SPY System Research Articles

Abstract: A Prospective Randomized Trial to Assess Perfusion and Patient Satisfaction in Nipple-Areola Skin Sparing Mastectomy with Immediate Reconstruction

BACKGROUND: Nipple-areola and skin sparing mastectomy (NASSM) is an accepted and sought after option for eligible patients, and the rate of women undergoing this operation continues to climb. The main advantage of the procedure is the ability utilize existing skin envelope and NAC for improved shape, fewer operations, and less psychological impact on patients. There are many possible incisions, each providing its own advantage from an oncologic or reconstructive perspective. Studies suggest that perfusion is received primarily from superior, medial, and lateral contributions. Therefore the lateral radial (LR) incision may lead to improved perfusion, however the mastectomy is more difficult via an inframammary (IMF) incision and this could lead to a higher complication rate. We aim to assess perfusion to nipple-areola complex in these two incision patterns and determine the impact of the incision type on overall outcomes, complications, and patient satisfaction. METHODS: Patients with age >18 with BMI 18–35, with estimated breast size 100-800g were included in this prospective study. Patients were randomized to receive either an IMF or LR incision unless one was given a strong preference by patient or surgeon. A BreastQ survey was administered preoperatively, and three-dimensional images of both breasts were captured. Mastectomies were performed by experienced breast surgical oncologists. Laser angiography (SPY system, Lifecell) was performed at 3 distinct time points: pre-operatively, post-NASSM, and post-reconstruction. Blood pressure was monitored closely throughout the operation. Patients were followed for at least 3 months after their permanent implant placement for complications. Three months post-operatively, the BreastQ survey was again administered and three-dimensional images were captured to measure aesthetic landmarks. Two-tailed Mann-Whitney U and Chi-squared tests were used to compare group medians and proportions with P<0.05 indicating significance. RESULTS: Fifty-five received an IMF incision, and twenty-four a LR incision. There was no difference in demographics, comorbidities, specimen weight, initial implant volume, or intraoperative blood pressure between groups. Similarly, there was no there a difference in distribution of breast perfusion pattern. The LR group did have a longer operative time (155 min vs 177 min, p=0.02). The decrease in perfusion to the whole breast did not differ between groups at each surgical stage. Patients with an IMF incision had significantly lower remaining perfusion to the inferior (21.94% vs 36.89%, p=0.001) and lateral portions of the flap (23.08% vs 40.70%, p=0.003) after reconstruction. Perfusion to the nipple was not significantly different (29.87% vs 40.03%, p=0.15) when adjusting for covariates. Rates of complications, including necrosis, infection, implant exposure or malposition, and explant did not differ between incision types. There was no difference in patient satisfaction based on BreastQ scores between incision types. Finally, there was no significant difference in mammographic measurements on three-dimensional imagining between groups. CONCLUSIONS: There is a significant decrease in blood flow to the inferior and lateral portions of the skin envelope using the IMF incision when compared to the LR incision, possibly due to differences in retraction and difficulty in technique. Despite this, there is no difference in complications, outcomes, or patient satisfaction with their surgical reconstruction over a 3 month period.

Rethinking the Role of Nitroglycerin Ointment in Ischemic Vascular Filler Complications

