Residual cancerous lesion and vein tumour thrombus identified intraoperatively using a fluorescence navigation system in liver surgery

Superstable homogeneous lipiodol-ICG formulation: initial feasibility and first-in-human clinical application for ruptured hepatocellular carcinoma

The most common treatment of spontaneous tumor rupture hemorrhage (STRH) is transcatheter arterial embolization (TAE) followed by liver resection, and surgical navigation using near-infrared fluorescence is effective method for detecting hidden lesions and ill-defined tumor boundaries. However, due to the blockage of the tumor-supplying artery after effective TAE treatment, it is difficult to deliver sufficient fluorescent probes to the tumor region. In this study, we report on the successful application of superstable homogeneous intermixed formulation technology (SHIFT) in precise conversion hepatectomy for ruptured hepatocellular carcinoma (HCC). A homogeneous lipiodol-ICG formulation obtained by SHIFT (SHIFT-ICG) was developed for clinical practice for STRH. A ruptured HCC patient received the combined protocol for embolization and fluorescence surgical navigation and exhibited excellent hemostatic effect. Lipiodol and ICG were both effectively deposited in the primary lesion, including a small metastatic lesion. In follow-up laparoscopic hepatectomy, SHIFT-ICG could clearly and precisely image the full tumor regions and boundaries in real time, and even indistinguishable satellite lesions still expressed a remarkable fluorescence intensity. In conclusion, the simple and green SHIFT-ICG formulation can be effectively used in emergency embolization hemostasis and later precise fluorescence navigation hepatectomy in patients with ruptured HCC bleeding and has high clinical application value.

A clinical trial of super-stable homogeneous lipiodol-nanoICG formulation-guided precise fluorescent laparoscopic hepatocellular carcinoma resection

Background

Applying traditional fluorescence navigation technologies in hepatocellular carcinoma is severely restricted by high false-positive rates, variable tumor differentiation, and unstable fluorescence performance.

Results

In this study, a green, economical and safe nanomedicine formulation technology was developed to construct carrier-free indocyanine green nanoparticles (nanoICG) with a small uniform size and better fluorescent properties without any molecular structure changes compared to the ICG molecule. Subsequently, nanoICG dispersed into lipiodol via a super-stable homogeneous intermixed formulation technology (SHIFT&nanoICG) for transhepatic arterial embolization combined with fluorescent laparoscopic hepatectomy to eliminate the existing shortcomings. A 52-year-old liver cancer patient was recruited for the clinical trial of SHIFT&nanoICG. We demonstrate that SHIFT&nanoICG could accurately identify and mark the lesion with excellent stability, embolism, optical imaging performance, and higher tumor-to-normal tissue ratio, especially in the detection of the microsatellite lesions (0.4 × 0.3 cm), which could not be detected by preoperative imaging, to realize a complete resection of hepatocellular carcinoma under fluorescence laparoscopy in a shorter period (within 2 h) and with less intraoperative blood loss (50 mL).

Conclusions

This simple and effective strategy integrates the diagnosis and treatment of hepatocellular carcinoma, and thus, it has great potential in various clinical applications.

Supplementary information

The online version contains supplementary material available at 10.1186/s12951-022-01467-w.

Fluorescence imaging in the surgical management of liver cancers: Current status and future perspectives

Over the last decades, imaging technologies have got significant developments and become indispensable in the surgical management of liver cancers. Real-time navigation afforded by intraoperative images has a significant impact on the success of liver surgeries. Fluorescence imaging in the near-infrared spectrum has shown potential for tumor detection and image-guided surgery in clinics. While predominantly focused on indocyanine green (ICG) imaging, there is also accelerated development of more specific molecular tracers. Compared to passive targeting contrast agents ICG, active targeting and activatable probes both shed new light for intraoperative navigation owing to the higher degree of specificity for the tumor target. A variety of fluorescence imaging probes have been developed to target biomarkers unique to cancer cells or tumor microenvironment and demonstrated promising results. In this review, we provide a comprehensive update on preclinical development and clinical applications of fluorescence imaging in the surgical management of liver cancers. By highlighting the current status, we aim to offer insight into the challenges and opportunities for further investigation.

