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Techniques in Coloproctology
Published in: Techniques in Coloproctology 4/2018

01-04-2018 | Original Article

Feasibility of fluorescence lymph node imaging in colon cancer: FLICC

Authors: M. Chand, D. S. Keller, H. M. Joshi, L. Devoto, M. Rodriguez-Justo, R. Cohen

Published in: Techniques in Coloproctology | Issue 4/2018

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Abstract

Background

In colon cancer, appropriate tumour excision and associated lymphadenectomy directly impact recurrence and survival outcomes. Currently, there is no standard for mesenteric lymphadenectomy, with a lymph node yield of 12 acting as a surrogate quality marker. Our goal was to determine the safety and feasibility of indocyanine green (ICG) fluorescence imaging to demonstrate lymphatic drainage in colon cancer in a dose-escalation study.

Methods

A prospective pilot study of colon cancer patients undergoing curative laparoscopic resection was performed. At surgery, peritumoural subserosal ICG injection was done to demonstrate lymphatic drainage of the tumour. A specialized fluorescence system excited the ICG and assessed lymphatics in real time. The primary outcome was the feasibility of ICG fluorescent lymphangiography for lymphatic drainage in colon cancer. Secondary outcomes were the optimal protocol for dose, injection site, and ICG lymphatic mapping timing.

Results

Ten consecutive patients were evaluated (six males, mean age 69.5 years). In all, lymphatic channels were seen around the tumour to a varying extent. Eight (80%) had drainage to the sentinel node. In all cases where the lymphatic map was seen, there was no further spread 10 min after injection. In 2 patients (20%), additional lymph nodes located outside of the proposed resection margins were demonstrated. In both cases the resection was extended to include the nodes and in both patients these nodes were positive on histopathology. Factors contributing to reduced lymphatic visualization were inadequate ICG concentrations, excess India ink blocking drainage, and inflammation from tattoo placement.

