Indocyanine Green Fluorescence Imaging Research Articles

Real-Time In Situ Navigation System With Indocyanine Green Fluorescence for Sentinel Lymph Node Biopsy in Patients With Breast Cancer.

BackgroundThe naked-eye invisibility of indocyanine green fluorescence limits the application of near-infrared fluorescence imaging (NIR) systems for real-time navigation during sentinel lymph node biopsy (SLNB) in patients with breast cancer undergoing surgery. This study aims to evaluate the effectiveness and safety of a novel NIR system in visualizing indocyanine green fluorescence images in the surgical field and the application value of combined methylene blue (MB) and the novel NIR system in SLNB.MethodsSixty patients with clinical node-negative breast cancer received indocyanine green (ICG) and MB as tracers. Two NIR system instruments, namely, lymphatic fluorescence imaging system (LFIS) designed by the University of Science and Technology of China and vascular imager by Langfang Mingde Medical Biotechnology Co., Ltd. (Langfang vascular imager), were used as navigation assistance to locate sentinel lymph nodes (SLNs). Excising the lymph nodes developed by both MB and ICG by two NIR systems or palpably suspicious as SLNs and undergoing rapid pathological examination.ResultsBoth instruments exhibited 95% (57/60) success for real-time lymphatic fluorescent images. A total of 186 SLNs were identified, of which two were pathologically confirmed as lacking any lymph node tissue. SLN identification rate was 100% (184/184) for MB plus LFIS and 86.96% (160/184) for MB alone. The median number of SLNs identified by LFIS combined with MB was 3 (range of 1–8), which was significantly higher than that by MB alone at 2 (range 1–7) (P<0.05).ConclusionLFIS effectively detects SLNs in breast cancer, projects the fluorescence signals during surgery, and provides a continuous surgical navigation system without the need for a remote monitor. The ICG method navigated by combined LFIS and MB may be a promising alternative tracer for radioisotope in SLN mapping.Clinical Trial RegistrationThis clinical trial was registered with the China Clinical Trial Center, registration number ChiCTR2000039542.

Application of indocyanine green fluorescence imaging technique in evaluation of intestinal perfusion in totally laparoscopic left hemicolectomy

Objective: To examine the safety and feasibility of using fusion indocyanine green fluorescence imaging (FIGFI) technique for intraoperative evaluation of colorectal perfusion in the totally laparoscopic left colectomy. Methods: A retrospective cohort study was conducted to collect the clinical data of 58 patients with left colon cancer who underwent totally laparoscopic surgery at the Colorectal Surgery Department, Cancer Hospital, Chinese Academy of Medical Sciences from October 2016 to December 2019. There were 39 males and 19 females, aging (57.0±10.1)years(range:28 to 75 years). According to whether the FIGFI was used during the operation, they were divided into 36 cases in the study group and 22 cases in the control group. The clinical pathological characteristics, operative and postoperative recovery of the two groups were compared by t test, χ2 test, and Fisher exact test. Results: All the 58 patients underwent R0 resection with totally laparoscopic surgery. In the study group, due to poor bowel blood flow after cutting the mesentery (Sherwinter score = 1), 1 patient had to be expanded the resection range until the blood flow was rich(Sherwinter score≥3), and 1 patient in the control group had the complication of postoperative anastomotic leakage of grade A. Compared with the control group, the operation time in the study group was shorter ((156.3±43.5) minutes vs. (180.4±41.3) minutes, t=-2.083, P=0.042). However, there were no significant differences in the amount of blood loss, postoperative hospital stay, postoperative time of anal exhaust, length of bowel resection, number of lymph nodes dissected, and in the incidence of postoperative complications between the two groups. Median follow-up period was 23 months (range: 18 to 37 months). There were no long-term postoperative complications such as ischemic enteritis and anastomotic stenosis in both groups. Conclusions: The FIGFI is safe and feasible to assess the blood supply of intestinal segment and anastomosis during totally laparoscopic left hemicolectomy, and is easy to operate. It is expected to reduce the incidence of anastomotic leakage.

