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Achterberg FB, Bijlstra OD, Slooter MD, Sibinga Mulder BG, Boonstra MC, Bouwense SA, Bosscha K, Coolsen MME, Derksen WJM, Gerhards MF, Gobardhan PD, Hagendoorn J, Lips D, Marsman HA, Zonderhuis BM, Wullaert L, Putter H, Burggraaf J, Mieog JSD, Vahrmeijer AL, Swijnenburg RJ. ICG-Fluorescence Imaging for Margin Assessment During Minimally Invasive Colorectal Liver Metastasis Resection. JAMA Netw Open 2024; 7:e246548. [PMID: 38639939 PMCID: PMC11031680 DOI: 10.1001/jamanetworkopen.2024.6548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/31/2024] [Indexed: 04/20/2024] Open
Abstract
Importance Unintended tumor-positive resection margins occur frequently during minimally invasive surgery for colorectal liver metastases and potentially negatively influence oncologic outcomes. Objective To assess whether indocyanine green (ICG)-fluorescence-guided surgery is associated with achieving a higher radical resection rate in minimally invasive colorectal liver metastasis surgery and to assess the accuracy of ICG fluorescence for predicting the resection margin status. Design, Setting, and Participants The MIMIC (Minimally Invasive, Indocyanine-Guided Metastasectomy in Patients With Colorectal Liver Metastases) trial was designed as a prospective single-arm multicenter cohort study in 8 Dutch liver surgery centers. Patients were scheduled to undergo minimally invasive (laparoscopic or robot-assisted) resections of colorectal liver metastases between September 1, 2018, and June 30, 2021. Exposures All patients received a single intravenous bolus of 10 mg of ICG 24 hours prior to surgery. During surgery, ICG-fluorescence imaging was used as an adjunct to ultrasonography and regular laparoscopy to guide and assess the resection margin in real time. The ICG-fluorescence imaging was performed during and after liver parenchymal transection to enable real-time assessment of the tumor margin. Absence of ICG fluorescence was favorable both during transection and in the tumor bed directly after resection. Main Outcomes and Measures The primary outcome measure was the radical (R0) resection rate, defined by the percentage of colorectal liver metastases resected with at least a 1 mm distance between the tumor and resection plane. Secondary outcomes were the accuracy of ICG fluorescence in detecting margin-positive (R1; <1 mm margin) resections and the change in surgical management. Results In total, 225 patients were enrolled, of whom 201 (116 [57.7%] male; median age, 65 [IQR, 57-72] years) with 316 histologically proven colorectal liver metastases were included in the final analysis. The overall R0 resection rate was 92.4%. Re-resection of ICG-fluorescent tissue in the resection cavity was associated with a 5.0% increase in the R0 percentage (from 87.4% to 92.4%; P < .001). The sensitivity and specificity for real-time resection margin assessment were 60% and 90%, respectively (area under the receiver operating characteristic curve, 0.751; 95% CI, 0.668-0.833), with a positive predictive value of 54% and a negative predictive value of 92%. After training and proctoring of the first procedures, participating centers that were new to the technique had a comparable false-positive rate for predicting R1 resections during the first 10 procedures (odds ratio, 1.36; 95% CI, 0.44-4.24). The ICG-fluorescence imaging was associated with changes in intraoperative surgical management in 56 (27.9%) of the patients. Conclusions and Relevance In this multicenter prospective cohort study, ICG-fluorescence imaging was associated with an increased rate of tumor margin-negative resection and changes in surgical management in more than one-quarter of the patients. The absence of ICG fluorescence during liver parenchymal transection predicted an R0 resection with 92% accuracy. These results suggest that use of ICG fluorescence may provide real-time feedback of the tumor margin and a higher rate of complete oncologic resection.
