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Sikkenk DJ, Sterkenburg AJ, Burghgraef TA, Akol H, Schwartz MP, Arensman R, Verheijen PM, Nagengast WB, Consten ECJ. Robot-assisted fluorescent sentinel lymph node identification in early-stage colon cancer. Surg Endosc 2023; 37:8394-8403. [PMID: 37721591 PMCID: PMC10615938 DOI: 10.1007/s00464-023-10394-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/13/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Patients with cT1-2 colon cancer (CC) have a 10-20% risk of lymph node metastases. Sentinel lymph node identification (SLNi) could improve staging and reduce morbidity in future organ-preserving CC surgery. This pilot study aimed to assess safety and feasibility of robot-assisted fluorescence-guided SLNi using submucosally injected indocyanine green (ICG) in patients with cT1-2N0M0 CC. METHODS Ten consecutive patients with cT1-2N0M0 CC were included in this prospective feasibility study. Intraoperative submucosal, peritumoral injection of ICG was performed during a colonoscopy. Subsequently, the near-infrared fluorescence 'Firefly' mode of the da Vinci Xi robotic surgical system was used for SLNi. SLNs were marked with a suture, after which a segmental colectomy was performed. The SLN was postoperatively ultrastaged using serial slicing and immunohistochemistry, in addition to the standard pathological examination of the specimen. Colonoscopy time, detection time (time from ICG injection to first SLNi), and total SLNi time were measured (time from the start of colonoscopy to start of segmental resection). Intraoperative, postoperative, and pathological outcomes were registered. RESULTS In all patients, at least one SLN was identified (mean 2.3 SLNs, SLN diameter range 1-13 mm). No tracer-related adverse events were noted. Median colonoscopy time was 12 min, detection time was 6 min, and total SLNi time was 30.5 min. Two patients had lymph node metastases present in the SLN, and there were no patients with false negative SLNs. No patient was upstaged due to ultrastaging of the SLN after an initial negative standard pathological examination. Half of the patients unexpectedly had pT3 tumours. CONCLUSIONS Robot-assisted fluorescence-guided SLNi using submucosally injected ICG in ten patients with cT1-2N0M0 CC was safe and feasible. SLNi was performed in an acceptable timespan and SLNs down to 1 mm were detected. All lymph node metastases would have been detected if SLN biopsy had been performed.
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Affiliation(s)
- Daan J Sikkenk
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - Andrea J Sterkenburg
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Thijs A Burghgraef
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - Halil Akol
- Department of Gastroenterology, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - René Arensman
- Department of Pathology, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - Paul M Verheijen
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Esther C J Consten
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands.
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Crafa F, Vanella S, Catalano OA, Pomykala KL, Baiamonte M. Role of one-step nucleic acid amplification in colorectal cancer lymph node metastases detection. World J Gastroenterol 2022; 28:4019-4043. [PMID: 36157105 PMCID: PMC9403438 DOI: 10.3748/wjg.v28.i30.4019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 06/03/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023] Open
Abstract
Current histopathological staging procedures in colorectal cancer (CRC) depend on midline division of the lymph nodes (LNs) with one section of hematoxylin and eosin staining. Cancer cells outside this transection line may be missed, which could lead to understaging of Union for International Cancer Control Stage II high-risk patients. The one-step nucleic acid amplification (OSNA) assay has emerged as a rapid molecular diagnostic tool for LN metastases detection. It is a molecular technique that can analyze the entire LN tissue using a reverse-transcriptase loop-mediated isothermal amplification reaction to detect tumor-specific cytokeratin 19 mRNA. Our findings suggest that the OSNA assay has a high diagnostic accuracy in detecting metastatic LNs in CRC and a high negative predictive value. OSNA is a standardized, observer-independent technique, which may lead to more accurate staging. It has been suggested that in stage II CRC, the upstaging can reach 25% and these patients can access postoperative adjuvant chemotherapy. Moreover, intraoperative OSNA sentinel node evaluation may allow early CRC to be treated with organ-preserving surgery, while in more advanced-stage disease, a tailored lymphadenectomy can be performed considering the presence of aberrant lymphatic drainage and skip metastases.
