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Nguyen CL, Dayaratna N, Graham S, Azimi F, Mak C, Pulitano C, Warrier S. Evolution of Indocyanine Green Fluorescence in Breast and Axilla Surgery: An Australasian Experience. Life (Basel) 2024; 14:135. [PMID: 38255750 PMCID: PMC10821188 DOI: 10.3390/life14010135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/05/2024] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
The evolution of indocyanine green (ICG) fluorescence in breast and axilla surgery from an Australasian perspective is discussed in this narrative review with a focus on breast cancer and reconstruction surgery. The authors have nearly a decade of experience with ICG in a high-volume institution, which has resulted in publications and ongoing future research evaluating its use for predicting mastectomy skin flap perfusion for reconstruction, lymphatic mapping for sentinel lymph node (SLN) biopsy, and axillary reverse mapping (ARM) for prevention of lymphoedema. In the authors' experience, routine use of ICG angiography during breast reconstruction postmastectomy was demonstrated to be cost-effective for the reduction of ischemic complications in the Australian setting. A novel tracer combination, ICG-technetium-99m offered a safe and effective substitute to the "gold standard" dual tracer for SLN biopsy, although greater costs were associated with ICG. An ongoing trial will evaluate ARM node identification using ICG fluorescence during axillary lymph node dissection and potential predictive factors of ARM node involvement. These data add to the growing literature on ICG and allow future research to build on this to improve understanding of the potential benefits of fluorescence-guided surgery in breast cancer and reconstruction surgery.
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Affiliation(s)
- Chu Luan Nguyen
- Department of Breast Surgery, Chris O’Brien Lifehouse, Camperdown, NSW 2050, Australia; (S.G.); (F.A.); (C.M.); (S.W.)
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia;
- Department of Surgery, The University of Sydney, Camperdown, NSW 2050, Australia;
| | - Nirmal Dayaratna
- Department of Surgery, The University of Sydney, Camperdown, NSW 2050, Australia;
| | - Susannah Graham
- Department of Breast Surgery, Chris O’Brien Lifehouse, Camperdown, NSW 2050, Australia; (S.G.); (F.A.); (C.M.); (S.W.)
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia;
- Department of Surgery, The University of Sydney, Camperdown, NSW 2050, Australia;
| | - Farhad Azimi
- Department of Breast Surgery, Chris O’Brien Lifehouse, Camperdown, NSW 2050, Australia; (S.G.); (F.A.); (C.M.); (S.W.)
- Department of Surgery, The University of Sydney, Camperdown, NSW 2050, Australia;
| | - Cindy Mak
- Department of Breast Surgery, Chris O’Brien Lifehouse, Camperdown, NSW 2050, Australia; (S.G.); (F.A.); (C.M.); (S.W.)
| | - Carlo Pulitano
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia;
- Department of Surgery, The University of Sydney, Camperdown, NSW 2050, Australia;
| | - Sanjay Warrier
- Department of Breast Surgery, Chris O’Brien Lifehouse, Camperdown, NSW 2050, Australia; (S.G.); (F.A.); (C.M.); (S.W.)
- Department of Surgery, The University of Sydney, Camperdown, NSW 2050, Australia;
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Izzo S, Molle M, Gesuete FP, De Intinis C, Izzo P, Izzo L, Nicoletti GF. Comparison of Different Techniques for the Assessment of Sentinel Lymph Node Biopsy in Melanoma: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5447. [PMID: 38145154 PMCID: PMC10745233 DOI: 10.1097/gox.0000000000005447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 10/03/2023] [Indexed: 12/26/2023]
Abstract
Background The gold standard for sentinel lymph node staging in melanoma is the use of the combined technique of radioisotope plus blue dye. New techniques and alternative methods have been proposed, with the promise of achieving comparable efficacy. We then carried out a literature search. Methods We conducted a literature search using the "sentinel lymph node biopsy" and "melanoma" keywords, then selected the case-control studies (the quality of which was assessed using the STROBE criteria). Results Twelve studies of 13,017 were selected, concerning the identification rate of indocyanine green fluorescence and indocyanine green-99mtc-nanocolloid techniques. We have found a comparable identification rate between the various techniques, even if given the small population present for some techniques, the results did not reach statistical significance. Conclusions The use of new techniques in sentinel lymph node detection promises results comparable to the gold standard techniques, but further studies are needed to validate these methods in the context of melanoma surgery.
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Affiliation(s)
- Sara Izzo
- From the Università Degli Studi Della Campania “L. Vanvitelli,” Naples, Italy
| | - Marcello Molle
- From the Università Degli Studi Della Campania “L. Vanvitelli,” Naples, Italy
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Nguyen CL, Zhou M, Easwaralingam N, Seah JL, Azimi F, Mak C, Pulitano C, Warrier S. Novel Dual Tracer Indocyanine Green and Radioisotope Versus Gold Standard Sentinel Lymph Node Biopsy in Breast Cancer: The GREENORBLUE Trial. Ann Surg Oncol 2023; 30:6520-6527. [PMID: 37402976 PMCID: PMC10507001 DOI: 10.1245/s10434-023-13824-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/14/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND The methods for sentinel lymph node (SLN) biopsy in breast cancer have been variable in type and number of tracers. Some units have abandoned the use of blue dye (BD) due to adverse reactions. Fluorescence-guided biopsy with indocyanine green (ICG) is a relatively novel technique. This study compared the clinical efficacy and costs between novel dual tracer ICG and radioisotope (ICG-RI) with "gold standard" BD and radioisotope (BD-RI). METHODS Single-surgeon study of 150 prospective patients with early breast cancer undergoing SLN biopsy (2021-2022) using ICG-RI compared with a retrospective cohort of 150 consecutive previous patients using BD-RI. Number of SLNs identified, rate of failed mapping, identification of metastatic SLNs, and adverse reactions were compared between techniques. Cost-minimisation analysis performed by using Medicare item numbers and micro-costing analysis. RESULTS Total number of SLNs identified with ICG-RI and BD-RI was 351 and 315, respectively. Mean number of SLNs identified with ICG-RI and BD-RI was 2.3 (standard deviation [SD] 1.4) and 2.1 (SD 1.1), respectively (p = 0.156). There were no cases of failed mapping with either dual technique. Metastatic SLNs were identified in 38 (25.3%) ICG-RI patients compared with 30 (20%) BD-RI patients (p = 0.641). There were no adverse reactions to ICG, whereas four cases of skin tattooing and anaphylaxis were associated with BD (p = 0.131). ICG-RI cost an additional AU$197.38 per case in addition to the initial cost for the imaging system. CLINICAL TRIAL REGISTRATION ACTRN12621001033831. CONCLUSIONS Novel tracer combination, ICG-RI, provided an effective and safe alternative to "gold standard" dual tracer. The caveat was the significantly greater costs associated with ICG.
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Affiliation(s)
- Chu Luan Nguyen
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, NSW, Australia.
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia.
| | - Michael Zhou
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
| | - Neshanth Easwaralingam
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, NSW, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
| | - Jue Li Seah
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, NSW, Australia
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
| | - Farhad Azimi
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, NSW, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
| | - Cindy Mak
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, NSW, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
| | - Carlo Pulitano
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
| | - Sanjay Warrier
- Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, NSW, Australia
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, Australia
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Fadel MG, Rauf S, Mohamed HS, Yusuf S, Hayes AJ, Power K, Smith MJ. The Use of Indocyanine Green and Near-Infrared Fluorescence Imaging Versus Blue Dye in Sentinel Lymph Node Biopsy in Cutaneous Melanoma: A Retrospective, Cohort Study. Ann Surg Oncol 2023; 30:4333-4340. [PMID: 37061649 DOI: 10.1245/s10434-023-13405-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/06/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND The use of indocyanine green (ICG) and near-infrared fluorescence imaging is a promising option for sentinel lymph node (SLN) mapping in cutaneous melanoma. The study objective was to compare the performance of ICG and blue dye at detecting SLNs with radioisotope nanocolloid (technetium-99). METHODS Between April 2018 and June 2022, 293 consecutive patients with cutaneous melanoma (Breslow thickness ≥ 0.8 mm) underwent wide local excision and SLN biopsy. Patients were divided into group A (ICG; n = 122) and group B (blue dye; n = 163). All patients underwent SPECT/CT imaging preoperatively. SLN detection parameters and complications were compared between the groups. RESULTS A total of 285 patients had complete data and were included in the analysis. The median age was 62.0 (range 10-91) years, and 139 (48.8%) were female patients. The mean Breslow thickness was 2.6 mm, 89 (31.2%) patients had ulceration, and 179 (62.8%) patients had mitosis ≥ 1 mm2. The mean number of SLNs detected per patient in group A was 1.58 and group B was 1.48. In groups A and B, the SLN detection rate was 96.7% versus 89.6% (p = 0.022) and the pathological SLN detection rate was 92.3% versus 97.1% (p = 0.481), respectively. CONCLUSIONS ICG had a higher SLN detection rate and equal pathological SLN detection rate to blue dye. ICG may not be inferior to blue dye and is a useful adjunct to radioisotope in SLN biopsy in cutaneous melanoma.
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Affiliation(s)
- Michael G Fadel
- The Sarcoma, Melanoma and Rare Tumours Unit, The Royal Marsden Hospital and Institute Cancer of Research, London, UK
| | - Sidra Rauf
- The Sarcoma, Melanoma and Rare Tumours Unit, The Royal Marsden Hospital and Institute Cancer of Research, London, UK
| | - Hesham S Mohamed
- The Sarcoma, Melanoma and Rare Tumours Unit, The Royal Marsden Hospital and Institute Cancer of Research, London, UK
| | - Siraj Yusuf
- The Sarcoma, Melanoma and Rare Tumours Unit, The Royal Marsden Hospital and Institute Cancer of Research, London, UK
| | - Andrew J Hayes
- The Sarcoma, Melanoma and Rare Tumours Unit, The Royal Marsden Hospital and Institute Cancer of Research, London, UK
| | - Kieran Power
- The Sarcoma, Melanoma and Rare Tumours Unit, The Royal Marsden Hospital and Institute Cancer of Research, London, UK
| | - Myles J Smith
- The Sarcoma, Melanoma and Rare Tumours Unit, The Royal Marsden Hospital and Institute Cancer of Research, London, UK.