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Affiliation(s)
- Friso B. Achterberg
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Okker D. Bijlstra
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Maxime D. Slooter
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Mark C. Boonstra
- Department of Surgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Stefan A. Bouwense
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Ziekenhuis, Den Bosch, the Netherlands
| | - Mariëlle M. E. Coolsen
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Wouter J. M. Derksen
- Department of Surgery, St. Antonius Hospital, Nieuwegein/Regionaal Academisch Kankercentrum Utrecht, Utrecht, the Netherlands
| | - Michael F. Gerhards
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | | | - Jeroen Hagendoorn
- Department of Surgery, University Medical Center Utrecht/Regionaal Academisch Kankercentrum Utrecht, Utrecht, the Netherlands
| | - Daan Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Hendrik A. Marsman
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Babs M. Zonderhuis
- Department of Surgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Lissa Wullaert
- Department of Surgery, Amphia Ziekenhuis, Breda, the Netherlands
- Department of Surgical Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Hein Putter
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands
| | - Jacobus Burggraaf
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
- Centre for Human Drug Research, Leiden, the Netherlands
| | - J. Sven D. Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Rutger-Jan Swijnenburg
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
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Stibbe JA, Hoogland P, Achterberg FB, Holman DR, Sojwal RS, Burggraaf J, Vahrmeijer AL, Nagengast WB, Rogalla S. Highlighting the Undetectable - Fluorescence Molecular Imaging in Gastrointestinal Endoscopy. Mol Imaging Biol 2023; 25:18-35. [PMID: 35764908 PMCID: PMC9971088 DOI: 10.1007/s11307-022-01741-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 05/08/2022] [Accepted: 05/10/2022] [Indexed: 11/27/2022]
Abstract
Flexible high-definition white-light endoscopy is the current gold standard in screening for cancer and its precursor lesions in the gastrointestinal tract. However, miss rates are high, especially in populations at high risk for developing gastrointestinal cancer (e.g., inflammatory bowel disease, Lynch syndrome, or Barrett's esophagus) where lesions tend to be flat and subtle. Fluorescence molecular endoscopy (FME) enables intraluminal visualization of (pre)malignant lesions based on specific biomolecular features rather than morphology by using fluorescently labeled molecular probes that bind to specific molecular targets. This strategy has the potential to serve as a valuable tool for the clinician to improve endoscopic lesion detection and real-time clinical decision-making. This narrative review presents an overview of recent advances in FME, focusing on probe development, techniques, and clinical evidence. Future perspectives will also be addressed, such as the use of FME in patient stratification for targeted therapies and potential alliances with artificial intelligence. KEY MESSAGES: • Fluorescence molecular endoscopy is a relatively new technology that enables safe and real-time endoscopic lesion visualization based on specific molecular features rather than on morphology, thereby adding a layer of information to endoscopy, like in PET-CT imaging. • Recently the transition from preclinical to clinical studies has been made, with promising results regarding enhancing detection of flat and subtle lesions in the colon and esophagus. However, clinical evidence needs to be strengthened by larger patient studies with stratified study designs. • In the future fluorescence molecular endoscopy could serve as a valuable tool in clinical workflows to improve detection in high-risk populations like patients with Barrett's esophagus, Lynch syndrome, and inflammatory bowel syndrome, where flat and subtle lesions tend to be malignant up to five times more often. • Fluorescence molecular endoscopy has the potential to assess therapy responsiveness in vivo for targeted therapies, thereby playing a role in personalizing medicine. • To further reduce high miss rates due to human and technical factors, joint application of artificial intelligence and fluorescence molecular endoscopy are likely to generate added value.
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Affiliation(s)
- Judith A Stibbe
- Department of Surgery, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
| | - Petra Hoogland
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Friso B Achterberg
- Department of Surgery, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
| | - Derek R Holman
- Department of Medicine, Division of Gastroenterology, Stanford University School of Medicine, Stanford, CA, USA
| | - Raoul S Sojwal
- Department of Medicine, Division of Gastroenterology, Stanford University School of Medicine, Stanford, CA, USA
| | - Jacobus Burggraaf
- Department of Surgery, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
- Centre for Human Drug Research, Leiden, The Netherlands
| | - Alexander L Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Stephan Rogalla
- Department of Medicine, Division of Gastroenterology, Stanford University School of Medicine, Stanford, CA, USA.
