吲哚靛青绿储留率判断切肝量及其与肝癌术后肝功能不全的关系

背景与目的:肝癌术前正确评估肝脏储备功能、术中合理掌握切肝量是避免肝功能衰竭的重要措施。近年来,吲哚靛青绿储留率(indocyaninegreenretentionrateat15min,ICGR15)已被认为是反映肝脏储备功能的灵敏指标。如何根据肝脏储备功能特别是ICGR15来决定所能切除的最大肝脏体积,目前未有定论。本研究旨在探讨术前ICGR15与术中切除肝体积对术后肝功能不全的影响。方法:对225例手术切除的肝细胞肝癌患者进行研究。观察指标包括术前ICGR15的测定,术中切除的肝段数以及术后患者出现肝功能不全的情况。结果:ICGR15<10%时,切除A组(切除肝段数相当于一个肝段以内)、B组(切除肝段数大于一个肝段,但在两个肝段以内)、C组(切除肝段数大于两个肝段)肝段的腹水产生率分别为21.2%、14.3%、15.4%(P>0.05);黄疸率分别为3.0%、7.1%、15.4%(P>0.05)。ICGR15介于10%～20%时,腹水产生率分别为26.8%、38.9%、50.0%(P>0.05);黄疸率分别为0、27.8%、20.0%,(P<0.01);其中2例死亡,均切除两个或以上肝段。ICGR15>20%时,6例切除A组肝段的患者中有2人出现腹水;而仅有2例切除B组肝段的患者均出现腹水和黄疸,其中1例死亡。结论:可根据ICGR15值粗略决定肝脏切除量。ICGR15<10%时,可切除两个或更多的肝段;ICGR15介于10%～20%时,切除一个肝     

The indocyanine green method is equivalent to the Tc-labeled radiotracer method for identifying the sentinel node in breast cancer: A concordance and validation study

Aims

The aim of this study was to assess concordance between the indocyanine green (ICG) method and ^99mTc-radiotracer method to identify the sentinel node (SN) in breast cancer. Evidence supports the feasibility and efficacy of the ICG to identify the SN, however this method has not been prospectively compared with the gold-standard radiotracer method in terms of SN detection rate.

Methods

Between June 2011 and January 2013, 134 women with clinically node-negative early breast cancer received subdermal/peritumoral injection of ^99mTc-labeled tracer for lymphoscintigraphy, followed by intraoperative injection of ICG for fluorescence detection of SNs using an exciting light source combined with a camera. In all patients, SNs were first identified by the fluorescence method (ICG-positive) and removed. A gamma ray-detecting probe was then used to determine whether ICG-positive SNs were hot (^99mTc-positive) and to identify and remove any ^99mTc-positive (ICG-negative) SNs remaining in the axilla. The study was powered to perform an equivalence analysis.

Results

The 134 patients provided 246 SNs, detected by one or both methods. 1, 2 and 3 SNs, respectively, were detected, removed and examined in 70 (52.2%), 39 (29.1%) and 17 (12.7%) patients; 4–10 SNs were detected and examined in the remaining 8 patients. The two methods were concordant for 230/246 (93.5%) SNs and discordant for 16 (6.5%) SNs. The ICG method detected 99.6% of all SNs.

Conclusions

Fluorescent lymphangiography with ICG allows easy identification of axillary SNs, at a frequency not inferior to that of radiotracer, and can be used alone to reliably identify SNs.     

近红外线吲哚氰绿荧光显像法在cN0口腔癌前哨淋巴结活检中的应用

目的 评价近红外线吲哚氰绿(ICG)荧光显像法在临床淋巴结阴性(cN0)口腔癌术中前哨淋巴结活检中的可行性和有效性.方法 符合条件且知情同意的cT1-3 N0 M0口腔(或口咽)癌患者30例入组.切开皮肤前用1 ml注射器抽取ICG(25 mg/5 ml)1 ml行瘤周四象限和基底注射;随后行常规颈清扫切口翻瓣游离胸锁乳突肌并将其向后牵拉,显露术野,用近红外线荧光成像系统扫描术区直至捕获荧光热点,切除热点淋巴结;离体淋巴结经再次扫描确认为荧光热点者定义为前哨淋巴结.完成颈清扫后将前哨淋巴结和非前哨淋巴结分别送病理检查.结果 全组30例均成功地获取前哨淋巴结,每例前哨淋巴结数目1～9枚,平均3.4枚.常规病理证实30例中5例(16.67％)有隐匿性转移,转移淋巴结全部为前哨淋巴结.全组未发生ICG相关的不良反应.结论 近红外线ICG荧光显像法对cN0口腔癌行术中前哨淋巴结活检成功率高,前哨淋巴结能准确评价颈淋巴结转移状况.该方法简单可行,有发展前景,值得进一步研究.     