Soft tissue dermal fillers, both temporary and permanent, are used frequently in facial rejuvenation. As the use of fillers increases, ischemic complications including skin necrosis are becoming more prevalent. In the literature, topical nitroglycerin paste has been recommended in the early treatment of patients presenting with ischemia. The purpose of this study was to evaluate the vascular perfusion effects of topical nitroglycerin paste in an animal model using indocyanine green (ICG) imaging. After Animal Research Committee approval, a rabbit ear model was used to create filler-associated skin ischemia. Ischemia was confirmed to occur after intra-arterial occlusion. Four commonly used soft tissue fillers were injected intra-arterially: Radiesse (Merz USA, Greensboro NC), Restylane (Galderma, Ft. Worth, TX), Juvederm Ultra (Allergan, Irvine CA), Belotero (Merz USA, Greensboro NC) (0.1 ml). A total of 15 ears were used, 1 control and 4 experimental per product. Thirty minutes after occlusion, nitroglycerin ointment USP, 2%(Nitro-Bid) was applied topically to the experimental ears. Vascular perfusion was evaluated with the SPY System (Novadaq Inc.) using ICG imaging. Perfusion images were obtained at baseline, immediately after, and 30 minutes after intra-arterial filler injection, and at 30, 60, 90, and 120 minutes after application of topical nitroglycerin ointment. In this rabbit ear model, no statistically significant improvement in perfusion was noted after topical application of nitroglycerin paste with ICG imaging. In addition, the skin of the rabbit ear post-nitroglycerin ointment appeared to have more of a congested appearance than the controls. Ischemic filler complications are becoming increasingly prevalent. Practitioners often treat these complications with topical nitroglycerin paste based on the knowledge that topical nitroglycerin causes vasodilation. In filler-induced tissue ischemia, however, filler product is present within arterioles. Theoretically, applying nitroglycerin paste, at least early, may not improve perfusion and could worsen ischemia with dilation of vessels and further propagation of product into the smaller arterioles and capillaries. In addition, nitroglycerin paste has systemic effects, including hypotension and dizziness, which may not be tolerated by some patients. Therefore, the authors caution the use of topical nitroglycerin paste in patients presenting with filler-associated ischemia. Further studies in the best treatment algorithms for patients presenting with ischemic complications need to be performed.

The Neisseria meningitidis CRISPR-Cas9 System Enables Specific Genome Editing in Mammalian Cells

The clustered regularly-interspaced short palindromic repeats (CRISPR)—CRISPR-associated (Cas) system from Streptococcus pyogenes (Spy) has been successfully adapted for RNA-guided genome editing in a wide range of organisms. However, numerous reports have indicated that Spy CRISPR-Cas9 systems may have significant off-target cleavage of genomic DNA sequences differing from the intended on-target site. Here, we report the performance of the Neisseria meningitidis (Nme) CRISPR-Cas9 system that requires a longer protospacer-adjacent motif for site-specific cleavage, and present a comparison between the Spy and Nme CRISPR-Cas9 systems targeting the same protospacer sequence. The results with the native crRNA and tracrRNA as well as a chimeric single guide RNA for the Nme CRISPR-Cas9 system were also compared. Our results suggest that, compared with the Spy system, the Nme CRISPR-Cas9 system has similar or lower on-target cleavage activity but a reduced overall off-target effect on a genomic level when sites containing three or fewer mismatches are considered. Thus, the Nme CRISPR-Cas9 system may represent a safer alternative for precision genome engineering applications.

Intraoperative indocyanine green angiography for the objective measurement of blood flow.

PurposeIntraoperative assessment of tissue perfusion is important to predict wound healing or improvement of symptoms in patients with peripheral arterial disease (PAD) or vascular trauma. There is no widely accepted standard for intraoperative measurement of tissue perfusion. Here, we report the use of indocyanine green (ICG)-based angiography to determine the blood flow in patients with PAD and vascular trauma.MethodsThe SPY fluorescent imaging system was utilized. A dose of 3–5 mL of ICG (2.5 mg/mL) was injected intravenously followed by a 10 mL normal saline flush. The SPY imaging system was used to quantitatively assess perfusion. During the study period, the SPY imaging system was applied in 4 patients with PAD and one patient with vascular trauma.ResultsIn 3 patients with PAD associated with an ischemic wound, complete wound healing was achieved with the indication of viable tissue by the SPY system. In one patient with severe claudication in both lower extremities, the ICG angiography was used to determine the increased blood flow after revascularization. In the case of vascular trauma, this imaging system enabled the delineation of viability of the injured tissue.ConclusionICG angiography can determine the surface tissue viability in PAD patients. In cases of severe vascular trauma,the SPY system can be used to determine tissue perfusion. Further study is warranted to define the definite utility of this technology to assess perfusion, response to revascularization, and potentially, to predict the likelihood of wound healing.

