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Park JH, Berlth F, Wang C, Wang S, Choi JH, Park SH, Suh YS, Kong SH, Park DJ, Lee HJ, Kwak Y, Kim WH, Yang HK. Mapping of the perigastric lymphatic network using indocyanine green fluorescence imaging and tissue marking dye in clinically advanced gastric cancer. Eur J Surg Oncol 2021; 48:411-417. [PMID: 34625304 DOI: 10.1016/j.ejso.2021.08.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/15/2021] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Using indocyanine green (ICG) fluorescence imaging and tissue marking dyes (TMDs), perigastric lymphatic mapping and their pathological correlation were examined to see whether ICG staining covers all metastatic lymph nodes (LNs) in advanced gastric cancer (AGC). METHODS Patients with AGC who underwent open distal or total gastrectomy were enrolled. ICG was serially injected intraoperatively into the subserosa along the greater and lesser curvatures. Stomach specimens were examined under a near-infrared camera. ICG-stained LNs were named, excised, and tattooed with different colored TMDs to retrace the exact location after pathological examinations. RESULTS A total of 687 LNs and 69 LN stations were examined from 11 patients. The map of the perigastric lymphatic network showing the topography of ICG-stained and ICG-unstained LNs, including metastatic information, was successfully reconstructed. The average number of ICG-stained and ICG-unstained LNs were 23.6 ± 12.3 (37.8%) and 38.8 ± 17.1 (62.2%), respectively. LN metastases were present in 28 LN stations of 8 patients. Of 8 cases with LN metastases, 40% (11.1-75% per case) of metastatic LNs were stained by ICG. Of 28 metastatic LN stations, 21 (75.0%) were covered by ICG, and actual metastatic LNs were stained in 16 LN stations (57.1%). In 4/8 cases (50%), all metastatic LN stations showed ICG signals. CONCLUSIONS ICG fluorescence imaging and TMD are useful tools for visualizing the perigastric lymphatic network and retracing the exact location of ICG-stained LNs in AGC. However, ICG imaging is still not recommended for selective LN dissection in AGC because of the limited staining of perigastric LNs.
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Affiliation(s)
- Ji-Hyeon Park
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Felix Berlth
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea; Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Chaojie Wang
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Sen Wang
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Jong-Ho Choi
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Shin-Hoo Park
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Yun-Suhk Suh
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Seong-Ho Kong
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea; Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Do Joong Park
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea; Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea; Cancer Research Institute, Seoul National University, Seoul, South Korea
| | - Hyuk-Joon Lee
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea; Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea; Cancer Research Institute, Seoul National University, Seoul, South Korea
| | - Yoonjin Kwak
- Department of Pathology, Seoul National University College of Medicine, Seoul, South Korea
| | - Woo Ho Kim
- Department of Pathology, Seoul National University College of Medicine, Seoul, South Korea
| | - Han-Kwang Yang
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea; Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea; Cancer Research Institute, Seoul National University, Seoul, South Korea.
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Matsuda S, Irino T, Kawakubo H, Takeuchi H, Kitagawa Y. Current status and challenges in sentinel node navigation surgery for early gastric cancer. Chin J Cancer Res 2021; 33:150-158. [PMID: 34158735 PMCID: PMC8181877 DOI: 10.21147/j.issn.1000-9604.2021.02.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
As an optimal surgical procedure to accurately evaluate lymph node (LN) metastasis during surgery with minimal surgical resection, we have been developing sentinel node (SN) biopsy for early gastric cancer since the 1990s. Twelve institutions from the Japanese Society of Sentinel Node Navigation Surgery (SNNS), including Keio University Hospital, conducted a multicenter prospective trial to validate the SN concept using the dual-tracer method with blue dye and a radioisotope. According to the results, 397 patients were included in the final analysis, and the overall accuracy in detecting LN metastasis using SN biopsy was 99% (383 of 387). Based on the validation study, we are targeting cT1N0 with a primary tumor of ≤4 cm in diameter as an indication for SN biopsy for gastric cancer. We are currently running a multicenter nonrandomized phase III trial to assess the safety and efficacy of SN navigation surgery. The Korean group has reported the result of a multicenter randomized phase III trial. Since meticulous gastric cancer in the remnant stomach was rescued by subsequent gastrectomy, the disease-specific survival was comparable between the two techniques, implying that SN navigation surgery can be an alternative to standard gastrectomy. With the development of SN biopsy procedure and treatment modalities, the application of SN biopsy will be expanded to achieve an individualized minimally invasive surgery.
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Affiliation(s)
- Satoru Matsuda
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Tomoyuki Irino
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Hamamatsu University School of Medicine, Shizuoka 431-3192, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
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Possibility of limited gastrectomy for early gastric cancer located in the upper third of the stomach, based on the distribution of sentinel node basins. Surg Today 2019; 49:529-535. [PMID: 30684050 DOI: 10.1007/s00595-019-1768-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 12/30/2018] [Indexed: 12/22/2022]
Abstract
PURPOSE Several recent studies have evaluated the feasibility of the sentinel node (SN) concept for gastric cancer. The aim of our study was to investigate limited gastrectomy with SN basin dissection in SN navigation surgery (SNNS) for patients with early-gastric cancer located in the upper-third of the stomach. METHODS 147 patients received SNNS for early-gastric cancer at our institution. Of these, 26 patients diagnosed with early-gastric cancer < 4 cm in size and located in the upper-third of the stomach were retrospectively analyzed for the distribution of SN and SN basins. RESULTS In three of the 26 patients, lymph node metastasis was limited to the left gastric artery (LGA) basin. The breakdown of the basins were as follows: A single LGA basin, 19 cases; a non-single LGA basin, seven cases. A non-single LGA basin was significantly associated with the clinicopathological factors, such as tumor spread to the middle-third of the stomach, tumor location at the center of the greater curvature, and undifferentiated adenocarcinoma, compared to the single LGA basin group. CONCLUSIONS Our data revealed that the distribution of the SN basins in early-gastric cancer measuring less than 4 cm in size and located in the upper-third of the stomach was significantly correlated with tumor spread, tumor location, and the pathological findings.