腹腔镜下吲哚菁绿示踪前哨淋巴结在保留生育功能宫颈癌手术中的应用

目的 探讨吲哚菁绿（indocyanine green,ICG）示踪前哨淋巴结在腹腔镜下保留生育功能宫颈癌手术中的应用效果并总结经验。方法 回顾性分析24例行腹腔镜下广泛宫颈切除+示踪前哨淋巴结（sentinel lymph node,SLN）切除宫颈癌患者的临床资料,所有患者均采用ICG示踪,进行前哨淋巴结活检（sentinel lymph node biopsy,SLNB）,分析显影情况、前哨淋巴结分布及数量。结果 24例患者均出现至少1个SLN显影,显影率为100%（24/24）,双侧显影率为93.8%（22/24）。不同示踪剂注射方法与术前是否行子宫锥切患者的SLN显影率差异无统计学意义（Ｐ＞0.05）。24例患者共切除前哨淋巴结210枚,平均8.75枚（3~19枚）,其中139枚SLN位于髂血管区域,占66.19%（139/210）。结论 在严格掌握指征和操作流程的情况下,ICG示踪前哨淋巴结可有效应用于腹腔镜下保留生育功能宫颈癌手术。     

Mapping of the perigastric lymphatic network using indocyanine green fluorescence imaging and tissue marking dye in clinically advanced gastric cancer

BackgroundUsing indocyanine green (ICG) fluorescence imaging and tissue marking dyes (TMDs), perigastric lymphatic mapping and their pathological correlation were examined to see whether ICG staining covers all metastatic lymph nodes (LNs) in advanced gastric cancer (AGC).MethodsPatients with AGC who underwent open distal or total gastrectomy were enrolled. ICG was serially injected intraoperatively into the subserosa along the greater and lesser curvatures. Stomach specimens were examined under a near-infrared camera. ICG-stained LNs were named, excised, and tattooed with different colored TMDs to retrace the exact location after pathological examinations.ResultsA total of 687 LNs and 69 LN stations were examined from 11 patients. The map of the perigastric lymphatic network showing the topography of ICG-stained and ICG-unstained LNs, including metastatic information, was successfully reconstructed. The average number of ICG-stained and ICG-unstained LNs were 23.6 ± 12.3 (37.8%) and 38.8 ± 17.1 (62.2%), respectively. LN metastases were present in 28 LN stations of 8 patients. Of 8 cases with LN metastases, 40% (11.1–75% per case) of metastatic LNs were stained by ICG. Of 28 metastatic LN stations, 21 (75.0%) were covered by ICG, and actual metastatic LNs were stained in 16 LN stations (57.1%). In 4/8 cases (50%), all metastatic LN stations showed ICG signals.ConclusionsICG fluorescence imaging and TMD are useful tools for visualizing the perigastric lymphatic network and retracing the exact location of ICG-stained LNs in AGC. However, ICG imaging is still not recommended for selective LN dissection in AGC because of the limited staining of perigastric LNs.     

