Higami A, Jiaxi H, Fujino M, et al. Usefulness and Prospects of Sentinel Lymph Node Biopsy for Patients With Breast Cancer Using the Medical Imaging Projection System. Front Oncol. 2021;11:674419. https://doi.org/10.3389/fonc.2021.674419 . Nishino H, Hatano E, Seo S, Nitta T, Saito T, Nakamura M, et al. Real-time Navigation for Liver Surgery Using Projection Mapping With Indocyanine Green Fluorescence: Development of the Novel Medical Imaging Projection System. Ann Surg. 2018;267:1134–40. https://doi.org/10.1097/sla.0000000000002172 . Sugie T, Ikeda T, Kawaguchi A, Shimizu A, Toi M. Sentinel lymph node biopsy using indocyanine green fluorescence in early-stage breast cancer: a meta-analysis. Int J Clin Oncol. 2017;22:11–7. https://doi.org/10.1007/s10147-016-1064-z . Lin SQ, Vo NP, Yen YC, Tam KW. Outcomes of Sentinel Node Biopsy for Women with Breast Cancer After Neoadjuvant Therapy: Systematic Review and Meta-Analysis of Real-World Data. Ann Surg Oncol. 2022;29:3038–49. https://doi.org/10.1245/s10434-021-11297-z . Boileau JF, Poirier B, Basik M, Holloway CM, Gaboury L, Sideris L, et al. Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: the SN FNAC study. J Clin Oncol. 2015;33:258–64. https://doi.org/10.1200/JCO.2014.55.7827 . Argentou MI, Iliopoulos E, Verras GI, Mulita F, Tchabashvili L, Spyridonidis T, et al. Study on intraoperative localization of sentinel lymph nodes using freehand SPECT in breast cancer patients. Wideochir Inne Tech Maloinwazyjne. 2022;17:641–51. https://doi.org/10.5114/wiitm.2022.116406 . Sun S, Bai J, Wang X. Comparative observation of common tracers in sentinel lymph node biopsy of breast cancer and a study on simplifying its surgical procedure. Front Surg. 2023;10:1180919. https://doi.org/10.3389/fsurg.2023.1180919 . van der Ploeg IM, Nieweg OE, van Rijk MC, Valdés Olmos RA, Kroon BB. Axillary recurrence after a tumour-negative sentinel node biopsy in breast cancer patients: A systematic review and meta-analysis of the literature. Eur J Surg Oncol. 2008;34:1277–84. https://doi.org/10.1016/j.ejso.2008.01.034 . Galimberti V, Ribeiro Fontana SK, Maisonneuve P, Steccanella F, Vento AR, Intra M, et al. Sentinel node biopsy after neoadjuvant treatment in breast cancer: Five-year follow-up of patients with clinically node-negative or node-positive disease before treatment. Eur J Surg Oncol. 2016;42:361–8. https://doi.org/10.1016/j.ejso.2015.11.019 . Wong SM, Basik M, Florianova L, Margolese R, Dumitra S, Muanza T, et al. Oncologic Safety of Sentinel Lymph Node Biopsy Alone After Neoadjuvant Chemotherapy for Breast Cancer. Ann Surg Oncol. 2021;28:2621–9. https://doi.org/10.1245/s10434-020-09211-0 . Cite Share Download PDF Status: Published Journal Publication published 10 May, 2025 Read the published version in Breast Cancer → Version 1 posted Editorial decision: Accept 26 Apr, 2025 Reviewers agreed at journal 22 Apr, 2025 Reviewers invited by journal 22 Apr, 2025 Editor assigned by journal 22 Apr, 2025 First submitted to journal 21 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5723931","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":446585269,"identity":"9d6c1925-91bf-48e8-ab4c-9454ea91d246","order_by":0,"name":"Marin Taguchi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFklEQVRIiWNgGAWjYPCCAzz8PAxsQEYCiih2xWxQLZI9MC1sRGphMDiDqQU70J3f/Pg1T80dGeMzZ8weFzCkJfbLNx9g5mGwk2dgPIvVGrNjbGbWPMee8Zid7TE3nsGQkzizjS0BqCXZsIHhXAJ2LQxmxrwNh3nMzvOYSfMwVCRuOMZj/puHgRmo/IwBdi3s38BajPsRWgyAttTj0cJj/BikxYC3B6QlB6blMB4tOWWMc44d5pE4c6xMeoZBmvHMtrQExjkGxw3bcPnl8PHNH97UHLbn70neJl1QkSzbz3z4AMObimp5fgnsIQYEbBIwFjODAYNjA5hpABI/g0MHA/MHhBYGBnuEBH8PLi2jYBSMglEwsgAAOrFZWosCJJkAAAAASUVORK5CYII=","orcid":"https://orcid.org/0009-0005-1895-2426","institution":"Kyoto University Hospital: Kyoto Daigaku Igakubu Fuzoku Byoin","correspondingAuthor":true,"prefix":"","firstName":"Marin","middleName":"","lastName":"Taguchi","suffix":""},{"id":446585270,"identity":"a4d903ee-367c-4744-9c41-d105efab295a","order_by":1,"name":"Masahiro Takada","email":"","orcid":"https://orcid.org/0000-0002-5954-1296","institution":"Kansai Medical University: Kansai Ika Daigaku","correspondingAuthor":false,"prefix":"","firstName":"Masahiro","middleName":"","lastName":"Takada","suffix":""},{"id":446585271,"identity":"1ba7d34e-ac59-456a-a839-781285441cc3","order_by":2,"name":"He Jiaxi","email":"","orcid":"","institution":"Kyoto University Hospital: Kyoto Daigaku Igakubu Fuzoku Byoin","correspondingAuthor":false,"prefix":"","firstName":"He","middleName":"","lastName":"Jiaxi","suffix":""},{"id":446585272,"identity":"a81105d2-36c8-41f2-bc02-4294e3d25bdf","order_by":3,"name":"Yukiko Fukui","email":"","orcid":"","institution":"Kyoto University Hospital: Kyoto Daigaku Igakubu Fuzoku Byoin","correspondingAuthor":false,"prefix":"","firstName":"Yukiko","middleName":"","lastName":"Fukui","suffix":""},{"id":446585273,"identity":"f270d218-6e5e-4ff9-ae61-05078d83da87","order_by":4,"name":"Hanako Shimizu","email":"","orcid":"","institution":"Kyoto University Hospital: Kyoto Daigaku Igakubu Fuzoku Byoin","correspondingAuthor":false,"prefix":"","firstName":"Hanako","middleName":"","lastName":"Shimizu","suffix":""},{"id":446585274,"identity":"b611b7d6-e640-48cc-bcf8-63ff96ee9ed8","order_by":5,"name":"Ayane Yamaguchi","email":"","orcid":"","institution":"Kyoto University Hospital: Kyoto Daigaku Igakubu Fuzoku Byoin","correspondingAuthor":false,"prefix":"","firstName":"Ayane","middleName":"","lastName":"Yamaguchi","suffix":""},{"id":446585275,"identity":"791718b0-6111-4321-bb43-b3a4f84b3390","order_by":6,"name":"Kosuke Kawaguchi","email":"","orcid":"","institution":"Kyoto University Hospital: Kyoto Daigaku Igakubu Fuzoku Byoin","correspondingAuthor":false,"prefix":"","firstName":"Kosuke","middleName":"","lastName":"Kawaguchi","suffix":""},{"id":446585276,"identity":"87033096-a1b8-4bc4-9953-7b4b4d120811","order_by":7,"name":"Masahiro Kawashima","email":"","orcid":"","institution":"Kyoto University Hospital: Kyoto Daigaku Igakubu Fuzoku Byoin","correspondingAuthor":false,"prefix":"","firstName":"Masahiro","middleName":"","lastName":"Kawashima","suffix":""},{"id":446585277,"identity":"6bb3580c-9b75-4f01-811f-632f8e6f5787","order_by":8,"name":"Nobuko Kawaguchi-Sakita","email":"","orcid":"","institution":"Kyoto University Hospital: Kyoto Daigaku Igakubu Fuzoku Byoin","correspondingAuthor":false,"prefix":"","firstName":"Nobuko","middleName":"","lastName":"Kawaguchi-Sakita","suffix":""},{"id":446585278,"identity":"1c15888d-cfe6-4ca7-822c-adc74d467856","order_by":9,"name":"Masakazu Toi","email":"","orcid":"","institution":"Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital: Tokyo Toritsu Komagome Byoin","correspondingAuthor":false,"prefix":"","firstName":"Masakazu","middleName":"","lastName":"Toi","suffix":""}],"badges":[],"createdAt":"2024-12-28 01:51:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5723931/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5723931/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s12282-025-01712-8","type":"published","date":"2025-05-10T15:56:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82537389,"identity":"8fec2c52-ac54-401e-b95d-ee272df4118a","added_by":"auto","created_at":"2025-05-12 15:59:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":694681,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5723931/v1/82989bb0-5a9e-4fa0-a520-a1b44e493d77.pdf"}],"financialInterests":"","formattedTitle":"Detection capability of the Medical Imaging Projection System for sentinel lymph node biopsy in patients with breast cancer with and without neoadjuvant chemotherapy: A retrospective study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBreast cancer is the most commonly diagnosed cancer in the world. There were approximately 2.3\u0026nbsp;million new cases of breast cancer in women in 2020 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], and it is presumed that its incidence rate will remain high for decades [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Multidisciplinary treatment, such as systemic therapy and radiotherapy, has improved the prognosis of patients with breast cancer. For patients with early breast cancer, the axillary nodal status is one of the important prognostic factors to make treatment decisions [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. While axillary dissection has been a standard technique for axillary staging, sentinel lymph node (SLN) biopsy has become the standard of care for patients with early breast cancer [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Patients with negative-SLNs can avoid axillary dissection without compromising prognosis. Randomized controlled trials have shown that patients with limited number of metastatic nodes in the SLNs can also avoid axillary dissection [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Several studies have investigated the feasibility of SLN biopsy after neoadjuvant chemotherapy (NAC) for patients who initially presented with clinically positive axillary nodes. These studies showed that the false-negative rate was \u0026gt;\u0026thinsp;10% in intent-to-treat population, but it was suggested that use of dual tracer or removal of three or more SLNs may reduce the false-negative rate to an acceptable level [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Targeted axillary dissection (TAD) is a technique for removing biopsy-proven positive axillary lymph nodes in addition to SLNs in patients who received NAC. TAD reportedly reduces the false-negative rate [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConventionally, the radioisotope (RI) and blue dye methods have been used to identify SLNs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In 2005, SLN identification with indocyanine green (ICG) fluorescence method was first reported [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and since then, ICG fluorescence imaging has shown a high identification rate in several clinical studies [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Meta-analyses have shown that there was no significant difference in SLN identification between the ICG fluorescence and RI methods, and the ICG fluorescence method was superior to the blue dye method in terms of the identification rate. In addition, the ICG fluorescence method identified more SLNs per patient compared to the RI or blue dye methods, suggesting that the ICG fluorescence method may reduce the false-negative rate in SLN identification after NAC [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Medical Imaging Projection System (MIPS) is an innovative near-infrared (NIR) fluorescence imaging system that projects ICG images directly onto the surgical field using projection mapping technology [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The MIPS-assisted ICG fluorescence method provides continuous real-time navigation for SLN biopsy, eliminating the need for surgeons to shift their visual focus from the surgical field. Previous studies have reported a high SLN identification rate with MIPS, comparable to the conventional ICG fluorescence and RI methods [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, prior evaluations of the clinical utility of SLN biopsy using MIPS were limited by small sample sizes and a low proportion of patients with positive SLNs, particularly in post-NAC settings.\u003c/p\u003e \u003cp\u003eIn this study, we aimed to evaluate SLN identification using the MIPS both with and without NAC administration and to compare its utility with the RI method.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and patients\u003c/h2\u003e \u003cp\u003eWe retrospectively reviewed medical records of patients with primary breast cancer who underwent SLN biopsy using the MIPS at Kyoto University Hospital between April 2020 and \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eDecember 2024\u003c/span\u003e. Eligibility criteria included histologically confirmed breast cancer and patients who underwent SLN biopsy using the MIPS. Patients with initially clinical node positive tumors who received NAC were also included. Exclusion criteria included patients with a previous history of axial surgery. \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eWe used the following methods when we performed SLN biopsies using MIPS and RI methods. The surgeon identified and excised the SLNs using MIPS, followed by the RI method to identify and excise any remaining SLNs. Each SLN removed was checked for fluorescence or RI signal and recorded.\u003c/span\u003e The study protocol was approved by the institutional review board of Kyoto University Hospital (approval no.: R4913).\u003c/p\u003e \u003cp\u003eWe collected data on age, sex, body mass index (BMI), tumor histology, subtype, administration of NAC, combined use of the RI method, number of SLNs identified, operating time of SLN biopsy, and pathology reports. A detailed description of the MIPS and its surgical procedure have been reported previously [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. MIPS is approved in Japan as a class II medical device, and in this study period, commercially available MPIS was used in clinical practice.