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Affiliation(s)
- Francesco Crafa
- Division of General and Surgical Oncology, St. Giuseppe Moscati Hospital, Center of National Excellence and High Specialty, Avellino 83100, Italy
| | - Serafino Vanella
- Division of General and Surgical Oncology, St. Giuseppe Moscati Hospital, Center of National Excellence and High Specialty, Avellino 83100, Italy
| | - Onofrio A Catalano
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Kelsey L Pomykala
- Department of Nuclear Medicine, Department of Radiological Sciences, David Geffen School of Medicine at University of California, Los Angeles, University Hospital Essen, University of Duisburg-Essen, Essen 45141, Germany
| | - Mario Baiamonte
- Division of General and Surgical Oncology, St. Giuseppe Moscati Hospital, Center of National Excellence and High Specialty, Avellino 83100, Italy
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Galema HA, Meijer RPJ, Lauwerends LJ, Verhoef C, Burggraaf J, Vahrmeijer AL, Hutteman M, Keereweer S, Hilling DE. Fluorescence-guided surgery in colorectal cancer; A review on clinical results and future perspectives. Eur J Surg Oncol 2021; 48:810-821. [PMID: 34657780 DOI: 10.1016/j.ejso.2021.10.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/07/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Colorectal cancer is the fourth most diagnosed malignancy worldwide and surgery is one of the cornerstones of the treatment strategy. Near-infrared (NIR) fluorescence imaging is a new and upcoming technique, which uses an NIR fluorescent agent combined with a specialised camera that can detect light in the NIR range. It aims for more precise surgery with improved oncological outcomes and a reduction in complications by improving discrimination between different structures. METHODS A systematic search was conducted in the Embase, Medline and Cochrane databases with search terms corresponding to 'fluorescence-guided surgery', 'colorectal surgery', and 'colorectal cancer' to identify all relevant trials. RESULTS The following clinical applications of fluorescence guided surgery for colorectal cancer were identified and discussed: (1) tumour imaging, (2) sentinel lymph node imaging, (3) imaging of distant metastases, (4) imaging of vital structures, (5) imaging of perfusion. Both experimental and FDA/EMA approved fluorescent agents are debated. Furthermore, promising future modalities are discussed. CONCLUSION Fluorescence-guided surgery for colorectal cancer is a rapidly evolving field. The first studies show additional value of this technique regarding change in surgical management. Future trials should focus on patient related outcomes such as complication rates, disease free survival, and overall survival.
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Affiliation(s)
- Hidde A Galema
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015, GD, Rotterdam, the Netherlands; Department of Otorhinolaryngology, Head and Neck Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015, GD, Rotterdam, the Netherlands
| | - Ruben P J Meijer
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, the Netherlands; Centre for Human Drug Research, Zernikedreef 8, 2333, CL, Leiden, the Netherlands
| | - Lorraine J Lauwerends
- Department of Otorhinolaryngology, Head and Neck Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015, GD, Rotterdam, the Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015, GD, Rotterdam, the Netherlands
| | - Jacobus Burggraaf
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, the Netherlands; Centre for Human Drug Research, Zernikedreef 8, 2333, CL, Leiden, the Netherlands
| | - Alexander L Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, the Netherlands
| | - Merlijn Hutteman
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, the Netherlands
| | - Stijn Keereweer
- Department of Otorhinolaryngology, Head and Neck Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015, GD, Rotterdam, the Netherlands
| | - Denise E Hilling
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015, GD, Rotterdam, the Netherlands; Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, the Netherlands.
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Picchetto A, Diana M, Swanström LL, Magliocca FM, Pronio A, Choppin E, Rocca SL, Marescaux J, D'Ambrosio G. Upstaging nodal status in colorectal cancer using ex vivo fluorescence sentinel lymph node mapping: preliminary results. MINIM INVASIV THER 2020; 31:223-229. [PMID: 32734804 DOI: 10.1080/13645706.2020.1798464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Sentinel lymph node (SLN) mapping using near-infrared fluorescence (NIRF) imaging is a recent technique to improve nodal staging in several tumors. The presence of colorectal cancer (CRC) micro-metastases has recently been defined as N1 disease and no longer as N1mi, determining the need for adjuvant chemotherapy. In CRC, the reported rate of SLN micro-metastases detected by ultrastaging techniques is as high as 30%. The aim of this prospective study is to report the preliminary results of the sensitivity analysis of NIRF imaging for ex vivo SLN mapping and the research of micro-metastases in CRC, in patients with node-negative disease (NND). MATERIAL AND METHODS On the specimen of 22 CRC patients, 1 mL of ICG (5 mg/mL) was injected submucosally around the tumor to identify SLNs. NND SLNs were further investigated with ultrastaging techniques. RESULTS Three-hundred and sixty-three lymph nodes were retrieved (59 SLNs; mean per case: 2.7). The detection, sensitivity and false-negative rate were 100%, 100% and 0% respectively. Ultrastaging investigations showed no micro-metastases in the NND SLNs. CONCLUSIONS The ex vivo SLN fluorescence-based detection in CRC was confirmed to be easy to perform and reliable. In this preliminary results report of an ongoing study, the SLN assay was congruent with the nodal status, as confirmed by histological investigations.