肝癌术前ICGR15测定对肝脏储备功能的评估

背景与目的:术前正确评估肝脏储备功能,是避免肝癌患者术后肝功能衰竭的重要措施.近年来,吲哚靛青绿储留率(indocyanine green retention rate at 15min,ICGR15)被认为能准确而灵敏地反映肝脏储备功能.本研究目的探讨肝癌切除术前ICGR15在评估肝硬化程度和肝脏储备功能中的作用,分析ICGR15与术后肝功能不全的关系,并与Child-Pugh分级进行比较.方法:分析225例手术切除的肝细胞癌患者术前常规肝功能检查、Child-Pugh分级及ICGR15的测定结果.结果:肝硬化患者及无肝硬化患者ICGR15均值分别为(9.90±6.20)%、(7.41±3.80)%,差异有显著性(P＜0.01);轻、中、重度肝硬化患者的ICGR15均值分别为(8.49±5.00)%、(10.70±5.70)%、(15.77±9.60)%,三组间两两比较差异有显著性(P＜0.05);术后发生腹水、黄疸患者的ICGR15均值分别为(11.49±6.80)%、(12.09±7.10)%,分别显著高于无腹水、无黄疸患者[(8.53±4.90)%、(8.96±5.30)%](P＜0.05).将可能影响术后并发症发生的多种因素以enter法引入多元logistic回归模型,ICGR15对术后发生腹水、黄疸均有显著影响(P＜0.05).Child-Pugh B级患者的ICGR15均值为(15.25±8.60)%,显著高于Child-Pugh A级患者(8.85±5.10)%(P＜0.01);212例Child-Pugh A级患者中有67例ICGR15大于10%,其中6例大于20%.结论:ICGR15随肝硬化程度的加重而升高,其对术后发生肝功能衰竭有显著影响;其与Child-Pugh分级有一定相关性.     

Estimation of the future remnant liver function is a better tool to predict post-hepatectomy liver failure than platelet-based liver scores

Introduction

Recently, there has been increasing interest in the preoperative prediction and prevention of post-hepatectomy liver failure (PHLF). This is a particular concern in colorectal liver metastases (CRLM), when surgery follows potentially hepatotoxic chemotherapy. Platelet-based liver scores (PBLS) such as APRI and FIB-4 are predictive of chemotherapy-associated liver injury (CALI) and PHLF. Estimation of the future liver remnant function (eFLRF) by combining ^99mTc-Mebrofenin Hepatobiliary Scintigraphy (HBS^BSA) with future liver remnant volume ratio (FLRV%), is predictive of PHLF and related mortality. We hypothesized that a HBS^BSA based formula was a better predictor for PHLF than PBLS in chemotherapy-pretreated CRLM.

Diagnostic accuracy of 3D imaging combined with intra-operative ultrasound in the prediction of post-hepatectomy liver failure

BackgroundThe risk of post-hepatectomy liver failure (PHLF) is difficult to predict preoperatively. Accurate preoperative assessment of residual liver volume is critical in PHLF. Three-dimensional (3D) imaging and intra-operative ultrasound (IOUS) offer significant advantages in calculating liver volume and have been widely used in hepatectomy risk assessment. Our research aimed to explore the accuracy of 3D imaging technique combining IOUS in predicting PHLF after hepatectomy.MethodsWe used a retrospective study design to analyze patients who underwent hepatectomy with 3D imaging combined with IOUS between 2017 and 2020. Utilizing 3D reconstruction, the patient’s residual liver volumes (PRLVs) and ratio of PRLV to standard liver volume (SLV) were calculated preoperatively. Hepatectomy were performed and actual hepatectomy volume (AHV) were measured. Consistency between preoperative planned hepatectomy volume (PPHV) and AHV was quantified postoperatively by Bland-Altman analysis. Multiple logistic regression and receiver-operating characteristic (ROC) curves were utilized to discuss the predictive value of PRLV/SLV in PHLF.ResultsAmong the 214 included patients, 58 (27.1%) had PHLF. Patients with PHLF had significantly higher residual rates of ICG-R15 (%) (P=0.000) and a lower PRLV/SLV ratio (P=0.000). Bland-Altman analysis showed that PPHV was consistent with AHV (P=0.301). Multivariate analysis confirmed that PRLV/SLV ratio >60% (OR, 0.178; 95% CI: 0.084–0.378; P<0.01) was a protective factor for PHLF. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 75.8% (95% CI: 64.5.3–87.2%), 66.6% (95% CI: 59.1–74.1%), 45.8%, and 88.1%, respectively. The area under the ROC curve (AUC) was 73.7% (95% CI: 65.7–85.8%) and the diagnostic accuracy of PRLV/SLV for PHLF was moderate (P<0.001). These results were validated in the validation cohort perfectly. The primary cohort included 214 patients with a PHLF rate of 27.1% (n=58, 28 grade B and 13 grade C). The validation cohort included 135 patients with a PHLF rate of 35.6% (n=48, 24 grade B and 11 grade C).ConclusionsThe calculation of PRLV/SLV has predictive value in PHLF and can be exploited as a predictive factor. The 3D imaging technique combined with IOUS may be useful for PHLF risk assessment in hepatectomy patients.     

