Robotically assisted fluorescence-guided lymph node mapping with ICG for gynecologic malignancies: A feasibility study
Highlights
► This study evaluates a novel technique for robotic lymph node mapping with near infrared imaging. ► A 1mg cervical Indocyanine green injection revealed a fluorescent sentinel lymph node in 88% of patients. ► Operating room times were not increased and no adverse events occurred.
Introduction
Lymphadenectomy is important in the surgical management of cervical and endometrial cancers, however, it is associated with long-term complications such as lymphedema, nerve injury and lymphocyst formation [1], [2], [3]. Minimally invasive surgical approaches have been shown to reduce peri-operative morbidities for radical hysterectomy and endometrial cancer staging [4], [5]. Sentinel lymph node (SLN) sampling may reduce the risk of long-term complications for patients with cervical and endometrial cancer by minimizing lymphatic disruption.
SLN biopsy is effective in detecting metastatic disease for melanoma, breast and vulvar cancer surgeries [6], [7], [8]. Traditional methods of sentinel node mapping use peri-tumoral injections of blue dyes and/or radioactive tracers. SLN's are identified intra-operatively with Geiger counters or visualization of blue lymph nodes. These methods have been applied to open and minimally invasive SLN detection for cervical and endometrial cancer and their results are promising to date [9], [10], [11]. However, these techniques are challenging to master with prolonged learning curves [12]. Medical dyes that fluoresce and are detected by specialized imagers are a promising alternative to the traditional modalities. They have been tested in gastric, breast and rectal cancers with preliminary results comparable to traditional techniques of SLN mapping [13], [14], [15]. Fluorescence imaging for SLN mapping has also been piloted for cervical cancer via laparotomy and open imagers with favorable results [16], [17].
We assessed the feasibility of a novel method of lymph node mapping using cervical injection of the fluorescing dye Indocyanine green (ICG) and endoscopic NIR imagers with robotic assistance. The primary objective was to determine the dose of ICG at which a minimum of one lymph node was mapped in 80% of subjects.
Section snippets
Methods
Permission was obtained from the Institutional Review Board and UNC Lineberger Comprehensive Cancer Center Protocol Review Committee to perform a prospective cohort study of 20 women with a pre-operative diagnosis of clinical stage 1 endometrial or cervical cancer. Patients consented to cervical stromal injections of ICG, a nontoxic, sterile, water-soluble tricarbocyanine dye, at the time of their definitive surgery. All subjects had planned bilateral pelvic and, in the case of endometrial
Results
Cervical ICG injections and robotically assisted SLN mapping were performed on 20 patients, including 16 patients with a preoperative diagnosis of endometrial cancer and 4 with cervical cancer. Nine (55%) of the sixteen patients with a preoperative diagnosis of endometrial cancer had a grade 1 lesion, with the remaining seven having high grade, type two or non-endometrial pathologies. Three of the four patients with cervical cancer had adenocarcinoma, with 1 having squamous cell carcinoma. The
Discussion
Lymphadenectomy is an important component of the surgical management of cervical and endometrial cancer. Lymph node status is a major factor determining prognosis for early stage cervical cancer [18]. While the role of lymphadenectomy for endometrial cancer is more controversial, ACOG recommends that “most women” with endometrial cancer should receive lymphadenectomy [19].
However, retroperitoneal lymphadenectomy is not without risk. It is associated with a 3.4 to 7.2% risk of lower extremity
Conclusions
Robotically assisted fluorescence imaging is a feasible, safe, reliable and time efficient method for lymphatic mapping and identification of SLN's. SLN's are identified in 88% of patients receiving a 1 mg injection of ICG into the uterine cervix. Subsequent studies with larger numbers of patients are required to determine if the nodes identified with this technique are able to sensitively predict metastatic disease.
Conflict of interest statement
The authors have no conflicts of interest to disclose.
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