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Affiliation(s)
- Andrea Picchetto
- General and Colorectal Surgery Division, Department of Cardiothoracic, Vascular Surgery and Organ Transplantation, Policlinico Umberto I University Hospital, Sapienza University of Rome, Rome, Italy
| | - Michele Diana
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,IRCAD, Research Institute against Cancer of the Digestive System, Strasbourg, France
| | - Lee L Swanström
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
| | - Fabio Massimo Magliocca
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Policlinico Umberto I University Hospital, Rome, Italy
| | - Annamaria Pronio
- General and Colorectal Surgery Division, Department of Cardiothoracic, Vascular Surgery and Organ Transplantation, Policlinico Umberto I University Hospital, Sapienza University of Rome, Rome, Italy
| | - Eleonore Choppin
- General and Colorectal Surgery Division, Department of Cardiothoracic, Vascular Surgery and Organ Transplantation, Policlinico Umberto I University Hospital, Sapienza University of Rome, Rome, Italy
| | - Stefania La Rocca
- General and Colorectal Surgery Division, Department of Cardiothoracic, Vascular Surgery and Organ Transplantation, Policlinico Umberto I University Hospital, Sapienza University of Rome, Rome, Italy
| | - Jacques Marescaux
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,IRCAD, Research Institute against Cancer of the Digestive System, Strasbourg, France
| | - Giancarlo D'Ambrosio
- General and Colorectal Surgery Division, Department of Cardiothoracic, Vascular Surgery and Organ Transplantation, Policlinico Umberto I University Hospital, Sapienza University of Rome, Rome, Italy
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Ankersmit M, Bonjer HJ, Hannink G, Schoonmade LJ, van der Pas MHGM, Meijerink WJHJ. Near-infrared fluorescence imaging for sentinel lymph node identification in colon cancer: a prospective single-center study and systematic review with meta-analysis. Tech Coloproctol 2019; 23:1113-1126. [PMID: 31741099 PMCID: PMC6890578 DOI: 10.1007/s10151-019-02107-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 10/26/2019] [Indexed: 12/12/2022]
Abstract
Background Near-infrared (NIR) fluorescence imaging has the potential to overcome the current drawbacks of sentinel lymph node mapping (SLNM) in colon cancer. Our aim was to provide an overview of current SLNM performance and of factors influencing successful sentinel lymph node (SLN) identification using NIR fluorescence imaging in colon cancer. Methods A systematic review and meta-analysis was conducted to identify currently used methods and results. Additionally, we performed a single-center study using indocyanine green (ICG) as SLNM dye in colon cancer patients scheduled for a laparoscopic colectomy. SLNs were analyzed with conventional hematoxylin-and-eosin staining and additionally with serial sectioning and immunohistochemistry (extended histopathological assessment). A true-positive procedure was defined as a tumor-positive SLN either by conventional hematoxylin-and-eosin staining or by extended histopathological assessment, independently of regional lymph node status. SLN procedures were determined to be true negatives if SLNs and regional lymph nodes revealed no metastases after conventional and advanced histopathology. SLN procedures yielding tumor-negative SLNs in combination with tumor-positive regional lymph nodes were classified as false negatives. Sensitivity, negative predictive value and detection rate were calculated. Results This systematic review and meta-analysis included 8 studies describing 227 SLN procedures. A pooled sensitivity of 0.63 (95% CI 0.51–0.74), negative predictive value 0.81 (95% CI 0.73–0.86) and detection rate of 0.94 (95% CI 0.85–0.97) were found. Upstaging as a result of extended histopathological assessment was 0.15 (95% CI 0.07–0.25). In our single-center study, we included 30 patients. Five false-negative SLNs were identified, resulting in a sensitivity of 44% and negative predictive value of 80%, with a detection rate of 89.7%. Eight patients had lymph node metastases, in three cases detected after extended pathological assessment, resulting in an upstaging of 13% (3 of 23 patients with negative nodes by conventional hematoxylin and eosin staining). Conclusions Several anatomical and technical difficulties make SLNM with NIR fluorescence imaging in colon cancer particularly challenging when compared to other types of cancer. As a consequence, reports of SLNM accuracy vary widely. Future studies should try to standardize the SLNM procedure and focus on early-stage colon tumors, validation of tracer composition, injection mode and improvement of real-time optical guidance. Electronic supplementary material The online version of this article (10.1007/s10151-019-02107-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M Ankersmit
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC-Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands.