Analysis of safety and efficacy of laparoscopic radical gastrectomy combined with or without indocyanine green tracer fluorescence technique in treatment of gastric cancer: a retrospective cohort study

BackgroundAn adequate resection margin and lymph node dissection are important factors for successful radical gastrectomy. The presence of near-infrared camera imaging with indocyanine green (ICG) gives new insight into radical gastrectomy. Laparoscopic radical gastrectomy with ICG is still in its initial stages and requires more evidence-based medical research. The aim of the present study was to evaluate the safety and availability of lymph node dissection and precise gastrectomy for gastric cancer patients undergoing radical resection under laparoscope with ICG, in the hope of providing evidence of application of ICG tracer fluorescence technique in radical gastrectomy.MethodsA retrospective cohort study was performed with 56 patients who underwent laparoscopic radical gastrectomy. The patients were categorized into the ICG (n=18) or the non-ICG (n=38) group based on whether preoperative endoscopic mucosal ICG injection was performed. Their clinical characteristics (age, tumor size, location, TNM stage and so on) were compared as baseline data. Perioperative outcomes (blood loss, time of first intestinal exhaust, early or long-term complications and so on) were used to assess safety. The status of lymph node dissection and tumor localization were analyzed to testify efficacy. SPSS version 26.0 was used for the statistical analysis.ResultsThere was no difference in clinical data at baseline. From the safety point of view, there was no difference in perioperative outcomes (operative time, blood loss, time of first intestinal exhaust and so on) between the two groups (all P>0.05). From the efficacy point of view, the number of lymph nodes <5 mm (21.84±1.86 vs. 16.24±2.10, P<0.001), the total number of lymph nodes (34.61±5.87 vs. 29.92±5.27, P=0.004), the number of lymph nodes dissected in perigastric regions (groups 1–7, 22.89±3.64 vs. 20.29±3.00, P=0.007), and the number of lymph nodes in extraperigastric regions (groups 8–12, 11.72±3.06 vs. 9.61±3.18, P=0.022) were greater in ICG group compared with non-ICG group. In ICG group, the average vertical distances between the top and bottom of the fluorescent edge and neoplastic edge were 2.65±0.58 and 2.67±0.65 cm, respectively. Fluorescent edge pathology was negative.ConclusionsICG fluorescence could be conducive to lymph node dissection and precise gastrectomy in laparoscopic radical gastrectomy.     

Extended preoperative chemotherapy,extent of liver resection and blood transfusion are predictive factors of liver failure following resection of colorectal liver metastasis

Aim

The aim of this study was to determine the incidence and prognostic factors of postoperative liver failure in patients submitted to liver resection for colorectal metastases.

Method

Patients with CLM who underwent hepatectomy from 1998 to 2009 were included in retrospective analysis. Postoperative liver failure was defined using either the 50–50 criteria or the peak of serum bilirubin level above 7 mg/dL independently.

Results

Two hundred and nine (209) procedures were performed in 170 patients. 120 surgeries were preceded by chemotherapy within six months. The overall morbidity rate was 53.1% and 90-day mortality was 2.3%. Postoperative liver failure occurred in 10% of all procedures, accounting for a mortality rate of 9.5% among this group of patients. In multivariate analysis, extent of liver resection, need of blood transfusion and more than eight preoperative chemotherapy cycles were independent prognostic factors of postoperative liver insufficiency. This complication was not related with the chemotherapy regimen used.

Conclusion

We conclude that postoperative liver failure has a relatively low incidence (10%) after CLM resection, but a remarkable impact on postoperative mortality rate. The amount of liver resected, the need of blood transfusion and extended preoperative chemotherapy are independent predictors of its occurrence and this knowledge can be used to prevent postoperative liver failure in a multidisciplinary approach.     