Intraoperative indocyanine green fluorescence angiography--an objective evaluation of anastomotic perfusion in colorectal surgery.

The essentials for any bowel anastomosis are: adequate perfusion, tension free, accurate tissue apposition, and minimal local spillage. Traditionally, perfusion is measured by assessing palpable pulses in the mesentery, active bleeding at cut edges, and lack of tissue discoloration. However, subjective methods lack predictive accuracy for an anastomotic leak. We used intraoperative indocyanine green (ICG) fluorescence angiography to objectively assess colon perfusion before a bowel anastomosis. Seventy-seven laparoscopic colorectal operations, between June 2013 and June 2014, were retrospectively reviewed. The perfusion to the colon and ileum was clinically assessed, and then measured using the SPY Elite Imaging System. The absolute value provided an objective number on a 0-256 gray-scale to represent differences in ICG fluorescence intensity. The lowest absolute value was used in data analysis for each anastomosis (including small bowel) to represent the theoretical least perfused/weakest anastomotic area. The lowest absolute value recorded was 20 in a patient who underwent a laparoscopic right hemicolectomy for an adenoma, with no postoperative complications. Four low anterior resection patients had additional segments of descending colon resected. There was one mortality in a patient who underwent a laparoscopic right hemicolectomy. This study illustrates an initial experience with the SPY system in colorectal surgery. The SPY provides an objective, numerical value of bowel perfusion. However, evidence is scant as to the significance of these numbers. Large-scale randomized controlled trials are required to determine specific cutoff values correlated with surgical outcomes, specifically anastomotic leak rates.

Detection of a PNS attack by means of the quasiprobability function of the weak coherent states with phase diffusion in a CV-QKD system

On this article, we present a technique to detect photon number splitting (PNS) attacks in the quantum channel of a continuous variable-quantum key distribution system using weak coherent states with phase diffusion by means of the S-parameterized quasiprobability function of a quantum state in steady state. Such quasiprobability function is obtained with an optoelectronic Costas loop. We compare the performances of PNS attack systems considering in first place just the attenuation and then the attenuation with the vacuum noise added due to a spy system. © 2015 Wiley Periodicals, Inc. Microwave Opt Technol Lett 57:1349–1352, 2015

Unusual Suspect, Unlikely Hero: A Life in the Reign of Alarm Francis ‘Ornament’ Wrangham (1769–1842)

Like many other young liberals of the 1790s victimized by William Pitt’s ‘Reign of Alarm’, Francis Wrangham is remembered today, if at all, only as a footnote to a more famous life: in his case, William Wordsworth’s. Wrangham was a year ahead of Wordsworth at Cambridge, a far more successful student than the poet, indeed a sometime victorious rival over the academic star of the Class of ‘90, the brilliant John Tweddell. Wrangham won the Brown Prize at Magdalen in 1787 and graduated third Wrangler from Trinity Hall in 1790. He was a brilliant classicist and liked the competition: he won five more prizes as an alumnus, between 1794 and 1812. It was as a classicist that he entered Wordsworth’s life. Between 1795 and 1797 the two of them collaborated on an imitation of Juvenal’s eighth satire, on the theme of true nobility – ‘virtue’ is its ‘one and only’ name. This is Juvenal’s rough satire (his tonal signature among the great Roman satirists) on the corrupt nobles of his time, who so little deserve their titles. Wrangham and Wordsworth translated and updated Juvenal, producing an outspoken diatribe against the behavior of the most ‘noble’ personages in England, not quite touching the King, but coming close: the Prince of Wales, and the dukes of Northumberland, Norfolk, and Manchester all come in for rough handling – especially in the parts composed by Wordsworth. The satire is very up-to-date for 1795, including snide remarks about Pitt’s spy system, especially its alarmist attacks on ordinary people, while grand dukes and duchesses are allowed to get away scot-free with the illegal gambling tables they ran at home for their friends:

El Congreso por la Libertad Cultural, visto desde las dinámicas de la Guerra Fría

The aim of this paper is to show how, at the height of the Cold War, the British intelligence services responded to the new spy system created by the Comintern developing a secret campaign of political and cultural propaganda, under the cover of prestigious foundations to channel intellectuals in defense of a liberal democracy. This spy system expected to carry out propaganda secret operations and manipulate the intellectuals from almost the very beginning of the Soviet Revolution. The keystone to win the battle of consciences was the Congress for Cultural Freedom and its editorials, magazines, exhibitions, scholarships, concerts, congresses and conferences. Finally, it will be noted how the Congress for Cultural Freedom implemented the political conception of "non-communist left" to sustain the social democracy in the Western bloc.

Perfusion Assessment with the SPY System after Arterial Venous Reversal for Upper Extremity Ischemia.

The timing and pattern of reperfusion following arterial- venous reversal (AVR) in patients with terminal ischemia of an upper extremity is not well understood. The current case series describes the timing and pattern of reperfusion observed in patients with terminal upper extremity ischemia who underwent AVR and repeated postoperative indocyanine green (ICG) angiography between 2004 and 2009. For all included patients, the SPY Near-Infrared Perfusion Assessment System permitted visualization of ICG-labeled blood flow for 60-second sampling periods at scheduled postoperative time points; outflow and rate and amplitude of inflow were objectively quantified with SPY-Q Analysis Toolkit image analysis software. The series comprised 6 male patients (mean age, 46 years) who presented with upper extremity ischemia related to hypothenar hammer syndrome (n = 2), embolism with patent foramen ovale (n = 2), atherosclerosis (n = 1), and avulsion amputation of the thumb (n = 1); the patient with the avulsion amputation was diagnosed with thromboangiitis obliterans at the time of replantation. AVR was successful in all 6 patients. In 5 of 6 patients, ICG angiography and SPY-based visualization/quantification showed that venous outflow and arterial inflow gradually normalized (versus unaffected digits) between postoperative days (PODs) 0 and 3 and was maintained at long-term follow-up (≥3 months); for the patient who underwent thumb replantation, perfusion normalized between POD 3 and month 5 follow-up. AVR effectively reestablished blood flow in patients with terminal upper extremity ischemia. ICG angiography with SPY technology revealed that, in most cases, kinetic curves, timing, and patterns of perfusion gradually normalized over several PODs.

Potential of the SPY intraoperative perfusion assessment system to reduce ischemic complications in immediate postmastectomy breast reconstruction

BackgroundThe quality and viability of mastectomy flaps remain a central challenge in reconstructive surgery, particularly for immediate breast reconstruction. Insufficient perfusion in tissue flaps is a leading cause of early complications following reconstructive procedures, and clinical judgment alone is not completely reliable for the assessment of flap viability. Accurate and reliable intraoperative methods for assessment of tissue perfusion are needed to help surgeons identify tissue at risk for ischemia and necrosis, thereby allowing for maneuvers to improve tissue flap viability.MethodsThis study evaluates the use of intraoperative laser angiography using the SPY System (LifeCell Corp., Branchburg, NJ) for the assessment of perfusion in mastectomy flaps for immediate breast reconstruction. The SPY System uses the contrast agent indocyanine green, which has an excellent safety profile and pharmacokinetics that allow for repeat evaluations during the same surgical procedure. In recent work, the SPY System has demonstrated high sensitivity and specificity for detection of tissues at risk for ischemia and necrosis during reconstructive surgery. Using a retrospective, chart-review design, the authors compared consecutive cases of immediate breast reconstruction using a prosthesis, before and after implementation of the SPY System.ResultsNinety-one subjects were included in the analysis: 52 prior to SPY (Pre-SPY) and 39 after implementation of SPY (Post-SPY). Baseline characteristics were similar between the groups. Both groups had high rates of comorbidities, chemotherapy, and radiation therapy. The rate of postoperative complications was two-fold higher in the Pre-SPY group compared to the Post-SPY group (36.5% vs. 17.9%); this difference was of borderline significance (P = 0.0631). However, mean number of repeat visits to the OR per patient was significantly higher in the Pre-SPY group (1.21 ± 1.47 vs. 0.41 ± 0.71; P = 0.0023). Of the seven patients with complications in the Post-SPY group, five were identified by SPY as having poor flap perfusion; none were identified by clinical judgment alone.ConclusionsThis study suggests that the SPY System can contribute to reduced ischemia-related complications in a population of women undergoing immediate breast reconstruction following mastectomy for breast cancer.