| | - H J Bonjer
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC-Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - G Hannink
- Department of Operating Rooms and MITeC Technology Center, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L J Schoonmade
- Medical Library, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - W J H J Meijerink
- Department of Operating Rooms and MITeC Technology Center, Radboud University Medical Center, Nijmegen, The Netherlands
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Esposito F, Noviello A, Moles N, Coppola Bottazzi E, Baiamonte M, Macaione I, Ferbo U, Lepore M, Miro A, Crafa F. Sentinel Lymph Node Analysis in Colorectal Cancer Patients Using One-Step Nucleic Acid Amplification in Combination With Fluorescence and Indocyanine Green. Ann Coloproctol 2019; 35:174-180. [PMID: 31487764 PMCID: PMC6732328 DOI: 10.3393/ac.2018.07.21.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 07/21/2018] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Analysis of the sentinel lymph node (SLN) in colorectal cancer (CRC) patients was proposed for more accurate staging and tailored lymphadenectomy. The aim of this study was to assess the ability to predict lymph node (LN) involvement through analysis of the SLN with a one-step nucleic acid (OSNA) technique in combination with peritumoral injection of indocyanine green (ICG) and near-infrared (NIR) lymphangiography in CRC patients. METHODS A total of 34 patients were enrolled. Overall, 51 LNs were analyzed with OSNA. LNs of 17 patients (50%) were examined simultaneously with hematoxylin and eosin (H&E) and OSNA. RESULTS SLN analysis of 17 patients examined with H&E and OSNA revealed that OSNA had a higher sensitivity (1 vs. 0.55), higher negative predictive value (1 vs. 0.66) and higher accuracy (100% vs. 76.4%) in predicting LN involvement. Overall, OSNA showed a sensitivity of 0.69, specificity of 1, accuracy of 88.2%, and stage migration of 8.8%. Compared to those who were OSNA (-), OSNA (+) patients had a greater number of LN metastases (4.8 vs. 0.16, P = 0.04), higher G3 rate (44.4% vs. 4%, P = 0.01), more advanced stage of disease (stage III: 77.8% vs. 16%; P = 0.00) and were more rapidly subjected to adjuvant chemotherapy (39.1 days vs. 50.2 days, P = 0.01). CONCLUSION SLN analysis with OSNA in combination with ICG-NIR lymphangiography is feasible and can detect LN involvement in CRC patients. Furthermore, it allows for more accurate staging reducing the delay between surgery and adjuvant chemotherapy.
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Affiliation(s)
- Francesco Esposito
- Oncological and General Surgery Unit, St. Giuseppe Moscati Hospital of National Relevance and High Specialty, Avellino, Italy
| | - Adele Noviello
- Oncological and General Surgery Unit, St. Giuseppe Moscati Hospital of National Relevance and High Specialty, Avellino, Italy
| | - Nicola Moles
- Oncological and General Surgery Unit, St. Giuseppe Moscati Hospital of National Relevance and High Specialty, Avellino, Italy
| | - Enrico Coppola Bottazzi
- Oncological and General Surgery Unit, St. Giuseppe Moscati Hospital of National Relevance and High Specialty, Avellino, Italy
| | - Mario Baiamonte
- General and Emergency Surgery Unit, Civico Benfratelli Di Cristina Hospital, Palermo, Italy
| | - Ina Macaione
- Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Palermo, Italy
| | - Umberto Ferbo
- Institute of Pathology, St. Giuseppe Moscati Hospital of National Relevance and High Specialty, Avellino, Italy
| | - Maria Lepore
- Institute of Pathology, St. Giuseppe Moscati Hospital of National Relevance and High Specialty, Avellino, Italy
| | - Antonio Miro
- Oncological and General Surgery Unit, St. Giuseppe Moscati Hospital of National Relevance and High Specialty, Avellino, Italy
| | - Francesco Crafa
- Oncological and General Surgery Unit, St. Giuseppe Moscati Hospital of National Relevance and High Specialty, Avellino, Italy
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Ankersmit M, Hoekstra OS, van Lingen A, Bloemena E, Jacobs MAJM, Vugts DJ, Bonjer HJ, van Dongen GAMS, Meijerink WJHJ. Perioperative PET/CT lymphoscintigraphy and fluorescent real-time imaging for sentinel lymph node mapping in early staged colon cancer. Eur J Nucl Med Mol Imaging 2019; 46:1495-1505. [PMID: 30798428 PMCID: PMC6533411 DOI: 10.1007/s00259-019-04284-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 02/04/2019] [Indexed: 01/22/2023]
Abstract