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Takeuchi H, Kitagawa Y. Sentinel node navigation surgery in esophageal cancer. Ann Gastroenterol Surg 2019; 3:7-13. [PMID: 30697605 PMCID: PMC6345658 DOI: 10.1002/ags3.12206] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 08/05/2018] [Accepted: 08/08/2018] [Indexed: 12/21/2022] Open
Abstract
Over the last 20 years, the sentinel node (SN) concept has been widely applied to the surgical staging of both breast cancer and melanoma. However, the validity of this concept has been controversial for esophageal cancer, because SN mapping for esophageal cancer is not considered to be technically easy because of the complicated multidirectional lymphatic networks of the esophagus and mediastinum. Nevertheless, studies including meta-analyses indicated that SN mapping may be feasible in early esophageal cancer. Transthoracic esophagectomy with three-field lymphadenectomy was developed as a potential curative procedure for thoracic esophageal cancer. However, this highly invasive procedure might increase morbidity and reduce patients' quality of life (QOL) after esophagectomy. Although further validation based on multicenter trials using the standard protocol of SN mapping for esophageal cancer is required, SN navigation surgery would enable us to carry out personalized and limited lymph node dissection which might reduce morbidity and maintain patients' QOL.
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Affiliation(s)
- Hiroya Takeuchi
- Department of SurgeryHamamatsu University School of MedicineHamamatsuJapan
| | - Yuko Kitagawa
- Department of SurgeryKeio University School of MedicineTokyoJapan
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He M, Jiang Z, Wang C, Hao Z, An J, Shen J. Diagnostic value of near‐infrared or fluorescent indocyanine green guided sentinel lymph node mapping in gastric cancer: A systematic review and meta‐analysis. J Surg Oncol 2018; 118:1243-1256. [DOI: 10.1002/jso.25285] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 10/05/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Meifeng He
- Chengde Medical UniversityChengde Hebei China
| | - Zhanwu Jiang
- Baoding First Central HospitalBaoding Hebei China
| | | | - Zhiwei Hao
- Baoding First Central HospitalBaoding Hebei China
| | - Jie An
- Baoding First Central HospitalBaoding Hebei China
| | - Jiankai Shen
- Baoding First Central HospitalBaoding Hebei China
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Near-Infrared Fluorescence Lymph Node Navigation Using Indocyanine Green for Gastric Cancer Surgery. ACTA ACUST UNITED AC 2018. [DOI: 10.7602/jmis.2018.21.3.95] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Kim DW, Jeong B, Shin IH, Kang U, Lee Y, Park YS, Ahn SH, Park DJ, Kim HH. Sentinel node navigation surgery using near-infrared indocyanine green fluorescence in early gastric cancer. Surg Endosc 2018; 33:1235-1243. [PMID: 30167947 DOI: 10.1007/s00464-018-6401-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 08/20/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the feasibility of indocyanine green (ICG) fluorescent method for sentinel lymph node detection in early gastric cancer. METHODS Between December 2012 and December 2014, 28 cases of pilot examination were performed at Seoul National University Bundang Hospital. Advanced version of multispectral fluorescence organoscope was used to identify sentinel node by quantitative estimation of ICG fluorescent signal intensity. Sensitivity, specificity, false positive value were analyzed and compared with dual tracer method. RESULTS A total of 443 lymph nodes in 28 cases were examined and 184 sentinel nodes (41.5%) were identified by dual tracer method. The sensitivity using near-infrared ICG method was 98.9%. The specificity was 76.0% and false positive rate was 25.4% compared with dual tracer method. The adequate threshold for sentinel node detection was considered as 10% of maximum signal intensity. CONCLUSION New near-infrared ICG fluorescent method could be a promising protocol for sentinel node navigation surgery in early gastric cancer.
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Affiliation(s)
- Dong-Wook Kim
- Department of Surgery, Seoul National University Bundang Hospital, 300 Gumi-dong Bundang-gu, Seongnam, Gyeonggi-do, 463-707, Republic of Korea
| | - Bosu Jeong
- Advanced Medical Device Research Division, Korea Electrotechnology Research Institute, Seoul, Republic of Korea
| | - Il-Hyung Shin
- Advanced Medical Device Research Division, Korea Electrotechnology Research Institute, Seoul, Republic of Korea
| | - Uk Kang
- Advanced Medical Device Research Division, Korea Electrotechnology Research Institute, Seoul, Republic of Korea
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yoontaek Lee
- Department of Surgery, Seoul National University Bundang Hospital, 300 Gumi-dong Bundang-gu, Seongnam, Gyeonggi-do, 463-707, Republic of Korea
| | - Young Suk Park
- Department of Surgery, Seoul National University Bundang Hospital, 300 Gumi-dong Bundang-gu, Seongnam, Gyeonggi-do, 463-707, Republic of Korea
| | - Sang-Hoon Ahn
- Department of Surgery, Seoul National University Bundang Hospital, 300 Gumi-dong Bundang-gu, Seongnam, Gyeonggi-do, 463-707, Republic of Korea.