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Achterberg FB, Mulder BGS, Janssen QP, Koerkamp BG, Hol L, Quispel R, Bonsing BA, Vahrmeijer AL, van Eijck CHJ, Roos D, Perk LE, van der Harst E, Coene PPLO, Doukas M, Smedts FMM, Kliffen M, van Velthuysen MLF, Terpstra V, Sarasqueta AF, Morreau H, Mieog JSD. Targeted next-generation sequencing has incremental value in the diagnostic work-up of patients with suspect pancreatic masses; a multi-center prospective cross sectional study. PLoS One 2023; 18:e0280939. [PMID: 36696439 PMCID: PMC9876380 DOI: 10.1371/journal.pone.0280939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 01/11/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The diagnostic process of patients with suspect pancreatic lesions is often lengthy and prone to repeated diagnostic procedures due to inconclusive results. Targeted Next-Generation Sequencing (NGS) performed on cytological material obtained with fine needle aspiration (FNA) or biliary duct brushing can speed up this process. Here, we study the incremental value of NGS for establishing the correct diagnosis, and subsequent treatment plan in patients with inconclusive diagnosis after regular diagnostic work-up for suspect pancreatic lesions. METHODS In this prospective cross-sectional cohort study, patients were screened for inclusion in four hospitals. NGS was performed with AmpliSeq Cancer Hotspot Panel v2 and v4b in patients with inconclusive cytology results or with an uncertain diagnosis. Diagnostic results were evaluated by the oncology pancreatic multidisciplinary team. The added value of NGS was determined by comparing diagnosis (malignancy, cystic lesion or benign condition) and proposed treatment plan (exploration/resection, neoadjuvant chemotherapy, follow-up, palliation or repeated FNA) before and after integration of NGS results. Final histopathological analysis or a 6-month follow-up period were used as the reference standard in case of surgical intervention or non-invasive treatment, respectively. RESULTS In 50 of the 53 included patients, cytology material was sufficient for NGS analysis. Diagnosis before and after integration of NGS results differed in 24% of the patients. The treatment plan was changed in 32% and the diagnosis was substantiated by the NGS data in 44%. Repetition of FNA/brushing was prevented in 14% of patients. All changes in treatment plan were correctly made after integration of NGS. Integration of NGS increased overall diagnostic accuracy from 68% to 94%. INTERPRETATION This study demonstrates the incremental diagnostic value of NGS in patients with an initial inconclusive diagnosis. Integration of NGS results can prevent repeated EUS/FNA, and can also rigorously change the final diagnosis and treatment plan.
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Affiliation(s)
- Friso B. Achterberg
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Quisette P. Janssen
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Lieke Hol
- Department of Gastro-Enterology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Rutger Quispel
- Department of Gastro-Enterology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Casper H. J. van Eijck
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Lars E. Perk
- Department of Gastro-Enterology, Haaglanden Medical Center, The Hague, The Netherlands
| | | | | | - Michail Doukas
- Department of Pathology, Erasmus Medical MC, University Medical Center, Rotterdam, The Netherlands
| | - Frank M. M. Smedts
- Department of Pathology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Mike Kliffen
- Department of Pathology, Maasstad Hospital, Rotterdam, The Netherlands
| | | | - Valeska Terpstra
- Department of Pathology, Haaglanden Medical Center, The Hague, The Netherlands
| | | | - Hans Morreau
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - J. Sven D. Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- * E-mail:
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Bijlstra OD, Broersen A, Oosterveer TTM, Faber RA, Achterberg FB, Hurks R, Burgmans MC, Dijkstra J, Mieog JSD, Vahrmeijer AL, Swijnenburg RJ. Integration of Three-Dimensional Liver Models in a Multimodal Image-Guided Robotic Liver Surgery Cockpit. Life (Basel) 2022; 12:life12050667. [PMID: 35629335 PMCID: PMC9144252 DOI: 10.3390/life12050667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 12/05/2022] Open
Abstract
Background: Robotic liver surgery represents the most recent evolution in the field of minimally-invasive liver surgery. For planning and guidance of liver resections, surgeons currently rely on preoperative 2-dimensional (2D) CT and/or MR imaging and intraoperative ultrasonography. Translating 2D images into digital 3-dimensional (3D) models may improve both preoperative planning and surgical guidance. The da Vinci® robotic surgical system is a platform suitable for the integration of multiple imaging modalities into one single view. In this study, we describe multimodal imaging options and introduce the Robotic Liver Surgery Cockpit; Methods: in-house developed software was used and validated for segmentation and registration to create a virtual reality 3D model of the liver based on preoperative imaging. The accuracy of the 3D models in the clinical setting was objectively assessed in 15 patients by measuring tumor diameters and subjectively with a postoperative conducted questionnaire; Results: Implementation and applicability of the 3D model in the surgical cockpit was feasible in all patients and the quality of the 3D reconstructions was high in 14 (93%) of cases. Tumor diameters measured on CT and/or MR imaging were comparable to automated measurements using the segmentation software and 3D models; Conclusions: the 3D model was successfully incorporated in the robotic surgery console as part of a multimodality imaging platform and aided the surgeon in planning and guidance of the resection. Future studies should focus on further automation of 3D rendering and progress into augmented reality.