Purpose Using current optical imaging techniques and gamma imaging modalities, perioperative sentinel lymph node (SLN) identification in colon cancer can be difficult when the SLN is located near the primary tumour or beneath a thick layer of (fat) tissue. Sentinel lymph node mapping using PET/CT lymphoscintigraphy combined with real-time visualization of the SLN using near-infrared imaging has shown promising results in several types of cancer and may facilitate the successful identification of the number and location of the SLN in early colon cancer. Methods Clinical feasibility of PET/CT lymphoscintigraphy using preoperative endoscopically injected [89Zr]Zr-Nanocoll and intraoperative injection of the near-infrared (NIR) tracer Indocyanine Green (ICG) was evaluated in ten early colon cancer patients. Three preoperative PET/CT scans and an additional ex vivo scan of the specimen were performed after submucosal injection of [89Zr]Zr-Nanocoll. All SLNs and other lymph nodes underwent extensive pathological examination for metastases. A histopathological proven lymph node visible at preoperative PET/CT and identified at PET/CT of the specimen was defined as SLN. Results A total of 27 SLNs were harvested in seven out of eight patients with successful injection of both tracers. In one patient no SLNs were assigned preoperatively. In two patients injection of [89Zr]Zr-Nanocoll failed due to incorrect needle positioning. Twenty-one (78%) SLNs were found intraoperatively using NIR-imaging. Eleven of the 27 (41%) SLNs were located near the primary tumour (< 2 cm). Those six SLNs not found intraoperatively with NIR-imaging were all located close to the tumour. In all seven patients at least one SLN could be assigned at preoperative imaging 24 h after tracer administration. One SLN contained metastases detected by immunohistochemistry. No metastases were found in the non-SLNs. Conclusions This study shows the potential of preoperative PET/CT lymphoscintigraphy to inform the surgeon about the number and location of SLNs in patients with early colon cancer. The additional use of NIR-imaging allows for intraoperative identification of these SLNs which are invisible with conventional white light imaging. Further research is necessary to improve and simplify the technique. We recommend perioperative SLN identification using a preoperative lymphoscintigraphy scan just before surgery approximately 24 h after injection. Additionally a postoperative scan of the specimen combined with intraoperative real-time NIR-imaging should be performed. Electronic supplementary material The online version of this article (10.1007/s00259-019-04284-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M Ankersmit
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, The Netherlands.
| | - O S Hoekstra
- Department of Radiology & Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - A van Lingen
- Department of Radiology & Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - E Bloemena
- Department of Pathology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M A J M Jacobs
- Department of Gastroenterology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - D J Vugts
- Department of Radiology & Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - H J Bonjer
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, The Netherlands
| | - G A M S van Dongen
- Department of Radiology & Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - W J H J Meijerink
- Department of Operation Rooms and MITeC Technology Center, Radboud University Medical Centre, Nijmegen, The Netherlands
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8
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Currie A. Intraoperative Sentinel Node Mapping in the Colon: Potential and Pitfalls. Eur Surg Res 2019; 60:45-52. [DOI: 10.1159/000494833] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 10/25/2018] [Indexed: 11/19/2022]
Abstract
Sentinel lymph node mapping (SLNM) may play a significant role in future delivery of colon cancer surgery because of an increase in early-stage, node-negative disease due to national bowel cancer screening programmes. Traditionally, colon lymphatic drainage has not been thought relevant as the operative approach cannot be tailored. Recent advances in local and endoscopic risk-reducing interventions for colonic malignancy have caused a rethink in approach. SLNM was initially attempted with blue dye techniques with limited success. Technological improvement has allowed surgeons to use near-infrared (NIR) light and NIR active tracers such as indocyanine green. This review provides an overview of the current status of intraoperative lymph node mapping in the colon, identifies challenges to the delivery of the techniques, and discusses potential solutions that may help SLNM play a role in improving the delivery of surgical care for patients with colon cancer.