| | - Do Joong Park
- Department of Surgery, Seoul National University Bundang Hospital, 300 Gumi-dong Bundang-gu, Seongnam, Gyeonggi-do, 463-707, Republic of Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyung-Ho Kim
- Department of Surgery, Seoul National University Bundang Hospital, 300 Gumi-dong Bundang-gu, Seongnam, Gyeonggi-do, 463-707, Republic of Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
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Sentinel Node Mapping Using a Fluorescent Dye and Visible Light During Laparoscopic Gastrectomy for Early Gastric Cancer: Result of a Prospective Study From a Single Institute. Ann Surg 2017; 265:766-773. [PMID: 27058946 DOI: 10.1097/sla.0000000000001739] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the feasibility of sentinel node mapping using a fluorescent dye and visible light in patients with gastric cancer. BACKGROUND Recently, fluorescent imaging technology offers improved visibility with the possibility of better sensitivity or accuracy in sentinel node mapping. METHODS Twenty patients with early gastric cancer, for whom laparoscopic distal gastrectomy with standard lymphadenectomy had been planned, were enrolled in this study. Before lymphadenectomy, the patients received a gastrofiberoscopic peritumoral injection of fluorescein solution. The sentinel basin was investigated via laparoscopic fluorescent imaging under blue light (wavelength of 440-490 nm) emitted from an LED curing light. The detection rate and lymph node status were analyzed in the enrolled patients. In addition, short-term clinical outcomes were also investigated. RESULTS No hypersensitivity to the dye was identified in any enrolled patients. Sentinel nodes were detected in 19 of 20 enrolled patients (95.0%), and metastatic lymph nodes were found in 2 patients. The latter lymph nodes belonged to the sentinel basin of each patient. Meanwhile, 1 patient (5.0%) experienced a postoperative complication that was unrelated to sentinel node mapping. No mortality was recorded among enrolled cases. CONCLUSIONS Sentinel node mapping with visible light fluorescence was a feasible method for visualizing sentinel nodes in patients with early gastric cancer. In addition, this method is advantageous in terms of visualizing the concrete relationship between the sentinel nodes and surrounding structures.
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Takahashi N, Nimura H, Fujita T, Mitsumori N, Shiraishi N, Kitano S, Satodate H, Yanaga K. Laparoscopic sentinel node navigation surgery for early gastric cancer: a prospective multicenter trial. Langenbecks Arch Surg 2016; 402:27-32. [PMID: 27999935 DOI: 10.1007/s00423-016-1540-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 12/09/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Prospective multicenter trials have shown the feasibility of sentinel node (SN) navigation surgery using a dual tracer of dye and radioisotope for early gastric cancer. However, comparable trials using the indocyanine green (ICG) and the infrared ray laparoscopic system (IRLS) have not been reported. On the basis of our cohort studies, we assumed that the ICG imaging with the IRLS is as effective as the dual tracer in detecting SNs. Therefore, we conducted a prospective multicenter trial to assess the effectiveness and generalizability of the infrared ICG technique in patients with early gastric cancer. PATIENTS AND METHODS Patients with previously untreated cT1 gastric adenocarcinomas less than 4 cm in gross diameter were eligible for inclusion in this study. SN mapping was performed by using ICG combined with IRLS technique. Following biopsy of the identified SNs, D2 or modified D2 laparoscopic gastrectomy was performed according to the current Japanese Gastric Cancer Association guidelines. RESULTS Among the 47 patients who gave written informed consent, 44 were eligible from the surgical findings, for whom SN biopsy was performed. The detection rate of the lymphatic basin by the ICG with IRLS was 100% (44/44). The accuracy was also 100% (7/7) for detecting metastatic lymph node, which was verified on the permanent pathologic examination. Following the median follow-up of 114 months (range, 60 to 120 months), no recurrence (0/40) was observed. Although the number of patients was unequally distributed among the hospitals participating in the trial, the detection rates of SNs in low-volume hospitals were comparable to those in high-volume hospitals. Consequently, there was no learning curve in this trial. CONCLUSION The infrared ICG imaging accurately detected the lymphatic basin and SNs with occult metastasis in SN-navigated gastrectomy for gastric cancer. This method was feasible even for low-volume surgeons and hospitals.
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Affiliation(s)
- Naoto Takahashi
- Department of Surgery, Kashiwa Hospital, The Jikei University School of Medicine, 163-1 Kashiwashita, Kashiwashi, Chiba, 277-0004, Japan.