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe primary endpoint of this study was the SLN identification rate using the MIPS, defined as the proportion of patients in whom at least one SLN was detected with the system. Secondary endpoints included the number of positive SLNs, number of SLNs detected per patient using the MIPS, operating time for SLN biopsy, and number of patients with axillary recurrence after SLN biopsy.\u003c/p\u003e \u003cp\u003eThe SLN identification rate and number of positive SLNs were analyzed for all procedures and specifically for those performed after NAC. The number of SLNs detected was compared between patient groups stratified by clinical factors, such as NAC administration or BMI, using the Wilcoxon rank-sum test. In cases where both the MIPS and RI methods were used, the number of SLNs identified and positive SLNs were compared between methods. Operating times were also compared between methods, with or without combination with the RI method, using the Wilcoxon rank-sum test.\u003c/p\u003e \u003cp\u003eStatistical significance was assessed with a two-sided level of 0.05. All analyses were conducted using the JMP\u0026reg; Pro software (version 17.0.0; SAS Institute, Inc., Cary, NC, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e452 patients (including 22 patients with bilateral breast cancer)\u003c/span\u003e underwent SLN biopsy using the MIPS between April 2020 and \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eDecember 2024\u003c/span\u003e. \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFour patients\u003c/span\u003e with unilateral breast cancer had a prior history of axial surgery. The analysis was based on a total of \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e470 procedures (448 patients)\u003c/span\u003e. The baseline characteristics of the patients and tumors are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The median age was 59 \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(range, 25\u0026thinsp;\u0026minus;\u0026thinsp;87)\u003c/span\u003e years and the median BMI was \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e21.7 (range, 15.6\u0026thinsp;\u0026minus;\u0026thinsp;43.0)\u003c/span\u003e kg/m\u003csup\u003e2\u003c/sup\u003e. Procedures performed for ductal carcinomas \u003cem\u003ein situ\u003c/em\u003e accounted for \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e18.5%\u003c/span\u003e, and approximately \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e80%\u003c/span\u003e of procedures were performed for T1\u0026ndash;T2 tumors. There were \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eeight patients (1.7%)\u003c/span\u003e with clinically node-positive breast cancer, and \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003esix\u003c/span\u003e of them underwent NAC. Of the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e470 procedures, 56 (11.9%)\u003c/span\u003e were conducted after NAC. Both the MIPS and RI methods were used in \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e327 (69.6%) procedures\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient and tumor characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll procedures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e470\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emedian (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (25\u0026ndash;87)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emedian (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.7 (15.6\u0026ndash;43.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1mi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNodal stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e462\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDCIS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIDC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e326\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eILC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubtype\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHR+, HER2-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e303\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHR+, HER+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHR-, HER2+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTriple negative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eunknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeoadjuvant chemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e414\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined use of radioisotope method\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e327\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e143\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBp\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e274\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAxillary dissection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e440\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eBMI, body mass index; DCIS, ductal carcinomas \u003cem\u003ein situ\u003c/em\u003e; IDC, invasive ductal carcinoma; ILC, invasive lobular carcinoma\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe identification rate of SLNs by the MIPS was \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e99.6% (468/470: 95% confidence interval [CI], 98.5\u0026ndash;99.9)\u003c/span\u003e in all procedures and \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e98.2% (55/56: 95% CI, 90.6\u0026ndash;99.7)\u003c/span\u003e in procedures after NAC.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eOf 1480 SLNs\u003c/span\u003e excised among the patients who underwent SLN biopsy using by the MIPS, there were \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e114 positive SLNs\u003c/span\u003e. Of \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e180 SLNs\u003c/span\u003e excised among patients who have undergone NAC, four positive SLNs were detected.