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Loverro M, Bizzarri N, Capomacchia FM, Watrowski R, Querleu D, Gioè A, Naldini A, Santullo F, Foschi N, Fagotti A, Scambia G, Fanfani F. Indocyanine green fluorescence applied to gynecologic oncology: beyond sentinel lymph node. Int J Surg 2024; 110:3641-3653. [PMID: 38489558 PMCID: PMC11175818 DOI: 10.1097/js9.0000000000001318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 02/26/2024] [Indexed: 03/17/2024]
Abstract
Indocyanine green (ICG), a well-known molecule employed in medicine for over five decades, has emerged as a versatile dye widely embraced across various surgical disciplines. In gynecologic oncology, its prevalent use revolves around the detection of sentinel lymph nodes. However, the true potential of ICG extends beyond this singular application, owing to its pragmatic utility, cost-effectiveness, and safety profile. Furthermore, ICG has been introduced in the theranostic landscape, marking a significant juncture in the evolution of its clinical utility. This narrative review aims to describe the expanding horizons of ICG fluorescence in gynecologic oncology, beyond the sentinel lymph node biopsy. The manifold applications reported within this manuscript include: 1) lymphography; 2) angiography; 3) nerve visualization; 4) ICG-driven resections; and 5) theranostic. The extensive exploration across these numerous applications, some of which are still in the preclinical phase, serves as a hypothesis generator, aiming to stimulate the development of clinical studies capable of expanding the use of this drug in our field, enhancing the care of gynecological cancer patients.
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Affiliation(s)
- Matteo Loverro
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS
| | - Nicolò Bizzarri
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS
| | | | - Rafał Watrowski
- Department of Gynecology and Obsterics, Helios Hospital Müllheim, Teaching Hospital of the University of Freiburg, 79379 Müllheim
- Faculty of Medicine, Medical Center - University of Freiburg, 79106 Freiburg, Germany
| | - Denis Querleu
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS
| | - Alessandro Gioè
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS
| | - Angelica Naldini
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS
| | - Francesco Santullo
- Operational Unit of Peritoneum and Retroperitoneum Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli
| | - Nazario Foschi
- Urology Division, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Anna Fagotti
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS
- Università Cattolica del Sacro Cuore
| | - Giovanni Scambia
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS
- Università Cattolica del Sacro Cuore
| | - Francesco Fanfani
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS
- Università Cattolica del Sacro Cuore
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Tascón Padrón L, Egger EK, Ralser DJ, Otten L, Toksöz ÖA, Kristiansen G, Stummer W, Mustea A. Optimized complete cytoreduction in ovarian cancer through intraoperative real-time tumor visualization by 5-ALA - a case report. Front Oncol 2023; 13:1288775. [PMID: 38146509 PMCID: PMC10749305 DOI: 10.3389/fonc.2023.1288775] [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] [Received: 09/04/2023] [Accepted: 11/20/2023] [Indexed: 12/27/2023] Open
Abstract
Introduction Complete macroscopic cytoreduction represents the most important prognostic parameter for overall survival in ovarian cancer. This dogma remains tenacious despite significant improvements in adjuvant systemic treatment. Hence, optimization of surgical therapy is an overarching goal to improve patients' outcomes. In this context, intraoperative tumor-specific imaging might facilitate optimized cytoreduction. In neurosurgery, intraoperative 5-aminolevulinic acid (5-ALA) guided imaging is applied in clinical routine to assess surgical resection margins. Here, we report the case of a patient with ovarian cancer in whom intraoperative 5-ALA tumor visualization led to optimized complete cytoreduction. Objective Intraoperative administration of 5-ALA led to improved complete cytoreduction by identification and resection of additional ovarian cancer tumor manifestations. Case The 39-year-old patient, Jehovah`s witness, presented to our department with a left sided ovarian mass, suspicious of ovarian cancer, based on clinical examination, sonographic suspicious features and a CA12-5 elevation. The patient's medical history and family history was unremarkable. Preoperative CT imaging of the thorax and abdomen showed no pathology besides the adnexal mass. Surgery was performed by a midline laparotomy with hysterectomy, bilateral adnexectomy, pelvic peritonectomy, omentectomy, ureterolysis, diaphragm stripping, adhesiolysis and the collection of peritoneal and rectal samples. Intraoperative 5-ALA imaging using a dedicated excitation and detection loupe system (Reveal, DVI) led to tumor detection at the diaphragm, the omentum and the rectum that was not detectable by palpation and visualization using white light. The pathology results revealed that the 5-ALA positive samples (diaphragm, rectum and omentum) obtained by intraoperative 5-ALA were positive for ovarian cancer. Conclusion Intraoperative administration of 5-ALA represents a promising approach to improve complete cytoreduction in ovarian cancer surgery thereby improving clinical outcomes. Hence, further research and clinical trials are required to investigate the potential of intraoperative 5-ALA imaging in ovarian cancer debulking surgery and its impact on long-term clinical outcomes.