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Pallara T, Annovazzi A, Cristiani R, Vinci F, Bertozzi E, Bonadies A, Romani C, Tedesco M, Bellei B, Papaccio F, Caputo S, Cota C, Sperduti I, Govoni FA, Morrone A, Migliano E. Nonvisualized sentinel node on preoperative lymphoscintigraphy in primary cutaneous melanoma: an 11-year retrospective survey. Nucl Med Commun 2023; 44:345-350. [PMID: 36826418 DOI: 10.1097/mnm.0000000000001671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
BACKGROUND Sentinel lymph node (SLN) biopsy in cutaneous melanoma patients evaluates the regional draining basin for occult micrometastatic disease. Occasionally, nonidentification of SLN impairs the acquisition of this important prognostic factor. OBJECTIVES To investigate the outcomes of melanoma patients with negative lymphoscintigraphic findings and patients who underwent SLN biopsy from 2004 to 2015 ( n = 1200) were retrospectively reviewed for tumor characteristics and clinical outcomes. METHODS Patients with nonvisualized lymph nodes (NV group) who underwent only preoperative lymphoscintigraphy were separated and compared with a cohort drawn from all melanoma patients who completed the surgical procedure within the same period (V group). RESULTS A negative lymphoscintigraphic scan was observed in 38 cases (3.2% of all patients). The NV group showed a significantly older age (median 66.0 vs. 48.3 years; P < 0.0001). Head and neck melanomas were more frequent in the NV group compared to the control group (25.1 vs. 7.8%; P = 0.009). Tumor characteristics such as ulceration and Breslow thickness do not influence the lymphoscintigraphy result. No differences were found in overall survival (OS) and disease-free survival (DFS) between the groups. CONCLUSIONS The nonvisualization of regional lymph nodes by lymphoscintigraphy is more frequent in older patients with head and neck melanomas. From the clinical point of view, no specific recommendation emerged for patients' management because the nonvisualization of the SLN did not show a significant influence on DFS and OS rates. However, lack of knowledge of lymph node status suggests performing a tighter follow-up eventually by ultrasound evaluation of all potential lymph node drainage basins.
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Affiliation(s)
- Tiziano Pallara
- Department of Plastic and Reconstructive Surgery, San Gallicano Dermatological Institute IRCCS
| | | | - Renzo Cristiani
- Department of Plastic and Reconstructive Surgery, San Gallicano Dermatological Institute IRCCS
| | - Federica Vinci
- Department of Plastic and Reconstructive Surgery, San Gallicano Dermatological Institute IRCCS
| | - Ettore Bertozzi
- Department of Plastic and Reconstructive Surgery, San Gallicano Dermatological Institute IRCCS
| | - Antonio Bonadies
- Department of Plastic and Reconstructive Surgery, San Gallicano Dermatological Institute IRCCS
| | - Claudia Romani
- Department of Plastic and Reconstructive Surgery, San Gallicano Dermatological Institute IRCCS
| | - Marinella Tedesco
- Department of Plastic and Reconstructive Surgery, San Gallicano Dermatological Institute IRCCS
| | - Barbara Bellei
- Laboratory of Cutaneous Physiopathology and Integrated Center of Metabolomics Research, San Gallicano Dermatological Institute IRCCS
| | - Federica Papaccio
- Laboratory of Cutaneous Physiopathology and Integrated Center of Metabolomics Research, San Gallicano Dermatological Institute IRCCS
| | - Silvia Caputo
- Laboratory of Cutaneous Physiopathology and Integrated Center of Metabolomics Research, San Gallicano Dermatological Institute IRCCS
| | - Carlo Cota
- Genetic Research, Molecular Biology and Dermatopathology Unit, San Gallicano Dermatological Institute IRCCS
| | - Isabella Sperduti
- Biostatistical Unit - Clinical Trials Center Regina Elena National Cancer Institute
| | | | - Aldo Morrone
- Scientific Director, San Gallicano Dermatological Institute IRCCS, Rome, Italy
| | - Emilia Migliano
- Department of Plastic and Reconstructive Surgery, San Gallicano Dermatological Institute IRCCS
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Smith T, Ferri FA, Frieder J, Montorfano L, Medina M. Detection of Sentinel Lymph Nodes Using Indocyanine Green After Failing Scintigraphy in Merkel Cell Carcinoma. Cureus 2023; 15:e38453. [PMID: 37273297 PMCID: PMC10234671 DOI: 10.7759/cureus.38453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 06/06/2023] Open
Abstract
Merkel cell carcinoma (MCC) is a rare but highly aggressive skin cancer that carries a high rate of lymph node involvement and death. The National Comprehensive Cancer Network recommends sentinel lymph node (SLN) biopsy for the staging of the disease. Scintigraphy using radioactive isotopes (RI) such as technetium 99m (Tc99) remains the gold standard for the detection of SLNs, however, recently indocyanine green (ICG) fluorescence imaging has been used to aid in the detection of SLNs.We present the case of a patient who presented with MCC of the face and two SLNs successfully identified with ICG fluorescence despite the fact that they were not detected by intraoperative scintigraphy using Tc99. The use of ICG fluorescence imaging in MCC is safe and improves the ability to detect SLNs when combined with RI.
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Affiliation(s)
| | - Francisco A Ferri
- Plastic and Reconstructive Surgery, Cleveland Clinic Florida, Weston, USA
| | | | | | - Michael Medina
- Head and Neck Surgery, Cleveland Clinic Florida, Weston, USA
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Jeremiasse B, van Scheltinga CEJT, Smeele LE, Tolboom N, Wijnen MHWA, van der Steeg AFW. Sentinel Lymph Node Procedure in Pediatric Patients with Melanoma, Squamous Cell Carcinoma, or Sarcoma Using Near-Infrared Fluorescence Imaging with Indocyanine Green: A Feasibility Trial. Ann Surg Oncol 2023; 30:2391-2398. [PMID: 36641516 PMCID: PMC10027760 DOI: 10.1245/s10434-022-12978-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/06/2022] [Indexed: 01/16/2023]
Abstract
BACKGROUND Standard sentinel lymph node procedure (SNP) in pediatric cancer consists of a preoperative injection with 99mtechnetium nanocolloid in combination with an optional intraoperative injection with blue dye. However, blue dye has disadvantages, and the detection rate is low, with only 60% of sentinel lymph nodes (SLNs) staining blue. In adult oncology, fluorescence imaging using indocyanine green (ICG) has been shown to be a safe and accurate method for visual detection of SLNs, with a higher sensitivity (up to 97%) compared with blue dye. Therefore, our aim is to determine the feasibility of the addition of ICG to 99mtechnetium nanocolloid (ICG-TC) for visual detection of SLN in pediatric patients. METHODS A total of 15 pediatric patients with melanoma, squamous cell carcinoma, and sarcoma were prospectively included. Preoperatively, patients were injected with ICG-TC and imaging with lymphoscintigraphy and single-photon emission computed tomography- computed tomography was performed. Intraoperatively, SLN was detected with fluorescence and the gamma probe. Postoperatively, fluorescence was quantified by tumor-to-background ratio (TBR) and surgeons evaluated the use of ICG using a standardized questionnaire. RESULTS In 10/15 (67%) patients, SLNs were visible transcutaneously. Of all intraoperatively detected SLNs, 35/37 (95%) were fluorescent and 37/37 (100%) were radioactive. Furthermore, ICG-TC led to the identification of six additional SLNs as compared with preoperative imaging. The median TBR in vivo was 6.5 (IQR 5.3). The surgical evaluation showed that ICG assisted in SLN detection and was easy to use. CONCLUSIONS ICG-TC for the SNP is a feasible procedure in pediatric patients. It showed an accurate detection rate, was helpful for visual guidance, and no adverse events occurred.
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Affiliation(s)
- Bernadette Jeremiasse
- Princess Maxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
| | | | - Ludwig E Smeele
- Princess Maxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
- Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Nelleke Tolboom
- Division Imaging and Oncology, Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Marc H W A Wijnen
- Princess Maxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
| | - Alida F W van der Steeg
- Princess Maxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands.
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Current Controversies in Melanoma Treatment. Plast Reconstr Surg 2023; 151:495e-505e. [PMID: 36821575 DOI: 10.1097/prs.0000000000009936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
LEARNING OBJECTIVES After reading this article and viewing the videos, the participant should be able to: 1. Discuss margins for in situ and invasive disease and describe reconstructive options for wide excision defects, including the keystone flap. 2. Describe a digit-sparing alternative for subungual melanoma. 3. Calculate personalized risk estimates for sentinel node biopsy using predictive nomograms. 4. Describe the indications for lymphadenectomy and describe a technique intended to reduce the risk of lymphedema following lymphadenectomy. 5. Offer options for in-transit melanoma management. SUMMARY Melanoma management continues to evolve, and plastic surgeons need to stay at the forefront of advances and controversies. Appropriate margins for in situ and invasive disease require consideration of the trials on which they are based. A workhorse reconstruction option for wide excision defects, particularly in extremities, is the keystone flap. There are alternative surgical approaches to subungual tumors besides amputation. It is now possible to personalize a risk estimate for sentinel node positivity beyond what is available for groups of patients with a given stage of disease. Sentinel node biopsy can be made more accurate and less morbid with novel adjuncts. Positive sentinel node biopsies are now rarely managed with completion lymphadenectomy. Should a patient require lymphadenectomy, immediate lymphatic reconstruction may mitigate the lymphedema risk. Finally, there are minimally invasive modalities for effective control of in-transit recurrences.
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The Use and Technique of Sentinel Node Biopsy for Skin Cancer. Plast Reconstr Surg 2022; 149:995e-1008e. [PMID: 35472052 DOI: 10.1097/prs.0000000000009010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand the indications for and prognostic value of sentinel lymph node biopsy in skin cancer. 2. Learn the advantages and disadvantages of various modalities used alone or in combination when performing sentinel lymph node biopsy. 3. Understand how to perform sentinel lymph node biopsy in skin cancer patients. SUMMARY Advances in technique used to perform sentinel lymph node biopsy to assess lymph node status have led to increased accuracy of the procedure and improved patient outcomes.
