New method of indocyanine green fluorescence sentinel node mapping for early gastric cancer

Abstract

BackgroundThe present study describes the retrospective feasibility study of ICG fluorescence SN mapping in back-table for early gastric cancer using PINPOINT®.MethodSN mapping were performed as following; the day before surgery, 0.5 ml ICG was injected endoscopically in four quadrants of the submucosa surrounding the gastric cancer using an endoscopic puncture. Intraoperatively, the gastrocolic ligament was divided to visualize all possible directions of lymphatic flow from the stomach. PINPOINT® (NOVADAQ, Canada) was used to illuminate regional lymph nodes from the serosal side. Positive staining was confirmed by at least 3 surgeons and an endoscopist during surgery (Figure 1). Lymph node dissection and gastrectomy were performed according to the criteria of gastric cancer treatment guidelines of JGCA.ResultAll 6 patients had gastrectomy with laparoscopic approach. ICG positive lymphatic flow and lymph nodes were able to be observed in all the patients. Final pathological diagnosis was all StageI and curative resection.All the patients had ICG positive lymphatic area in left gastric artery (LGA) area.Two patients with tumor located in L area had ICG positive flow to right gastroepipoloic artery (RGEA) area. The mean of ICG positive lymph nodes was 8.6. One patient had a metastatic lymph node in station No.4, which was positive for ICG.ConclusionOur method made identification of ICG positive lymph nodes easy in SN mapping in back-table under room light. Although further accumulation and analysis are necessary, we may be able to apply this method for intraoperative SN mapping of laparoscopic gastric cancer surgey.

Near-Infrared Fluorescence Lymph Node Navigation Using Indocyanine Green for Gastric Cancer Surgery

“…Subserosal injection seems to be beneficial given that the surgeon can control the injection by her/himself. 21,[23][24][25][26][27]30,31 Additionally, in my personal opinion, ICG injected into the subserosal layer reaches to the lymphatic pathway more quickly compared with ICG injected into the submucosal layer. However, the location of the primary tumor is frequently difficult to identify using the external view unless the tumor is too advanced to be easily visualized.…”

“…29 Both systems provide fused images from white light and NIR imaging. 30 Other companies have reported prototypes of laparoscopic systems from other companies, 31 and several laparoscopic systems, including the D-light TM system (Karl-Storz, Tuttlingen, Germany), AIM ENV TM system (Stryker, San Jose, CA, USA), and IR TM system (Olympus, Tokyo, Japan), are currently available in the market (Fig. 1).…”

“…In contrast, submucosal injection via an endoscopic needle has more advantages given accurate localization of the tumor and less technical difficulties of injection depending on the location. 21,[23][24][25][26][27]30,31 Endoscopic injection has a risk of penetration of the gastric wall and spillage of the ICG into the peritoneal space, so some a learning period may be required for beginners.…”

The role of sentinel lymph node detection in early gastric cancer – literature review

“…An interesting method which demonstrated the utility of indocyanine green injection in early gastric cancer patients was described by Hironori Ohdaira et al in 2017; the authors proposed preoperative injection of indocyanine green via endoscopy in the four quadrants of the submucosal area, one day before surgery; at the time of surgery the Pinpoint system was used in order to illuminate the region and detect the sentinel lymph nodes after dissecting the gastrocolic ligament. By using this method, the authors reported a successful identification of the sentinel lymph node in six cases; one case presenting a positive lymph node for indocyanine green staining was finally proved to have metastatic deposits 20 .…”

The Short-term and Long-term Outcomes of Indocyanine Green Tracer-Guided Laparoscopic Radical Gastrectomy in Patients with Gastric Cancer

“…In recent years, near-infrared (NIR) imaging with indocyanine green (ICG) has been developed for the visualization of sentinel lymph nodes and real-time guidance of lymph nodes dissection in various cancers [6][7][8][9] . Due to the ne tissue penetration of signal, ICG-mediated NIR uorescent imaging has become a promising technique in navigational laparoscopic surgery 10,11 .…”