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Currie AC, Brigic A, Thomas-Gibson S, Suzuki N, Moorghen M, Jenkins JT, Faiz OD, Kennedy RH. A pilot study to assess near infrared laparoscopy with indocyanine green (ICG) for intraoperative sentinel lymph node mapping in early colon cancer. Eur J Surg Oncol 2017; 43:2044-2051. [PMID: 28919031 DOI: 10.1016/j.ejso.2017.05.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 04/17/2017] [Accepted: 05/11/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Previous attempts at sentinel lymph node (SLN) mapping in colon cancer have been compromised by ineffective tracers and the inclusion of advanced disease. This study evaluated the feasibility of fluorescence detection of SLNs with indocyanine green (ICG) for lymphatic mapping in T1/T2 clinically staged colonic malignancy. METHODS Consecutive patients with clinical T1/T2 stage colon cancer underwent endoscopic peritumoral submucosal injection of indocyanine green (ICG) for fluorescence detection of SLN using a near-infrared (NIR) camera. All patients underwent laparoscopic complete mesocolic excision surgery. Detection rate and sensitivity of the NIR-ICG technique were the study endpoints. RESULTS Thirty patients mean age = 68 years [range = 38-80], mean BMI = 26.2 (IQR = 24.7-28.6) were studied. Mesocolic sentinel nodes (median = 3/patient) were detected by fluorescence within the standard resection field in 27/30 patients. Overall, ten patients had lymph node metastases, with one of these patients having a failed SLN procedure. Of the 27 patients with completed SLN mapping, nine patients had histologically positive lymph nodes containing malignancy. 3/9 had positive SLNs with 6 false negatives. In five of these false negative patients, tumours were larger than 35 mm with four also being T3/T4. CONCLUSION ICG mapping with NIR fluorescence allowed mesenteric detection of SLNs in clinical T1/T2 stage colonic cancer. CLINICALTRIALS.GOV: ID: NCT01662752.
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Affiliation(s)
- A C Currie
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK.
| | - A Brigic
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK.
| | - S Thomas-Gibson
- Wolfson Department of Endoscopy, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK; Department of Surgery and Cancer, Imperial College London, London, UK.
| | - N Suzuki
- Wolfson Department of Endoscopy, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK; Department of Surgery and Cancer, Imperial College London, London, UK.
| | - M Moorghen
- Department of Pathology, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK.
| | - J T Jenkins
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK; Department of Surgery and Cancer, Imperial College London, London, UK.
| | - O D Faiz
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK; Department of Surgery and Cancer, Imperial College London, London, UK.
| | - R H Kennedy
- Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK; Department of Surgery and Cancer, Imperial College London, London, UK.
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10
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Pedrazzani C, Lauka L, Sforza S, Ruzzenente A, Nifosì F, Delaini G, Guglielmi A. Management of nodal disease from colon cancer in the laparoscopic era. Int J Colorectal Dis 2015; 30:303-14. [PMID: 25416529 DOI: 10.1007/s00384-014-2075-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2014] [Indexed: 02/06/2023]
Abstract
PURPOSE In colon cancer (CC), nodal involvement is the main prognostic factor following potentially curative (R0) resection. The purpose of this study was to examine data from the literature to provide an up-to-date analysis of the management of nodal disease with special reference to laparoscopic treatment. METHODS MEDLINE and EMBASE databases were searched for potentially eligible studies published in English up to July 15, 2014. RESULTS In CC, nodal involvement is a frequent event and represents the main risk of cancer recurrence. Node negative patients recur in 10-30 % of cases most likely due to underdiagnosed or undertreated nodal disease. Extended colonic resections (complete mesocolic excision with central vascular ligation; D3 lymphadenectomy) provides a survival benefit and better local control. Sentinel lymph node mapping in addition to standard surgical resection represents an option for improving staging of clinical node negative patients. Both extended resection and sentinel lymph node mapping are feasible in a laparoscopic setting. CONCLUSIONS Both extended colonic resection and sentinel lymph node mapping should play a role in the laparoscopic treatment of CC with the purpose of improving control and staging of nodal disease.