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Affiliation(s)
- Laura Tascón Padrón
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
| | - Eva K. Egger
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
| | - Damian Johannes Ralser
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
| | - Lucia Otten
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
| | - Özer-Altan Toksöz
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | | | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Alexander Mustea
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
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Kim J, Jang Y, Choi SH, Jung YW, Kim ML, Yun BS, Seong SJ, Jun HS. Intraoperative Fluorescent Ureter Visualization in Complex Laparoscopic or Robotic-Assisted Gynecologic Surgery. J Pers Med 2023; 13:1345. [PMID: 37763114 PMCID: PMC10532563 DOI: 10.3390/jpm13091345] [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: 07/31/2023] [Revised: 08/28/2023] [Accepted: 08/28/2023] [Indexed: 09/29/2023] Open
Abstract
This study aimed to demonstrate the feasibility of ureteral navigation using intraoperative indocyanine green (ICG) and near-infrared fluorescence (NIRF) imaging during complex laparoscopic or robot-assisted gynecologic surgery (LRAGS). Twenty-six patients at high risk of ureteral injury with complex pelvic pathology (CPP) due to pelvic organ prolapse (POP), multiple myomas, large intraligamentary or cervical myoma, severe pelvic adhesions, or cervical atresia underwent LRAGS. All patients underwent cystoscopic intraureteral ICG instillation before LRAGS and ureteral navigation under NIRF imaging intraoperatively. Both ureteral pathways were identified from the pelvic brim downwards through NIRF imaging in all patients, even though some were not visualized under the white light mode. The fluorescent ureters were visualized immediately after the beginning of surgery and typically lasted for >5 h during surgery. There were no cases of iatrogenic ureteral injury. The hemoglobin decrement was 1.47 ± 1.13 g/dL, and no transfusion was required. In our study, both ureters in all patients were identified with ICG-NIRF imaging during LRAGS, and these techniques made surgeries easier and safer. Despite the CPP, there was no ureteral injury or transfusion following surgery. Further prospective studies are needed to introduce intraoperative ureteral guidelines for ICG-NIRF imaging during LRAGS with CPP.
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Affiliation(s)
- Jiyoun Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University School of Medicine, Seoul 06135, Republic of Korea; (J.K.); (Y.J.); (S.H.C.); (Y.W.J.); (M.-L.K.); (S.J.S.)
| | - Yoon Jang
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University School of Medicine, Seoul 06135, Republic of Korea; (J.K.); (Y.J.); (S.H.C.); (Y.W.J.); (M.-L.K.); (S.J.S.)
| | - Su Hyeon Choi
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University School of Medicine, Seoul 06135, Republic of Korea; (J.K.); (Y.J.); (S.H.C.); (Y.W.J.); (M.-L.K.); (S.J.S.)
| | - Yong Wook Jung
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University School of Medicine, Seoul 06135, Republic of Korea; (J.K.); (Y.J.); (S.H.C.); (Y.W.J.); (M.-L.K.); (S.J.S.)
| | - Mi-La Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University School of Medicine, Seoul 06135, Republic of Korea; (J.K.); (Y.J.); (S.H.C.); (Y.W.J.); (M.-L.K.); (S.J.S.)
| | - Bo Seong Yun
- Department of Obstetrics and Gynecology, CHA Ilsan Medical Center, CHA University School of Medicine, Goyang 10414, Republic of Korea;
| | - Seok Ju Seong
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University School of Medicine, Seoul 06135, Republic of Korea; (J.K.); (Y.J.); (S.H.C.); (Y.W.J.); (M.-L.K.); (S.J.S.)
| | - Hye Sun Jun
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University School of Medicine, Seoul 06135, Republic of Korea; (J.K.); (Y.J.); (S.H.C.); (Y.W.J.); (M.-L.K.); (S.J.S.)