Near-infrared laparoscopy with indocyanine green for axillary sentinel lymph node biopsy in early breast cancer: preliminary experience of a single unit.

A sentinel lymph node biopsy (SLNB) is a routine procedure for axillary staging in cN0 breast cancer (BC) patients. Indocyanine green (ICG) fluorescence can detect sentinel lymph nodes with higher sensitivity than carbon nanoparticle suspension (CNS). The present study investigated the availability and benefits of a near-infrared (NIR) laparoscopy-assisted SLNB using ICG and carbon nanoparticle suspension as tracers. Forty patients with invasive BC, who had clinically negative axillary lymph nodes, participated in this observational study. ICG and CNS tracers were injected into the periareolar region simultaneously or sequentially. In the endoscopy-assisted group (n=20), the patients were given NIR laparoscopic SLNB based on ICG fluorescence and CNS staining. In the open-surgery group, the patients were given traditional SLNB using an open incision, and CNS tracers were injected into the same region as that in the endoscopy-assisted group. In the endoscopy-assisted group, lymphatic vessels and sentinel lymph nodes (SLNs) were successfully identified using ICG fluorescence imaging in most patients (19/20). The average number of SLNs removed was 2.85 (range, 1-4) in the endoscopy-assisted group, and 3.40 (range, 1-7) in the open-surgery group. There was no significant difference between the number of detected nodes (P=0.30). The patients who underwent endoscopy-assisted SLNBs had similar operating times, blood loss and hospital-stay lengths, but lower postoperative drainage volumes and higher satisfaction scores, as they did not have axillary incisions. The NIR laparoscopy-assisted ICG-guided technique is a feasible and surgeon-friendly method for SLNB with good efficacy and acceptable safety. When combined with CNS, more SLNs can be detected and dissected.

Successful laparoscopic resection of gastric lymphangioma under the intraoperative guidance of indocyanine green fluorescence imaging: A case report

Gastric lymphangioma (GLA) is an extremely rare tumor without an established therapeutic strategy. Surgical resection is considered the mainstay of treatment, although there is a high risk of local recurrence if negative margins are not achieved. A 51-year-old man underwent routine abdominal ultrasonography, which incidentally detected a 20-mm tumor adjacent to the lesser curvature of the stomach. GLA was suspected based on its polycystic appearance. After a 16-month monitoring period, laparoscopic resection was performed because of tumor growth and involvement of the left gastric artery. Intraoperative indocyanine green (ICG) navigation system revealed lymphatic drainage from the tumor, which we used to help determine the optimal excision line and minimize the loss of gastric volume. Pathological examination confirmed complete resection with negative margins and supported a diagnosis of lymphangioma. We performed laparoscopic radical resection of GLA under guidance from intraoperative ICG fluorescence imaging, which allowed us to maximize residual gastric volume.

ICG fluorescence imaging in colorectal surgery: a snapshot from the ICRAL study group

BackgroundFluorescence-guided visualization is a recently proposed technology in colorectal surgery. Possible uses include evaluating perfusion, navigating lymph nodes and searching for hepatic metastases and peritoneal spread. Despite the absence of high-level evidence, this technique has gained considerable popularity among colorectal surgeons due to its significant reliability, safety, ease of use and relatively low cost. However, the actual use of this technique in daily clinical practice has not been reported to date.MethodsThis survey was conducted on April 2020 among 44 centers dealing with colorectal diseases and participating in the Italian ColoRectal Anastomotic Leakage (iCral) study group. Surgeons were approximately equally divided based on geographical criteria from multiple Italian regions, with a large proportion based in public (89.1%) and nonacademic (75.7%) centers. They were invited to answer an online survey to snapshot their current behaviors regarding the use of fluorescence-guided visualization in colorectal surgery. Questions regarding technological availability, indications and techniques, personal approaches and feelings were collected in a 23-item questionnaire.ResultsQuestionnaire replies were received from 37 institutions and partially answered by 8, as this latter group of centers do not implement fluorescence technology (21.6%). Out of the remaining 29 centers (78,4%), fluorescence is utilized in all laparoscopic colorectal resections by 72.4% of surgeons and only for selected cases by the remaining 27.6%, while 62.1% of respondents do not use fluorescence in open surgery (unless the perfusion is macroscopically uncertain with the naked eye, in which case 41.4% of them do). The survey also suggests that there is no agreement on dilution, dosing and timing, as many different practices are adopted based on personal judgment. Only approximately half of the surgeons reported a reduced leak rate with fluorescence perfusion assessment, but 65.5% of them strongly believe that this technique will become a minimum requirement for colorectal surgery in the future.ConclusionThe survey confirms that fluorescence is becoming a widely used technique in colorectal surgery. However, both the indications and methods still vary considerably; furthermore, the surgeons' perceptions of the results are insufficient to consider this technology essential. This survey emphasizes the need for further research to reach recommendations based on solid scientific evidence.