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Affiliation(s)
- Corrado Pedrazzani
- Department of Surgery, Chirurgia Generale e Epatobiliare, G.B. Rossi University Hospital, University of Verona, Verona, Italy,
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11
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Tiernan JP, Ansari I, Hirst NA, Millner PA, Hughes TA, Jayne DG. Intra-operative tumour detection and staging in colorectal cancer surgery. Colorectal Dis 2012; 14:e510-20. [PMID: 22564278 DOI: 10.1111/j.1463-1318.2012.03078.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM Surgical resection for colorectal cancer involves segmental resection and regional lymphadenectomy. The appropriateness of this 'one-size-fits-all' strategy is questioned as bowel cancer screening programmes result in a shift to earlier stage disease. Currently, the nodal status of a colorectal cancer can only be reliably determined by histopathological examination of the resected specimen. New methods of intra-operative staging are required to allow surgical resection to be tailored to the stage of the disease. METHOD A literature search was performed of PubMed and Embase databases using the terms 'colon' OR 'colorectal' AND 'intra-operative detection' OR 'intra-operative staging' OR 'intra-operative detection' OR 'radioimmunoguided surgery'. Articles published between January 1980 and January 2012 were included. Technologies that have the potential to allow intra-operative staging and treatment stratification were identified and further searches performed. RESULTS Established techniques such as sentinel lymph node mapping and radioimmunoguided surgery have benefited from combination with other technologies to allow real-time intra-operative staging. Intra-operative fluorescence, using naturally fluorescent biomarkers or fluorescent tumour probes, probably offers the most practical means of intra-operative lymph node staging and may be facilitated using nanotechnology. Optical coherence tomography and real-time elastography have the potential to provide an in vivo'virtual biopsy'. CONCLUSION Technological advances may allow accurate intra-operative lymph node staging to facilitate tailored surgical resection. This may become the next paradigm shift in colorectal cancer surgery.
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Affiliation(s)
- J P Tiernan
- Section of Translational Anaesthetic and Surgical Sciences, Leeds Institute of Molecular Medicine, St James's University Hospital, Leeds, UK.
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12
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Kato S, Kawamura J, Kawada K, Hasegawa S, Sakai Y. Fluorescence diagnosis of metastatic lymph nodes using 5-aminolevulinic acid (5-ALA) in a mouse model of colon cancer. J Surg Res 2011; 176:430-6. [PMID: 22221602 DOI: 10.1016/j.jss.2011.10.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 09/12/2011] [Accepted: 10/24/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND Lymph node metastasis is one of the most critical prognostic factors in patients with colorectal cancer. Although regional lymph nodes should be surgically resected and pathologically examined, techniques for the intraoperative diagnosis of lymph node metastasis remain to be well established. Fluorescence diagnosis using 5-aminolevulinic acid (5-ALA) is a promising technique for evaluating various malignancies. After exogenous administration of 5-ALA, protoporphyrin IX (PPIX) accumulates in malignant cells and can be detected as red fluorescence. In this study, we investigated the usefulness of fluorescence diagnosis using 5-ALA for the detection of lymph node metastasis in a mouse model of colon cancer. MATERIALS AND METHODS An orthotopic colon cancer model was prepared by inoculating the cecal wall of nude mice with HCA7, a human colon adenocarcinoma cell line. After 3 wk, 40 mg/kg of 5-ALA was administered intraperitoneally (IP) or orally (PO). Fluorescence diagnosis with a D-Light System (Karl Storz) was then performed after 3 or 6 h. RESULTS In the IP group, PPIX fluorescence was detected in metastatic lymph nodes as well as in other malignant lesions, including primary tumors and abdominal implantations, while non-metastatic nodes were fluorescence-negative. In contrast, no obvious fluorescence was detected in cancerous tissues in the PO group. CONCLUSIONS PPIX fluorescence induced by intraperitoneal injection of 5-ALA allows metastatic lymph nodes to be accurately diagnosed in this mouse model. This technique may facilitate the intraoperative diagnosis of lymph node metastases from colon cancer in a clinical setting.
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Affiliation(s)
- Shigeru Kato
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
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13
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Brigic A, Fraser C, Sibbons P, Cahill RA, Kennedy RH. Individualization of surgical management for early-stage colonic cancer. Colorectal Dis 2011; 13 Suppl 7:59-62. [PMID: 22098521 DOI: 10.1111/j.1463-1318.2011.02784.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A significant number of patients each year undergo radical segmental colectomy for node-negative colonic cancer in the UK. They are likely to represent 50% of our colonic cancer population in the future due to the implementation of the National Bowel Cancer Screening Programme. Short-term morbidity rates of up to 40% are associated with the current surgical treatment and need serious consideration. In this article, we discuss a combination of two techniques that will allow minimally invasive treatment in an increasing number of patients with early colonic cancer.
