metricas
covid
Buscar en
Cirugía Española (English Edition)
Toda la web
Inicio Cirugía Española (English Edition) Detection of the Sentinel Node in Pancreatic Cancer by Fluorescence Imaging
Journal Information
Vol. 98. Issue 5.
Pages 301-303 (May 2020)
Vol. 98. Issue 5.
Pages 301-303 (May 2020)
Scientific letter
Full text access
Detection of the Sentinel Node in Pancreatic Cancer by Fluorescence Imaging
Detección del ganglio centinela en el cáncer de páncreas mediante imagen de fluorescencia
Visits
1644
Carlota Matallana
Corresponding author
carlota.matallana@gmail.com

Corresponding author.
, Fernando Pardo, Francisco Espín, Manel Cremades, Esteban Cugat
Unidad de Cirugía Hepatobiliopancreática, Hospital Universitari Germans Trias i Pujol, Badalona (Barcelona), Spain
This item has received
Article information
Full Text
Bibliography
Download PDF
Statistics
Figures (1)
Full Text

The overall 5-year survival rate for pancreatic cancer does not exceed 10%,1 and, despite the fact that surgery continues to be the only curative treatment, the survival rate of resected patients remains low, with a 5-year rate of no more than 25%.

The main causes of this poor prognosis are mainly due to the lack of early detection, rapid spread, and poor response to systemic treatments.2

Among the prognostic factors, lymph node involvement is one of the most relevant, although its preoperative study continues to be insufficient.3 Endoscopic ultrasound has a sensitivity for detection of lymphadenopathy superior to computed tomography (CT) and magnetic resonance imaging (MRI), ranging between 41% and 86%.4

In the absence of tools for proper lymph node staging, we believe that indocyanine green may play an important role in pancreatic cancer.

We present the case of a 78-year-old woman who was referred to our hospital after CT scan diagnosed a tumor in the head of the pancreas. The study was completed with gastroscopy and MRI, which confirmed the presence of a tumor measuring 1.7cm causing choledochal stenosis measuring 4cm in length and significant dilation of the extrahepatic bile duct. No pathological lymphadenopathies were detected in the preoperative study.

After being assessed by a multidisciplinary committee, a surgical intervention was indicated. A Whipple procedure (pancreaticoduodenectomy) and lymphadenectomy were performed with prior detection of the sentinel node lymph by fluorescence imaging and perilesional injection of indocyanine.5

The technique entailed preparing a diluted solution of 25mg of indocyanine green in 10cc of saline.6 During the procedure, once the Kocher maneuver had been performed, 1cc of saline was injected near the surface of the tumor to create a wheal to facilitate the diffusion of the dye. Subsequently, 1cc (2.5mg) of the prepared indocyanine green solution was injected in the wheal created. After injection, the fluorescence image was emitted and processed, and fluorescence vision was maintained for 4min. Within a few seconds, we observed the presence of 2 foci of uptake (primary tumor and lymph node), which captured the green dye with greater intensity than the rest of the tissue (Fig. 1).

Fig. 1.

Lymphadenopathy (A) Axial CT scan: tumor in the head of the pancreas (marked with a circle); (B) Coronal CT scan: dilation of the bile duct (red arrow) caused by a tumor in the head of the pancreas; (C) Intraoperative image with indocyanine green dye of a tumor in the head of the pancreas, with synchronous uptake of a common hepatic artery lymph node. The images indicated with an arrow correspond to the actual green color that arises from the fluorescent effect created with indocyanine.

Lower arrow: pancreatic head tumor (ductal adenocarcinoma); upper arrow: lymphadenopathy of the common hepatic artery chain.

(0.14MB).

The largest mass corresponded with the tumor of the head of the pancreas, and the second, located at the top of the image, was associated with a lymphadenopathy found in the lymph node chain of the common hepatic artery, which was resected and marked with a suture to be processed histologically. After 4min, we continued with the rest of the surgical procedure, without incident.

The definitive pathology report confirmed the presence of a well-differentiated ductal adenocarcinoma of the head of the pancreas, with free resection margins and associated lymphovascular and perineural invasion. In terms of lymph node involvement, 13 lymph nodes were isolated, and it was confirmed that the only node positive for tumor invasion was the node that captured the indocyanine green during the procedure, stage pT1N1.

The use of indocyanine green for the detection of the sentinel lymph node is more widespread in other types of tumors, such as gastric cancer6 or breast cancer.7 In pancreatic cancer, however, its usefulness and applicability have yet to be demonstrated.8,9

Lymph node involvement is one of the most important prognostic factors, and the reality is that locoregional recurrence in patients with pancreatic adenocarcinoma undergoing surgery with curative intent remains an unsolved problem.

Extended lymph node dissection has not been shown to be superior to standard lymphadenectomy in terms of overall survival,10 and recurrence rates after surgery continue to be high (1, 2, and 5-year rates of 56.7%, 76.6%, and 84.1%, respectively11).