| | - Hiroshi Nimura
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Tetsuji Fujita
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Norio Mitsumori
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Norio Shiraishi
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Yufu, Oita, Japan
| | - Seigo Kitano
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Yufu, Oita, Japan
| | - Hitoshi Satodate
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Katsuhiko Yanaga
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Santos FAV, Drummond-Lage AP, Rodrigues MA, Cabral MA, Pedrosa MS, Braga H, Wainstein AJA. Sentinel node biopsy using blue dye and technetium99 in advanced gastric cancer: anatomical drainage and clinical application. ACTA ACUST UNITED AC 2016; 49:S0100-879X2016000800701. [PMID: 27409337 PMCID: PMC4954739 DOI: 10.1590/1414-431x20165341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 04/28/2016] [Indexed: 12/11/2022]
Abstract
Lymph node metastases are an independent prognosis factor in gastric carcinoma (GC) patients. Radical lymphadenectomy can improve survival but it can also increase surgical morbidity. As a principle, sentinel node (SN) navigation surgery can avoid unnecessary lymphadenectomy without compromising prognosis. In this pilot study, 24 patients with untreated GC were initially screened for SN navigation surgery, of which 12 were eligible. Five patients had T2 tumors, 5 had T3 tumors and 2 had T1 tumors. In 33% of cases, tumor diameter was greater than 5.0 cm. Three hundred and eighty-seven lymph nodes were excised with a median of 32.3 per patient. The SN navigation surgery was feasible in all patients, with a median of 4.5 SNs per patient. The detection success rate was 100%. All the SNs were located in N1 and N2 nodal level. In 70.9% of cases, the SNs were located at lymphatic chains 6 and 7. The SN sensitivity for nodal staging was 91.6%, with 8.3% of false negative. In 4 patients who were initially staged as N0, the SNs were submitted to multisection analyses and immunohistochemistry, confirming the N0 stage, without micrometastases. In one case initially staged as negative for nodal metastases based on SN analyses, metastases in lymph nodes other than SN were found, resulting in a 20% skip metastases incidence. This surgery is a reproducible procedure with 100% detection rate of SN. Tumor size, GC location and obesity were factors that imposed some limitations regarding SN identification. Results from nodal multisection histology and immunohistochemistry analysis did not change initial nodal staging.
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Affiliation(s)
- F A V Santos
- Departamento de Cirurgia, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - A P Drummond-Lage
- Instituto de Pós Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, MG, Brasil
| | - M A Rodrigues
- Departamento de Cirurgia, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - M A Cabral
- Departamento de Cirurgia, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - M S Pedrosa
- Departamento de Cirurgia, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - H Braga
- Departamento de Cirurgia, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - A J A Wainstein
- Instituto de Pós Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, MG, Brasil
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Matsuda T, Takeuchi H, Tsuwano S, Nakahara T, Mukai M, Kitagawa Y. Sentinel node mapping in adenocarcinoma of the esophagogastric junction. World J Surg 2015; 38:2337-44. [PMID: 24752362 DOI: 10.1007/s00268-014-2573-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The incidence of adenocarcinoma of the esophagogastric junction (AEG) is increasing, but the surgical strategy for AEG remains controversial. We hypothesized that sentinel node (SN) mapping for AEG could be validated to avoid unnecessary lymphadenectomy and permit minimally invasive surgery. We examined the feasibility of SN mapping for AEG. METHODS We enrolled 15 patients with preoperatively diagnosed cT1 N0 M0 primary AEG (Siewert type I, N = 3; Siewert type II, N = 12) lesions measuring <4 cm in diameter. The dual tracer method employing radioactive colloid and blue dye was used to detect SNs. The distribution of SNs was compared with that of metastatic lymph nodes in 52 patients who were surgically treated without SN mapping. RESULTS SNs were successfully identified in all the patients. Two patients with lymph node metastasis had positive SNs identified via an intraoperative pathological examination, and the diagnostic sensitivity and accuracy based on the SN status were both 100 %. For Siewert type II AEG, the SNs were not detected in the lower mediastinum by intraoperative gamma probing. Thus, all surgical procedures were performed via a transhiatal approach. No patient without SN metastasis experienced cancer recurrence during a 38-month median follow-up. The distribution of SNs was similar to that of lymph node metastasis in the patients who were surgically treated without SN mapping. CONCLUSIONS We achieved 100 % SN detection. Our results suggested that SN mapping is feasible for AEG and highly sensitive and accurate in diagnosing lymph node metastasis. SN mapping may clarify the necessity of mediastinal lymph node dissection and individualize minimally invasive surgery.
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Affiliation(s)
- Tatsuo Matsuda
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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Fujimura T, Fushida S, Tsukada T, Kinoshita J, Oyama K, Miyashita T, Takamura H, Kinami S, Ohta T. A new stage of sentinel node navigation surgery in early gastric cancer. Gastric Cancer 2015; 18:210-7. [PMID: 25433568 DOI: 10.1007/s10120-014-0446-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 11/17/2014] [Indexed: 02/07/2023]
Abstract
Sentinel node (SN) navigation surgery is expected to realize organ- and function-preserving surgery with SN mapping, and has been applied in operations for breast cancer and melanoma. But there has been no definite evidence for the SN concept in gastric cancer. A prospective multicenter trial to confirm the SN concept for gastric cancer conducted by the Japan Society of Sentinel Node Navigation Surgery reported that the SN detection rate, sensitivity of positive SNs, and accuracy of nodal status are 97.5% (387/397), 93% (53/57), and 99% (383/387), respectively. A detailed analysis of the trial suggested that strictly the "lymphatic basin concept" rather than the "SN concept" was confirmed in early gastric cancer. The Japan Society of Sentinel Node Navigation Surgery started a new trial of function-preserving gastrectomy with lymphatic basin dissection (LBD) for early gastric cancer without metastasis in SNs on the basis of this promising outcome of the trial. It is supposed that LBD guarantees curability in SN navigation surgery for early gastric cancer. Full-thickness resection or endoscopic submucosal dissection in combination with laparoscopic LBD will soon be a new treatment option for early gastric cancer.