\u003c/p\u003e \u003cp\u003eThe median number of SLNs identified per patient was 3 (range, 2\u0026ndash;4) by the MIPS and 2 \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(range, 1\u0026ndash;3)\u003c/span\u003e by the RI method (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The median number of SLNs identified by the MIPS per patient who had received NAC was 3 (range, 2\u0026ndash;4). This study showed no significant difference in the number of SLNs between patients who received NAC and those who did not (3 vs 3, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eP=0.84\u003c/span\u003e). There was no significant difference in the median number of SLNs detected by the MIPS between patients with a high BMI (\u0026ge;\u0026thinsp;22 kg/m\u003csup\u003e2\u003c/sup\u003e) and those with a low BMI (\u0026lt;\u0026thinsp;22 kg/m\u003csup\u003e2\u003c/sup\u003e) (3 vs 3, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eP\u0026thinsp;=\u0026thinsp;0.41\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNumber of SLNs identified by the MIPS\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e244\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNAC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e414\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBp\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e274\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eBMI, body mass index; NAC, neo adjuvant chemotherapy; IQR, interquartile range\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA total of \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e1062 SLNs\u003c/span\u003e were excised in \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e327 procedures\u003c/span\u003e, in which the MIPS and RI methods were used (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea). Among them, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e657 (62%) SLNs\u003c/span\u003e were identified by both the MIPS and RI methods, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e394 (37%)\u003c/span\u003e only by the MIPS, four (0.38%) only by the RI method, and \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eseven (0.66%)\u003c/span\u003e by neither the MIPS nor RI method (palpation). A total of \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e78 positive SLNs\u003c/span\u003e were excised and all of them were identified by the MIPS. No positive SLNs were identified by the RI method alone. Among procedures which were conducted after NAC, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e147 SLNs\u003c/span\u003e were identified in \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e44 procedures\u003c/span\u003e, in which both the MIPS and RI methods were used (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb). All SLNs were identified by the MIPS. There were \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003efour positive SLNs\u003c/span\u003e, which were identified by both the MIPS and RI methods.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNumber of SLNs among cases using MIPS and RI a) Among all procedures (n\u0026thinsp;=\u0026thinsp;327):\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSLN biopsy procedures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIdentified SLNs\u003c/p\u003e \u003cp\u003e(total N\u0026thinsp;=\u0026thinsp;1062)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePositive SLNs\u003c/p\u003e \u003cp\u003e(total N\u0026thinsp;=\u0026thinsp;78)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMIPS and RI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e657\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMIPS only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e394\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRI only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeither MIPS nor RI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eb) Among procedures following NAC (n\u0026thinsp;=\u0026thinsp;44):\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe median operating time for SLN biopsy using only the MIPS was \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e26 (range, 19\u0026ndash;39)\u003c/span\u003e min \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eand using the MIPS and the RI method was 31 (range, 22\u0026ndash;45) min (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01)\u003c/span\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). At a median follow-up of \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e32 (range, 2\u0026ndash;58) months\u003c/span\u003e, no patient experienced axillary recurrence following SLN biopsy.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOperating time using MIPS according to the combination of the RI method\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMethod\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMIPS and RI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e326\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u0026ndash;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMIPS only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eIQR, interquartile range; MIPS, Medical Imaging Projection System; RI, radioisotope\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study reinforces our previous findings demonstrating a high SLN identification rate using the ICG fluorescence method with MIPS [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Notably, even among patients who received NAC, the SLN identification rate with MIPS remained high. There was no significant difference in the median number of SLNs detected per patient by MIPS between those who received NAC and those who did not. In procedures utilizing both the MIPS and RI methods, all positive SLNs were identified by MIPS, with none identified solely by the RI method.\u003c/p\u003e \u003cp\u003eA prior meta-analysis reported SLN identification rates of 88.6\u0026ndash;100% with the ICG fluorescence method and 85\u0026ndash;100% with the RI method [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. A recent meta-analysis focusing on post-NAC SLN biopsies showed an identification rate of 90.6% (95% CI, 89.1\u0026ndash;92.2) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In this study, the SLN identification rate by MIPS was \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e99.6% (95% CI, 98.5\u0026ndash;99.9)\u003c/span\u003e across all patients and \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e98.2% (95% CI, 90.6\u0026ndash;99.7)\u003c/span\u003e in those who received NAC. These findings indicate that the SLN identification rate with MIPS is comparable to conventional methods, regardless of NAC status. \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eThe near-infrared camera equipped in MIPS is the same as the conventional one. Therefore, MIPS showed a high SLN identification rate similar to the conventional ICG fluorescence methods. Compared to conventional near-infrared camera systems, MIPS has the advantage of real-time visibility of the fluorescence signal in the operative field, allowing for a smoother surgical procedure.