Indocyanine green fluorescence imaging, sentinel lymph node mapping in patients with vulvar cancer: peritumoral injection dosage and waiting times in our experience

BackgroundVulvar cancer is a rare gynecological malignancy that primarily affects women of postmenopausal age. Treatment is mainly surgical, particularly for vulvar squamous cell carcinoma, the most prevalent histotype. In patients with unifocal tumors with a maximum diameter of <4 cm, in the absence of suspected inguinal lymph nodes, sentinel lymph node (SLN) biopsy is recommended. The use of a radioactive tracer is mandatory; the use of the vital blue dye is optional.ResultsTwo patients diagnosed with vulvar squamous cell carcinoma (FIGO IB stage) underwent bilateral radical vulvectomy, SLN search and removal, and bilateral inguinal lymphadenectomy at the Cannizzaro Hospital Operative Unit of Obstetrics and Gynecology Department (Catania, Italy). Three milliliters of indocyanine green (ICG) 0.5 mg/mL was administered in 3 peritumoral injections under general anesthesia to screen the SLN. The images were acquired using an intraoperative infrared camera system, which allowed intraoperative visualization of the SLN. An SLN was identified for each patient. The lymph nodes examined by the pathologist were negative for metastatic localization of the disease. However, patients underwent bilateral inguinofemoral lymphadenectomy, as this procedure is not currently codified as a gold standard for the detection of SLN in vulvar cancer. All the lymph nodes removed were negative for the localization of vulvar carcinoma metastases.ConclusionsThe potential of the administration of indocyanine green (ICG) allows the execution of SLN biopsy, avoiding the multiple administrations of radiocolloid in the pre-operative phase, painful for the patient, elimination, and exposure to radioactivity. Therefore, while requiring standardization of the methodology and a large-scale application, this procedure could open a new surgical management perspective in patients with early-stage vulvar cancer.

Novel method of intraoperative liver tumour localisation with indocyanine green and near-infrared imaging

Fluorescence imaging (FI) with indocyanine green (ICG) is increasingly implemented as an intraoperative navigation tool in hepatobiliary surgery to identify hepatic tumours. This is useful in minimally invasive hepatectomy, where gross inspection and palpation are limited. This study aimed to evaluate the feasibility, safety and optimal timing of using ICG for tumour localisation in patients undergoing hepatic resection. From 2015 to 2018, a prospective multicentre study was conducted to evaluate feasibility and safety of ICG in tumour localisation following preoperative administration of ICG either on Day 0-3 or Day 4-7. Among 32 patients, a total of 46 lesions were resected: 23 were hepatocellular carcinomas (HCCs), 12 were colorectal liver metastases (CRLM) and 11 were benign lesions. ICG FI identified 38 (82.6%) lesions prior to resection. The majority of HCCs were homogeneous fluorescing lesions (56.6%), while CLRM were homogeneous (41.7%) or rim-enhancing (33.3%). The majority (75.0%) of the lesions not detected by ICG FI were in cirrhotic livers. Most (84.1%) of ICG-positive lesions detected were < 1 cm deep, and half of the lesions ≥ 1 cm in depth were not detected. In cirrhotic patients with malignant lesions, those given ICG on preoperative Day 0-3 and Day 4-7 had detection rates of 66.7% and 91.7%, respectively. There were no adverse events. ICG FI is a safe and feasible method to assist tumour localisation in liver surgery. Different tumours appear to display characteristic fluorescent patterns. There may be no disadvantage of administering ICG closer to the operative date if it is more convenient, except in patients with liver cirrhosis.