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Affiliation(s)
- A Brigic
- Department of Surgery, St Mark's Hospital, Harrow, UK
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14
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Abstract
PURPOSE OF REVIEW Colorectal cancer screening and prevention is a pivotal element in every gastroenterologist practice. Recent advances in imaging technology and treatment opened the field for endoscopic management of large flat colorectal polyps and early cancer. RECENT FINDINGS High-definition white light colonoscopy allowed for better characterization of colon polyps, particularly flat lesions. Chromoendoscopy facilitated the identification of colon polyps as well as better endoscopic polyp characterization, with strong correlation with final pathological diagnosis, opening the field of 'virtual' biopsy. One particular technology, confocal endomicroscopy can magnify an image approximately 1000 times resembling optical microscopy with very good correlation with histology. Endoscopic mucosal resection has gained great acceptance to manage flat colorectal polyps with the two major complications being bleeding and perforation, both now under 5% in experienced hands. Endoscopic submucosal resection was developed to increase en-bloc resection (less residual disease) of a flat colorectal lesion but one has to accept a higher perforation rate around 10%. SUMMARY Current technology allows for better polyp identification and characterization, which can be managed endoscopically.
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15
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Cahill RA, Mortensen NJ. Natural orifice transluminal endoscopic surgery and localized resection for colorectal neoplasia. World J Gastrointest Surg 2010; 2:199-202. [PMID: 21160874 PMCID: PMC2999237 DOI: 10.4240/wjgs.v2.i6.199] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2009] [Revised: 02/04/2010] [Accepted: 02/11/2010] [Indexed: 02/06/2023] Open
Abstract
Modern methods of surgical intervention have the potential to provide effective, definitive management of early stage colorectal neoplasia by truly minimally invasive means. Margin-free clearance of early colonic neoplasia from within the intestinal lumen can already now be effected by endoscopic submucosal dissection in the colon and transluminal endoscopic microsurgery (TEM) in the rectum. Natural orifice transluminal endoscopic surgery (NOTES) offers the potential for providing transmural, full thickness excision as TEM does but at sites in the colon proximal to the rectum. The next conceptual advance required to make this practice an effective reality lies in evolving surgical regional staging strategies to effectively partner localized resective approaches and allow their deployment as definitive curative therapy. As the most compelling modality for nodal status ascertainment in the absence of lymphatic basin excision for other malignant disease processes, it seems timely to reconsider sentinel node biopsy in cancer of the colon and rectum. Whether by this means or indeed any other, such an ability to confidently identify patients with node negative disease would allow nascent innovative techniques flourish as definitive management for confined (N0) T1 and T2 cancers and so allow the application of available advanced technology for clinical benefit. Conversely, the development of a specific clinical niche for NOTES (whether, as here, for full thickness localized colonic excision or nodal staging alone) would greatly benefit the evolution and incorporation of this surgical strategy into clinical care paradigms.
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Affiliation(s)
- Ronan A Cahill
- Ronan A Cahill, Neil J Mortensen, Department of Colorectal Surgery, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, United Kingdom
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16
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Abstract
Natural Orifice Transluminal Endoscopic Surgery (NOTES) has captured the attention of physicians and patients alike. Although clinical experience remains limited as technological capacity lags someway behind concept, this revolutionary approach is already prompting reassessment of conventional surgical dogma. Indeed, this very aspect may in fact represent the greatest legacy of current endeavour aimed at progressing natural orifice intervention as the biological insights so gleaned may then be used to help hone standard operations further towards perfection. As a corollary, rather than viewing it as a mere means of reformatting laparoscopic operation without the abdominal wall access component, NOTES should be investigated fully from the perspective of how it may complement (rather than compete with) current conventional techniques. In this way patients may in due course be allowed benefit by selection of the procedure of 'best fit' from an expanded array of surgical interventions. A clear focus on identifying specific clinical niches that are currently imperfectly addressed would also considerably advance the rationale for new surgical innovations such as NOTES and allow them to be engineered in the directions most likely to result in therapeutic advance. Thus while NOTES approaches for operations for neoplasia of the colon and even rectum clearly require more nuanced deliberation and care than does for example cholecystectomy for uncomplicated cholelithiasis, the gain from such investment seems likely to more considerably aid both the development and stature of NOTES as well as providing the greater likelihood of clinical progress for our patients.
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Affiliation(s)
- Ronan A Cahill
- Department of Colorectal Surgery, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, United Kingdom.
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