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Mukunda DC, Rodrigues J, Joshi VK, Raghushaker CR, Mahato KK. A comprehensive review on LED-induced fluorescence in diagnostic pathology. Biosens Bioelectron 2022; 209:114230. [PMID: 35421670 DOI: 10.1016/j.bios.2022.114230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 03/19/2022] [Accepted: 03/25/2022] [Indexed: 11/02/2022]
Abstract
Sensitivity, specificity, mobility, and affordability are important criteria to consider for developing diagnostic instruments in common use. Fluorescence spectroscopy has been demonstrating substantial potential in the clinical diagnosis of diseases and evaluating the underlying causes of pathogenesis. A higher degree of device integration with appropriate sensitivity and reasonable cost would further boost the value of the fluorescence techniques in clinical diagnosis and aid in the reduction of healthcare expenses, which is a key economic concern in emerging markets. Light-emitting diodes (LEDs), which are inexpensive and smaller are attractive alternatives to conventional excitation sources in fluorescence spectroscopy, are gaining a lot of momentum in the development of affordable, compact analytical instruments of clinical relevance. The commercial availability of a broad range of LED wavelengths (255-4600 nm) has opened up new avenues for targeting a wide range of clinically significant molecules (both endogenous and exogenous), thereby diagnosing a range of clinical illnesses. As a result, we have specifically examined the uses of LED-induced fluorescence (LED-IF) in preclinical and clinical evaluations of pathological conditions, considering the present advancements in the field.
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Affiliation(s)
| | - Jackson Rodrigues
- Department of Biophysics, Manipal School of Life Sciences, Manipal Academy of Higher Education, Manipal, Karnataka-576104, India
| | - Vijay Kumar Joshi
- Department of Biophysics, Manipal School of Life Sciences, Manipal Academy of Higher Education, Manipal, Karnataka-576104, India
| | - Chandavalli Ramappa Raghushaker
- Department of Biophysics, Manipal School of Life Sciences, Manipal Academy of Higher Education, Manipal, Karnataka-576104, India
| | - Krishna Kishore Mahato
- Department of Biophysics, Manipal School of Life Sciences, Manipal Academy of Higher Education, Manipal, Karnataka-576104, India.
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Patel N, Allen M, Arianpour K, Keidan R. The utility of ICG fluorescence for sentinel lymph node identification in head and neck melanoma. Am J Otolaryngol 2021; 42:103147. [PMID: 34237540 DOI: 10.1016/j.amjoto.2021.103147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/16/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Perform an evidence-based review to determine the utility of indocyanine green fluorescence (ICG) to detect sentinel lymph nodes (SLN) in patients with head and neck melanoma compared to blue dye or radiocolloid injection (RI). MATERIALS AND METHODS A systematic review of the literature was performed to identify patients with head and neck melanoma managed with ICG fluorescence. PubMed, Embase, and Cochrane Library databases were searched. Included studies were assessed for level of evidence. Patient demographics and data on SLN identification were determined. RESULTS Twenty-two studies encompassing 399 patients (75% male, 25% female, average age 57.1 years) met inclusion criteria. Publications comprised of two case reports, four retrospective case series, twelve cohort studies, and four clinical trials. Most common site of melanoma was scalp/temple/forehead (35%), cheek/midface (22%), and ear (17%) with an average Breslow thickness of 3.32 mm. SLN was identified in 80.7% (n = 201/249) of patients using ICG-RI, 85.2% (n = 75/88) using RI alone, and 63.4% (n = 52/82) using blue dye-RI. CONCLUSIONS ICG-99mTc-nanocolloid hybrid tracer may be a superior alternative to blue dye + adiocolloid and has theoretical advantages compared to RI alone. Additional prospective randomized controlled trials are needed to further compare these methods and obtain data on false negative rates, operating room time, and cost effectiveness to fully elucidate the utility of ICG-99mTc-nanocolloid over current methods used for SLN identification in this patient population.
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Abstract
Sentinel lymph node biopsy is a key tool in the care of many patients with melanoma. The indications for the procedure have gradually become clearer over the 3 decades since the technique was developed. For appropriately selected patients, it carries enormous significance. Although it is a minimally invasive procedure, it does carry some risk. It is also a multidisciplinary procedure, requiring knowledge and experience from several specialties including nuclear medicine, surgery, and pathology.
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Affiliation(s)
- Jessica Crystal
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, USA
| | - Mark B Faries
- The Angeles Clinic and Research Institute, Cedars-Sinai Medical Center, 11800 Wilshire Boulevard, Suite 300, Los Angeles, CA 90025, USA.
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14
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Indocyanine Green Fluorescence Imaging with Lymphoscintigraphy Improves the Accuracy of Sentinel Lymph Node Biopsy in Melanoma. Plast Reconstr Surg 2021; 148:83e-93e. [PMID: 34181617 DOI: 10.1097/prs.0000000000008096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite advances in melanoma management, there remains room for improvement in the accuracy of sentinel lymph node biopsy. The authors analyzed a prospective cohort of patients with primary cutaneous melanoma who underwent sentinel lymph node biopsy with lymphoscintigraphy and indocyanine green fluorescence to evaluate the quality and accuracy of this technique. METHODS Consecutive primary cutaneous melanoma patients who underwent sentinel lymph node biopsy with radioisotope lymphoscintigraphy and indocyanine green fluorescence from 2012 to 2018 were prospectively enrolled. Analysis was performed of melanoma characteristics, means of identifying sentinel lymph nodes, sentinel lymph node status, and recurrence. RESULTS Five hundred ninety-four melanomas and 1827 nodes were analyzed; 1556 nodes (85.2 percent) were identified by radioactivity/fluorescence, 255 (14 percent) by radioactivity only, and 16 (0.9 percent) with indocyanine green only. There were 163 positive sentinel nodes. One hundred forty-seven (90.2 percent) were identified by radioactivity/fluorescence, 13 (8 percent) by radioactivity only, and three (0.6 percent) with fluorescence only. Of the 128 patients with a positive biopsy, eight patients' (6.3 percent) nodes were identified by radioactivity only and four (3.4 percent) with fluorescence only. There were 128 patients with a positive biopsy, 454 with a negative biopsy, and 12 patients who had a negative biopsy with subsequent nodal recurrence. Mean follow-up was 2.8 years. CONCLUSIONS In the study of the largest cohort of patients with primary cutaneous melanoma who underwent a sentinel lymph node biopsy with radioisotope lymphoscintigraphy and indocyanine green-based technology, the quality and accuracy of this technique are demonstrated. This has important implications for melanoma patients, as the adoption of this approach with subsequent accurate staging, adjuvant workup, and treatment may improve survival outcomes. . CLINICAL QUESTION/LEVEL OF EVIDENCE Diagnostic, II.
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Ferri F, Montorfano L, Bordes SJ, Forleiter C, Newman MI. Near-Infrared Fluorescence Imaging for Sentinel Lymph Node Identification in Melanoma Surgery. Cureus 2021; 13:e14550. [PMID: 34079661 PMCID: PMC8159349 DOI: 10.7759/cureus.14550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Although less common than other types of skin cancers, melanoma is accountable for the majority of skin cancer-related deaths. The standard management for patients with clinically negative nodes includes a sentinel lymph node (SLN) biopsy, which is commonly performed using a combination of radioactive tracer (Tc-99) and a blue dye (isosulfan or patent blue). There are numerous drawbacks associated with Tc-99 and blue dyes such as elevated costs, logistical challenges, and anaphylactic reactions among others. In recent years, near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) has emerged as a safe, effective, less costly, and more convenient alternative for the identification of SLNs in melanoma. We discuss the case of a 51-year-old man with melanoma in his left upper back. Two SLNs in the left axilla were successfully identified using NIR fluorescence. NIR fluorescence with ICG for SLN identification has proven to increase the sensitivity and accuracy when used in combination with lymphoscintigraphy.
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Affiliation(s)
| | | | - Stephen J Bordes
- Surgical Anatomy, Tulane University School of Medicine, New Orleans, USA
| | - Craig Forleiter
- Plastic and Reconstructive Surgery, Cleveland Clinic Florida, Weston, USA
| | - Martin I Newman
- Plastic and Reconstructive Surgery, Cleveland Clinic Florida, Weston, USA
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Pogue BW, Rosenthal EL. Review of successful pathways for regulatory approvals in open-field fluorescence-guided surgery. JOURNAL OF BIOMEDICAL OPTICS 2021; 26:JBO-210023VR. [PMID: 33715318 PMCID: PMC7955139 DOI: 10.1117/1.jbo.26.3.030901] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 02/23/2021] [Indexed: 06/12/2023]
Abstract
SIGNIFICANCE The modern use of fluorescence in surgery came iteratively through new devices and pre-existing imaging agents, with indications that were paved via regulatory approvals and device clearances. These events led to a growing set of surgery subspecialty uses. AIM This article outlines the key milestones that initiated commercially marketed systems and agents by highlighting temporal sequences and strategic decisions between them, with the goal of helping to inform future successes. APPROACH A review of successful regulatory approvals and the sequences between them was completed for companies that achieved US Food and Drug Administration (FDA) premarket approval or new drug approvals (NDAs) or device clearances in the fields of fluorescent imaging agents, open surgery imaging devices, and their approved medical indications. RESULTS Angiography agents, indocyanine green and fluorescein, were approved for human use as absorbing dyes, and this use in retinal imaging was the precursor to lateral translation into tissue perfusion imaging in the last two decades with a growing number of devices. Many FDA cleared devices for open fluorescence-guided surgery used the predicate created by the SPY SP2000 system. This first system was 510(k) cleared for angiography imaging with a unique split predicate from x-ray imaging of vasculature and retinal fluorescence angiography. Since that time, the lateral spread of open surgery devices being cleared for new indications has been occurring with a growth of adoption in surgical subspecialties. Growth into new surgical subspecialties has been achieved by leveraging different NDAs and clearances between indications, such that medical uses have broadened over time. CONCLUSIONS Key decisions made by developers to advance specific device clearances and NDAs have been based upon existing optical fluorescent agents. The historical lessons and regulatory trends in newer indications and contrast agents can help the field evolve via successful investment in new systems and applications.