Current Status of Indocyanine Green Tracer-Guided Lymph Node Dissection in Minimally Invasive Surgery for Gastric Cancer

With the rapid development and popularization of laparoscopic and robotic radical gastrectomy, gastric cancer surgery has gradually entered a new era of precise minimally invasive surgery. The era of precision medicine has put forth new requirements for minimally invasive surgical treatment of patients with gastric cancer at different disease stages. For patients with early gastric cancer, avoiding surgical trauma caused by excessive lymph node dissection improves quality of life while pursuing radical treatment of the tumor. In patients with advanced gastric cancer, systematic lymph node dissection can be achieved without increasing surgical complications. With the successful application of indocyanine green (ICG) fluorescence imaging technology in minimally invasive surgical instrumentation in recent years, researchers have found that ICG fluorescence imaging yields good tissue penetration and can identify lymph nodes in fat tissue better than other dyes. Therefore, whether ICG fluorescence imaging technology can guide surgeons in performing safe and effective lymph node dissection has attracted much attention. The present review discusses the clinical applications and research progress of ICG tracer-guided lymph node dissection in patients with gastric cancer.

The application of indocyanine green (ICG) and near-infrared (NIR) fluorescence imaging for assessment of the lymphatic system in reconstructive lymphaticovenular anastomosis surgery

ABSTRACT Introduction Lymphedema has traditionally been managed through noninvasive means with complete decongestive therapy. However, complete decongestive therapy is an intensive program that requires lifelong adherence by patients with lymphedema. More recently, reconstructive surgical procedures have shown promise in improving lymphedema by physiologically restoring lymphatic function. One of these types of procedures, lymphaticovenular anastomosis, relies on technological advances in imaging, particularly indocyanine green lymphangiography. Areas covered This article reviews indocyanine green and near-infrared fluorescence imaging. In addition, this article discusses the application of this imaging to the preoperative, intraoperative, and postoperative assessment of the lymphatic system in the setting of lymphaticovenular anastomosis surgery. Expert opinion Indocyanine green lymphangiography offers significant advantages over other types of imaging of the lymphatic system. In the future, it is hopeful that additional options for these imaging devices will become available which may increase their accessibility by centers interested in performing reconstructive lymphatic surgery, including in relation to cost. Finally, more studies with higher levels of evidence are needed to better define the long-term outcomes associated with lymphatic surgery including LVA. In this regard, practitioners should fully harness the information conferred by ICG lymphangiography as both a clinical and research tool.

Indocyanine green fluorescence imaging-guided laparoscopic right posterior hepatectomy.