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Affiliation(s)
- Takashi Fujimura
- Gastroenterologic Surgery, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641, Japan,
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Kim H, Lee SK, Kim YM, Lee EH, Lim SJ, Kim SH, Yang J, Lim JS, Hyung WJ. Fluorescent iodized emulsion for pre- and intraoperative sentinel lymph node imaging: validation in a preclinical model. Radiology 2014; 275:196-204. [PMID: 25474180 DOI: 10.1148/radiol.14141159] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE To validate the usefulness of a newly developed tracer for preoperative gastric sentinel lymph node (LN) (SLN) mapping and intraoperative navigation after a single preoperative submucosal injection in rat and beagle models. MATERIALS AND METHODS This study was approved by the Experimental Animal Ethical Committee of Yonsei University College of Medicine according to the eighth edition of the Guide for the Care and Use of Laboratory Animals published in 2011. An emulsion was developed that contained indocyanine green in iodized oil, which can be visualized with both computed tomography (CT) and near-infrared (NIR) optical imaging and has the property of delayed washout. This emulsion was injected into the footpad of rats (n = 6) and the gastric submucosa of beagles (n = 8). CT lymphography was performed. The degree of enhancement of popliteal LNs was measured in rats, and the enhancing LNs were identified and the degree of enhancement of the enhancing LNs was measured in beagles. Next, NIR imaging was performed in beagles during open, laparoscopic, and robotic surgery to identify LNs containing the fluorescent signals of indocyanine green. The enhanced LNs detected with CT lymphography and NIR imaging were matched to see if they corresponded. RESULTS Preoperative CT lymphography facilitated SLN mapping, and 26 SLNs were identified in eight beagles. NIR imaging enabled high-spatial-resolution visualization of both SLNs and the intervening lymphatic vessels and was useful for intraoperative SLN navigation. CONCLUSION SLN mapping with fluorescent iodized oil emulsion is effective and feasible for both CT and NIR imaging.
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Affiliation(s)
- Honsoul Kim
- From the Department of Radiology (H.K., J.Y., J.S.L.), Research Institute of Radiological Science (H.K., J.S.L.), Gastric Cancer Clinic (H.K., S.K.L., J.S.L., W.J.H.), and Department of Internal Medicine (S.K.L.), Department of Pathology (S.H.K.), YUHS-KRIBB Medical Convergence Research Institute (J.Y.), Department of Surgery (W.J.H.), and Robot and MIS Center (W.J.H.), Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea; Department of Surgery, Bundang CHA Hospital, CHA University College of Medicine, Seongnam, Republic of Korea (Y.M.K.); Department of Bioscience and Bioengineering, Sejong University, Seoul, Republic of Korea (E.H.L., S.J.L.)
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Mayanagi S, Takeuchi H, Kamiya S, Niihara M, Nakamura R, Takahashi T, Wada N, Kawakubo H, Saikawa Y, Omori T, Nakahara T, Mukai M, Kitagawa Y. Suitability of sentinel node mapping as an index of metastasis in early gastric cancer following endoscopic resection. Ann Surg Oncol 2014; 21:2987-93. [PMID: 24682720 DOI: 10.1245/s10434-014-3662-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND When pathological diagnosis following endoscopic resection (ER) for early gastric cancer (EGC) suggests probable lymph node metastasis, additional surgery with lymphadenectomy should be performed. The sentinel node (SN) concept has yet to be applied to tumors following ER. The aim of this study was to evaluate the feasibility of SN navigation surgery for such tumors. METHODS Forty patients diagnosed with EGC lesions <4 cm in diameter underwent gastrectomy with SN mapping following ER. A technetium-99 m tin colloid solution and a dye were injected into the submucosal layer around the post-ER scar in all four abdominal quadrants. We then compared the SN distribution and metastases among the patients who underwent ER and controls (n = 192). RESULTS SNs were identifiable in all patients, and the mean number of SNs per case was 4.9. The location of the SN basin was similar in the patients who underwent ER and the controls. One patient (3 %) whose primary tumor had invaded the submucosal layer had a metastatic SN. The median time from ER to surgery was 73 days. No postoperative recurrence was observed in any patient over a median follow-up of 1,023 days. CONCLUSIONS Our findings suggest that the SN basin is not greatly affected by ER. The SN concept could be suitable for tumors following ER, but conventional gastrectomy with lymphadenectomy involving the SN basin should be used at present.
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Affiliation(s)
- Shuhei Mayanagi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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Alves JR, Lopes LR, Meirelles LRD, Ramos CD, Sasasaki T, Andreollo NA. Animal model for training in sentinel lymph node biopsy of the stomach through combined methods. Acta Cir Bras 2012. [PMID: 23207748 DOI: 10.1590/s0102-86502012001200002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Create and validate a proposed animal model for training in sentinel lymph node biopsy of the stomach. METHODS In thirty-two rabbits, through a laparotomy, they received a subserosal injection of 0.1 ml of phytate labeled with technetium-99m (0.2 mCi) in the anterior wall of the gastric corpus, followed by 0.2 ml of Blue Patent V(®) 2.5%, through the same puncture site. Suspicious lymph nodes were searched in vivo at five, ten and 20 minutes, both visually (Blue Patent stained lymph nodes) and with a manual gamma radiation detector (to detect suspected radioactive lymph nodes). After 20 minutes, was performed resection of these for further evaluation of radioactivity (ex vivo) and histological study. RESULTS Lymph nodes were identified in 30 rabbits (Average of 2.2 lymph nodes per animal). Of the 90 suspected lymph nodes that occurred in the study, 70 cases (77.8%) were histologically confirmed for lymphoid tissue. Of these, the majority were located in the periesophageal region of the gastric fundus. The sample presented a mortality rate of 6.25% and nine complications related to the method, which interfered in the identification of the lymph nodes. CONCLUSION The animal model for sentinel node biopsy in rabbit stomachs proved to be feasible, with low complexity and reproduced the difficulties encountered for gastric lymph node biopsy in humans, being adequate for surgical training.
