Laparoscopic detection and resection of occult liver tumors of multiple cancer types using real-time near-infrared fluorescence guidance

Abstract

Background Tumor recurrence after radical resection of hepatic tumors is not uncommon, suggesting that malignant lesions are missed during surgery. Intraoperative navigation using fluorescence guidance is an innovative technique enabling real-time identification of (sub)capsular liver tumors. The objective of the current study was to compare fluorescence imaging (FI) and conventional imaging modalities for laparoscopic detection of both primary and metastatic tumors in the liver. Methods Patients undergoing laparoscopic resection of a malignant hepatic tumor were eligible for inclusion. Patients received standard-of-care, including preoperative CT and/or MRI. In addition, 10 mg indocyanine green was intravenously administered one day prior to surgery. After introduction of the laparoscope, inspection, FI, and laparoscopic ultrasonography (LUS) were performed. Histopathological examination of resected suspect tissue was considered the gold standard. Results Twenty-two patients suspected to have hepatocellular carcinoma (n=4), cholangiocarcinoma (n=2) or liver metastases from colorectal carcinoma (n=12), uveal melanoma (n=2) and breast cancer (n=2) were included. Two patients were excluded because their surgery was unexpectedly postponed several days. Twenty-six malignancies were resected in the remaining 20 patients. Sensitivity for various modalities was 80% (CT), 84% (MRI), 62% (inspection), 86% (LUS) and 92% (FI), respectively. Three metastases (12%) were identified solely by FI. All 26 malignancies could be detected by combining LUS and FI (100% sensitivity). Conclusion This study demonstrates added value of FI during laparoscopic resections of several hepatic tumors. Although larger series will be needed to confirm long-term patient outcome, the technology already aids the surgeon by providing real-time fluorescence guidance.

Long-term follow-up after near-infrared fluorescence-guided resection of colorectal liver metastases: A retrospective multicenter analysis

“…[1–3] One of the main problems is the fact that subcentimeter lesions cannot be detected easily, neither before nor during surgery. [5–7, 17] Even with state-of-the-art scanners and up-to-date protocols, metastases are still being missed, as experienced in this study. Moreover, metastases may arise and/or grow in the period between preoperative imaging and surgery.…”

“…Intraoperative results of some of the included patients have been reported previously. [15–17, 24] At the LUMC, adjuvant chemotherapy was no longer standard-of-care since 2013, resulting in a significant difference between the LUMC and SMGH experimental cohorts. Furthermore, patients from SMGH had more comorbidity, including COPD, diabetes and cardiovascular events, resulting in a significantly higher ASA score.…”

“…NIRF imaging using ICG identifies (sub)capsular micrometastases missed by conventional modalities in up to 17% of CRLM patients. [12–17] In addition, screening of resection margins can detect residual tumor, enabling complete removal of all tumor tissue (R0 resection). [17, 18] Intravenous administration of ICG is safe; adverse reactions are reported in less than 1 in 40,000 patients.…”

“…[12–17] In addition, screening of resection margins can detect residual tumor, enabling complete removal of all tumor tissue (R0 resection). [17, 18] Intravenous administration of ICG is safe; adverse reactions are reported in less than 1 in 40,000 patients. [19] ICG is widely used for clinical applications (e.g.…”

Fluorescence-guided laparoscopic hepatectomy

“…Boogerd et al in their series of laparoscopic fluorescence-guided hepatectomies, describe additional hepatic malignancies visualized with ICG such as metastatic uveal melanoma and breast cancer (13). …”