Laparoscopic right posterior hepatectomy is considered difficult on the basis of the surgery difficulty scoring system. In this study, we evaluated the safety and effectiveness of the technical application of indocyanine green (ICG) fluorescence imaging-guided laparoscopic right posterior hepatectomy. Twenty-six patients who underwent ICG fluorescence imaging-guided laparoscopic right posterior hepatectomy at Hepatobiliary and Pancreatic Surgery Department of Zhongnan Hospital, Wuhan University, from June 2018 to December 2019, were included. The influence of patient position, trocar placement, hepatic inflow occlusion, central venous pressure (CVP), and the ICG fluorescence imaging-guided method were analyzed. In 17 patients, the left lateral position was maintained when the main tumor was in the S7, and in the remaining nine patients, the supine position was maintained with the right side of the body raised when the main tumor was in the S6. Ten patients who underwent preoperative injection of ICG were successfully developed for nonanatomical hepatectomy. Sixteen patients received intraoperative ICG injection for anatomical hepatectomy (2 cases had positive imaging findings, 14 cases had negative imaging findings, and 2 cases had failed imaging findings). All patients underwent the Pringle maneuver during the procedure. Four patients were preset with subhepatic vena cava blocking and one patient with suprahepatic inferior vena cava blocking. CVP was controlled at 3.00 ± 0.63 (mean ± SD) cmH2O. The operative time was 216.14 ± 52.05min, and the bleeding volume was 128.57 ± 75.55ml. Four patients had Clavien-Dindo level I complications, and one had level III complications. Postoperative hospitalization duration was 6.19 ± 1.40days. There were 14 patients with hepatocellular carcinoma, 9 with metastatic liver malignancies, 2 with hepatic hemangioma, 1 with focal nodular hyperplasia of the liver, and 10 with hepatitis B liver cirrhosis. ICG fluorescence imaging guidance could be helpful for the safe implementation of laparoscopic right posterior hepatectomy.

Application of Indocyanine Green Fluorescence as an Adjuvant to Laparoscopic Ultrasound in Minimally Invasive Liver Resection.

Background: Indocyanine green (ICG) fluorescence imaging has been extensively used in a variety of applications in visceral surgery. In minimally invasive liver resections, the detection of small superficial hepatic lesions using an intravenous injection of ICG before surgery represents a promising application. Methods: We analyzed 18 consecutive patients who underwent laparoscopic liver resection for superficial malignant tumors, namely 11 patients with hepatocellular carcinoma (HCC), 5 patients with colorectal liver metastases (CRLM), 1 patient with intrahepatic cholangiocarcinoma (ICC), and 1 patient with thyroid cancer metastasis, using ICG fluorescence as an adjuvant tool to intraoperative laparoscopic ultrasound (LUS). Results: An optimal ICG 15-minute clearance retention rate (R15 < 10%) and ICG plasma disappearance rate (<18%/minute) were present in 11 patients (61.1%) and in 14 patients (77.7%), respectively. Liver tumors were 29 in total, including 14 HCCs (48.3%), 13 CRLMs (44.8%), 1 ICC (3.4%), and 1 thyroid cancer metastasis (3.4%). Twenty-nine tumors (100%) were correctly visualized with ICG/fluorescence, as compared with 21 tumors identified with LUS (72.4%). After complete liver mobilization, ICG staining allowed to identify more superficial lesions (early HCC and small CRLM) in posterolateral segments (Segments 6 and 7) as compared with LUS (14 versus 10 lesions). In addition, in segments usually treated laparoscopically (e.g., left lateral segments), ICG was superior to LUS (10 versus 6 lesions) to identify superficial early HCC in patients with macronodular cirrhosis. Conclusions: ICG visual feedback might substitute the tactile feedback of the hand and might in some cases act as a "booster" of LUS for superficial hepatic lesions.

Widespread anorectal lymphovascular networks and tissue drainage: analyses from submucosal India ink injection and indocyanine green fluorescence imaging.

AimAbdominoperineal resection is associated with poor prognosis in patients with advanced lower rectal cancer. This study aimed to analyse the functional lymphovascular network and tissue drainage in the anorectal region.MethodsIn this descriptive study, we performed microanatomical evaluations and intra‐operative imaging analysis in a cadaver and patients with rectal cancer. Specimens with India ink injection were collected from a cadaver and from six patients who underwent abdominoperineal resection. Intra‐operative indocyanine green fluorescence imaging was performed on four patients who underwent surgery for lower rectal cancer. India ink was injected into the submucosa at the dentate line of specimens. Tissue sections were examined by immunohistochemistry for D2‐40 and CD31. Intra‐operative indocyanine green was injected into the submucosa at the dentate line. Lymph flow was traced using a near‐infrared camera system.ResultsFascia branching from the rectal longitudinal muscle layer extended to the posterior hiatal ligament and lateral endopelvic fascia connective tissue lamina on the surface of the levator ani muscle. The fascia contained veins labelled with ink in their lumina and initial lymphatics. Intra‐operative indocyanine green fluorescence imaging revealed extensive lymph flow from the muscle layer of the anal canal to the hiatal ligament and endopelvic fascia along the longitudinal muscle layer fibres.ConclusionsThe anorectal region contained widespread venous and lymphatic networks in proportion to its specific connective tissue framework around the longitudinal‐muscle‐layer‐extending muscle bundles, which provides extensive networks for tissue fluid and cells.