\u003c/span\u003e\u003c/p\u003e \u003cp\u003eAccurate SLN biopsy is critical for early-stage breast cancer management, as the number of positive SLNs informs decisions regarding additional local axillary treatment and systemic adjuvant therapy. In this study, all positive SLNs excised were identified by MIPS, with none detected by the RI method alone. These results align with previous research [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], suggesting that the RI method may not provide additional value over MIPS in identifying positive SLNs. \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eThe results of the meta-analysis indicate that the ICG fluorescence method has a similar SLN identification rate as the RI method\u003c/span\u003e [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSugie et al. also showed that the ICG fluorescence and RI combination had a significantly higher SLN identification rate than RI alone\u003c/span\u003e [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eBecause this study was a retrospective study, it was not possible to conclude whether the RI method should be used in addition to MIPS, and further studies are needed.\u003c/span\u003e\u003c/p\u003e \u003cp\u003eThe SLN identification rate is reportedly lower and the false-negative rate is higher in patients who received NAC compared to those who did not [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. A recent meta-analysis indicated that removing at least three SLNs may reduce the false-negative rate in patients post-NAC [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In our study, the median number of SLNs identified per patient using the MIPS was 3 (95% CI, 2\u0026ndash;4), consistent even among patients post-NAC, where 3 (range, 2\u0026ndash;4) SLNs were identified. As previous studies have shown, the use of dual tracers for SLN detection may further reduce the false-negative rate [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eOur study included eight patients with clinically node-positive breast cancer and six of them underwent NAC. All procedures were conducted both by the MIPS and the RI method, and all SLNs including metastatic SLNs excised were identified by the MIPS. Among six procedures conducted after NAC, there were no metastatic nodes in five procedures leading to avoiding axillary dissection. Although TAD was not routinely conducted in our facility, considering that there was no patient who experienced axillary recurrence following SLN biopsy, use of dual tracer and detecting stable number of SLNs could improve the feasibility of SLN biopsy.\u003c/span\u003e \u003c/p\u003e \u003cp\u003eOur study found \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003esignificant difference\u003c/span\u003e in SLN biopsy operating time between procedures conducted solely with MIPS and those combining MIPS and RI methods. \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eAlthough the addition of the RI method may lead to longer operating time than only by the MIPS, it was suggested that use of dual tracer may reduce the false-negative rate\u003c/span\u003e [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe MIPS-assisted ICG fluorescence method enables real-time navigation during SLN biopsy, potentially streamlining the procedure. In this study, the median operating time for SLN biopsy was \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e26 (range, 19\u0026ndash;39)\u003c/span\u003e min using MIPS alone and \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e31 (range, 22\u0026ndash;45)\u003c/span\u003e min with MIPS and RI methods combined. These durations are comparable to SLN biopsy times using conventional methods [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Operating times can be influenced by various factors, such as surgeon skill level or patient BMI. Although we did not collect specific data on SLN biopsy times with conventional NIR devices, these findings suggest that MIPS does not prolong surgery compared to conventional methods.\u003c/p\u003e \u003cp\u003eA systematic review reported an axillary recurrence rate of 0.3% in clinically node-negative patients with breast cancer and SLN-negative findings [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. For patients who initially presented with clinically positive axillary nodes but became node-negative after NAC, the reported axillary recurrence rate was \u0026lt;\u0026thinsp;1% [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Consistent with these findings, no axillary recurrences have been observed in our cohort following SLN biopsy to date.\u003c/p\u003e \u003cp\u003eThe current study had some limitations. First, as this study was conducted at a single center, the generalizability of the findings may have been limited. Further multi-institutional studies are necessary to validate the efficacy and utility of MIPS. Second, procedures conducted after NAC accounted for \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eonly 12%\u003c/span\u003e of the total cohort, and the sample size of patients with clinical node-positive breast cancer was small. Although the results demonstrated high SLN identification rates with MIPS in patients who have undergone NAC, larger studies are required to confirm these findings and establish broader applicability. Third, the follow-up duration at the time of this investigation was insufficient to thoroughly evaluate the recurrence rate. Additionally, safety assessments of the procedures were not included in this study. Extended follow-up and more comprehensive analyses are needed to address these gaps.\u003c/p\u003e \u003cp\u003eDespite these limitations, MIPS achieved an SLN identification rate of \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e99.6%\u003c/span\u003e and \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e98.2%\u003c/span\u003e overall and in patients who received NAC, respectively, showcasing its robustness across varied clinical scenarios. The MIPS method can serve as a reliable approach to identifying positive SLNs and consistently removing a stable number of SLNs, regardless of whether systemic chemotherapy was administered. Furthermore, it holds potential to reduce the false-negative rate, supporting its utility in SLN biopsies.