Lymph node metastases in endocervical adenocarcinoma: Correlation with Silva pattern of invasion.

e16518 Background: Endocervical adenocarcinoma (EA) is the 2nd most common uterine cervical malignancy (after squamous cell carcinoma). Early stage tumors are defined by depth of invasion (DOI); although used to guide nodal dissection, DOI not an entirely reliable criteria, and most patients have negative nodes. Thus, pathologic criteria that better predict risk of nodal metastases are needed. A prior study of 352 cases from 12 US and international institutions, with complete pathological and clinical follow-up averaging 52 months, found classifying EA by a newly proposed ‘Silva Pattern of Invasion’ (SPI) is the best predictor of nodal metastases. SPI are defined as A: no destructive stromal invasion or lymph-vascular invasion (LVI); B: small foci (&lt;4 mm) of fragmented, angulated glands, solid aggregates or individual tumor cells associated with desmoplastia or LVI; and C: diffuse destructive invasion. Pattern A, 25% of cases, had no nodal metastases or recurrences. Approximately 25% were B, with 5% nodal metastases, 2% recurrence, and no tumor deaths. Pattern C cases: nodal metastases 23%, recurrences 21%, and death from tumor 9%. SPI appeared simple to diagnose, but a formal assessment of reproducibility is needed. Methods: Reproducibility for diagnosing SPI, and for the standard measurement of DOI is compared. Four Gynecological Pathologists, who have read the initial manuscript, but not involved in the original study nor from the participating institutions, and blinded to clinical information examine 1or 2 hematoxylin and eosin-stained glass slides from 90 cases from the original series. Results: 30 cases each of Pattern A, B, and C are reviewed. Kappa statistics will be estimated. With 90 samples, we will have &gt;80% power to detect a true kappa of 0.7 in a test of the null hypothesis that kappa = 0.5 vs the alternative that kappa≠0.5 with equal frequencies in each SPI category. Conclusions: A good reproducibility outcome would indicate that the SPI could be applied in general practice. Accurate use of SPI requires examination of the entire lesion unless pattern B or C is found in the biopsy specimen. Use of the SPI system to guide nodal dissection will require validation in a large series.

Use of intraoperative indocyanin-green angiography to minimize wound healing complications in abdominal wall reconstruction

Complication rates following abdominal wall reconstruction (AWR) remain high. Early complications are related to skin necrosis and delayed healing, whereas late complications are related to recurrence. When concomitant body contouring procedures are performed, complication rates can be further increased. It is hypothesised that fluorescent angiography using indocyanin green (ICG) can identify poorly perfused tissues and thus reduce the incidence of delayed healing. A retrospective review was conducted of all patients who underwent AWR with concomitant panniculectomy from 2007–2012. Intraoperative ICG angiography with the SPY system (LifeCell Corp.) was used to determine the amount of resection for body contouring in patients who underwent reconstruction in a cohort of patients. SPY-Q was used to assess relative perfusion of analysed areas. Preoperative, postoperative, and operative details were analyzed. Seventeen patients met inclusion criteria, 12 patients were included in the non-ICG cohort, while five patients were included in the ICG cohorts. Wound-healing complications occurred in 5/12 (42%) patients in the non-ICG cohort vs 1/5 (20%) of the ICG cohorts. A description of the sole patient with complications in the ICG cohort is illustrated. Operative debridement and wound infection development occurred more frequently in the non-ICG cohort compared with the ICG cohort (17%, 17% vs 0%, 0%, respectively). Average time to wound healing was 41.1 days. Intraoperative ICG angiography can accurately detect perfusion abnormalities and can decrease wound healing related complications in complex hernia repair with concomitant panniculectomy. Assessing and ensuring skin viability can decrease the need for operative debridement.