Indocyanine green fluorescence imaging for laparoscopic complex upper urinary tract reconstructions: a comparative study.

BackgroundTo describe our technique for using an intraureteral injection of indocyanine green (ICG) and visualization under near-infrared fluorescence (NIRF) to facilitate challenging upper urinary tract reconstructions (UUTRs) and to present the comparative outcomes.MethodsWe collected 36 patients who underwent laparoscopic UUTRs between April 2019 and March 2020, and we divided the patients into two groups based on the use of ICG (ICG group and non-ICG group). Demographic characteristics, perioperative outcomes, and functional outcomes were compared between the two groups.ResultsThere were 18 cases in the ICG group and 18 cases in the non-ICG group, respectively. There were no differences in the baseline characteristics between the two groups. The intraoperative time to identification of the ureter (TIU; 20.9±11.7 vs. 30.0±14.6 min, P=0.03) and length of postoperative hospital stay (LPHS; 11.1±3.0 vs. 16.6±10.0 days, P=0.03) were significantly shorter in the ICG group. There was also a trend for lesser time for locating the stricture (43.0±27.9 vs. 55.4±18.6 min, P=0.14) and lower estimated blood loss (EBL) in the ICG group patients (88.3±75.4 vs. 91.7±46.2 mL, P=0.22). During the mean 3.8-month follow-up for the ICG group and the 6.2-month for the non-ICG group, there was a trend for more severe complications in the non-ICG group.ConclusionsVisualizing intraureteral ICG under NIRF is useful in challenging UUTRs, allows for rapid ureteral identification and accurate real-time delineation of the ureteral stricture margins, and provides encouraging follow-up outcomes compared with those in the non-ICG group.

INDOCYANINE GREEN FLUORESCENCE IMAGING IN ROBOTIC SURGERY: STATE OF ART, TIPS AND TRICKS IN CURRENT APPLICATIONS

Fluorescent imaging with indocyanine green is an emerging technology whose benefits are put in perspective. This article reports essential principles and approaches of intraoperative fluorescence in general surgery bringing familiarity to its practical usage. Our group describes possible pitfalls and provides tips and tricks for training surgeons making their attempts easier and reproducible during practice. This study overviews the most structured concepts, practical applications and its tricks in robotic fluorescence guided imaging surgery with indocyanine green. Possible pitfalls are emphasized and emerging fields of application are put in a perspective. Guided information and practical applications in several surgical fields are described for a safe and reproducible indocyanine green fluorescence imaging use. Robotic assisted surgery combined to fluorescence imaging technology represents a logical evolution in image guided surgery and technology familiarity with guided information may represent a wider and safer spectrum of use in surgeons' hands.

The Advantages of Indocyanine Green Fluorescence Imaging in Detecting and Treating Pediatric Hepatoblastoma: A Preliminary Experience.