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Affiliation(s)
- Brian W. Pogue
- Thayer School of Engineering at Dartmouth, Center for Imaging Medicine, Hanover, New Hampshire, United States
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, United States
| | - Eben L. Rosenthal
- Stanford University School of Medicine, Palo Alto, California, United States
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Zanoni DK, Stambuk HE, Madajewski B, Montero PH, Matsuura D, Busam KJ, Ma K, Turker MZ, Sequeira S, Gonen M, Zanzonico P, Wiesner U, Bradbury MS, Patel SG. Use of Ultrasmall Core-Shell Fluorescent Silica Nanoparticles for Image-Guided Sentinel Lymph Node Biopsy in Head and Neck Melanoma: A Nonrandomized Clinical Trial. JAMA Netw Open 2021; 4:e211936. [PMID: 33734415 PMCID: PMC7974643 DOI: 10.1001/jamanetworkopen.2021.1936] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
IMPORTANCE Sentinel lymph node (SLN) mapping agents approved for current surgical practice lack sufficient brightness and target specificity for high-contrast, sensitive nodal visualization. OBJECTIVE To evaluate whether an ultrasmall, molecularly targeted core-shell silica nanoparticle (Cornell prime dots) can safely and reliably identify optically avid SLNs in head and neck melanoma during fluorescence-guided biopsy. DESIGN, SETTING, AND PARTICIPANTS This nonrandomized clinical trial enrolled patients aged 18 years or older with histologically confirmed melanoma in whom SLN mapping was indicated. Exclusion criteria included known pregnancy, breast-feeding, or medical illness unrelated to the tumor. The trial was conducted between February 2015 and March 2018 at Memorial Sloan Kettering Cancer Center, with postoperative follow-up of 2 years. Data analysis was conducted from February 2015 to March 2018. INTERVENTIONS Patients received standard-of-care technetium Tc 99m sulfur colloid followed by a microdose administration of integrin-targeting, dye-encapsulated nanoparticles, surface modified with polyethylene glycol chains and cyclic arginine-glycine-aspartic acid-tyrosine peptides (cRGDY-PEG-Cy5.5-nanoparticles) intradermally. MAIN OUTCOMES AND MEASURES The primary end points were safety, procedural feasibility, lowest particle dose and volume for maximizing nodal fluorescence signal, and proportion of nodes identified by technetium Tc 99m sulfur colloid that were optically visualized by cRGDY-PEG-Cy5.5-nanoparticles. Secondary end points included proportion of patients in whom the surgical approach or extent of dissection was altered because of nodal visualization. RESULTS Of 24 consecutive patients enrolled (median [interquartile range] age, 64 [51-71] years), 18 (75%) were men. In 24 surgical procedures, 40 SLNs were excised. Preoperative localization of SLNs with technetium Tc 99m sulfur colloid was followed by particle dose-escalation studies, yielding optimized doses and volumes of 2 nmol and 0.4 mL, respectively, and maximum SLN signal-to-background ratios of 40. No adverse events were observed. The concordance rate of evaluable SLNs by technetium Tc 99m sulfur colloid and cRGDY-PEG-Cy5.5-nanoparticles was 90% (95% CI, 74%-98%), 5 of which were metastatic. Ultrabright nanoparticle fluorescence enabled high-sensitivity SLN visualization (including difficult-to-access anatomic sites), deep tissue imaging, and, in some instances, detection through intact skin, thereby facilitating intraoperative identification without extensive dissection of adjacent normal tissue or nerves. CONCLUSIONS AND RELEVANCE This study found that nanoparticle-based fluorescence-guided SLN biopsy in head and neck melanoma was feasible and safe. This technology holds promise for improving lymphatic mapping and SLN biopsy procedures, while potentially mitigating procedural risks. This study serves as a first step toward developing new multimodal approaches for perioperative care. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02106598.
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Affiliation(s)
- Daniella Karassawa Zanoni
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hilda E. Stambuk
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Brian Madajewski
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Pablo H. Montero
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Danielli Matsuura
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Klaus J. Busam
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kai Ma
- Department of Materials Science and Engineering, Cornell University, Ithaca, New York
| | - Melik Z. Turker
- Department of Materials Science and Engineering, Cornell University, Ithaca, New York
| | - Sonia Sequeira
- Regulatory Oversight and Product Development, Research Technology and Management, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Pat Zanzonico
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ulrich Wiesner
- Department of Materials Science and Engineering, Cornell University, Ithaca, New York
- Memorial Sloan Kettering–Cornell Center for Translation of Cancer Nanomedicines, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michelle S. Bradbury
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
- Memorial Sloan Kettering–Cornell Center for Translation of Cancer Nanomedicines, Memorial Sloan Kettering Cancer Center, New York, New York
- Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Snehal G. Patel
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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pHLIP ICG for delineation of tumors and blood flow during fluorescence-guided surgery. Sci Rep 2020; 10:18356. [PMID: 33110131 PMCID: PMC7591906 DOI: 10.1038/s41598-020-75443-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/14/2020] [Indexed: 12/18/2022] Open
Abstract
Fluorescence imaging has seen enduring use in blood flow visualization and is now finding a new range of applications in image-guided surgery. In this paper, we report a translational study of a new fluorescent agent for use in surgery, pHLIP ICG, where ICG (indocyanine green) is a surgical fluorescent dye used widely for imaging blood flow. We studied pHLIP ICG interaction with the cell membrane lipid bilayer, the pharmacology and toxicology in vitro and in vivo (mice and dogs), and the biodistribution and clearance of pHLIP ICG in mice. The pHLIP ICG tumor targeting and imaging efficacy studies were carried out in several murine and human mouse tumor models. Blood vessels were imaged in mice and pigs. Clinical Stryker imaging instruments for endoscopy and open surgery were used in the study. Intravenously administered pHLIP ICG exhibits a multi-hour circulation half-life, offering protracted delineation of vasculature. As it clears from the blood, pHLIP ICG targets tumors and tumor stroma, marking them for surgical removal. pHLIP ICG is non-toxic, marks blood flow for hours after injection, and effectively delineates tumors for improved resection on the day after administration.
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Lafreniere AS, Shine JJ, Nicholas CR, Temple-Oberle CF. The use of indocyanine green and near-infrared fluorescence imaging to assist sentinel lymph node biopsy in cutaneous melanoma: A systematic review. Eur J Surg Oncol 2020; 47:935-941. [PMID: 33121851 DOI: 10.1016/j.ejso.2020.10.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 10/19/2020] [Accepted: 10/23/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Despite the use of blue dye and radioisotopes, sentinel lymph node biopsy (SLNB) is still associated with a high false-negative rate (FNR). The off-label use of indocyanine green (ICG) and near-infrared fluorescence (NIRF) imaging has been introduced with the objective of assisting SLNB and thereby improving regional control in melanoma. The objective of this study was to review and summarize the general experience, protocols and outcomes of the use of ICG and NIRF to assist SLNB in melanoma. METHODS A systematic literature review was performed in December 2019 as per the PRISMA guidelines. Inclusion criteria were articles written in English describing the applications of ICG in patients with melanoma. Systematic reviews, animal studies, case reports and letters to editors were excluded. RESULTS Of the 585 studies retrieved, 13 articles met the inclusion criteria. The reported sentinel lymph node (SLN) detection rate using ICG was between 86 and 100% of nodes identified by lymphoscintigraphy. The average number of nodes per patient detected using ICG was 2. ICG fluorescence imaging contributed to the identification of 2.0% of the total number of SLNs harvested. CONCLUSIONS ICG fluorescence may be a useful adjunct to lymphoscintigraphy, although high-level comparative data is lacking. It was found to be superior to blue dye at detecting sentinel lymph nodes.
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Jeremiasse B, van den Bosch CH, Wijnen MWHA, Terwisscha van Scheltinga CEJ, Fiocco MF, van der Steeg AFW. Systematic review and meta-analysis concerning near-infrared imaging with fluorescent agents to identify the sentinel lymph node in oncology patients. Eur J Surg Oncol 2020; 46:2011-2022. [PMID: 32826112 DOI: 10.1016/j.ejso.2020.07.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/03/2020] [Accepted: 07/09/2020] [Indexed: 02/05/2023] Open
Abstract
Sentinel node procedures (SNP) are performed with the use of tracer-agents, mainly radio-colloid and/or blue dye. Fluorescent agents have emerged as a new tracer-agent to identify the SLN intra-operatively with near-infrared imaging. Our aim is to compare the detection rate of fluorescent agents to current "golden standards" (blue dye and/or radio-colloid) for the SNP by means of a systematic review and meta-analysis without any restrictions based on tumor type. A systematic search in PubMed, Embase and The Cochrane Library was performed. Articles that compared the detection rates of fluorescent agents with radio-colloid and/or blue dye were included. Meta-analyses were performed for breast, gynecological and dermatological cancer using a random effects model. In total 6195 articles were screened which resulted in a final inclusion of 55 articles. All studies used indocyanine green (ICG) as fluorescent agent. Meta-analyses comparing ICG with blue dye showed a significant and clinically relevant difference in detection rate in favor of ICG, for both breast, dermatological and gynecological cancer. Meta-analyses comparing ICG with radio-colloid did not show any significant differences, with the exception of ICG versus radio-colloid + blue dye for the bilateral SLN detection in gynecological cancer. Near-infrared fluorescence imaging using ICG provides a higher detection rate compared to blue dye for the SNP in a range of different tumor types. SLN detection rates of ICG are comparable to radio-colloid. Due to their complementary characteristics in terms of spatial resolution and transdermal sensitivity, we suggest to use a combination of both ICG and a radio-colloid.