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Takeuchi H, Kitagawa Y. New Sentinel Node Mapping Technologies for Early Gastric Cancer. Ann Surg Oncol 2012; 20:522-32. [DOI: 10.1245/s10434-012-2602-1] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Indexed: 12/12/2022]
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Takeuchi H, Kawakubo H, Takeda F, Omori T, Kitagawa Y. Sentinel node navigation surgery in early-stage esophageal cancer. Ann Thorac Cardiovasc Surg 2012; 18:306-13. [PMID: 22673610 DOI: 10.5761/atcs.ra.12.01951] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The sentinel node (SN) concept has revolutionized the surgical staging of both melanoma and breast cancer over the past two decades. However, the validity of the SN hypothesis has been controversial for esophageal cancer, because SN mapping for esophageal cancer is technically complicated, and the number of early-stage esophageal cancer is very limited. Nevertheless previous studies nicely demonstrated that SN mapping may be feasible in patients with early-stage esophageal cancer. Transthoracic extended esophagectomy with three-field radical lymph node dissection has been recognized as a curative procedure for thoracic esophageal cancer in Japan. However, uniform application of this highly invasive procedure might increase the morbidity and markedly reduce the quality of life (QOL) after surgery. Although further accumulation of evidence based on multicenter clinical trials using a standard protocol is needed, SN mapping and SN navigation surgery would provide significant information to perform individualized selective lymphadenectomy which might reduce the morbidity and retain the patients' QOL. In addition, technical innovation including the development of new tracers is expected to confirm the accuracy and reliability of SN mapping in esophageal cancer.
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Affiliation(s)
- Hiroya Takeuchi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan.
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18
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Takeuchi H, Oyama T, Kamiya S, Nakamura R, Takahashi T, Wada N, Saikawa Y, Kitagawa Y. Laparoscopy-assisted proximal gastrectomy with sentinel node mapping for early gastric cancer. World J Surg 2012; 35:2463-71. [PMID: 21882026 DOI: 10.1007/s00268-011-1223-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Laparoscopy-assisted proximal gastrectomy (LAPG) remains a relatively uncommon procedure because of certain technical issues, such as curability, safety, and retention of postoperative patients' quality of life. The aim of the present study was to evaluate the feasibility of a newly developed LAPG procedure for early-stage proximal gastric cancer. METHODS We enrolled 37 consecutive patients who were preoperatively diagnosed with cT1N0M0 primary gastric cancer in the upper third of the stomach with the primary tumor diameter less than 4 cm. Laparoscopy-assisted proximal gastrectomy with sentinel node (SN) mapping and esophagogastric anastomosis with a circular stapler and transoral placement of the anvil was attempted. RESULTS The LAPG procedure was completed in 36 patients. It was converted to laparoscopy-assisted total gastrectomy in one patient because one SN detected intraoperatively was positive for metastasis by intraoperative pathological diagnosis. There were no severe postoperative complications in any patient. Only one patient (3%) complained of mild reflux symptoms immediately after operation, which were graded endoscopically as B by the Los Angeles Classification of gastroesophageal reflux disease; however, the symptoms were controlled well by a proton-pump inhibitor. Sentinel nodes were detected successfully in 37 (100%) of our patients. The mean number of dissected lymph nodes and identified SNs per case was 29.7 and 5.8, respectively. The sensitivity of prediction of nodal metastasis (including isolated tumor cells) and diagnostic accuracy based on SN status were 100% (3/3) and 100% (37/37), respectively. All patients have been free from recurrence for a median follow-up period of 26 months. CONCLUSIONS This study reveals that our novel LAPG approach is curative and represents a feasible minimally invasive surgical procedure with minimal morbidity and postoperative reflux esophagitis in patients with upper-third early-stage gastric cancer.
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Affiliation(s)
- Hiroya Takeuchi
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
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Yoshida M, Kubota K, Kuroda J, Ohta K, Nakamura T, Saito J, Kobayashi M, Sato T, Beck Y, Kitagawa Y, Kitajima M. Indocyanine green injection for detecting sentinel nodes using color fluorescence camera in the laparoscopy-assisted gastrectomy. J Gastroenterol Hepatol 2012; 27 Suppl 3:29-33. [PMID: 22486868 DOI: 10.1111/j.1440-1746.2012.07067.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIM We seek for the accurate and simple method for detecting sentinel nodes of gastric cancer which can be popularized in community hospitals. The indocyanine green (ICG) fluorescence-guided method is reported to be sensitive. However, the ordinal fluorescence cameras have gray scale imaging and require a dark room. We have developed a new device, Hyper Eye Medical System (HEMS) which can simultaneously detect color and near-infrared rays and can be used under room light. This study was planned to examine whether submucosal injection of 0.5 mL × 4 of 50 µg/mL ICG on the day before operation is the adequate administration for detecting sentinel nodes using HEMS in the gastric cancer surgery. METHODS The patients underwent gastrectomy for clinical T1a (mucosa)-T2 (muscularis propria) and clinical N0 were enrolled in the present study. As a preliminary trial, one case each of the ICG 25 and 100 µg/mL, injected on the day before operation and intraoperative injection, was examined. Then, 10 cases injected 50 µg/mL ICG on the day before operation were examined. RESULTS The ICG fluorescence of the patient injected 100 µg/mL was too intense and that of the patient injected 25 µg/mL was too faint. Sentinel lymph nodes were detected in all of 10 cases injected 50 µg/mL, the day before operation and number of sentinel lymph nodes per patient was 3.6 ± 2.1. Metastasis was observed in one case. All of ICG fluorescence-positive sentinel nodes were positive for the metastasis. In the patient who underwent intraoperative injection, sentinel lymphatic basins could be identified. CONCLUSION The present study shows that HEMS-guided abdominal surgery is feasible under room light. Submucosal injection of 0.5 mL × 4 of 50 µg/mL ICG on the day before operation is the adequate administration for detecting sentinel nodes using HEMS in the gastric cancer surgery.