Background: Currently, indocyanine green (ICG) fluorescence imaging enables radical surgical resection in hepatoblastoma (HB) and has beneficial uses; however, its usage in pediatric patients is still limited.Methods: From 2015 to 2019, 17 hepatoblastoma patients underwent 22 fluorescence-guided surgery using ICG. ICG (0.3 mg/kg) was intravenously injected 24–48 h before the operation. With ICG/NIR camera, intraoperative identification of biological structures and demarcation of mass were conducted.Results: ICG fluorescence-guided surgery was performed for hepatoblastoma in 22 cases: 16, 1, and 2 cases underwent anatomic resection, partial hepatectomy, and liver transplantation, respectively. Six patients accompanied lung metastasis at the time of surgery, and two patients underwent lung surgery using ICG. The median interval from ICG injection to surgery was 38.3 h (range, 20.5–50.3 h). The median tumor size was 36.5 mm (range, 2–132 mm). According to the pathologic finding, the median safety margin was secured for 6 mm (range, 0–11 mm) and there was no residual finding at the liver at the follow-up computed tomography (CT).Conclusions: ICG fluorescence imaging in children with HB was feasible and safe for tumor demarcation and enhancing the accuracy of radical tumor resection.

Application of Near-Infrared Fluorescence Imaging Technology in Liver Cancer Surgery.

Background. Hepatocellular carcinoma, among the most common malignant digestive system tumorsworldwide, is most effectively treated with precise surgical resection. Near-infrared fluorescence imaging technology is being increasingly used clinically and has achieved great initial results in the navigation of liver cancer surgery. Methods. This review describes the application of indocyanine green fluorescence (ICG) imaging technology with near-infrared window I in the navigation of liver cancer surgery, explores novel fluorescent probes and near-infrared window II fluorescence imaging technology, and discusses the development status of the 2 emerging tools. Results. ICG fluorescence imaging technology can precisely localize the tumor, reveal the boundary of liver cancer or liver segment, and identify the bile leakage. The novel fluorescent probe is more targeted than ICG, which makes the detection of cancer more accurate. Near-infrared window II fluorescence imaging technology can lead to outstanding gains in deeper detection, higher resolution, and fidelity. But, due to the shortcomings of machine and probe, it is not widely used in clinical. Conclusion. Near-infrared fluorescence imaging has great development potential. With the advent of precision medicine and the progress of various biotechnology studies, fluorescence imaging technology will be better developed and applied in the diagnosis, surgical navigation, and treatment of liver cancer.

Tissue texture extraction in indocyanine green fluorescence imaging for breast-conserving surgery

A two-camera fluorescence system for indocyanine green (ICG) signal detection has been developed and tested in a clinical feasibility trial of ten patients, with a resolution in the submillimetre scale. Immediately after systemic ICG injection, the two-camera system can detect ICG signals in vivo (∼2.5 mg or 3.2 × M). Qualitative assessment has shown that the fluorescence signal does not always correlate with the cancer location in the surgical scene. Conversely, fluorescence image texture metrics when used with the logistic regression model yields good accuracy scores in detecting cancer. We have demonstrated that intraoperative fluorescence imaging for resection guidance is a feasible solution to tackle the current challenge of positive resection margins in breast conserving surgery.

Jejunal limb obstruction by a tumor thrombus from pancreatic metastasis of renal cell carcinoma: a case report

BackgroundRenal cell carcinoma (RCC) is a primary tumor with the highest frequency of pancreatic metastasis. Although surgical resection can improve the prognosis of some patients with pancreatic metastasis of RCC (PM-RCC), the role of palliative surgery remains unclear. Herein, we described a case of jejunal limb occlusion caused by a tumor thrombus arising from a PM-RCC which was treated by surgical resection.Case presentationA 75-year-old, male patient with metastatic RCC was admitted to our hospital with new-onset dysphagia and weight loss. Twenty years earlier he underwent a right nephrectomy with an adrenalectomy for the first surgical resection of RCC, and 12 years ago he underwent a left partial nephrectomy for metachronous primary RCC. Nine years later, multiple pancreatic metastases were detected. After discontinuing interferon therapy, he was followed up at his request without anticancer treatment. Multiple, pulmonary metastases developed 3 years ago, and resection of a brain metastasis was performed 6 months ago. He had also undergone a total gastrectomy with Roux-en Y reconstruction and splenectomy for gastric cancer 23 years ago. Computed tomography revealed a metastatic lesion in the pancreatic tail extending into the jejunal limb, which was obstructed by a tumor thrombus. Jejunal limb resection was performed concomitantly with a distal pancreatectomy as palliative surgery. The jejunal limb remnant was approximately 30 cm long and was re-anastomosed to the esophagus using a circular stapler. Blood perfusion at the anastomotic site was confirmed by indocyanine green fluorescence imaging. He was discharged on postoperative day 24 and was followed in the outpatient clinic. He achieved sufficient oral intake at 8 months postoperatively.ConclusionsPM-RCC can invade the gastrointestinal tract and cause tumor thrombus formation resulting in bowel occlusion requiring surgical intervention.

