Scientific letter
Detection of the Sentinel Node in Pancreatic Cancer by Fluorescence Imaging
Detección del ganglio centinela en el cáncer de páncreas mediante imagen de fluorescencia
Carlota Matallana
, Fernando Pardo, Francisco Espín, Manel Cremades, Esteban Cugat
Corresponding author
Unidad de Cirugía Hepatobiliopancreática, Hospital Universitari Germans Trias i Pujol, Badalona (Barcelona), Spain
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B) Imagen TC (corte coronal): dilatación de la vía biliar (flecha roja) causada por tumoración en cabeza de páncreas. C) Imagen intraoperatoria con colorante verde de indocianina de tumoración en cabeza de páncreas, con captación sincrónica de ganglio en cadena linfática de arteria hepática común. Las imágenes indicadas con flecha se corresponden con el color verde real que surge del efecto fluorescente creado con indocianina.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Flecha inferior: tumoración en cabeza pancreática (adenocarcinoma ductal); flecha superior: adenopatía de cadena linfática de la arteria hepática común.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Carlota Matallana, Fernando Pardo, Francisco Espín, Manel Cremades, Esteban Cugat" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Carlota" "apellidos" => "Matallana" ] 1 => array:2 [ "nombre" => "Fernando" "apellidos" => "Pardo" ] 2 => array:2 [ "nombre" => "Francisco" "apellidos" => "Espín" ] 3 => array:2 [ "nombre" => "Manel" "apellidos" => "Cremades" ] 4 => array:2 [ "nombre" => "Esteban" "apellidos" => "Cugat" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173507720300788" "doi" => "10.1016/j.cireng.2020.04.006" "estado" 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The images indicated with an arrow correspond to the actual green color that arises from the fluorescent effect created with indocyanine.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Lower arrow: pancreatic head tumor (ductal adenocarcinoma); upper arrow: lymphadenopathy of the common hepatic artery chain.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The overall 5-year survival rate for pancreatic cancer does not exceed 10%,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> 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%.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The main causes of this poor prognosis are mainly due to the lack of early detection, rapid spread, and poor response to systemic treatments.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Among the prognostic factors, lymph node involvement is one of the most relevant, although its preoperative study continues to be insufficient.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a> Endoscopic ultrasound has a sensitivity for detection of lymphadenopathy superior to computed tomography (CT) and magnetic resonance imaging (MRI), ranging between 41% and 86%.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In the absence of tools for proper lymph node staging, we believe that indocyanine green may play an important role in pancreatic cancer.</p><p id="par0025" class="elsevierStylePara elsevierViewall">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 1.7<span class="elsevierStyleHsp" style=""></span>cm causing choledochal stenosis measuring 4<span class="elsevierStyleHsp" style=""></span>cm in length and significant dilation of the extrahepatic bile duct. No pathological lymphadenopathies were detected in the preoperative study.</p><p id="par0030" class="elsevierStylePara elsevierViewall">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.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The technique entailed preparing a diluted solution of 25<span class="elsevierStyleHsp" style=""></span>mg of indocyanine green in 10<span class="elsevierStyleHsp" style=""></span>cc of saline.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> During the procedure, once the Kocher maneuver had been performed, 1<span class="elsevierStyleHsp" style=""></span>cc of saline was injected near the surface of the tumor to create a wheal to facilitate the diffusion of the dye. Subsequently, 1<span class="elsevierStyleHsp" style=""></span>cc (2.5<span class="elsevierStyleHsp" style=""></span>mg) 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 4<span class="elsevierStyleHsp" style=""></span>min. 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 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">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 4<span class="elsevierStyleHsp" style=""></span>min, we continued with the rest of the surgical procedure, without incident.</p><p id="par0045" class="elsevierStylePara elsevierViewall">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.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The use of indocyanine green for the detection of the sentinel lymph node is more widespread in other types of tumors, such as gastric cancer<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> or breast cancer.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> In pancreatic cancer, however, its usefulness and applicability have yet to be demonstrated.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">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.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Extended lymph node dissection has not been shown to be superior to standard lymphadenectomy in terms of overall survival,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> and recurrence rates after surgery continue to be high (1, 2, and 5-year rates of 56.7%, 76.6%, and 84.1%, respectively<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a>).</p><p id="par0065" class="elsevierStylePara elsevierViewall">The multiple lymphatic drainage pathways raise the possibility that there is no dominant sentinel node<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a> 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.</p><p id="par0070" class="elsevierStylePara elsevierViewall">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.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a> 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.</p><p id="par0075" class="elsevierStylePara elsevierViewall">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.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">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.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 564 "Ancho" => 2343 "Tamanyo" => 148876 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">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.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Lower arrow: pancreatic head tumor (ductal adenocarcinoma); upper arrow: lymphadenopathy of the common hepatic artery chain.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0070" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "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" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Huang" 1 => "L. Jansen" 2 => "Y. Balavarca" 3 => "M. Babaei" 4 => "L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 0 | 5 |
| 2024 October | 24 | 1 | 25 |
| 2024 September | 36 | 14 | 50 |
| 2024 August | 28 | 13 | 41 |
| 2024 July | 28 | 3 | 31 |
| 2024 June | 17 | 3 | 20 |
| 2024 May | 22 | 3 | 25 |
| 2024 April | 19 | 9 | 28 |
| 2024 March | 38 | 7 | 45 |
| 2024 February | 44 | 2 | 46 |
| 2024 January | 32 | 0 | 32 |
| 2023 December | 40 | 3 | 43 |
| 2023 November | 51 | 6 | 57 |
| 2023 October | 57 | 1 | 58 |
| 2023 September | 30 | 5 | 35 |
| 2023 August | 30 | 0 | 30 |
| 2023 July | 38 | 5 | 43 |
| 2023 June | 19 | 1 | 20 |
| 2023 May | 60 | 2 | 62 |
| 2023 April | 37 | 5 | 42 |
| 2023 March | 20 | 1 | 21 |
| 2023 February | 16 | 1 | 17 |
| 2023 January | 19 | 5 | 24 |
| 2022 December | 24 | 6 | 30 |
| 2022 November | 57 | 10 | 67 |
| 2022 October | 41 | 6 | 47 |
| 2022 September | 24 | 8 | 32 |
| 2022 August | 26 | 14 | 40 |
| 2022 July | 15 | 7 | 22 |
| 2022 June | 18 | 11 | 29 |
| 2022 May | 14 | 8 | 22 |
| 2022 April | 30 | 11 | 41 |
| 2022 March | 32 | 11 | 43 |
| 2022 February | 26 | 8 | 34 |
| 2022 January | 54 | 6 | 60 |
| 2021 December | 17 | 12 | 29 |
| 2021 November | 20 | 6 | 26 |
| 2021 October | 59 | 15 | 74 |
| 2021 September | 38 | 9 | 47 |
| 2021 August | 43 | 12 | 55 |
| 2021 July | 11 | 5 | 16 |
| 2021 June | 21 | 10 | 31 |
| 2021 May | 26 | 10 | 36 |
| 2021 March | 0 | 2 | 2 |
| 2021 February | 1 | 5 | 6 |
| 2021 January | 0 | 5 | 5 |
| 2020 December | 0 | 2 | 2 |
| 2020 November | 0 | 1 | 1 |
| 2020 October | 3 | 4 | 7 |
| 2020 September | 19 | 10 | 29 |
| 2020 August | 4 | 8 | 12 |
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