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Affiliation(s)
- Masashi Yoshida
- Department of Surgery, Center for Digestive Diseases, International University of Health and Welfare, Mita Hospital, Japan.
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Takeuchi H, Kitagawa Y. Sentinel node navigation surgery in upper gastrointestinal cancer: what can it teach us? Ann Surg Oncol 2011; 18:1812-3. [PMID: 21503791 DOI: 10.1245/s10434-011-1721-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Yaguchi Y, Sugasawa H, Tsujimoto H, Takata H, Nakabayashi K, Ichikura T, Ono S, Hiraki S, Sakamoto N, Horio T, Kumano I, Otomo Y, Mochizuki H, Yamamoto J, Hase K. One-step nucleic acid amplification (OSNA) for the application of sentinel node concept in gastric cancer. Ann Surg Oncol 2011; 18:2289-96. [PMID: 21301968 DOI: 10.1245/s10434-011-1591-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Indexed: 12/19/2022]
Abstract
PURPOSE This study was designed to apply safely the sentinel node navigation surgery (SNNS) to the malignancies, an accurate and prompt intraoperative diagnosis of SN is essential, and micrometastasis has been frequently missed by conventional frozen sections. Recently, a novel molecular-based rapid diagnosis for the lymph node (LN) metastases has been developed using (OSNA) in breast cancer, which takes approximately 30 min to obtain a final result. We evaluated the efficacy of OSNA in terms of the intraoperative diagnosis of LN metastasis in patients with gastric cancer. METHODS A total of 162 LNs dissected from 32 patients with gastric cancer was included in this study; 45 LNs were pathologically diagnosed as metastatic LNs and 117 LNs were negative. The LNs were bisected; halves were examined with H&E stain, and the opposite halves were subjected to OSNA analyses of CK19 mRNA. The CK19 mRNA expression was examined in the positive or negative metastatic LNs, and the correlation between the tumor volume and CK19 mRNA expression in the metastatic LNs was examined. RESULTS The CK19 mRNA expressions in the positive metastatic LNs were significantly higher than those of negative LNs. When 250 copies/μl was set as a cutoff value, the concordance rate was 94.4%, the sensitivity was 88.9%, and the specificity was 96.6%. The OSNA expression was significantly correlated with the estimated tumor volumes in the metastatic LNs. CONCLUSIONS The OSNA method is feasible and acceptable for detecting LN metastases in patients with gastric cancer. This should be applied for the intraoperative diagnosis in the SN-navigation surgery in gastric cancer.
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Affiliation(s)
- Yoshihisa Yaguchi
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
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Tsujimoto H, Yaguchi Y, Sakamoto N, Kumano I, Takahata R, Matsumoto Y, Yoshida K, Sugasawa H, Ono S, Ichikura T, Yamamoto J, Hase K. Computed tomography lymphography for the detection of sentinel nodes in patients with gastric carcinoma. Cancer Sci 2010; 101:2586-90. [PMID: 20796000 PMCID: PMC11158999 DOI: 10.1111/j.1349-7006.2010.01706.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The sentinel node (SN) concept has been found to be feasible in gastric cancer. However, the lymphatic network of gastric cancer may be more complex, and it may be difficult to visualize all the SN distributed in unexpected areas by conventional modalities. In this study, we evaluate the feasibility and efficacy of CT lymphography for the detection of SN in gastric cancer. A total 24 patients with early gastric cancer were enrolled in the study. Three modalities (CT lymphography, dye and radioisotope [RI] methods) were used for the detection of SN. The images of CT lymphography were obtained at 10 min after injection of contrast agents. The SN were successfully identified by CT lymphography in 83.3% of patients; detection rates by the dye and RI methods were 95% and 100%, respectively. Most patients, in whom SN were successfully detected by CT lymphography, had positive results at 5 min after injection of the contrast material. The SN stations detected by CT lymphography were consistent with or included those detected by dye and/or RI methods. In conclusion, CT lymphography for the detection of SN in gastric cancer is feasible and has several advantages. However, based on this initial experience, CT lymphography had a relatively low detection rate compared with conventional methods, and further efforts will be necessary to improve the detection rate and widen the clinical application of CT lymphography for the detection of SN in gastric cancer.
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Affiliation(s)
- Hironori Tsujimoto
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
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Lymph node dissection in the resection of gastric cancer: review of existing evidence. Gastric Cancer 2010; 13:137-48. [PMID: 20820982 DOI: 10.1007/s10120-010-0560-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2010] [Accepted: 05/21/2010] [Indexed: 02/06/2023]
Abstract
Gastric cancer is one of the leading causes of cancer-related death worldwide. Surgery is the only curative therapy for localized gastric cancer, but the extent of regional lymphadenectomy has been a matter of considerable debate. Extended resections that are regarded as standard procedures in some Asian countries, including Japan and Korea, have not been shown to be as effective in Western countries. The extent of lymphadenectomy for advanced gastric cancer has been studied in many prospective randomized controlled trials. On the other hand, patients with early gastric cancer have an excellent survival rate (>90%) after radical surgery. Lymph node metastasis from early gastric cancer is relatively infrequent. Therefore, it might be practical to perform less invasive surgery for early gastric cancer. In this review article, we examine the evidence for lymph node dissection as radical surgery in advanced gastric cancer and the possibility of limited resection for early gastric cancer.