A visual quantification of tissue distinction in robotic transabdominal lateral adrenalectomy: comparison of indocyanine green and conventional views.

Recent studies have reported the feasibility of indocyanine green fluorescence imaging of adrenal tumors to guide dissection. Although the adrenal has been reported to concentrate the dye more than surrounding tissues, the amount of tissue distinction and how this compares with conventional vision has not been quantified before. The aim of this study is to quantify this distinction using color analysis. This was an institutional review board-approved retrospective study. By excluding adrenal cortical carcinoma, metastasis and pheochromocytoma, video recordings of 50 patients who underwent robotic transabdominal lateral adrenalectomy with indocyanine green (ICG) imaging for adrenocortical tumors between August 2015 and May 2018 were reviewed. Using a color analysis software, the pixel intensity of adrenal tumors versus adjacent retroperitoneal tissues was calculated for conventional red, green and blue, as well as indocyanine green (ICG) scales. Statistical analysis was performed using ANOVA. A total of 50 patients underwent unilateral robotic transabdominal lateral adrenalectomy. All procedures were completed robotically without a conversion to laparoscopy or open. Morbidity was 4%. Measured pixel intensity of adrenal tumors was higher than adjacent retroperitoneal tissues for all conventional color and ICG modes (p < 0.0001), with the gradient being more pronounced for ICG green versus conventional red, green and blue modes. To our knowledge this is the first study attempting to encode tissue planes in robotic adrenalectomy. The results show that the visual contrast distinction observed between adrenal and adjacent retroperitoneal tissues can be quantified using pixel intensity. ICG enabled the distinction of tissue planes with a wider gradient compared to conventional RGB view, quantifying its subjective benefits reported in prior studies.

Fluorescence Imaging of Tumor-Accumulating Antibody-IR700 Conjugates Prior to Near-Infrared Photoimmunotherapy (NIR-PIT) Using a Commercially Available Camera Designed for Indocyanine Green.

Near-infrared photoimmunotherapy (NIR-PIT) is a newly developed cancer treatment that uses antibody-IRDye700DX (IR700) conjugates and was recently approved in Japan for patients with inoperable head and neck cancer. Exposure of the tumor with NIR light at a wavelength of 690 nm leads to physicochemical changes in the antibody-IR700 conjugate-cell receptor complex, resulting in increased hydrophobicity and damage to the integrity of the cell membrane. However, it is important that the tumor be completely exposed to light during NIR-PIT, and thus, a method to provide real-time information on tumor location would help clinicians direct light more accurately. IR700 is a fluorophore that emits at 702 nm; however, there is no clinically available device optimized for detecting this fluorescence. On the other hand, many indocyanine green (ICG) fluorescence imaging devices have been approved for clinical use in operating rooms. Therefore, we investigated whether LIGHTVISION, one of the clinically available ICG cameras, could be employed for NIR-PIT target tumor detection. Due to the limited benefits of adding IR700 molecules, the additional conjugation of IRDye800CW (IR800) or ICG-EG4-Sulfo-OSu (ICG-EG4), which has an overlapping spectrum with ICG, to trastuzumab-IR700 conjugates was performed. Conjugation of second NIR dyes did not interfere the efficacy of NIR-PIT. The dual conjugation of IR800 and IR700 to trastuzumab clearly visualized target tumors with LIGHTVISION by detecting emission light of IR800. We demonstrated that the conjugation of second NIR dyes enables us to provide a real-time feedback of tumor locations prior to NIR-PIT.