Conclusions

ICG can be safely injected into the peritumoural subserosal and demonstrate lymphatic drainage in colon cancer. This proof of concept and proposed standards for the procedure can lead to future studies to optimize the application of image-guided precision surgery in colon cancer. Furthermore, this technique may be of value in indicating the need for more extended lymphadenectomy.
Literature
1.
2.
3.
Hohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S (2009) Standardized surgery for colonic cancer: complete mesocolic excision and central ligation–technical notes and outcome. Colorectal Dis 11:354–364 (discussion 364)CrossRefPubMed
4.
West NP, Hohenberger W, Weber K, Perrakis A, Finan PJ, Quirke P (2010) Complete mesocolic excision with central vascular ligation produces an oncologically superior specimen compared with standard surgery for carcinoma of the colon. J Clin Oncol 28:272–278CrossRefPubMed
5.
Zheng MH, Zhang S, Feng B (2016) Complete mesocolic excision: lessons from anatomy translating to better oncologic outcome. World J Gastrointest Oncol 8:235–239CrossRefPubMedPubMedCentral
6.
Bertelsen CA, Neuenschwander AU, Jansen JE et al (2016) Short-term outcomes after complete mesocolic excision compared with ‘conventional’ colonic cancer surgery. Br J Surg 103:581–589CrossRefPubMed
7.
Emmanuel A, Haji A (2016) Complete mesocolic excision and extended (D3) lymphadenectomy for colonic cancer: Is it worth that extra effort? A review of the literature. Int J Colorectal Dis 31:797–804CrossRefPubMed
8.
Bertelsen CA, Kirkegaard-Klitbo A, Nielsen M, Leotta SM, Daisuke F, Gögenur I (2016) Pattern of colon cancer lymph node metastases in patients undergoing central mesocolic lymph node excision: a systematic review. Dis Colon Rectum 59:1209–1221CrossRefPubMed
9.
10.
Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane JK (1998) Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978–1997. Arch Surg 133:894–899CrossRefPubMed
11.
Tuech JJ, Pessaux P, Regenet N, Bergamaschi R, Colson A (2004) Sentinel lymph node mapping in colon cancer. Surg Endosc 18:1721–1729CrossRefPubMed
12.
Keller DS, Joshi HM, Rodriguez-Justo M, Walsh D, Coffey JC, Chand M (2017) Using fluorescence lymphangiography to define the ileocolic mesentery: proof of concept for the watershed area using real-time imaging. Tech Coloproctol 21:757–760CrossRefPubMed
13.
Joshi HM, Keller DS, Chand M (2017) Utilization of Indocyanine green to demonstrate lymphatic mapping in colon cancer. J Surg Oncol 116:1005–1007CrossRefPubMed
14.
Keller DS, Ishizawa T, Cohen R, Chand M (2017) Indocyanine green fluorescence imaging in colorectal surgery: overview, applications, and future directions. Lancet Gastroenterol Hepatol 2:757–766CrossRefPubMed
15.
Ris F, Hompes R, Cunningham C, Lindsey I et al (2014) Near-infrared (NIR) perfusion angiography in minimally invasive colorectal surgery. Surg Endosc 28:2221–2226CrossRefPubMedPubMedCentral
16.
Cahill RA, Ris F, Mortensen NJ (2011) Near-infrared laparoscopy for real-time intra-operative arterial and lymphatic perfusion imaging. Colorectal Dis 13(Suppl 7):12–17CrossRefPubMed
17.
Jafari MD, Lee KH, Halabi WJ et al (2013) The use of indocyanine green fluorescence to assess anastomotic perfusion during robotic assisted laparoscopic rectal surgery. Surg Endosc 27:3003–3008CrossRefPubMed
18.
Jafari MD, Wexner SD, Martz JE et al (2015) Perfusion assessment in laparoscopic left-sided/anterior resection (PILLAR II): a multi-institutional study. J Am Coll Surg 220(82–92):e1
19.
Boni L, Fingerhut A, Marzorati A, Rausei S, Dionigi G, Cassinotti E (2017) Indocyanine green fluorescence angiography during laparoscopic low anterior resection: results of a case-matched study. Surg Endosc 31:1836–1840CrossRefPubMed
20.
Hojo T, Nagao T, Kikuyama M, Akashi S, Kinoshita T (2010) Evaluation of sentinel node biopsy by combined fluorescent and dye method and lymph flow for breast cancer. Breast 19:210–213CrossRefPubMed
21.
Wishart GC, Loh SW, Jones L, Benson JR (2012) A feasibility study (ICG-10) of indocyanine green (ICG) fluorescence mapping for sentinel lymph node detection in early breast cancer. Eur J Surg Oncol 38:651–656CrossRefPubMed
22.
Hirche C, Engel H, Hirche Z et al (2014) Real-time lymphography by indocyanine green fluorescence: improved navigation for regional lymph node staging. Ann Plast Surg 73:701–705CrossRefPubMed
23.
Bjurlin MA, Zhao LC, Kenigsberg AP, Mass AY, Taneja SS, Huang WC (2017) Novel use of fluorescence lymphangiography during robotic groin dissection for penile cancer. Urology 107:267CrossRefPubMed
24.
Verbeek FP, Tummers QR, Rietbergen DD et al (2015) Sentinel lymph node biopsy in vulvar cancer using combined radioactive and fluorescence guidance. Int J Gynecol Cancer 25:1086–1093CrossRefPubMedPubMedCentral