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Affiliation(s)
- B Jeremiasse
- Department of Surgery, Princess Maxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, the Netherlands.
| | - C H van den Bosch
- Department of Surgery, Princess Maxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, the Netherlands.
| | - M W H A Wijnen
- Department of Surgery, Princess Maxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, the Netherlands.
| | | | - M F Fiocco
- Trial and Data Center, Princess Maxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, the Netherlands; Institute of Mathematics, Leiden University, Niels Bohrweg 1, 2333CA, Leiden, the Netherlands; Department of Biomedical Data Science, Section Medical Statistics, Leiden University Medical Center, Albinusdreef 2, 2300RC, Leiden, the Netherlands.
| | - A F W van der Steeg
- Department of Surgery, Princess Maxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, the Netherlands.
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Knackstedt R, Couto RA, Ko J, Cakmakoglu C, Wu D, Gastman B. Indocyanine Green Fluorescence Imaging with Lymphoscintigraphy for Sentinel Node Biopsy in Melanoma: Increasing the Sentinel Lymph Node-Positive Rate. Ann Surg Oncol 2019; 26:3550-3560. [PMID: 31313036 DOI: 10.1245/s10434-019-07617-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Indexed: 12/17/2023]
Abstract
INTRODUCTION The goal of this study was to analyze patients who underwent a sentinel lymph node biopsy (SLNB) in melanoma with the combination of radioisotope lymphoscintigraphy and indocyanine green (ICG) fluorescence imaging to compare our true positive (TP) rate, a means to perform immediate analysis of the SLNB, with that of the literature. METHODS Consecutive cutaneous melanoma patients who underwent SLNB with lymphoscintigraphy and ICG-based fluorescence imaging by the senior author (BG) from 2012 to 2018 were prospectively enrolled. The average expected SLN-positive rate per T stage was calculated based on three studies and compared with our SLN-positive rate. RESULTS Overall, 574 consecutive patients were analyzed. Average Breslow thickness was 1.9 mm. A total of 1754 sentinel nodes were sampled; 1497 were identified by gamma probe signaling and ICG, 241 were identified by gamma probe signaling only, and 16 were identified by ICG only. There were 123 (21.4%) patients with at least one positive SLN; 113 (91.9%) had at least one positive node identified with both gamma probe signaling and ICG, 8 (6.5%) had positive node(s) identified with gamma probe signaling only, and 2 (1.6%) had positive node(s) identified with ICG only. There was an overall 21.4% SLN-positive rate, with 8% T1, 18.5% T2, 41.1% T3, and 52.4% T4, which is higher than the predicted rates for each stage. CONCLUSIONS With the largest cohort of patients reported who underwent a melanoma SLNB with lymphoscintigraphy and ICG, we demonstrated that this technique results in higher SLN-positive rates than predicted. Patients are being followed but, given the TP data, knowledge of our results may foster the use of this modality to improve staging and treatment options.
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Affiliation(s)
- Rebecca Knackstedt
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Rafael A Couto
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jennifer Ko
- Department of Anatomic Pathology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Cagri Cakmakoglu
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Daisy Wu
- University of Toledo Medical School, Toledo, OH, USA
| | - Brian Gastman
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.
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Clinical application and technical standardization of indocyanine green (ICG) fluorescence imaging in pediatric minimally invasive surgery. Pediatr Surg Int 2019; 35:1043-1050. [PMID: 31273452 DOI: 10.1007/s00383-019-04519-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE We reported our preliminary experience using ICG fluorescence in pediatric minimally invasive surgery (MIS) with the aim to standardize indications, dose, timing, and modality of administration of ICG according to different organs. METHODS ICG technology was adopted in 46 MIS procedures performed in our unit over the last 18 months: 30 left varicocele repairs; 5 cholecystectomies in obese adolescents; 3 tumor excisions; 3 nephrectomies; 2 partial nephrectomies; 3 lymphoma excisions. ICG solution was injected intravenously in all cases except for varicocelectomy in which it was injected into the testis. The ICG injection was performed intra-operatively in all cases except for cholecystectomy in which it was injected 18 h prior to the procedure. RESULTS All procedures were completed laparoscopically without conversions or intra-operative complications. No adverse or allergic reactions to ICG were reported. CONCLUSION Our preliminary experience showed that ICG fluorescence is a safe, useful, and versatile technique to adopt in pediatric MIS to achieve a better identification of anatomy and an easier surgical dissection or resection in challenging cases. Currently, the main indications are varicocelectomy, difficult cholecystectomy, tumor excision, nephrectomy, and partial nephrectomy. The main limitation is the needing of a special equipment to use ICG technology.
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Tang JC, Partono A, Anvari B. Near-Infrared-Fluorescent Erythrocyte-Mimicking Particles: Physical and Optical Characteristics. IEEE Trans Biomed Eng 2019; 66:1034-1044. [PMID: 30130175 PMCID: PMC6382600 DOI: 10.1109/tbme.2018.2866368] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Exogenous fluorescent materials activated by near-infrared (NIR) light can offer deep optical imaging with subcellular resolution, and enhanced image contrast. We have engineered NIR particles by doping hemoglobin-depleted erythrocyte ghosts (EGs) with indocyanine green (ICG). We refer to these optical particles as NIR erythrocyte-mimicking transducers (NETs). A particular feature of NETs is that their diameters can be tuned from micrometer to nanometer scale, thereby, providing a capability for broad NIR biomedical imaging applications. Herein, we investigate the effects of ICG concentration on key material properties of micrometer-sized NETs, and nanometer-sized NETs fabricated by either sonication or mechanical extrusion of EGs. The zeta potentials of NETs do not vary significantly with ICG concentration, suggesting that ICG is encapsulated within NETs regardless of particle size or ICG concentration. Loading efficiency of ICG into the NETs monotonically decreases with increasing values of ICG concentration. Based on quantitative analyses of the fluorescence emission spectra of the NETs, we determine that 20 μM ICG utilized during fabrication of NETs presents an optimal concentration that maximizes the integrated fluorescence emission for micrometer- and nanometer-sized NETs. Encapsulation of the ICG in these constructs also enhances the fluorescence stability and quantum yield of ICG. These results guide the engineering of NETs with maximal NIR emission for imaging applications such as fluorescence-guided tumor resection and real-time angiography.
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Sirvan SS, Demir IA, Irmak F, Kafi M, Budak K, Karsidag S. Does Wide Excisional Biopsy in Skin Cancer Prevent Finding The Real Sentinel Lymph Node? J INVEST SURG 2019; 33:741-747. [DOI: 10.1080/08941939.2018.1559898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Selami S Sirvan
- Plastic, Reconstructive and Aesthetic Surgery Department, University of Health Sciences Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Isil Akgun Demir
- Plastic, Reconstructive and Aesthetic Surgery Department, University of Health Sciences Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Fatih Irmak
- Plastic, Reconstructive and Aesthetic Surgery Department, University of Health Sciences Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Mesut Kafi
- Nuclear Medicine Department, University of Health Sciences Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Kenan Budak
- Nuclear Medicine Department, University of Health Sciences Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Semra Karsidag
- Plastic, Reconstructive and Aesthetic Surgery Department, University of Health Sciences Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Summarize the changes to the American Joint Committee on Cancer Eighth Edition Melanoma Staging System. 2. List advances in genetic, molecular, and histopathologic melanoma diagnosis and prognostication. 3. Recommend sentinel lymph node biopsy and appropriate surgical margins based on individualized patient needs. 4. Recognize the currently available treatments for in-transit metastasis and advanced melanoma. 5. Describe current and future therapies for melanoma with distant visceral or brain metastases. SUMMARY Strides in melanoma surveillance, detection, and treatment continue to be made. The American Joint Committee on Cancer Eighth Edition Cancer Staging System has improved risk stratification of patients, introduced new staging categories, and resulted in stage migration of patients with improved outcomes. This review summarizes melanoma advances of the recent years with an emphasis on the surgical advances, including techniques and utility of sentinel node biopsy, controversies in melanoma margin selection, and the survival impact of time-to-treatment metrics. Once a disease manageable only with surgery, a therapeutic paradigm shift has given a more promising outlook to melanoma patients at any stage. Indeed, a myriad of novel, survival-improving immunotherapies have been introduced for metastatic melanoma and more recently in the high-risk adjuvant setting.
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Valente SA, Al-Hilli Z, Radford DM, Yanda C, Tu C, Grobmyer SR. Near Infrared Fluorescent Lymph Node Mapping with Indocyanine Green in Breast Cancer Patients: A Prospective Trial. J Am Coll Surg 2018; 228:672-678. [PMID: 30582975 DOI: 10.1016/j.jamcollsurg.2018.12.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 12/10/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Near infrared (NIR) fluorescence imaging is an emerging modality that can enable real-time image-guided procedures. Indocyanine green (ICG) is an FDA-approved, inexpensive, and widely available NIR dye. We hypothesized that axillary lymphatic mapping with ICG is equivalent to lymphatic mapping with technetium 99m (99mTc) in breast cancer patients. STUDY DESIGN Breast cancer patients (cT1-2, N0) were prospectively enrolled. Patients underwent lymphatic mapping with 99mTc preoperatively and ICG mapping intraoperatively (0.8 mL). Sentinel lymph node (SLN) biopsy was guided by NIR camera and gamma probe. Rate of failed mapping, number of SLNs identified, and rate of identifying pathologically positive SLNs were compared between the 2 techniques (p < 0.05 was considered statistically significant). RESULTS Ninety-two female patients were enrolled (median age 59 years). Mean transit time from ICG injection in the breast to localization in the axilla was 5 minutes (range 2 to 29 minutes). No adverse reactions to ICG were noted. Mean number of SLNs identified with ICG and 99mTc was 2.4 (SD 1.42) and 2.2 (SD 1.23), respectively (p = 0.34). Pathologically positive SLNs were identified in 18 (19.8%) patients. A total of 24 pathologically positive SLNs in 18 patients were identified by ICG in 24 of 24 (100%) patients and by 99mTc in 23 of 24 (96%) patients (p = 0.99). CONCLUSIONS Indocyanine green with NIR fluorescence imaging can be safely and efficiently used for real-time intraoperative lymphatic mapping in breast cancer patients. Indocyanine green performs similarly to 99mTc with regard to the number of SLNs identified, rate of failed mapping, and identification of pathologically positive SLNs.