Targeting Contrast Agents With Peak Near-Infrared-II (NIR-II) Fluorescence Emission for Non-invasive Real-Time Direct Visualization of Thrombosis

Thrombosis within the vasculature arises when pathological factors compromise normal hemostasis. On doing so, arterial thrombosis (AT) and venous thrombosis (VT) can lead to life-threatening cardio-cerebrovascular complications. Unfortunately, the therapeutic window following the onset of AT and VT is insufficient for effective treatment. As such, acute AT is the leading cause of heart attacks and constitutes ∼80% of stroke incidences, while acute VT can lead to fatal therapy complications. Early lesion detection, their accurate identification, and the subsequent appropriate treatment of thrombi can reduce the risk of thrombosis as well as its sequelae. As the success rate of therapy of fresh thrombi is higher than that of old thrombi, detection of the former and accurate identification of lesions as thrombi are of paramount importance. Magnetic resonance imaging, x-ray computed tomography (CT), and ultrasound (US) are the conventional non-invasive imaging modalities used for the detection and identification of AT and VT, but these modalities have the drawback of providing only image-delayed indirect visualization of only late stages of thrombi development. To overcome such limitations, near-infrared (NIR, ca. 700-1,700 nm) fluorescence (NIRF) imaging has been implemented due to its capability of providing non-invasive real-time direct visualization of biological structures and processes. Contrast agents designed for providing real-time direct or indirect visualization of thrombi using NIRF imaging primarily provide peak NIR-I fluorescence emission (ca. 700-1,000 nm), which affords limited tissue penetration depth and suboptimal spatiotemporal resolution. To facilitate the enhancement of the visualization of thrombosis via providing detection of smaller, fresh, and/or deep-seated thrombi in real time, the development of contrast agents with peak NIR-II fluorescence emission (ca. 1000-1,700 nm) has been recently underway. Currently, however, most contrast agents that provide peak NIR-II fluorescence emissions that are purportedly capable of providing direct visualization of thrombi or their resultant occlusions actually afford only the indirect visualization of such because they only provide for the (i) measuring of the surrounding vascular blood flow and/or (ii) simple tracing of the vasculature. These contrast agents do not target thrombi or occlusions. As such, this mini review summarizes the extremely limited number of targeting contrast agents with peak NIR-II fluorescence emission developed for non-invasive real-time direct visualization of thrombosis that have been recently reported.

Application of Near-Infrared Fluorescence Imaging Technology in Liver Cancer Surgery

Background. Hepatocellular carcinoma, among the most common malignant digestive system tumorsworldwide, is most effectively treated with precise surgical resection. Near-infrared fluorescence imaging technology is being increasingly used clinically and has achieved great initial results in the navigation of liver cancer surgery. Methods. This review describes the application of indocyanine green fluorescence (ICG) imaging technology with near-infrared window I in the navigation of liver cancer surgery, explores novel fluorescent probes and near-infrared window II fluorescence imaging technology, and discusses the development status of the 2 emerging tools. Results. ICG fluorescence imaging technology can precisely localize the tumor, reveal the boundary of liver cancer or liver segment, and identify the bile leakage. The novel fluorescent probe is more targeted than ICG, which makes the detection of cancer more accurate. Near-infrared window II fluorescence imaging technology can lead to outstanding gains in deeper detection, higher resolution, and fidelity. But, due to the shortcomings of machine and probe, it is not widely used in clinical. Conclusion. Near-infrared fluorescence imaging has great development potential. With the advent of precision medicine and the progress of various biotechnology studies, fluorescence imaging technology will be better developed and applied in the diagnosis, surgical navigation, and treatment of liver cancer.

Meta-analysis of infrahepatic inferior vena cava clamping combined with the pringle maneuver during hepatectomy

This meta-analysis was conducted to evaluate the effectiveness and safety of infrahepatic inferior vena cava clamping combined with the Pringle maneuver during. hepatectomies. Clinical studies were retrieved from the PubMed, Embase, Cochrane Library, Medline and Web of Science databases. Study-specific effect sizes and their 95% confidence intervals (CIs) were combined to calculate the pooled value using a fixed-effects or random-effects model.Nine studies with 1008 patients in total were included. The infrahepatic inferior vena cava clamping combined with Pringle maneuver group experienced less total operative blood loss (mean difference [MD] = -327.11; 95% CI: -386.50-267.72; P < 0.00001), less blood loss during transection (MD = -270.19; 95% CI: -344.99-195.38; P < 0.00001), fewer blood transfusions (odds ratio [OR] = 0.36; 95% CI: 0.25-0.53;P < 0.00001) and fewer postoperative complications (OR = 0.70; 95% CI: 0.52-0.95; P = 0.02) than did the control group. Operative time (MD = 8.54; 95% CI: 4.68-12.40; P < 0.0001) was similar in both groups. liver transection time,hospital stay, postoperative liver function and renal function did not differ between groups.Applying infrahepatic inferior vena cava clamping combined with the Pringle maneuver can effectively reduce intraoperative bleeding, blood transfusion rates, and postoperative complications, while adding minimal time to the operation.