Use of Panitumumab‐IRDye800 to Image Cutaneous Head and Neck Cancer in Mice

To assess the feasibility of panitumumab in real-time fluorescent imaging and histologic processing of cutaneous squamous cell carcinoma (cSCC) in mice. A near-infrared (NIR) fluorescent probe (IRDye800CW) was covalently linked to a monoclonal antibody-targeting epidermal growth factor receptor (panitumumab) or nonspecific IgG and injected into mice bearing flank xenografts from a cSCC cell line (SCC-13 or SRB-12; n = 7), human split-thickness skin grafts (STSGs; n = 3), or a human tumor explant (n = 1). The tumor and lymph nodes were imaged and dissected using fluorescence guidance with the SPY imaging system and verified with a charge-coupled NIR system. An NIR scanning device (Odyssey) was used to measure fluorescence intensity in histological sections. Immunodeficient mice. In vivo and in vitro imaging lab. Tumor tissue could be delineated from the human STSG with tumor-to-background ratios of 4.5 (Pearl) and 3.4 (SPY). Tumor detection was substantially improved with panitumumab-IRDye800 compared with IgG-IRDye800. Biopsies positive for fluorescence were assessed by histology and immunohistochemistry (n = 18/18) to confirm the presence of tumor, yielding a 100% sensitivity. Biopsies of nonfluorescent tissue negative for malignancy (n = 18/18) yielded a specificity of 100%. Furthermore, the SPY system was able to detect residual disease as small as 200 µm in diameter. In addition, the Odyssey confirmed fluorescence of microscopic disease (in tumor samples of frozen and paraffin-embedded histologic specimens) but not in adjacent noncancerous tissue. These data suggest panitumumab-IRDye800 may have clinical utility in detection and removal of subclinical cSCC using Food and Drug Administration-approved imaging hardware.

Intraoperative laser angiography using the SPY system: review of the literature and recommendations for use

Inadequate tissue perfusion is a key contributor to early complications following reconstructive procedures. Accurate and reliable intraoperative evaluation of tissue perfusion is critical to reduce complications and improve clinical outcomes. Clinical judgment is the most commonly used method for evaluating blood supply, but when used alone, is not always completely reliable. A variety of other methodologies have been evaluated, including Doppler devices, tissue oximetry, and fluorescein, among others. However, none have achieved widespread acceptance. Recently, intraoperative laser angiography using indocyanine green was introduced to reconstructive surgery. This vascular imaging technology provides real-time assessment of tissue perfusion that correlates with clinical outcomes and can be used to guide surgical decision making. Although this technology has been used for decades in other areas, surgeons may not be aware of its utility for perfusion assessment in reconstructive surgery. A group of experts with extensive experience with intraoperative laser angiography convened to identify key issues in perfusion assessment, review available methodologies, and produce initial recommendations for the use of this technology in reconstructive procedures.

The Use of Intraoperative Indocyanin-Green Angiography To Minimize Wound Healing Complications in Abdominal Wall Reconstruction