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Affiliation(s)
- Stephanie A Valente
- Division of Breast Surgery, Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Zahraa Al-Hilli
- Division of Breast Surgery, Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Diane M Radford
- Division of Breast Surgery, Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Courtney Yanda
- Division of Breast Surgery, Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Chao Tu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Stephen R Grobmyer
- Division of Breast Surgery, Department of General Surgery, Cleveland Clinic, Cleveland, OH.
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Knackstedt RW, Knackstedt T, Gastman B. Utilization of Indocyanine Green to Aid in Identifying Sentinel Lymph Nodes in Merkel Cell Cancer. J Surg Res 2018; 232:365-368. [DOI: 10.1016/j.jss.2018.06.070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 05/28/2018] [Accepted: 06/20/2018] [Indexed: 10/28/2022]
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Favril S, Stock E, Hernot S, Hesta M, Polis I, Vanderperren K, de Rooster H. Sentinel lymph node mapping by near-infrared fluorescence imaging and contrast-enhanced ultrasound in healthy dogs. Vet Comp Oncol 2018; 17:89-98. [PMID: 30311430 DOI: 10.1111/vco.12449] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 09/04/2018] [Accepted: 09/24/2018] [Indexed: 02/06/2023]
Abstract
Sentinel lymph node (SLN) mapping is a valuable and crucial diagnostic procedure in staging malignancies. We compared two non-invasive techniques, near-infrared (NIR) fluorescence imaging and contrast-enhanced ultrasound (CEUS), to identify the SLNs in three superficial anatomical regions in an animal model. Six healthy laboratory dogs were included in a proof-of-concept trial. A NIR fluorescent dye (Indocyanine Green) and microbubbles (Sonovue) were consecutively injected subdermally in the Inguinal, axillary and popliteal region to map the SLNs. Transcutaneous NIR fluorescence imaging identified SLNs in 17 out of a total of 18 occasions. CEUS identified SLNs in all regions (18/18). Whereas NIR fluorescence imaging performed better in the visualization of the afferent lymphatic tract, CEUS demonstrated different filling patterns of the SLNs, a feature potentially critical for the concept of SLN mapping in cancer patients. Both NIR fluorescence imaging and CEUS are safe, non-invasive, practical and accurate methods to perform real-time transcutaneous SLN mapping with potential in a clinical setting.
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Affiliation(s)
- Sophie Favril
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium.,Cancer Research Institute Ghent (CRIG), Ghent, Belgium
| | - Emmelie Stock
- Department of Medical Imaging of Domestic Animals, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Sophie Hernot
- Laboratory in vivo Cellular and Molecular Imaging (ICMI-BEFY/MIMA), Vrije Universiteit Brussel, Brussels, Belgium
| | - Myriam Hesta
- Laboratory of Animal Nutrition, Department of Nutrition, Genetics and Ethology, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Ingeborgh Polis
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Katrien Vanderperren
- Department of Medical Imaging of Domestic Animals, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Hilde de Rooster
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium.,Cancer Research Institute Ghent (CRIG), Ghent, Belgium
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Pavri SN, Gary C, Martinez RS, Kim S, Han D, Ariyan S, Narayan D. Nonvisualization of Sentinel Lymph Nodes by Lymphoscintigraphy in Primary Cutaneous Melanoma: Incidence, Risk Factors, and a Review of Management Options. Plast Reconstr Surg 2018; 142:527e-534e. [PMID: 30020233 DOI: 10.1097/prs.0000000000004771] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Lymphoscintigraphy is often performed before sentinel lymph node biopsy, especially in areas likely to have multiple or aberrant drainage patterns. This study aims to determine the incidence and characteristics of melanoma patients with negative lymphoscintigraphic findings and to review the management options and surgical recommendations. METHODS This is a retrospective study of patients with primary cutaneous melanoma who underwent sentinel lymph node biopsy between 2005 and 2016. Patients with nonvisualized lymph nodes on preoperative lymphoscintigraphy were compared in a 1:4 ratio with a randomly selected unmatched cohort drawn from all melanoma patients who underwent preoperative lymphoscintigraphy within the period of the study. Demographic, clinical, and outcome data were compared between these groups. RESULTS A negative lymphoscintigraphic scan was seen in 2.3 percent of all cases (25 of 1073). In both univariate and multivariate analyses, predictive patient- and tumor-specific factors for negative lymphoscintigraphy included older age and head and neck location. Patients with a nonvisualized sentinel lymph node had significantly worse overall survival compared with patients who had a visualized sentinel lymph node, but there was no difference in melanoma-specific survival. In 16 of the 25 cases (64 percent), at least one sentinel lymph node was found intraoperatively despite the negative lymphoscintigraphic findings. CONCLUSIONS Older patients with head and neck melanomas are more likely to experience nodal nonvisualization on lymphoscintigraphy. In patients who have nodal nonvisualization, the surgeon should attempt sentinel lymph node biopsy at the time of excision of the primary lesion because a sentinel lymph node can still be found in a majority of cases, and it offers prognostic information. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Affiliation(s)
- Sabrina Nicole Pavri
- From the Department of Surgery, Sections of Plastic and Reconstructive Surgery and Surgical Oncology, Yale University School of Medicine
| | - Cyril Gary
- From the Department of Surgery, Sections of Plastic and Reconstructive Surgery and Surgical Oncology, Yale University School of Medicine
| | - Rajendra Sawh Martinez
- From the Department of Surgery, Sections of Plastic and Reconstructive Surgery and Surgical Oncology, Yale University School of Medicine
| | - Samuel Kim
- From the Department of Surgery, Sections of Plastic and Reconstructive Surgery and Surgical Oncology, Yale University School of Medicine
| | - Dale Han
- From the Department of Surgery, Sections of Plastic and Reconstructive Surgery and Surgical Oncology, Yale University School of Medicine
| | - Stephan Ariyan
- From the Department of Surgery, Sections of Plastic and Reconstructive Surgery and Surgical Oncology, Yale University School of Medicine
| | - Deepak Narayan
- From the Department of Surgery, Sections of Plastic and Reconstructive Surgery and Surgical Oncology, Yale University School of Medicine
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Favril S, Abma E, Blasi F, Stock E, Devriendt N, Vanderperren K, de Rooster H. Clinical use of organic near-infrared fluorescent contrast agents in image-guided oncologic procedures and its potential in veterinary oncology. Vet Rec 2018; 183:354. [DOI: 10.1136/vr.104851] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 04/11/2018] [Accepted: 04/17/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Sophie Favril
- Small Animal Department, Faculty of Veterinary Medicine; Ghent University; Merelbeke Belgium
- Cancer Research Institute Ghent (CRIG); Ghent Belgium
| | - Eline Abma
- Small Animal Department, Faculty of Veterinary Medicine; Ghent University; Merelbeke Belgium
- Cancer Research Institute Ghent (CRIG); Ghent Belgium
| | - Francesco Blasi
- Ephoran Multi-Imaging Solutions s.r.l.; Colleretto Giacosa Italy
| | - Emmelie Stock
- Department of Medical Imaging of Domestic Animals, Faculty of Veterinary Medicine; Ghent University; Merelbeke Belgium
| | - Nausikaa Devriendt
- Small Animal Department, Faculty of Veterinary Medicine; Ghent University; Merelbeke Belgium
| | - Katrien Vanderperren
- Department of Medical Imaging of Domestic Animals, Faculty of Veterinary Medicine; Ghent University; Merelbeke Belgium
| | - Hilde de Rooster
- Small Animal Department, Faculty of Veterinary Medicine; Ghent University; Merelbeke Belgium
- Cancer Research Institute Ghent (CRIG); Ghent Belgium
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Vahabzadeh-Hagh AM, Blackwell KE, Abemayor E, St John MA. Sentinel lymph node biopsy in cutaneous melanoma of the head and neck using the indocyanine green SPY Elite system. Am J Otolaryngol 2018; 39:485-488. [PMID: 29803536 DOI: 10.1016/j.amjoto.2018.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 05/17/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE Lymph node status is the single most important prognostic factor for patients with early-stage cutaneous melanoma. Sentinel lymph node biopsy (SLNB) has become the standard of care for intermediate depth melanomas. Modern SLNB implementation includes technetium-99 lymphoscintigraphy combined with local administration of a vital blue dye. However, sentinel lymph nodes may fail to localize in some cases and false-negative rates range from 0 to 34%. Here we demonstrate the feasibility of a new sentinel lymph node biopsy technique using indocyanine green (ICG) and the SPY Elite near-infrared imaging system. MATERIALS AND METHODS Cases of primary cutaneous melanoma of the head and neck without locoregional metastasis, underwent SLNB at a single quaternary care institution between May 2016 and June 2017. Intraoperatively, 0.25 mL of ICG was injected intradermal in 4 quadrants around the primary lesion. 10-15 minute circulation time was permitted. SPY Elite identified the sentinel lymph node within the nodal basin marked by lymphoscintigraphy. Target first echelon lymph nodes were confirmed with a gamma probe and ICG fluorescence. RESULTS 14 patients were included with T1a to T4b cutaneous melanomas. Success rates for sentinel lymph node identification using lymphoscintigraphy and the SPY Elite system were both 86%. Zero false negatives occurred. Median length of follow-up was 323 days. CONCLUSIONS In this pilot study, Indocyanine green near-infrared fluorescence demonstrates a safe, and facile method of sentinel lymph node biopsy for cutaneous melanoma of the head and neck compared with lymphoscintigraphy and vital blue dyes.
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Affiliation(s)
- Andrew M Vahabzadeh-Hagh
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave, 62-132, Los Angeles, CA 90095, USA.
| | - Keith E Blackwell
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave, 62-132, Los Angeles, CA 90095, USA.
| | - Elliot Abemayor
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave, 62-132, Los Angeles, CA 90095, USA.
| | - Maie A St John
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave, 62-132, Los Angeles, CA 90095, USA.
