Laparoscopic Fluorescence to Detect and Treat Subcapsular “Very Small” Hepatocellular Carcinoma in Patients on Waiting List for Liver Transplantation

Abstract

Introduction: Last year M. Sakoda and H. Kudo described intraoperative fluorescence imaging techniques using indocyanine green (ICG) and surgeons began to use them clinically to delineate cancers in the liver during laparoscopic procedures (hepatectomy and/or ablation). Intraoperatively, cancers in the liver can be identified through visualization of ICG, which remains only in the hepatocellular carcinoma (HCC) tissues. Transplantation is the best option for patients with advanced cirrhosis and HCC; however, there is an increasing organ shortage. Therefore, a strong recipient selection for HCC criteria is mandatory. Moreover, the laparoscopic ablation could obtain a strong tumor downstaging. ICG fluorescence imaging is easy to perform and facilitates identification of subcapsular HCC during laparoscopic procedures. Methods: A 60-year-old w/c male was admitted for HCC and alcoholic cirrhosis (Child A6, MELD 12). The medical history showed the following: diabetes not insulin dependent, hypertension, ischemic cardiomyopathy, aortic insufficiency, and esophageal varices stage II. The liver function tests were within the normal limits. The alpha-fetoprotein level was 1.9 ng/mL (NV: <4 ng/mL). Patient was on waiting list for liver transplantation. We injected intravenously a bolus of 3 mg of ICG (Infracyanine® 25 mg/10 mL; SERB™, Paris, France) 12 hours before surgery. During this video, we show a laparoscopic exploration of a cirrhotic liver by fluorescence that confirmed the presence of three suspected nodules, viewed at MRI, plus another 3 mm nodule not detected on intraoperative ultrasound. Results: During the wedge resection of the segment IVa nodule, the fluorescence guided us to achieve a good resection margin. Furthermore, during the ablation of the others two suspected nodules, we noticed that during the ablation, the intensity of the fluorescence of the nodules decreased progressively till it disappeared completely. Imaging at the 3-month follow-up showed no cancer recurrence. The histology of the resected sample and the biopsied nodules confirmed HCC. Conclusion: In conclusion, the laparoscopic fluorescence may have a great sensitivity to detect subcapsular “very small” (<5 mm) HCC, facilitating the liver resection comparing to the only intraoperative ultrasound. The ICG may improve the selection of the patients on waiting list for liver transplantation due to HCC. In fact, patients beyond the Milan criteria will be removed from the transplant list. Furthermore, the fluorescence may be a good marker to know if the ablation procedure is completed or not. Its application can be used also in the setting of liver resection and ablation procedures outside liver transplantation. No competing financial interests exist. Runtime of video: 7 mins