INTRODUCTION: Complication rates following complex abdominal wall reconstruction remains high. Early complications are usually related to skin necrosis and delayed healing; whereas, late complications are usually related to recurrence. When concomitant body contouring procedures are performed, complication rates can be further increased. It is hypothesized that, fluorescent angiography using indocyanin green (ICG) will identify poorly perfused tissues and thus reduce the incidence of delayed healing. METHODS: An IRB-approved, retrospective review was conducted of all patients who underwent abdominal wall reconstruction with concomitant panniculectomy from 2007-2012. Intraoperative ICG angiography with the SPY system (LifeCell Corp.) was used to determine amount of resection for body contouring in patients who underwent reconstruction from 2011-2012. SPY-Q was used to assess relative perfusion of analyzed areas. Preoperative, postoperative, and operative details were analyzed. RESULTS: 17 patients met inclusion criteria; 12 patients were included in the non-ICG cohort, while 5 patients were included in the ICG cohorts. Demographic variables were similar between groups. Wound-healing related complications occurred in 5/12 (42%) patients in the non-ICG cohort versus 1/5 (20%) of the ICG cohorts. In the sole patient with delayed healing in the ICG cohort, SPY-Q system predicted poor tissue perfusion but the results were ignored based on visual tissue appearance. Operative debridement and wound infection development occurred more frequently in the non-ICG cohort compared to the ICG cohort (17%, 17% versus 0%, 0%, respectively). Average time to complete wound healing was 41.1 days. Non-wound healing complications occurred in 3/12 (25%) vs. 1/5 (20%) in the non-ICG and ICG cohorts, respectively. CONCLUSION: Intraoperative ICG angiography can accurately detect perfusion abnormalities and can decrease wound healing related complications in complex hernia repair with concomitant panniculectomy. Assessing and ensuring skin viability can decrease the need for operative debridement.

Continuously observing cutaneous vitality of DIEP flap in rat model

Objective To carried out rat as deep inferior epigastic perforator (DIEP) flap necrosis model,to reveal the continuous blood fluid change in process of flap necrosis.Methods Seven SpragueDawley rats of male were used.The designed DIEP flap model was pedicled on the right-sided cranial perforator.Near-infrared fluorescent angiography was performed using SPY imaging system pre-and-aft operation and all angiography videos were compared and analyzed.Results Using SPY imaging system could observe the process of the blood fluid scattered from perforator through choke anastomoses to next vascular territories in living body.The study could clearly observe sequence change of blood fluid pr-and-aft operation,which could give the important information in revealing the reason of necrosis in DIEP flap.Cross-midline traffic vascular sparse and eventually could no longer wear through the contralateral abdominal wall vessel area and open in the region of lateral thoracic vascular occlusion of blood vessels to reach the flap to the far left side,and showed no blood flow in the dark zone.Conclusion The reasons of necrosis of contralateral distal zone of the flap model,are the choke anastomoses across the midline to the contralateral side appeared small,less intensity and the blood supply to contralatral distal zone should through twice choke anastomoses. Key words: Perforator flap; DIEP flap; Animal model; SPY system

Imaging Cutaneous Head and Neck Cancer with Panitumumab‐IRDye

Objective: To determine if intraoperative, real-time fluorescence imaging hardware (SPY System, Novadaq, Toronto, Canada) and lab-based fluorescence optical imaging of histological sections (Odyssey scanner, LiCor) are capable of detecting micrometastatic cutaneous squamous cell carcinoma (SCC) in preclinical models. Method: An NIR fluorescent probe (IRDye800) was covalently linked to a monoclonal antibody targeting EGFR (panitumumab) or non-specific IgG and injected into mice bearing flank xenografts derived from a cutaneous SCC cell line (SCC-13). The primary tumor and regional lymph nodes were imaged and dissected using fluorescence guidance with the SPY system and verified with a charge-coupled NIR system (Pearl). An NIR charged-coupled device (Odyssey) was used to measure fluorescence intensity of cut sections of tumor and were confirmed with immunohistochemical staining (cytokeratin, CD147). Results: Tumors were clearly delineated from normal tissue with tumor-to-background ratios of 4.5 (Pearl) and 3.4 (SPY). Disease detection was significantly improved with panitumumab-IRDye compared to IgG-IRDye800 ( P &lt; .05). Tissue biopsies positive for fluorescence were confirmed for pathologic disease by histology and immunohistochemistry (n = 10/10); while biopsies of non-fluorescent tissue were proven to be negative for malignancy (n = 12/12). The SPY system was able to detect regional lymph node metastasis (&lt;1.0 mm) and microscopic areas of disease as small as 200 micrometers in diameter. Additionally, the Odyssey successfully detected residual microscopic disease in both frozen and paraffin-embedded histologic specimens. Conclusion: These data suggest that panitumumab-IRDye800 may have clinical utility in detection and removal of cutaneous SCC using existing optical imaging hardware. This technique may prove useful in the detection of microscopic disease grossly and in histological sections.