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Cianci S, Gueli Alletti S. Editorial: Insights in gynecologic surgery 2021. Front Surg 2023; 10:1219534. [PMID: 37492620 PMCID: PMC10364591 DOI: 10.3389/fsurg.2023.1219534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/27/2023] [Indexed: 07/27/2023] Open
Affiliation(s)
- S. Cianci
- Department of Human Pathology of Adult and Childhood “G. Barresi”, Unit of Gynecology and Obstetrics, University of Messina, Messina, Italy
| | - S. Gueli Alletti
- Obstetrics and Gynecology Unit, Department of Woman and Child, Ospedale Buccheri La Ferla Fatebenefratelli, Palermo, Italy
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Sutton PA, van Dam MA, Cahill RA, Mieog S, Polom K, Vahrmeijer AL, van der Vorst J. Fluorescence-guided surgery: comprehensive review. BJS Open 2023; 7:7162090. [PMID: 37183598 PMCID: PMC10183714 DOI: 10.1093/bjsopen/zrad049] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 04/02/2023] [Accepted: 04/03/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Despite significant improvements in preoperative workup and surgical planning, surgeons often rely on their eyes and hands during surgery. Although this can be sufficient in some patients, intraoperative guidance is highly desirable. Near-infrared fluorescence has been advocated as a potential technique to guide surgeons during surgery. METHODS A literature search was conducted to identify relevant articles for fluorescence-guided surgery. The literature search was performed using Medical Subject Headings on PubMed for articles in English until November 2022 and a narrative review undertaken. RESULTS The use of invisible light, enabling real-time imaging, superior penetration depth, and the possibility to use targeted imaging agents, makes this optical imaging technique increasingly popular. Four main indications are described in this review: tissue perfusion, lymph node assessment, anatomy of vital structures, and tumour tissue imaging. Furthermore, this review provides an overview of future opportunities in the field of fluorescence-guided surgery. CONCLUSION Fluorescence-guided surgery has proven to be a widely innovative technique applicable in many fields of surgery. The potential indications for its use are diverse and can be combined. The big challenge for the future will be in bringing experimental fluorophores and conjugates through trials and into clinical practice, as well as validation of computer visualization with large data sets. This will require collaborative surgical groups focusing on utility, efficacy, and outcomes for these techniques.
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Affiliation(s)
- Paul A Sutton
- The Colorectal and Peritoneal Oncology Centre, Christie Hospital, Manchester, UK
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Martijn A van Dam
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Ronan A Cahill
- RAC, UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland
- RAC, Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sven Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Karol Polom
- Clinic of Oncological, Transplantation and General Surgery, Gdansk Medical University, Gdansk, Poland
| | | | - Joost van der Vorst
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Petusseau AF, Bruza P, Pogue BW. Protoporphyrin IX delayed fluorescence imaging: a modality for hypoxia-based surgical guidance. JOURNAL OF BIOMEDICAL OPTICS 2022; 27:106005. [PMID: 36217225 PMCID: PMC9549807 DOI: 10.1117/1.jbo.27.10.106005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/20/2022] [Indexed: 06/16/2023]
Abstract
SIGNIFICANCE Hypoxia imaging for surgical guidance has never been possible, yet it is well known that most tumors have microregional chronic and/or cycling hypoxia present as well as chaotic blood flow. The ability to image oxygen partial pressure (pO2) is therefore a unique control of tissue metabolism and can be used in a range of disease applications to understand the complex biochemistry of oxygen supply and consumption. AIM Delayed fluorescence (DF) from the endogenous molecule protoporphyrin IX (PpIX) has been shown to be a truly unique reporter of the local oxygen partial pressure in tissue. PpIX is endogenously synthesized by mitochondria in most tissues, and the particular property of DF emission is directly related to low microenvironmental oxygen concentration. Here, it is shown that PpIX has a unique emission in hypoxic tumor tissue regions, which is measured as a DF signal in the red to near-infrared spectrum. APPROACH A time-gated imaging system was used for PpIX DF for wide field direct mapping of pO2 changes. Acquiring both prompt and DF in a rapid sequential cycle allowed for imaging oxygenation in a way that was insensitive to the PpIX concentration. By choosing adequate parameters, the video rate acquisition of pO2 images could be achieved, providing real-time tissue metabolic information. RESULTS In this report, we show the first demonstration of imaging hypoxia signals from PpIX in a pancreatic cancer model, exhibiting >5X contrast relative to surrounding normal oxygenated tissues. Additionally, tissue palpation amplifies the signal and provides intuitive temporal contrast based upon neoangiogenic blood flow differences. CONCLUSIONS PpIX DF provides a mechanism for tumor contrast that could easily be translated to human use as an intrinsic contrast mechanism for oncologic surgical guidance.
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Affiliation(s)
- Arthur F. Petusseau
- Dartmouth College, Thayer School of Engineering and Dartmouth Cancer Center, Hanover, New Hampshire, United States
| | - Petr Bruza
- Dartmouth College, Thayer School of Engineering and Dartmouth Cancer Center, Hanover, New Hampshire, United States
| | - Brian W. Pogue
- University of Wisconsin–Madison, Department of Medical Physics, Madison, Wisconsin, United States
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Cianci S, Gueli Alletti S, Fanfani F. Editorial: New Development of Tracers Uses in Gynecologic Surgery. Front Oncol 2022; 12:912267. [PMID: 35712472 PMCID: PMC9197588 DOI: 10.3389/fonc.2022.912267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/19/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Stefano Cianci
- Department of Human Pathology of Adult and Childhood “G. Barresi” Unit of Gynecology and Obstetric, University of Messina, Messina, Italy
- *Correspondence: Stefano Cianci,
| | - Salvatore Gueli Alletti
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Francesco Fanfani
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Institute of Obstetrics and Gynecology, Universita’ Cattolica del Sacro Cuore, Rome, Italy
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