Detection of sentinel lymph nodes in minimally invasive surgery using indocyanine green and near-infrared fluorescence imaging for uterine and cervical malignancies

https://doi.org/10.1016/j.ygyno.2014.02.028Get rights and content

Highlights

  • The use of indocyanine green is associated with a high detection of sentinel lymph nodes.

  • The use of indocyanine green is associated with a high sentinel lymph node bilateral detection rate.

Abstract

Objectives

Our primary objective was to assess the detection rate of sentinel lymph nodes (SLNs) using indocyanine green (ICG) and near-infrared (NIR) fluorescence imaging for uterine and cervical malignancies.

Methods

NIR fluorescence imaging for the robotic platform was obtained at our institution in 12/2011. We identified all cases planned for SLN mapping using fluorescence imaging from 12/2011–4/2013. Intracervical ICG was the fluorophobe in all cases. Four  cc (1.25 mg/mL) of ICG was injected into the cervix alone divided into the 3- and 9-o'clock positions, with 1 cc deep into the stroma and 1 cc submucosally before initiating laparoscopic entry. Blue dye was concurrently injected in some cases.

Results

Two hundred twenty-seven cases were performed. Median age was 60 years (range, 28–90 years). Median BMI was 30.2 kg/m2 (range, 18–60 kg/m2). The median SLN count was 3 (range, 1–23 ). An SLN was identified in 216 cases (95%), with bilateral pelvic mapping in 179 (79%). An aortic SLN was identified in 21 (10%) of the 216 mapped cases. When ICG alone was used to map cases, 188/197 patients mapped, for a 95% detection rate compared to 93% (28/30) in cases in which both dyes were used (P = NS). Bilateral mapping was seen in 156/197 (79%) ICG-only cases and 23/30 (77%) ICG and blue dye cases (P = NS).

Conclusions

NIR fluorescence imaging with intracervical ICG injection using the robotic platform has a high bilateral SLN detection rate and appears favorable to using blue dye alone and/or other modalities. Combined use of ICG and blue dye appears unnecessary.

Section snippets

Background

The importance of sentinel lymph node (SLN) mapping in the prognostication of cancer was first described over a half century ago and has since been incorporated into the routine management of various solid tumor types [1], [2], [3], [4]. In gynecologic cancer, the SLN concept is most accepted for vulvar carcinomas, as seen with the publication of Gynecologic Oncology Group (GOG) protocol 174 and the Groningen international study on sentinel nodes in vulvar cancer (GROINSS V-1) [5], [6], [7].

Methods

Institutional review board approval was obtained for this retrospective study. All consecutive cases planned for SLN mapping using fluorescence imaging from 12/2011 to 4/2013 were identified and prospectively entered into our database, which is maintained for quality assurance purposes for all our robotic cases. Intracervical ICG was the fluorophobe used in all cases. The concentration used was 1.25 mg/mL. For each patient, a 25 mg vial with ICG powder was diluted in 20 cc of aqueous sterile

Results

Two hundred twenty-seven patients with endometrial or cervical cancer were identified. The median age of the patients was 60 years (range, 28–90 years), median BMI was 30.2 kg/m2 (range, 18–60 kg/m2), and median EBL was 50 cc (range, 5–1000 cc). The majority of patients (138/227, 61%) were diagnosed with grade 1 or 2 endometrioid adenocarcinoma of the uterus. The median surgical time to complete the SLN mapping was 30 min with some cases being mapped within 3 min (range, 3–84 min). The median number of

Discussion

The use of SLN mapping in the management of melanoma and breast cancers has become the standard of care [1], [2], [3], [4]. SLN mapping for uterine and cervical malignancies has been gaining acceptance and may offer a potential alternative to full LND in the future [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32]. Optimization of detection techniques and rates, with a goal toward convenience,

Conflict of interest statement

Dr. Leitao is a surgical proctor and consultant for Intuitive Surgical.

Dr. Jewell is a consultant for Intuitive Surgical and Covidien.

References (36)

Cited by (0)

Presented as an oral plenary at the 2013 Society of Gynecologic Oncology Annual Meeting on Women's Cancer in Los Angeles, CA.

View full text