Use of panitumumab-IRDye800 to image microscopic head and neck cancer in an orthotopic surgical model.

Fluorescence imaging hardware (SPY) has recently been developed for intraoperative assessment of blood flow via detection of probes emitting in the near-infrared (NIR) spectrum. This study sought to determine if this imaging system was capable of detecting micrometastatic head and neck squamous cell carcinoma (HNSCC) in preclinical models. A NIR fluorescent probe (IRDye800CW) was covalently linked to a monoclonal antibody targeting epidermal growth factor receptor (EGFR; panitumumab) or nonspecific IgG. HNSCC flank (SCC-1) and orthotopic (FADU and OSC19) xenografts were imaged 48-96h after systemic injection of labeled panitumumab or IgG. The primary tumor and regional lymph nodes were dissected using fluorescence guidance with the SPY system and grossly assessed with a charge-coupled NIR system (Pearl). Histologic slides were also imaged with a NIR charged-coupled device (Odyssey) and fluorescence intensity was correlated with pathologic confirmation of disease. Orthotopic tongue tumors were clearly delineated from normal tissue with tumor-to-background ratios of 2.9 (Pearl) and 2.3 (SPY). Disease detection was significantly improved with panitumumab-IRDye compared to IgG-IRDye800 (P<0.05). Tissue biopsy samples (average size 3.7mm) positive for fluorescence were confirmed for pathologic disease by histology and immunohistochemistry (n=25 of 25). Biopsy samples of nonfluorescent tissue were proven to be negative for malignancy (n=28 of 28). The SPY was able to detect regional lymph node metastasis (<1.0mm) and microscopic areas of disease. Standard histological assessment in both frozen and paraffin-embedded histologic specimens was augmented using the Odyssey. Panitumumab-IRDye800 may have clinical utility in detection and removal of microscopic HNSCC using existing intraoperative optical imaging hardware and may augment analysis of frozen and permanent pathology.

Near Infrared Fluorescence Imaging After Intravenous Indocyanine Green: Initial Clinical Experience With Open Partial Nephrectomy for Renal Cortical Tumors

To evaluate the safety of near infrared fluorescence (NIRF) of intravenously injected indocyanine green (ICG) during open partial nephrectomy, and to demonstrate the feasibility of this technology to identify the renal vasculature and distinguish renal cortical tumors from normal parenchyma. Patients undergoing open partial nephrectomy provided written informed consent for inclusion in this institutional review board-approved study. Perirenal fat was removed to allow visualization of the renal parenchyma and lesions to be excised. The patients received intravenous injections of ICG, and NIRF imaging was performed using the SPY system. Intraoperative NIRF video images were evaluated for differentiation of tumor from normal parenchyma and for renal vasculature identification. A total of 15 patients underwent 16 open partial nephrectomies. The mean cold ischemia time was 26.6 minutes (range 20-33). All 14 malignant lesions were afluorescent or hypofluorescent compared with the surrounding normal renal parenchyma. NIRF imaging of intravenously injected ICG clearly identified the renal hilar vessels and guided selective arterial clamping in 3 patients. No adverse reactions to ICG were noted, and all surgical margins were negative on final pathologic examination. The intravenous use of ICG combined with NIRF is safe during open renal surgery. This technology allows the surgeon to distinguish renal cortical tumors from normal tissue and highlights the renal vasculature, with the potential to maximize oncologic control and nephron sparing during open partial nephrectomy. Additional study is needed to determine whether this imaging technique will help improve the outcomes during open partial nephrectomy.

Deltec selects 3-D SPI system from Viscom

Deltec selects 3-D SPI system from Viscom