25.
Yuasa Y, Seike J, Yoshida T et al (2012) Sentinel lymph node biopsy using intraoperative indocyanine green fluorescence imaging navigated with preoperative CT lymphography for superficial esophageal cancer. Ann Surg Oncol 19:486–493CrossRefPubMed
26.
Kusano M, Tajima Y, Yamazaki K, Kato M, Watanabe M, Miwa M (2008) Sentinel node mapping guided by indocyanine green fluorescence imaging: a new method for sentinel node navigation surgery in gastrointestinal cancer. Dig Surg 25:103–108CrossRefPubMed
27.
KleinJan GH, Karakullukçu B, Klop WMC, Engelen T, van den Berg NS, van Leeuwen FWB (2017) Introducing navigation during melanoma-related sentinel lymph node procedures in the head-and-neck region. EJNMMI Res 7:65CrossRefPubMedPubMedCentral
28.
Hirche C, Mohr Z, Kneif S et al (2012) Ultrastaging of colon cancer by sentinel node biopsy using fluorescence navigation with indocyanine green. Int J Colorectal Dis 27:319–324CrossRefPubMed
29.
van der Pas MH, Ankersmit M, Stockmann HB et al (2013) Laparoscopic sentinel lymph node identification in patients with colon carcinoma using a near-infrared dye: description of a new technique and feasibility study. J Laparoendosc Adv Surg Tech A 23:367–371CrossRefPubMed
30.
Nishigori N, Koyama F, Nakagawa T et al (2016) Visualization of lymph/blood flow in laparoscopic colorectal cancer surgery by ICG fluorescence imaging (Lap-IGFI). Ann Surg Oncol 23(Suppl 2):S266–S274CrossRefPubMed
31.
Marano A, Priora F, Lenti LM, Ravazzoni F, Quarati R, Spinoglio G (2013) Application of fluorescence in robotic general surgery: review of the literature and state of the art. World J Surg 37:2800–2811CrossRefPubMed
32.
Emile SH, Elfeki H, Shalaby M et al (2017) Sensitivity and specificity of indocyanine green near-infrared fluorescence imaging in detection of metastatic lymph nodes in colorectal cancer: Systematic review and meta-analysis. J Surg Oncol 116:730–740CrossRefPubMed
33.
Watanabe J, Ota M, Suwa Y, Ishibe A, Masui H, Nagahori K (2016) Real-time indocyanine green fluorescence imaging-guided complete mesocolic excision in laparoscopic flexural colon cancer surgery. Dis Colon Rectum 59:701–705CrossRefPubMed
34.
Cahill RA, Anderson M, Wang LM, Lindsey I, Cunningham C, Mortensen NJ (2012) Near-infrared (NIR) laparoscopy for intraoperative lymphatic road-mapping and sentinel node identification during definitive surgical resection of early-stage colorectal neoplasia. Surg Endosc 26:197–204CrossRefPubMed
35.
Boni L, David G, Mangano A et al (2015) Clinical applications of indocyanine green (ICG) enhanced fluorescence in laparoscopic surgery. Surg Endosc 29:2046–2055CrossRefPubMed
36.
Handgraaf HJ, Boogerd LS, Verbeek FP et al (2016) Intraoperative fluorescence imaging to localize tumors and sentinel lymph nodes in rectal cancer. Minim Invasive Ther Allied Technol 25:48–53CrossRefPubMed
37.
Kazanowski M, Al Furajii H, Cahill RA (2015) Near-infrared laparoscopic fluorescence for pelvic side wall delta mapping in patients with rectal cancer–’PINPOINT’ nodal assessment. Colorectal Dis 17(Suppl 3):32–35CrossRefPubMed
38.
Liberale G, Vankerckhove S, Galdon MG, Donckier V, Larsimont D, Bourgeois P (2015) Fluorescence imaging after intraoperative intravenous injection of indocyanine green for detection of lymph node metastases in colorectal cancer. Eur J Surg Oncol 41:1256–1260CrossRefPubMed
39.
Liberale G, Galdon MG, Moreau M et al (2016) Ex vivo detection of tumoral lymph nodes of colorectal origin with fluorescence imaging after intraoperative intravenous injection of indocyanine green. J Surg Oncol 114:348–353CrossRefPubMed
40.
Liberale G, Vankerckhove S, Caldon MG et al (2016) Fluorescence imaging after indocyanine green injection for detection of peritoneal metastases in patients undergoing cytoreductive surgery for peritoneal carcinomatosis from colorectal cancer: a pilot study. Ann Surg 264:1110–1115CrossRefPubMed
41.
Nagata J, Fukunaga Y, Akiyoshi T et al (2016) Colonic marking with near-infrared, light-emitting, diode-activated indocyanine green for laparoscopic colorectal surgery. Dis Colon Rectum 59:e14–e18CrossRefPubMed
42.
Watanabe M, Murakami M, Ozawa Y, Yoshizawa S, Matsui N, Aoki T (2017) Intraoperative identification of colonic tumor sites using a near-infrared fluorescence endoscopic imaging system and indocyanine green. Dig Surg 34:495–501CrossRefPubMed
Metadata
Title
Feasibility of fluorescence lymph node imaging in colon cancer: FLICC
Authors
M. Chand
D. S. Keller
H. M. Joshi
L. Devoto
M. Rodriguez-Justo
R. Cohen
Publication date
01-04-2018
Publisher
Springer International Publishing
Published in
Techniques in Coloproctology / Issue 4/2018
Print ISSN: 1123-6337
Electronic ISSN: 1128-045X
DOI
https://doi.org/10.1007/s10151-018-1773-6

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