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Pameijer CR, Leung A, Neves RI, Zhu J. Indocyanine green and fluorescence lymphangiography for sentinel node identification in patients with melanoma. Am J Surg 2018; 216:558-561. [DOI: 10.1016/j.amjsurg.2018.01.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 11/29/2017] [Accepted: 01/04/2018] [Indexed: 10/18/2022]
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Indocyanine green fluorescence imaging with lymphoscintigraphy for sentinel node biopsy in head and neck melanoma. J Surg Res 2018; 228:77-83. [DOI: 10.1016/j.jss.2018.02.064] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 11/11/2017] [Accepted: 02/27/2018] [Indexed: 02/05/2023]
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Determining the False-Negative Rate Using Fluorescence Image–Assisted Sentinel Lymph Node Biopsy in Cutaneous Melanoma. Ann Plast Surg 2018; 80:54-58. [DOI: 10.1097/sap.0000000000001211] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Use of Indocyanine Green for Sentinel Lymph Node Biopsy: Case Series and Methods Comparison. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1566. [PMID: 29263967 PMCID: PMC5732673 DOI: 10.1097/gox.0000000000001566] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 09/22/2017] [Indexed: 11/03/2022]
Abstract
Introduction: Sentinel lymph node biopsy is indicated for patients with biopsy-proven thickness melanoma greater than 1.0 mm. Use of lymphoscintigraphy along with vital blue dyes is the gold standard for identifying sentinel lymph nodes intraoperatively. Indocyanine green (ICG) has recently been used as a method of identifying sentinel lymph nodes. We herein describe a case series of patients who have successfully undergone ICG-assisted sentinel lymph node biopsy for melanoma. We compare 2 imaging systems that are used for ICG-assisted sentinel lymph node biopsy. Methods: Fourteen patients underwent ICG-assisted sentinel lymph node biopsy for melanoma using the SPY Elite system (Novadaq, Mississigua, Canada) and the Hamamatsu PDE-Neo probe system (Mitaka USA, Park City, Utah). We analyzed costs for 2 systems that utilize ICG for sentinel lymph node biopsies. Results: Intraoperative use of ICG for sentinel lymph node biopsies was successful in correctly identifying sentinel lymph nodes. There was no difference between the Hamamatsu PDE-Neo probe and SPY Elite systems in the ability to detect sentinel lymph nodes; however, the former was associated with a lower operating cost and ease of use compared with the latter. Conclusion: ICG-assisted sentinel lymph biopsy using the SPY Elite or the Hamamatsu PDE-Neo probe systems for melanoma are comparable in terms of sentinel node detection. The Neo probe system delivers pertinent clinical data with the advantages of lower cost and ease of operation.
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Burnier P, Niddam J, Bosc R, Hersant B, Meningaud JP. Indocyanine green applications in plastic surgery: A review of the literature. J Plast Reconstr Aesthet Surg 2017; 70:814-827. [PMID: 28292569 DOI: 10.1016/j.bjps.2017.01.020] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 12/12/2016] [Accepted: 01/31/2017] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Use of indocyanine green (ICG) near-infrared fluorescence as a dye to assess tissue vascularization is now well standardized. The aim of this literature review was to review and resume the most recent recommendations for ICG use in its plastic surgery applications. METHODS A systematic literature review was performed using Medline, EMBASE, and PubMed databases to obtain the latest recommendations for ICG in plastic surgery. Inclusion criteria were all articles written in English language that evaluated pre-, intra-, or postoperative ICG applications in surgical procedures usually performed by plastic surgeons. Case reports, reviews, meta-analyses, and experimental studies on animals or cadavers were excluded after title and abstract screening. RESULTS Of the 1389 article titles retrieved, 41 full-text articles met the inclusion criteria. ICG applications in plastic surgery were ICG lymphangiography used in sentinel lymph node mapping for breast cancer and melanoma and in microsurgery for the staging and treatment of secondary chronic lymphedema. The latest updates of ICG angiography in assessing free flaps, pedicled flaps, or large skin paddles were also retrieved. CONCLUSIONS Large prospective studies suggest that ICG lymphography could be used as a single tracer to reliably perform sentinel lymph node biopsy. In the case of cutaneous melanoma, ICG lymphography increases node detection sensitivity and accuracy in conjunction with lymphoscintigraphy. In chronic lymphedema, it is useful for pre- and postoperative staging and intraoperative anatomical location of lymphatic pathways when lymphovenous bypass is indicated. ICG angiography is used intraoperatively to assess free flap anastomosis and design skin paddles and postoperatively to monitor buried flaps. In pedicled perforator flaps or for large skin paddles, intraoperative ICG angiography is strongly correlated with postoperative outcomes. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Pierre Burnier
- Department of Plastic & Reconstructive Surgery, Henri Mondor Hospital, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil 94010, France
| | - Jérémy Niddam
- Department of Plastic & Reconstructive Surgery, Henri Mondor Hospital, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil 94010, France.
| | - Romain Bosc
- Department of Plastic & Reconstructive Surgery, Henri Mondor Hospital, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil 94010, France
| | - Barbara Hersant
- Department of Plastic & Reconstructive Surgery, Henri Mondor Hospital, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil 94010, France
| | - Jean-Paul Meningaud
- Department of Plastic & Reconstructive Surgery, Henri Mondor Hospital, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil 94010, France
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Oude Ophuis CM, Koppert L(LB, Monyé CD, Deurzen CHV, Koljenović S, Akkooi ACV, Verhoef C(K, Grünhagen DJ. Gamma probe and ultrasound guided fine needle aspiration cytology of the sentinel node (GULF) trial - overview of the literature, pilot and study protocol. BMC Cancer 2017; 17:258. [PMID: 28403815 PMCID: PMC5389093 DOI: 10.1186/s12885-017-3236-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 03/25/2017] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Sentinel node (SN) biopsy (SNB) detects clinically occult metastases of breast cancer and melanoma in 20-30%. Wound infections, seroma and lymph edema occur in up to 10%. Targeted ultrasound (US) of the SN, (with fine needle aspiration cytology (FNAC) if appropriate) has been investigated as a minimally invasive alternative, but reported sensitivity rates are too low to replace SNB. Our hypothesis is that the use of a handheld gamma probe concomitant with US may improve sensitivity. Our aim is to provide an overview of the current literature on preoperative nodal staging of clinical N0 melanoma patients, report on a pilot, and present a study protocol for a minimally invasive alternative to the SNB: Gamma probe and Ultrasound guided Fine needle aspiration cytology of the sentinel node (GULF trial). METHODS The GULF trial is a multicenter open single arm observational trial. Newly diagnosed cT1b-4N0M0 cutaneous melanoma or cT1-3N0M0 breast cancer patients, aged >18 years, presenting for SNB are eligible. 120 patients will be included for preoperative targeted gamma probe guided US and FNAC of the SN. Afterwards all patients proceed to surgical SNB. Primary endpoint is the sensitivity of FNAC. Secondary endpoints include SN identification rate and the histopathological compatibility of Core Needle Biopsy and FNAC vs. SNB. Secondary endpoints were investigated in a pilot with 10 FNACs and marker placements, and 10 FNACs combined with Core Needle Biopsy. RESULTS A pilot in 20 patients showed that SN identification rate was 90%, supporting the feasibility of this technique. DISCUSSION There is broad experience with US (in combination with FNAC) prior to SNB, but sensitivity and specificity are too low to completely abandon SNB. Promising alternative techniques potentially will replace SNB in the future but more evidence is needed in the form of prospective studies. Accurate identification of the SN for US-FNAC has been proven feasible in our pilot. When adequate sensitivity can be reached, US-FNAC provides a minimally invasive alternative for the surgical SNB procedure. TRIAL REGISTRATION The GULF trial is registered in the Netherlands Trial Registry (NTR), ID: NRT5193 . May 1st 2015.
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Affiliation(s)
- Charlotte M.C. Oude Ophuis
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 Rotterdam, EA The Netherlands
| | - Lisa (Linetta) B. Koppert
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 Rotterdam, EA The Netherlands
| | - Cécile de Monyé
- Department of Radiology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 Rotterdam, EA The Netherlands
| | | | - Senada Koljenović
- Department of Pathology, Erasmus Medical Center, Wytemaweg 80, 3015 Rotterdam, CN The Netherlands
| | - Alexander C.J. van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute – Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 Amsterdam, CX The Netherlands
| | - Cornelis (Kees) Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 Rotterdam, EA The Netherlands
| | - Dirk J. Grünhagen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 Rotterdam, EA The Netherlands
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Madu M, Wouters M, van Akkooi A. Sentinel node biopsy in melanoma: Current controversies addressed. Eur J Surg Oncol 2017; 43:517-533. [DOI: 10.1016/j.ejso.2016.08.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 08/11/2016] [Accepted: 08/12/2016] [Indexed: 12/17/2022] Open
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Göppner D, Nekwasil S, Jellestad A, Sachse A, Schönborn K, Gollnick H. Indocyanine green‐assisted sentinel lymph node biopsy in melanoma using the “FOVIS“ system. J Dtsch Dermatol Ges 2017; 15:169-178. [DOI: 10.1111/ddg.12794] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 07/08/2015] [Indexed: 12/22/2022]
Affiliation(s)
- Daniela Göppner
- Department of Dermatology and VenereologyOtto von Guericke University Magdeburg Germany
| | - Stephan Nekwasil
- Department of Dermatology and VenereologyOtto von Guericke University Magdeburg Germany
| | - Anne Jellestad
- Department of Dermatology and VenereologyOtto von Guericke University Magdeburg Germany
| | | | | | - Harald Gollnick
- Department of Dermatology and VenereologyOtto von Guericke University Magdeburg Germany
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Göppner D, Nekwasil S, Jellestad A, Sachse A, Schönborn K, Gollnick H. Sentinel‐Lymphknoten‐Biopsie des Melanoms mittels Indocyaningrün und „FOVIS“‐System. J Dtsch Dermatol Ges 2017; 15:169-179. [DOI: 10.1111/ddg.12794_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 07/08/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Daniela Göppner
- Klinik für Dermatologie und VenerologieOtto‐von‐Guericke‐Universität Magdeburg
| | - Stephan Nekwasil
- Klinik für Dermatologie und VenerologieOtto‐von‐Guericke‐Universität Magdeburg
| | - Anne Jellestad
- Klinik für Dermatologie und VenerologieOtto‐von‐Guericke‐Universität Magdeburg
| | | | | | - Harald Gollnick
- Klinik für Dermatologie und VenerologieOtto‐von‐Guericke‐Universität Magdeburg
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Watanabe J, Ota M, Suwa Y, Ishibe A, Masui H, Nagahori K. Evaluation of lymph flow patterns in splenic flexural colon cancers using laparoscopic real-time indocyanine green fluorescence imaging. Int J Colorectal Dis 2017; 32:201-207. [PMID: 27695977 DOI: 10.1007/s00384-016-2669-4] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE The treatment of splenic flexural colon cancer is not standardized because the lymphatic drainage is variable. The aim of this study is to evaluate the lymph flow at the splenic flexure. METHODS From July 2013 to January 2016, consecutive patients of the splenic flexural colon cancer with a preoperative diagnosis of N0 who underwent laparoscopic surgery were enrolled. Primary outcome is frequency of the direction of lymph flow from splenic flexure. We injected indocyanine green (2.5 mg) into the submucosal layer around the tumor and observed lymph flow using the laparoscopic near-infrared camera system in 30 min after injection. RESULTS Thirty-one patients were enrolled in this study. The lymph flow was visualized in 31 patients (100 %) without any complications. No case exhibited lymph flow in both the left colic artery (LCA) and left branch of the middle colic artery (lt-MCA) areas. There were 19 cases (61.3 %) with lymph flow directed to the area of the root of the inferior mesenteric vein (IMV), regardless of the presence of the left accessory aberrant colic artery. Lymph node metastases were observed in six cases (19.4 %), and all of the involved lymph nodes existed in lymph flow areas determined by real-time indocyanine green fluorescence imaging. CONCLUSIONS The findings of the lymph flow pattern of splenic flexure suggest that lymph node dissection at the root of the IMV area is important, and it may be not necessary to ligate both the lt-MCA and LCA, at least in cases without widespread lymph node metastases.