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Affiliation(s)
- Okker D. Bijlstra
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (R.A.F.); (F.B.A.); (J.S.D.M.); (A.L.V.)
- Department of Surgery, Amsterdam University Medical Center, Cancer Center Amsterdam, University of Amsterdam, 1081 HV Amsterdam, The Netherlands;
- Correspondence:
| | - Alexander Broersen
- Section of Image Processing, Department of Radiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (A.B.); (J.D.)
| | - Timo T. M. Oosterveer
- Section of Interventional Radiology, Department of Radiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (T.T.M.O.); (M.C.B.)
| | - Robin A. Faber
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (R.A.F.); (F.B.A.); (J.S.D.M.); (A.L.V.)
| | - Friso B. Achterberg
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (R.A.F.); (F.B.A.); (J.S.D.M.); (A.L.V.)
| | - Rob Hurks
- Department of Radiology, Amsterdam University Medical Center, 1081 HV Amsterdam, The Netherlands;
| | - Mark C. Burgmans
- Section of Interventional Radiology, Department of Radiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (T.T.M.O.); (M.C.B.)
| | - Jouke Dijkstra
- Section of Image Processing, Department of Radiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (A.B.); (J.D.)
| | - J. Sven D. Mieog
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (R.A.F.); (F.B.A.); (J.S.D.M.); (A.L.V.)
| | - Alexander L. Vahrmeijer
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (R.A.F.); (F.B.A.); (J.S.D.M.); (A.L.V.)
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Amsterdam University Medical Center, Cancer Center Amsterdam, University of Amsterdam, 1081 HV Amsterdam, The Netherlands;
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Achterberg FB, Deken MM, Meijer RPJ, Mieog JSD, Burggraaf J, van de Velde CJH, Swijnenburg RJ, Vahrmeijer AL. Clinical translation and implementation of optical imaging agents for precision image-guided cancer surgery. Eur J Nucl Med Mol Imaging 2021; 48:332-339. [PMID: 32783112 PMCID: PMC7835299 DOI: 10.1007/s00259-020-04970-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 07/22/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The field of tumor-specific fluorescence-guided surgery has seen a significant increase in the development of novel tumor-targeted imaging agents. Studying patient benefit using intraoperative fluorescence-guided imaging for cancer surgery is the final step needed for implementation in standard treatment protocols. Translation into phase III clinical trials can be challenging and time consuming. Recent studies have helped to identify certain waypoints in this transition phase between studying imaging agent efficacy (phase I-II) and proving patient benefit (phase III). TRIAL INITIATION Performing these trials outside centers of expertise, thus involving motivated clinicians, training them, and providing feedback on data quality, increases the translatability of imaging agents and the surgical technique. Furthermore, timely formation of a trial team which oversees the translational process is vital. They are responsible for establishing an imaging framework (camera system, imaging protocol, surgical workflow) and clinical framework (disease stage, procedure type, clinical research question) in which the trial is executed. Providing participating clinicians with well-defined protocols with the aim to answer clinically relevant research questions within the context of care is the pinnacle in gathering reliable trial data. OUTLOOK If all these aspects are taken into consideration, tumor-specific fluorescence-guided surgery is expected be of significant value when integrated into the diagnostic work-up, surgical procedure, and follow-up of cancer patients. It is only by involving and collaborating with all stakeholders involved in this process that successful clinical translation can occur. AIM Here, we discuss the challenges faced during this important translational phase and present potential solutions to enable final clinical translation and implementation of imaging agents for image-guided cancer surgery.
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Affiliation(s)
- F B Achterberg
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - M M Deken
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - R P J Meijer
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - J S D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - J Burggraaf
- Centre for Human Drug Research (CHDR), Leiden, The Netherlands
| | - C J H van de Velde
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - R J Swijnenburg
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A L Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
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Bijlstra OD, Achterberg FB, Tummers QRJG, Mieog JSD, Hartgrink HH, Vahrmeijer AL. Near-infrared fluorescence-guided metastasectomy for hepatic gastrointestinal stromal tumor metastases using indocyanine green: A case report. Int J Surg Case Rep 2020; 78:250-253. [PMID: 33360978 PMCID: PMC7772365 DOI: 10.1016/j.ijscr.2020.12.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 12/18/2020] [Accepted: 12/18/2020] [Indexed: 01/20/2023] Open
Abstract
Near-infrared fluorescence imaging should be considered as an additional imaging technique to intraoperative ultrasound during surgery for hepatic metastasis. Near-infrared fluorescence imaging can aid surgeons in the identification of preoperatively identified liver metastases from primary GIST. For the detection of additional superficially located liver metastases from primary GIST near-infrared fluorescence imaging can be used. Real-time evaluation of resection margins with NIRF imaging may lead to a lower number of R1 resections.
