Abstract
BackgroundNear-infrared (NIR) fluorescence imaging has the potential to overcome the current drawbacks of sentinel lymph node mapping (SLNM) in colon cancer. Our aim was to provide an overview of current SLNM performance and of factors influencing successful sentinel lymph node (SLN) identification using NIR fluorescence imaging in colon cancer.MethodsA systematic review and meta-analysis was conducted to identify currently used methods and results. Additionally, we performed a single-center study using indocyanine green (ICG) as SLNM dye in colon cancer patients scheduled for a laparoscopic colectomy. SLNs were analyzed with conventional hematoxylin-and-eosin staining and additionally with serial sectioning and immunohistochemistry (extended histopathological assessment). A true-positive procedure was defined as a tumor-positive SLN either by conventional hematoxylin-and-eosin staining or by extended histopathological assessment, independently of regional lymph node status. SLN procedures were determined to be true negatives if SLNs and regional lymph nodes revealed no metastases after conventional and advanced histopathology. SLN procedures yielding tumor-negative SLNs in combination with tumor-positive regional lymph nodes were classified as false negatives. Sensitivity, negative predictive value and detection rate were calculated.ResultsThis systematic review and meta-analysis included 8 studies describing 227 SLN procedures. A pooled sensitivity of 0.63 (95% CI 0.51–0.74), negative predictive value 0.81 (95% CI 0.73–0.86) and detection rate of 0.94 (95% CI 0.85–0.97) were found. Upstaging as a result of extended histopathological assessment was 0.15 (95% CI 0.07–0.25). In our single-center study, we included 30 patients. Five false-negative SLNs were identified, resulting in a sensitivity of 44% and negative predictive value of 80%, with a detection rate of 89.7%. Eight patients had lymph node metastases, in three cases detected after extended pathological assessment, resulting in an upstaging of 13% (3 of 23 patients with negative nodes by conventional hematoxylin and eosin staining).ConclusionsSeveral anatomical and technical difficulties make SLNM with NIR fluorescence imaging in colon cancer particularly challenging when compared to other types of cancer. As a consequence, reports of SLNM accuracy vary widely. Future studies should try to standardize the SLNM procedure and focus on early-stage colon tumors, validation of tracer composition, injection mode and improvement of real-time optical guidance.
Highlights
Colon cancer is one of the most common malignancies in the Western world and the number of early-stage tumors (T1 and T2) identified is expected to increase as a result of the introduction of nationwide screening programs [1]
Articles were included if they fulfilled the following criteria: (1) description of the use of NIR imaging for sentinel lymph node mapping (SLNM) in colon cancer; (2) prospective design to assess the effectiveness of identification and diagnostic performance of the sentinel lymph node (SLN) procedure in colon cancer; (3) separate results for colon and rectal cancer
SLN procedures yielding tumor-negative SLNs in combination with tumor-positive regional lymph nodes were classified as false negatives
Summary
Colon cancer is one of the most common malignancies in the Western world and the number of early-stage tumors (T1 and T2) identified is expected to increase as a result of the introduction of nationwide screening programs [1]. Up to 20–30% patients with early-stage disease will develop distant metastasis and eventually die from colon cancer [4]. This high recurrence rate in nodenegative colon tumors could be the result of understaging due to missed occult tumor cells (e.g., isolated tumor cells or micrometastases) during routine histopathological examination or inadequate lymph node harvesting [5,6,7,8]. Eight patients had lymph node metastases, in three cases detected after extended pathological assessment, resulting in an upstaging of 13% (3 of 23 patients with negative nodes by conventional hematoxylin and eosin staining). Future studies should try to standardize the SLNM procedure and focus on early-stage colon tumors, validation of tracer composition, injection mode and improvement of real-time optical guidance
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