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all investigators and patients who participated in this study for their contributions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe would like to thank Editage (www.editage.jp) for English language editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with Ethical Standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDisclosure of potential conflicts of interest\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMasahiro Takada received a research grant from Yakult Honsha, Guardant Health Japan and Medbis, and received lecture fees from Daiichi Sankyo, AstraZeneca, Taiho, Eli-Lilly, MSD, Pfizer, Eisai, Chugai, Devicor Medical Japan, Kyowa Kirin, and Mitaka Kohki; Masahiro Kawashima received a research grant from Nippon Kayaku, Kyowa Kirin and Advalife Science. He received lecture fees from Guardant Health AMEA, Chugai, Daiichi-Sankyo, Pfizer, Eisai, Taiho and Devicor Medical Japan; Nobuko Kawaguchi-Sakita received personal fees from Chugai, Kyowa Kirin, Eisai, Zene, Daiichi-Sankyo, Taiho, Astra Zeneca, Yakult, PRiME-R, HUG, IHC, NTT, CANNON Medical and Meiji Seika Pharma; Masakazu Toi received a research grant from Chugai, Takeda, Pfizer, Taiho, JBCRG assoc., KBCRN assoc., Eisai, Eli-Lilly and companies, Daiichi-Sankyo, AstraZeneca, Astellas, Shimadzu, Yakult, Nippon Kayaku, AFI technology, Luxonus, Shionogi, GL Science and Sanwa Shurui. He has funding from Chugai, Takeda, Pfizer, Kyowa-Kirin, Taiho, Eisai, Daiichi-Sankyo, AstraZeneca, Eli Lilly and companies, MSD, Exact Science, Novartis, Shimadzu, Yakult, Nippon Kayaku, Devicore Medical Japan and Sysmex as compensation for Lecture honoraria or lecture chairs. He has funding from Daiichi-Sankyo, Eli Lilly and companies, BMS, Athenex Oncology, Bertis, Terumo, Kansai Medical Net for Advisory board. He has funding from British Journal of Cancer, Scientific Reports, Breast Cancer Research and Treatment, Cancer Science, Asian Journal of Surgery, and Asian Journal of Breast Surgery for Associate editor; Marin Taguchi, He Jiaxi, Yukiko Fukui, Hanako Shimizu, Ayane Yamaguchi and Kosuke Kawaguchi have no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eResearch involving Human Participants\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study protocol was approved by the institutional review board of Kyoto University Hospital (approval no.: R4913).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInformed consent\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFormal consent was not required owing to the retrospective nature of the study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71:209\u0026ndash;49. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3322/caac.21660\u003c/span\u003e\u003cspan address=\"10.3322/caac.21660\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArnold M, Morgan E, Rumgay H, Mafra A, Singh D, Laversanne M, et al. Current and future burden of breast cancer: Global statistics for 2020 and 2040. Breast. 2022;66:15\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.breast.2022.08.010\u003c/span\u003e\u003cspan address=\"10.1016/j.breast.2022.08.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurstein HJ, Curigliano G, Thurlimann B, Weber WP, Poortmans P, Regan MM, et al. Customizing local and systemic therapies for women with early breast cancer: the St. Gallen International Consensus Guidelines for treatment of early breast cancer 2021. Ann Oncol. 2021;32:1216\u0026ndash;35. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.annonc.2021.06.023\u003c/span\u003e\u003cspan address=\"10.1016/j.annonc.2021.06.023\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVeronesi U, Paganelli G, Viale G, Luini A, Zurrida S, Galimberti V, et al. Sentinel-lymph-node biopsy as a staging procedure in breast cancer: update of a randomised controlled study. Lancet Oncol. 2006;7:983\u0026ndash;90. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s1470-2045(06)70947-0\u003c/span\u003e\u003cspan address=\"10.1016/s1470-2045(06)70947-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrag DN, Anderson SJ, Julian TB, Brown AM, Harlow SP, Costantino JP, et al. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol. 2010;11:927\u0026ndash;33. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s1470-2045(10)70207-2\u003c/span\u003e\u003cspan address=\"10.1016/s1470-2045(10)70207-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiuliano AE, Ballman KV, McCall L, Beitsch PD, Brennan MB, Kelemen PR, et al. Effect of Axillary Dissection vs No Axillary Dissection on 10-Year Overall Survival Among Women With Invasive Breast Cancer and Sentinel Node Metastasis: The ACOSOG Z0011 (Alliance) Randomized Clinical Trial. JAMA. 2017;318:918\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jama.2017.11470\u003c/span\u003e\u003cspan address=\"10.1001/jama.2017.11470\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBartels SAL, Donker M, Poncet C, Sauv\u0026eacute; N, Straver ME, van de Velde CJH, et al. Radiotherapy or Surgery of the Axilla After a Positive Sentinel Node in Breast Cancer: 10-Year Results of the Randomized Controlled EORTC 10981\u0026ndash;22023 AMAROS Trial. J Clin Oncol. 2023;41:2159\u0026ndash;65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1200/jco.22.01565\u003c/span\u003e\u003cspan address=\"10.1200/jco.22.01565\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eS\u0026aacute;volt \u0026Aacute;, P\u0026eacute;ley G, Polg\u0026aacute;r C, Udvarhelyi N, Rubovszky G, Kov\u0026aacute;cs E, et al. Eight-year follow up result of the OTOASOR trial: The Optimal Treatment Of the Axilla - Surgery Or Radiotherapy after positive sentinel lymph node biopsy in early-stage breast cancer: A randomized, single centre, phase III, non-inferiority trial. Eur J Surg Oncol. 2017;43:672\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ejso.2016.12.011\u003c/span\u003e\u003cspan address=\"10.1016/j.ejso.2016.12.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTinterri C, Gentile D, Gatzemeier W, Sagona A, Barbieri E, Testori A, et al. Preservation of Axillary Lymph Nodes Compared with Complete Dissection in T1-2 Breast Cancer Patients Presenting One or Two Metastatic Sentinel Lymph Nodes: The SINODAR-ONE Multicenter Randomized Clinical Trial. Ann Surg Oncol. 2022;29:5732\u0026ndash;44. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1245/s10434-022-11866-w\u003c/span\u003e\u003cspan address=\"10.1245/s10434-022-11866-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoughey JC, Suman VJ, Mittendorf EA, Ahrendt GM, Wilke LG, Taback B, et al. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA. 2013;310:1455\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jama.2013.278932\u003c/span\u003e\u003cspan address=\"10.1001/jama.2013.278932\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuehn T, Bauerfeind I, Fehm T, Fleige B, Hausschild M, Helms G, et al. Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicentre cohort study. Lancet Oncol. 2013;14:609\u0026ndash;18. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S1470-2045(13)70166-9\u003c/span\u003e\u003cspan address=\"10.1016/S1470-2045(13)70166-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaudle AS, Yang WT, Krishnamurthy S, Mittendorf EA, Black DM, Gilcrease MZ, et al. Improved Axillary Evaluation Following Neoadjuvant Therapy for Patients With Node-Positive Breast Cancer Using Selective Evaluation of Clipped Nodes: Implementation of Targeted Axillary Dissection. J Clin Oncol. 2016;34:1072\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1200/JCO.2015.64.0094\u003c/span\u003e\u003cspan address=\"10.1200/JCO.2015.64.0094\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiso C, de Torres J, Esgueva-Colmenarejo A, Espinosa-Bravo M, Rus N, Cordoba O, et al. Intraoperative Ultrasound-Guided Excision of Axillary Clip in Patients with Node-Positive Breast Cancer Treated with Neoadjuvant Therapy (ILINA Trial): A New Tool to Guide the Excision of the Clipped Node After Neoadjuvant Treatment. Ann Surg Oncol. 2018;25:784\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1245/s10434-017-6270-z\u003c/span\u003e\u003cspan address=\"10.1245/s10434-017-6270-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarc\u0026iacute;a-Novoa A, Acea-Nebril B, D\u0026iacute;az Carballada C, Bouz\u0026oacute;n Alejandro A, Conde C, Cereijo Garea C, et al. Combining Wire Localization of Clipped Nodes with Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy in Node-Positive Breast Cancer: Preliminary Results from a Prospective Study. Ann Surg Oncol. 2021;28:958\u0026ndash;67. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1245/s10434-020-08925-5\u003c/span\u003e\u003cspan address=\"10.1245/s10434-020-08925-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKitai T, Inomoto T, Miwa M, Shikayama T. Fluorescence navigation with indocyanine green for detecting sentinel lymph nodes in breast cancer. Breast Cancer. 2005;12:211\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2325/jbcs.12.211\u003c/span\u003e\u003cspan address=\"10.2325/jbcs.12.211\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSugie T, Sawada T, Tagaya N, Kinoshita T, Yamagami K, Suwa H, et al. Comparison of the indocyanine green fluorescence and blue dye methods in detection of sentinel lymph nodes in early-stage breast cancer. Ann Surg Oncol. 2013;20:2213\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1245/s10434-013-2890-0\u003c/span\u003e\u003cspan address=\"10.1245/s10434-013-2890-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSugie T, Kinoshita T, Masuda N, Sawada T, Yamauchi A, Kuroi K, et al. Evaluation of the Clinical Utility of the ICG Fluorescence Method Compared with the Radioisotope Method for Sentinel Lymph Node Biopsy in Breast Cancer. Ann Surg Oncol. 2016;23:44\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1245/s10434-015-4809-4\u003c/span\u003e\u003cspan address=\"10.1245/s10434-015-4809-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoonawardena J, Yong C, Law M. Use of indocyanine green fluorescence compared to radioisotope for sentinel lymph node biopsy in early-stage breast cancer: systematic review and meta-analysis. Am J Surg. 2020;220:665\u0026ndash;76. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.amjsurg.2020.02.001\u003c/span\u003e\u003cspan address=\"10.1016/j.amjsurg.2020.02.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKedrzycki MS, Leiloglou M, Ashrafian H, Jiwa N, Thiruchelvam PTR, Elson DS, et al. Meta-analysis Comparing Fluorescence Imaging with Radioisotope and Blue Dye-Guided Sentinel Node Identification for Breast Cancer Surgery. Ann Surg Oncol. 2021;28:3738\u0026ndash;48. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1245/s10434-020-09288-7\u003c/span\u003e\u003cspan address=\"10.1245/s10434-020-09288-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTakada M, Takeuchi M, Suzuki E, Sato F, Matsumoto Y, Torii M, et al. Real-time navigation system for sentinel lymph node biopsy in breast cancer patients using projection mapping with indocyanine green fluorescence. Breast Cancer. 2018;25:650\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12282-018-0868-2\u003c/span\u003e\u003cspan address=\"10.1007/s12282-018-0868-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNakamura Y, Takada M, Imamura M, Higami A, Jiaxi H, Fujino M, et al. Usefulness and Prospects of Sentinel Lymph Node Biopsy for Patients With Breast Cancer Using the Medical Imaging Projection System. Front Oncol. 2021;11:674419. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fonc.2021.674419\u003c/span\u003e\u003cspan address=\"10.3389/fonc.2021.674419\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNishino H, Hatano E, Seo S, Nitta T, Saito T, Nakamura M, et al. Real-time Navigation for Liver Surgery Using Projection Mapping With Indocyanine Green Fluorescence: Development of the Novel Medical Imaging Projection System. Ann Surg. 2018;267:1134\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/sla.0000000000002172\u003c/span\u003e\u003cspan address=\"10.1097/sla.0000000000002172\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSugie T, Ikeda T, Kawaguchi A, Shimizu A, Toi M. Sentinel lymph node biopsy using indocyanine green fluorescence in early-stage breast cancer: a meta-analysis. Int J Clin Oncol. 2017;22:11\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10147-016-1064-z\u003c/span\u003e\u003cspan address=\"10.1007/s10147-016-1064-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin SQ, Vo NP, Yen YC, Tam KW. Outcomes of Sentinel Node Biopsy for Women with Breast Cancer After Neoadjuvant Therapy: Systematic Review and Meta-Analysis of Real-World Data. Ann Surg Oncol. 2022;29:3038\u0026ndash;49. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1245/s10434-021-11297-z\u003c/span\u003e\u003cspan address=\"10.1245/s10434-021-11297-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoileau JF, Poirier B, Basik M, Holloway CM, Gaboury L, Sideris L, et al. Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: the SN FNAC study. J Clin Oncol. 2015;33:258\u0026ndash;64. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1200/JCO.2014.55.7827\u003c/span\u003e\u003cspan address=\"10.1200/JCO.2014.55.7827\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArgentou MI, Iliopoulos E, Verras GI, Mulita F, Tchabashvili L, Spyridonidis T, et al. Study on intraoperative localization of sentinel lymph nodes using freehand SPECT in breast cancer patients. Wideochir Inne Tech Maloinwazyjne. 