Introduction and importance Gastrointestinal stromal tumors are the most prevalent mesenchymal tumors of the gastrointestinal tract. Distant metastases are most often found in the liver or peritoneum with surgery being the preferred treatment option. In our center, fluorescence-guided surgery with indocyanine green is used as standard-of-care for hepatic metastases in colorectal cancer. This case report describes fluorescence-guided metastasectomy for a hepatic gastrointestinal stromal tumor in two patients undergoing open liver resection and radiofrequency ablation. Case presentation A 69-year old women was seen during follow-up after laparoscopic resection of a GIST in the lesser curvature of the stomach. Contrast-enhanced computed tomography imaging showed two suspicious lesions in liver segment VI and VIII. Intraoperative near-infrared fluorescence imaging of the liver clearly revealed the lesion in segment VIII, and an additional lesion in segment V – which was not seen on preoperative CT-imaging, neither on intraoperative ultrasonography. The lesion in segment VI was not seen with NIRF imaging due to its deeper location in the liver parenchyma. The second case is an 82-year old man who was also diagnosed with liver metastases from a GIST in the stomach and was scheduled for near-infrared fluorescence-guided liver resection and radio frequency ablation. Clinical discussion In this case report we demonstrated the feasibility of fluorescence-guided surgery in detection of liver metastases and treatment planning of two patients with hepatic GIST metastases using indocyanine green. Conclusion NIRF-imaging with ICG is useful for identification of preoperatively discovered lesions, surgical resection planning and margin evaluation, and for detection of additional hepatic GIST metastases.
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Affiliation(s)
- O D Bijlstra
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands.
| | - F B Achterberg
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Q R J G Tummers
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - J S D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - H H Hartgrink
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - A L Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
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Achterberg FB, Sibinga Mulder BG, Meijer RPJ, Bonsing BA, Hartgrink HH, Mieog JSD, Zlitni A, Park SM, Farina Sarasqueta A, Vahrmeijer AL, Swijnenburg RJ. Real-time surgical margin assessment using ICG-fluorescence during laparoscopic and robot-assisted resections of colorectal liver metastases. Ann Transl Med 2020; 8:1448. [PMID: 33313193 PMCID: PMC7723628 DOI: 10.21037/atm-20-1999] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Almost a third of the resections in patients with colorectal liver metastases (CRLM) undergoing curative surgery, end up being tumor-margin positive (≤1 mm margin). Near-infrared fluorescent (NIRF) imaging using the fluorescent contrast agent indocyanine green (ICG) has been studied for many different applications. When administered in a relatively low dose (10 mg) 24 hours prior to surgery, ICG accumulated in hepatocytes surrounding the CRLM. This results in the formation of a characteristic fluorescent 'rim' surrounding CRLM when located at the periphery of the liver. By resecting the metastasis with the entire surrounding fluorescent rim, in real-time guided by NIRF imaging, the surgeon can effectively acquire margin-negative (>1 mm) resections. This pilot study aims to describe the surgical technique for using near-infrared fluorescence imaging to assess tumor-margins in vivo in patients with CRLM undergoing laparoscopic or robot-assisted resections. Methods Out of our institutional database we selected 16 CRLM based on margin-status (R0; n=8, R1; n=8), which were resected by a minimally-invasive approach using ICG-fluorescence. NIRF images acquired during surgery, from both the resection specimen and the wound bed, were analysed for fluorescent signal. We hypothesized that a protruding fluorescent rim at the parenchymal side of the resection specimen could indicate a too close proximity to the tumor and could be predictive for a tumor-positive surgical margin. NIRF images were correlated to final histopathological assessment of the resection margin. Results All lesions with a NIRF positive resection plane in vivo were reported as having a tumor-positive margin. Lesions that showcased no protruding rim in the wound bed in vivo were diagnosed as having a tumor-negative margin in 88% of cases. A 5-step surgical workflow is described to document the NIRF signal was used assess the resection margin in vivo for future clinical studies. Conclusions The pilot study shows that image-guided surgery using real-time ICG-fluorescence has the potential to aid surgeons in achieving a tumor-negative margin in minimally invasive liver metastasectomies. The national multi-centre MIMIC-Trial will prospectively study the effect of this technique on surgical tumor-margins (Dutch Trial Register number NL7674).
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Affiliation(s)
- Friso B Achterberg
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.,Molecular Imaging Program at Stanford (MIPS), Department of Radiology, Stanford University School of Medicine, Stanford, USA
| | | | - Ruben P J Meijer
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Henk H Hartgrink
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Aimen Zlitni
- Molecular Imaging Program at Stanford (MIPS), Department of Radiology, Stanford University School of Medicine, Stanford, USA
| | - Seung-Min Park
- Molecular Imaging Program at Stanford (MIPS), Department of Radiology, Stanford University School of Medicine, Stanford, USA
| | - Arantza Farina Sarasqueta
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Rutger-Jan Swijnenburg
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Park SM, Won DD, Lee BJ, Escobedo D, Esteva A, Aalipour A, Ge TJ, Kim JH, Suh S, Choi EH, Lozano AX, Yao C, Bodapati S, Achterberg FB, Kim J, Park H, Choi Y, Kim WJ, Yu JH, Bhatt AM, Lee JK, Spitler R, Wang SX, Gambhir SS. Publisher Correction: A mountable toilet system for personalized health monitoring via the analysis of excreta. Nat Biomed Eng 2020; 4:662. [PMID: 32382068 DOI: 10.1038/s41551-020-0562-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
An amendment to this paper has been published and can be accessed via a link at the top of the paper.
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Affiliation(s)
- Seung-Min Park
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.,Molecular Imaging Program at Stanford, Stanford University School of Medicine, Stanford, CA, USA
| | - Daeyoun D Won
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.,Department of Surgery, Seoul Song Do Hospital, Seoul, Republic of Korea.,Cancer Immunology Laboratory, Seoul Song Do Hospital, Seoul, Republic of Korea
| | - Brian J Lee
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.,Molecular Imaging Program at Stanford, Stanford University School of Medicine, Stanford, CA, USA
| | - Diego Escobedo
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Amin Aalipour
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.,Molecular Imaging Program at Stanford, Stanford University School of Medicine, Stanford, CA, USA
| | - T Jessie Ge
- Department of Urology, Stanford University School of Medicine, Stanford, CA, USA
| | - Jung Ha Kim
- Department of Surgery, Seoul Song Do Hospital, Seoul, Republic of Korea
| | - Susie Suh
- Department of Pharmacology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Elliot H Choi
- Department of Pharmacology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Alexander X Lozano
- Department of Materials Science and Engineering, Stanford University, Stanford, CA, USA.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Chengyang Yao
- Department of Electrical Engineering, Stanford University, Stanford, CA, USA
| | - Sunil Bodapati
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Friso B Achterberg
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.,Molecular Imaging Program at Stanford, Stanford University School of Medicine, Stanford, CA, USA.,Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeesu Kim
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.,Molecular Imaging Program at Stanford, Stanford University School of Medicine, Stanford, CA, USA.,Department of Creative IT Engineering, Pohang University of Science and Technology (POSTECH), Pohang, Republic of Korea
| | - Hwan Park
- College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Youngjae Choi
- College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Woo Jin Kim
- College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jung Ho Yu
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.,Molecular Imaging Program at Stanford, Stanford University School of Medicine, Stanford, CA, USA
| | - Alexander M Bhatt
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Jong Kyun Lee
- Department of Surgery, Seoul Song Do Hospital, Seoul, Republic of Korea.,Cancer Immunology Laboratory, Seoul Song Do Hospital, Seoul, Republic of Korea
| | - Ryan Spitler
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.,Precision Health and Integrated Diagnostic Center (PHIND), Stanford University School of Medicine, Palo Alto, CA, USA
| | - Shan X Wang
- Department of Materials Science and Engineering, Stanford University, Stanford, CA, USA.,Department of Electrical Engineering, Stanford University, Stanford, CA, USA.,Canary Center at Stanford for Cancer Early Detection, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Sanjiv S Gambhir
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA. .,Molecular Imaging Program at Stanford, Stanford University School of Medicine, Stanford, CA, USA. .,Department of Materials Science and Engineering, Stanford University, Stanford, CA, USA. .,Department of Bioengineering, Stanford University, Stanford, CA, USA. .,Precision Health and Integrated Diagnostic Center (PHIND), Stanford University School of Medicine, Palo Alto, CA, USA. .,Canary Center at Stanford for Cancer Early Detection, Stanford University School of Medicine, Palo Alto, CA, USA.
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