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Cahill RA, Mortensen NJ. Natural orifice transluminal endoscopic surgery and localized resection for colorectal neoplasia. World J Gastrointest Surg 2010; 2:199-202. [PMID: 21160874 PMCID: PMC2999237 DOI: 10.4240/wjgs.v2.i6.199] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2009] [Revised: 02/04/2010] [Accepted: 02/11/2010] [Indexed: 02/06/2023] Open
Abstract
Modern methods of surgical intervention have the potential to provide effective, definitive management of early stage colorectal neoplasia by truly minimally invasive means. Margin-free clearance of early colonic neoplasia from within the intestinal lumen can already now be effected by endoscopic submucosal dissection in the colon and transluminal endoscopic microsurgery (TEM) in the rectum. Natural orifice transluminal endoscopic surgery (NOTES) offers the potential for providing transmural, full thickness excision as TEM does but at sites in the colon proximal to the rectum. The next conceptual advance required to make this practice an effective reality lies in evolving surgical regional staging strategies to effectively partner localized resective approaches and allow their deployment as definitive curative therapy. As the most compelling modality for nodal status ascertainment in the absence of lymphatic basin excision for other malignant disease processes, it seems timely to reconsider sentinel node biopsy in cancer of the colon and rectum. Whether by this means or indeed any other, such an ability to confidently identify patients with node negative disease would allow nascent innovative techniques flourish as definitive management for confined (N0) T1 and T2 cancers and so allow the application of available advanced technology for clinical benefit. Conversely, the development of a specific clinical niche for NOTES (whether, as here, for full thickness localized colonic excision or nodal staging alone) would greatly benefit the evolution and incorporation of this surgical strategy into clinical care paradigms.
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Affiliation(s)
- Ronan A Cahill
- Ronan A Cahill, Neil J Mortensen, Department of Colorectal Surgery, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, United Kingdom
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Kelder W, Nimura H, Takahashi N, Mitsumori N, van Dam GM, Yanaga K. Sentinel node mapping with indocyanine green (ICG) and infrared ray detection in early gastric cancer: an accurate method that enables a limited lymphadenectomy. Eur J Surg Oncol 2010; 36:552-8. [PMID: 20452171 DOI: 10.1016/j.ejso.2010.04.007] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Revised: 01/19/2010] [Accepted: 04/12/2010] [Indexed: 02/07/2023] Open
Abstract
AIM This study compares lymphatic mapping in early gastric cancer with ICG and infrared ray electronic endoscopy (IREE) to ICG alone. It examines the optimal method for intra-operative detection of metastases and shows long term follow up results. METHODS 212 patients underwent the SN procedure with IREE and peritumoural ICG injection. Evaluated parameters were detection of sentinel nodes with IREE versus ICG alone, intra-operative detection rate of lymph node (LN) metastasis with node picking versus lymphatic basin dissection (LBD) and lymphatic drainage patterns. RESULTS 34 patients had LN metastases. The SN identification rate and sensitivity for IREE versus ICG alone were 99.5 versus 85.8% and 97.0 versus 48.4% respectively. Intra-operative accuracy for detecting LN metastasis was 50% with node picking versus 92.3% with LBD. LN metastases were always in the SN basin. Lymphatic invasion and T-stage were risk factors for nodal metastases. Two patients showed recurrent disease. Both had a tumour with signet cell differentiation. One patient had a T3 tumour, the other patient had a tumour with a diameter of 85 mm. CONCLUSION The SN procedure with IREE can detect the SN and is better than ICG alone. LBD of the SN basin is required for accurate intra-operative diagnosis of metastases. LBD dissection based on IREE is a safe method of nodal dissection in patients with T1 or limited T2 tumours.
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Affiliation(s)
- W Kelder
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, Groningen, The Netherlands
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Abstract
BACKGROUND Radio-guided detection of sentinel lymph nodes (SLN) has been used to predict regional lymph node metastasis in patients with melanoma and breast cancer. However, the validity of the SLN hypothesis is still controversial for esophageal cancer. The aim of this study is to evaluate the feasibility and accuracy of radio-guided SLN mapping for esophageal cancer. METHODS Seventy-five consecutive patients who were diagnosed preoperatively with T1N0M0 or T2N0M0 primary esophageal cancer were enrolled. Endoscopic injection of technetium-99m tin colloid was performed before surgery and radioactive SLNs were identified with preoperative lymphoscintigraphy and gamma probe. Standard radical esophagectomy with lymphadenectomy was performed in all patients and all resected nodes were evaluated by routine pathologic examination. RESULTS SLNs were identified successfully in 71 (95%) of 75 patients. The mean number of identified SLNs per case was 4.7. Twenty-nine (88%) of 33 cases with lymph node metastasis showed positive SLNs. The diagnostic accuracy based on SLN status was 94% (67/71). Distribution of identified SLNs was widely spread from the cervical to abdominal areas. CONCLUSIONS This study reveals that radio-guided SLN mapping is an accurate diagnostic procedure for detecting lymph node metastasis in patients with early-stage esophageal cancer.
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