2022;17:641\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5114/wiitm.2022.116406\u003c/span\u003e\u003cspan address=\"10.5114/wiitm.2022.116406\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSun S, Bai J, Wang X. Comparative observation of common tracers in sentinel lymph node biopsy of breast cancer and a study on simplifying its surgical procedure. Front Surg. 2023;10:1180919. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fsurg.2023.1180919\u003c/span\u003e\u003cspan address=\"10.3389/fsurg.2023.1180919\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan der Ploeg IM, Nieweg OE, van Rijk MC, Vald\u0026eacute;s Olmos RA, Kroon BB. Axillary recurrence after a tumour-negative sentinel node biopsy in breast cancer patients: A systematic review and meta-analysis of the literature. Eur J Surg Oncol. 2008;34:1277\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ejso.2008.01.034\u003c/span\u003e\u003cspan address=\"10.1016/j.ejso.2008.01.034\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGalimberti V, Ribeiro Fontana SK, Maisonneuve P, Steccanella F, Vento AR, Intra M, et al. Sentinel node biopsy after neoadjuvant treatment in breast cancer: Five-year follow-up of patients with clinically node-negative or node-positive disease before treatment. Eur J Surg Oncol. 2016;42:361\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ejso.2015.11.019\u003c/span\u003e\u003cspan address=\"10.1016/j.ejso.2015.11.019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWong SM, Basik M, Florianova L, Margolese R, Dumitra S, Muanza T, et al. Oncologic Safety of Sentinel Lymph Node Biopsy Alone After Neoadjuvant Chemotherapy for Breast Cancer. Ann Surg Oncol. 2021;28:2621\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1245/s10434-020-09211-0\u003c/span\u003e\u003cspan address=\"10.1245/s10434-020-09211-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"breast-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"brca","sideBox":"Learn more about [Breast Cancer](http://link.springer.com/journal/12282)","snPcode":"12282","submissionUrl":"https://www.editorialmanager.com/brca/default2.aspx","title":"Breast Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"breast cancer, indocyanine green fluorescence method, neoadjuvant chemotherapy, projection mapping, sentinel lymph node biopsy","lastPublishedDoi":"10.21203/rs.3.rs-5723931/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5723931/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe Medical Imaging Projection System (MIPS) projects fluorescence ICG images on the surgical field. In this study, we aimed to assess sentinel lymph node (SLN) identification by the MIPS in patients with and without neoadjuvant chemotherapy (NAC) administration and compare the utility of the MIPS with the radioisotope (RI) method.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe retrospectively reviewed medical records of patients with primary breast cancer who underwent SLN biopsy using the MIPS at Kyoto University Hospital between April 2020 and \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eDecember 2024\u003c/span\u003e. The primary endpoint was the identification rate of SLNs. \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSecondary endpoints included the number of positive SLNs and SLNs detected per patient.\u003c/span\u003e\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eThe analysis included 470 procedures (448 patients), of which 56 (11.9%) were conducted after NAC.\u003c/span\u003e The identification rate of SLNs by the MIPS was \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e99.6% (95% confidence interval [CI], 98.5\u0026ndash;99.9)\u003c/span\u003e in all procedures and \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e98.2% (95% CI, 90.6\u0026ndash;99.7)\u003c/span\u003e after NAC. The median number of SLNs identified per patient was 3 (range, 2\u0026ndash;4) by the MIPS and 2 \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(range, 1\u0026ndash;3)\u003c/span\u003e by the RI method (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No significant difference was observed in the number of SLNs between patients who received NAC and those who did not (3 vs 3, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eP=0.84\u003c/span\u003e). \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSeventy-eight\u003c/span\u003e positive SLNs were excised, all of which were accurately identified by the MIPS.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study suggested that the identification rate of SLNs by the MIPS was high regardless of the presence or absence of preceding systemic chemotherapy.\u003c/p\u003e","manuscriptTitle":"Detection capability of the Medical Imaging Projection System for sentinel lymph node biopsy in patients with breast cancer with and without neoadjuvant chemotherapy: A retrospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-24 18:31:50","doi":"10.21203/rs.3.rs-5723931/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accept","date":"2025-04-26T07:37:02+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2025-04-22T23:52:01+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-22T23:20:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-22T10:39:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"Breast Cancer","date":"2025-04-22T00:29:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"breast-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"brca","sideBox":"Learn more about [Breast Cancer](http://link.springer.com/journal/12282)","snPcode":"12282","submissionUrl":"https://www.editorialmanager.com/brca/default2.aspx","title":"Breast Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"304e887f-87bb-4577-b55e-fe6fcff2c1b9","owner":[],"postedDate":"April 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-12T15:58:01+00:00","versionOfRecord":{"articleIdentity":"rs-5723931","link":"https://doi.org/10.1007/s12282-025-01712-8","journal":{"identity":"breast-cancer","isVorOnly":false,"title":"Breast Cancer"},"publishedOn":"2025-05-10 15:56:51","publishedOnDateReadable":"May 10th, 2025"},"versionCreatedAt":"2025-04-24 18:31:50","video":"","vorDoi":"10.1007/s12282-025-01712-8","vorDoiUrl":"https://doi.org/10.1007/s12282-025-01712-8","workflowStages":[]},"version":"v1","identity":"rs-5723931","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5723931","identity":"rs-5723931","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}