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Affiliation(s)
- Jun Watanabe
- Department of Surgery, Yokosuka Kyosai Hospital, 1-16 Yonegahama Street, Yokosuka, 238-8558, Japan.
| | - Mitsuyoshi Ota
- Department of Surgery, Gastroenterological Center, Yokohama City University, Yokohama, Japan
| | - Yusuke Suwa
- Department of Surgery, Yokosuka Kyosai Hospital, 1-16 Yonegahama Street, Yokosuka, 238-8558, Japan
| | - Atsushi Ishibe
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, 236-0004, Japan
| | - Hidenobu Masui
- Department of Surgery, Yokosuka Kyosai Hospital, 1-16 Yonegahama Street, Yokosuka, 238-8558, Japan
| | - Kaoru Nagahori
- Department of Surgery, Yokosuka Kyosai Hospital, 1-16 Yonegahama Street, Yokosuka, 238-8558, Japan
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Real-Time Indocyanine Green Fluorescence Imaging-Guided Complete Mesocolic Excision in Laparoscopic Flexural Colon Cancer Surgery. Dis Colon Rectum 2016; 59:701-5. [PMID: 27270525 DOI: 10.1097/dcr.0000000000000608] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Laparoscopic surgery for colon cancer located in the hepatic flexure or splenic flexure is not standardized, because lymphatic drainage at this site may vary and the precise site of lymphatic dissection is uncertain. TECHNIQUE Indocyanine green was injected into the submucosal layer around the tumor at 2 points with a 23-gauge localized injection before lymph node dissection and the lymph flow was observed using a near-infrared camera system 30 minutes after injection. In addition, a complete mesocolic excision with central vascular ligation guided the region where the lymph flow was fluorescently observed. RESULTS A total of 20 consecutive patients (hepatic flexure, 10 patients; splenic flexure, 10 patients) were enrolled in this study. All of the procedures were safely performed without any complications. The lymph flow was visualized in 19 patients (95%) intraoperatively. Modification of the operative methods was required for 5 patients (modification in the separation line of the mesocolon and vessel selection for central vascular ligation) because the area of lymph flow observed during surgery differed from that of the preoperative diagnosis. CONCLUSION Intraoperative real-time visualization of the lymph flow using indocyanine green fluorescence imaging during laparoscopic colon cancer surgery, especially flexural colon cancer surgery, is feasible and a helpful technique for identifying appropriate central vessels to be dissected and for determining an appropriate separation line of the mesentery.
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Kamila S, McEwan C, Costley D, Atchison J, Sheng Y, Hamilton GRC, Fowley C, Callan JF. Diagnostic and Therapeutic Applications of Quantum Dots in Nanomedicine. Top Curr Chem (Cham) 2016; 370:203-24. [DOI: 10.1007/978-3-319-22942-3_7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Zelken JA, Tufaro AP. Current Trends and Emerging Future of Indocyanine Green Usage in Surgery and Oncology: An Update. Ann Surg Oncol 2015; 22 Suppl 3:S1271-83. [PMID: 26193966 DOI: 10.1245/s10434-015-4743-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Indocyanine green (ICG) is a widely available dye of clinical importance that has been used for more than 50 years. Near-infrared (NIR) ICG fluorescence imaging has found a niche in cancer care since 2005, and was reviewed in 2011. There is a need for a comprehensive update and we aim to provide this through a review of the most recent literature. METHODS A systematic review of the literature using PubMed, EMBASE, and MEDLINE databases of articles published from 2000 to June 2015 evaluated topics pertinent to NIR fluorescence imaging with ICG in the diagnosis and surgical treatment of cancer. Articles previously referenced in a 2011 review and a 2015 meta-analysis were excluded, while articles that referenced future directions and economics were included in this current review. RESULTS Since 2011, the literature has grown exponentially, with significant advances at the molecular level. Significant findings from 89 select articles and 10 reviews, most of which were published between 2011 and 2015, are summarized. Preclinical studies are currently underway investigating tumor-specific fluorescence and targeted therapeutic delivery. The potential for ICG exists at every level of cancer care, from diagnosis to surveillance. CONCLUSION The indications, applications, and potential for ICG have grown exponentially in the past decade; an updated review of the literature is overdue and we present the most comprehensive review to date.
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Affiliation(s)
- Jonathan A Zelken
- Finesse Plastic Surgery, Orange, CA, USA. .,Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
| | - Anthony P Tufaro
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.,Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Hospital, Baltimore, MD, USA
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Cloyd JM, Wapnir IL, Read BM, Swetter S, Greco RS. Indocyanine green and fluorescence lymphangiography for sentinel lymph node identification in cutaneous melanoma. J Surg Oncol 2014; 110:888-92. [PMID: 25124992 DOI: 10.1002/jso.23745] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 07/01/2014] [Accepted: 07/10/2014] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Sentinel lymph node (SLN) biopsy has become the standard method of determining regional lymph node involvement in cutaneous melanoma. Although traditionally performed via injection of radioisotope tracers and blue dyes, fluorescent lymphangiography with indocyanine green (ICG) is an attractive alternative. METHODS Fifty two consecutive patients with cutaneous melanoma of the trunk or extremities underwent SLNB. Preoperative lymphoscintigraphy was performed with technetium-99m sulfur colloid (TSC). Peritumoral intradermal injection of isosulfan blue (ISB) and ICG was then performed. Successful identification of a sentinel lymph node via each modality was then assessed. RESULTS A total of 77 lymph nodes were identified from the 52 patients (range 1-3). The majority of melanomas were extremity-based, superficial spreading type, and had SLN localized to the axilla. There were no complications related to IcG administration. Rates of SLN detection were 96.2% for TSC, 59.6% for ISB, and 88.5% for IcG (P < 0.05 for ICG vs ISB). On univariate logistic regression analysis, no factors were found to be associated with failure of ICG. CONCLUSIONS Fluorescent lymphangiography using ICG is an effective method of SLN identification in patients with cutaneous melanoma of the trunk and extremities. When ICG and TSC are used in combination, ISB offers no additional advantage and may be safely omitted.
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Affiliation(s)
- Jordan M Cloyd
- Department of Surgery, Stanford University, Stanford, CA
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Boni L, David G, Mangano A, Dionigi G, Rausei S, Spampatti S, Cassinotti E, Fingerhut A. Clinical applications of indocyanine green (ICG) enhanced fluorescence in laparoscopic surgery. Surg Endosc 2014; 29:2046-55. [PMID: 25303914 PMCID: PMC4471386 DOI: 10.1007/s00464-014-3895-x] [Citation(s) in RCA: 314] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 09/08/2014] [Indexed: 02/06/2023]
Abstract
Background Recently major developments in video imaging have been achieved: among these, the use of high definition and 3D imaging systems, and more recently indocyanine green (ICG) fluorescence imaging are emerging as major contributions to intraoperative decision making during surgical procedures. The aim of this study was to present our experience with different laparoscopic procedures using ICG fluorescence imaging.
Patients and methods 108 ICG-enhanced fluorescence-guided laparoscopic procedures were performed: 52 laparoscopic cholecystectomies, 38 colorectal resections, 8 living-donor nephrectomies, 1 laparoscopic kidney autotransplantation, 3 inguino-iliac/obturator lymph node dissections for melanoma, and 6 miscellanea procedures. Visualization of structures was provided by a high definition stereoscopic camera connected to a 30° 10 mm scope equipped with a specific lens and light source emitting both visible and near infra-red (NIR) light (KARL STORZ GmbH & Co. KG, Tuttlingen, Germany). After injection of ICG, the system projected high-resolution NIR real-time images of blood flow in vessels and organs as well as highlighted biliary excretion . Results No intraoperataive or injection-related adverse effects were reported, and the biliary/vascular anatomy was always clearly identified. The imaging system provided invaluable information to conduct a safe cholecystectomy and ensure adequate vascular supply for colectomy, nephrectomy, or find lymph nodes. There were no bile duct injuries or anastomotic leaks. Conclusions In our experience, the ICG fluorescence imaging system seems to be simple, safe, and useful. The technique may well become a standard in the near future in view of its different diagnostic and oncological capabilities. Larger studies and more specific evaluations are needed to confirm its role and to address its disadvantages.
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Affiliation(s)
- Luigi Boni
- Minimally Invasive Surgery Research Center, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy,
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