The multiple lymphatic drainage pathways raise the possibility that there is no dominant sentinel node12 and that, to achieve optimal oncological results, it is necessary to perform systematic lymphadenectomy. However, there are no validated studies that demonstrate or refute the existence of the sentinel node in pancreatic cancer.

In recent years, the use of fluorescence imaging has increased significantly in hepatobiliary and pancreatic surgery, but there are no comparative studies that define its intraoperative applicability for lymph nodes.13 The complexity of the pathways for lymphatic dissemination of pancreatic adenocarcinoma makes it a difficult-to-define terrain, in which technological advances can play a fundamental role helping us to clarify these lymphatic routes.

In this context, we believe that the use of intraoperative indocyanine green for the detection of the sentinel node using fluorescence imaging can help outline the involved lymph node territory, thereby achieving better targeted lymph node dissection.

References
[1]
L. Huang, L. Jansen, Y. Balavarca, M. Babaei, L. Van der Geest, V. Lemmens, et al.
Stratified survival of resected and overall pancreatic cancer patients in Europe and the USA in the early twenty-first century: a large, international population-based study.
[2]
Pancreatic adenocarcinoma clinical guidelines in Oncology. National Comprehensive Cancer Network.
NCCN, (April 2019),
[3]
S.J. Yang, H.K. Hwang, M. Kang Ch, W.J. Lee.
Preoperative defining system for pancreatic head cancer considering surgical resection.
World J Gastroenerol, 22 (2016), pp. 6076-6082
[4]
J.C. Ardengh, C.V. Lopes, E.R. de Lima-Filho, R. Kemp, J.S. dos Santos.
Impact of endoscopic ultrasound-guided fine-needle aspiration on incidental pancreatic cysts. A prospective study.
Scand J Gastroenterol, 49 (2014), pp. 114-120
[5]
S. Hirono, M. Tani, M. Kawai, H. Okada, M. Miyazawa, A. Shimizu, et al.
Identification of the lymphatic drainage from the pancreatic head guided by indocyanine green fluorescence imaging during pancreaticoduodenectomy.
Dig Surg, 29 (2012), pp. 132-139
[6]
M. He, Z. Jiang, C. Wang, Z. Hao, J. An, J. Shen.
Diagnosis value of near-infrared or fluorescent indocyanine green guided sentinel lymph node mapping in gastric cancer: a systematic review and meta-analysis.
J Surg Oncol, 118 (2018), pp. 1243-1256
[7]
J. Guo, H. Yang, S. Wang, Y. Cao, M. Liu, F. Xie, et al.
Comparison of sentinel lymph node biopsy guided by indocyanine green, blue dye and their combination in breast cancer patients: a prospective cohort study.
World J Surg Oncol, 15 (2017), pp. 196
[8]
S.Y. Rho, J.S. Kim, J.U. Chong, H.K. Hwang, D.S. Yoon, W.J. Lee, et al.
Indocyanine green perfusion imaging-guided laparoscopic pancreaticoduodenectomy: potential application in retroperitoneal margin dissection.
J Gastrointest Surg, 22 (2018), pp. 1470-1474
[9]
S. Paiella, M. de Pastena, L. Landoni, A. Esposito, L. Casetti, M. Miotto, et al.
Is there a role for near-infrared technology in laparoscopic resection of pancreatineuroendocrine tumors? Results of the COLPAN “color and ressect the pancreas” study.
Surg Endosc, 31 (2017), pp. 4478-4484
[10]
B. Dasari, S. Pasquali, R. Vohra, A. Smith, M. Taylor, R. Sutcliffe, et al.
Extended versus standard lymphadenectomy for pancreatic head cancer: meta-analysis of randomized controlled trial.
J Gastrointest Surg, 19 (2015), pp. 1725-1732
[11]
A. Van den broeck, G. Sergeant, N. Ectors, W. van Steenbergen, R. Aerts, B. Topal.
Patterns of recurrence after curative resection of pancreatic ductal adenocarcinoma.
Eur J Surg Oncol, 35 (2009), pp. 600-604
[12]
M. Kanda, T. Fujii, S. Nagai, Y. Kodera, A. Kanzaki, T.T. Sahin, et al.
Pattern of lymph node metástasis spread in pancreatic cancer.
Br J Cancer, 40 (2011), pp. 951-955
[13]
G.L. Baiocchi, M. Diana, L. Boni.
Indocyanine green-based fluorescence imaging in visceral and hepatobiliary and pancreatic surgery: state of the art and future directions.
Word J Gastroenterol, 24 (2018), pp. 2921-2930

Please cite this article as: Matallana C, Pardo F, Espín F, Cremades M, Cugat E. Detección del ganglio centinela en el cáncer de páncreas mediante imagen de fluorescencia. Cir Esp. 2020;98:301–303.

Copyright © 2019. AEC
Download PDF
Article options
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos