Mapping of the perigastric lymphatic network using indocyanine green fluorescence imaging and tissue marking dye in clinically advanced gastric cancer
Introduction
The precise drainage pattern of lymphatic vessels and location of each lymph node (LN) can provide important information for predicting lymphatic metastases in gastric cancer. Even though numerous studies have been conducted to visualize lymphatics and LNs using different methods, most of the studies were done under the concept of sentinel LN surgery [1,2]. Therefore, previous studies have shown only a part of the sentinel LNs and/or lymphatics originating from a major gastric cancer lesion and not the perigastric lymphatic network between lymphatics and every single LN.
In gastric cancer surgery, the invisible and complex nature of the lymphatic system makes it technically difficult to accurately visualize the connections between the perigastric lymphatics and the location of every single LN [3]. Recently, indocyanine green (ICG) fluorescence imaging under a near-infrared (NIR) camera has become the most widely used method in the surgical field as it provides a more specific and in-depth visualization of lymphatics and LNs than that achieved with dye-, radio-guided, or combined methods [[4], [5], [6], [7], [8]]. However, since the concentration of ICG, injection method, and type of NIR camera differed between previous study, it is important to plan a standard study protocol suitable for the study purpose [9].
Lymphatic mapping is commonly performed in early gastric cancer (EGC) or tumor-node-metastasis (TNM) stage clinical T2 (cT2) gastric cancer, rather than in advanced gastric cancer (AGC), during sentinel LN surgery for oncological safety [[10], [11], [12], [13], [14]]. Since most lymphatic mapping studies have been conducted in EGC, where LN metastasis itself is uncommon, the findings obtained could not provide sufficient evidence for clinical applications of those methods [15,16]. In AGC, however, because the risk of LN metastasis is significantly higher than that in EGC, it would be essential to visualize the perigastric lymphatics and LNs and understand the LN metastatic pattern.
In this study, we first attempted to visualize LN metastasis patterns by mapping all lymphatic vessels and LNs around the stomach as much as possible, contrary to the concept of sentinel LN surgery. Specifically, we established a mapping method for the perigastric lymphatic network using ICG fluorescence imaging and tissue marking dye (TMD) and investigated their correlation with lymphatic metastasis in clinically AGC.
Section snippets
Ethical statements
This study was approved by the Institutional Review Board of the Seoul National University Hospital (IRB: 1705-034-852). Informed written consent was obtained from all patients preoperatively. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and its later versions.
Patients
Korean patients who were diagnosed with clinically advanced gastric adenmocarcinoma,
Results
All 11 patients successfully underwent open distal (n = 7) or total (n = 4) gastrectomy with D2 LN dissection, except one patient who underwent palliative total gastrectomy. No adverse reactions due to the ICG injection were observed. The clinical characteristics of all 11 patients are listed in Supplementary Table 1.
A total of 687 LNs and 69 LN stations were examined from 11 patients. A total of 198 LNs were assumed as ICG-stained LNs in the back-table examination. However, a total of 260 LNs
Discussion
Many studies dealing with the sentinel LN theory have reported successful lymphatic mapping using different staining methods [19,20], and recently, ICG fluorescence imaging under an NIR camera has become one of the most popular methods for visualizing the lymphatic systems [21]. Fluorescence imaging allows for the in-depth visualization of the target, with a low concentration of ICG, using separate wavelengths for illumination and recording [22,23]. However, the type of NIR camera,
Funding
Experimental instrument (SPY® Elite) was supported by Stryker, USA.
Declaration of competing interest
None of the authors have any conflicts of interest to declare. The paper is not based on a previous communication to a society or meeting.
Acknowledgements
We are deeply grateful to Stryker for providing experimental instrument (SPY® Elite, Stryker, USA) during the study period.
References (31)
- et al.
Application of sentinel node biopsy to gastric cancer surgery
Surgery
(2001) - et al.
Area of nodal metastasis and radioisotope uptake in sentinel nodes of upper gastrointestinal cancer
J Surg Res
(2006) - et al.
Sentinel node biopsy for cT1 and cT2a gastric cancer
Eur J Surg Oncol
(2006) - et al.
Sentinel lymph node biopsy to direct treatment in gastric cancer. A systematic review of the literature
Eur J Surg Oncol
(2011) - et al.
Sentinel lymph node mapping for gastric cancer using a dual procedure with dye- and gamma probe-guided techniques
J Am Coll Surg
(2003) - et al.
Comparative study of the subserosal versus submucosal dye injection method for sentinel node biopsy in gastric cancer
Eur J Surg Oncol
(2005) - et al.
Anaphylactic shock after intravenous administration of indocyanine green during robotic partial nephrectomy
Urol Case Reports [Internet]
(2017) - et al.
Sentinel node mapping for gastric cancer: a prospective multicenter trial in Japan
J Clin Oncol
(2013) - et al.
Mapping sentinel nodes in patients with early-stage gastric carcinoma
Br J Surg
(2003) - et al.
Analysis of the lymphatic stream to predict sentinel nodes in gastric cancer patients
Ann Surg Oncol
(2014)
Radio-guided sentinel node detection for gastric cancer [1]
Br J Surg
Sentinel node mapping guided by indocyanine green fluorescence imaging: a new method for sentinel node navigation surgery in gastrointestinal cancer
Dig Surg
Simultaneous indocyanine green and 99mTc-antimony sulfur colloid-guided laparoscopic sentinel basin dissection for gastric cancer
Ann Surg Oncol
Near-infrared fluorescence lymph node navigation using indocyanine green for gastric cancer surgery
J Minim Invasive Surg
Sentinel node biopsy using blue dye and technetium 99 in advanced gastric cancer: anatomical drainage and clinical application
Brazilian J Med Biol Res
Cited by (9)
Global trends in indocyanine green fluorescence navigation in the field of gastric cancer: bibliometrics and knowledge atlas analysis
2023, Quantitative Imaging in Medicine and SurgeryA narrative review of intraoperative use of indocyanine green fluorescence imaging in gastrointestinal cancer: situation and future directions
2023, Journal of Gastrointestinal OncologyThe primary application of indocyanine green fluorescence imaging in surgical oncology
2023, Frontiers in SurgeryTracers in Gastric Cancer Surgery
2022, Cancers
- 1
Ji-Hyeon Park and Felix Berlth contributed equally to this work.