A comparison of ICG-NIR with blue dye and technetium for the detection of sentinel lymph nodes in vulvar cancer

IntroductionThe sentinel lymph node (SLN) procedure for vulva cancer is a safe alternative to a radical inguino-femoral lymphadenectomy (IFLN) for small unifocal tumours. SLN evaluation through biopsy and ultra-staging has helped gynaecological oncology surgeons improve operative morbidity with no cost to oncologic safety. Established techniques for groin SLN detection and excision in vulvar cancer use ^99mTc-nanocolloid radiotracer and blue dye (BD) for identification of the SLN. Indocyanine green (ICG)-near infrared (ICG-NIR) techniques for SLN mapping have proven utility in other gynaecological cancer sites and is gaining interest as a technique for SLN mapping in vulvar cancerMethodsFifty consecutive patients with unifocal vulvar squamous cell cancers of <40 mm lateral diameter and with depth of invasion > 1 mm underwent SLN mapping and excision using a combination of ^99mTc-nanocolloid, BD and ICG. SLN detection results were recorded on a per-patient and per-groin basis. The success rates SLN for detection by individual tracer substance or combinations of tracer were determined by presence of one or more tracer, detectable in the SLN specimen.Results92% of patients had a successful SLN procedure. The per-groin detection rate was 84%. All successfully mapped SLN were identified with the combination of ICG-NIR and ^99mTc-nanocolloid compared to 69% with BD ^99mTc-nanocolloid. Success rates for the SLN procedure were not dependent on prior excision of the primary lesion or operator experience.ConclusionsIncorporation of ICG-NIR into standard SLN mapping protocols may allow for the abandonment of routine use of BD and its poor side effect profile.     

Sentinel node mapping with indocyanine green (ICG) and infrared ray detection in early gastric cancer: An accurate method that enables a limited lymphadenectomy

Aim

This study compares lymphatic mapping in early gastric cancer with ICG and infrared ray electronic endoscopy (IREE) to ICG alone. It examines the optimal method for intra-operative detection of metastases and shows long term follow up results.

Methods

212 patients underwent the SN procedure with IREE and peritumoural ICG injection. Evaluated parameters were detection of sentinel nodes with IREE versus ICG alone, intra-operative detection rate of lymph node (LN) metastasis with node picking versus lymphatic basin dissection (LBD) and lymphatic drainage patterns.

Results

34 patients had LN metastases. The SN identification rate and sensitivity for IREE versus ICG alone were 99.5 versus 85.8% and 97.0 versus 48.4% respectively. Intra-operative accuracy for detecting LN metastasis was 50% with node picking versus 92.3% with LBD. LN metastases were always in the SN basin. Lymphatic invasion and T-stage were risk factors for nodal metastases. Two patients showed recurrent disease. Both had a tumour with signet cell differentiation. One patient had a T3 tumour, the other patient had a tumour with a diameter of 85 mm.

Conclusion

The SN procedure with IREE can detect the SN and is better than ICG alone. LBD of the SN basin is required for accurate intra-operative diagnosis of metastases. LBD dissection based on IREE is a safe method of nodal dissection in patients with T1 or limited T2 tumours.     

吲哚菁绿联合纳米炭双示踪技术在腔镜甲状腺乳头状癌手术中的应用

目的:探讨吲哚菁绿（indocyanine green,ICG）联合纳米炭（carbon nanoparticles,CN）在腔镜甲状腺乳头状癌（papillary thyroid carcinoma,PTC）手术中的临床疗效。方法:将经胸乳入路行腔镜PTC手术的102例患者随机分为三组。单纯ICG组（n=33）术中显露甲状腺后于外周静脉注射ICG。根据静脉注射ICG正显影甲状旁腺,负显影淋巴结原理。在荧光腔镜系统下寻找荧光显影的甲状旁腺,并切除无荧光显影的中央区淋巴结。单纯CN组（n=32）术中显露甲状腺后于患侧腺体内注射CN混悬液。根据腺体内注射CN正显影淋巴结,负显影甲状旁腺原理。在腔镜下将黑染的中央区淋巴结和脂肪组织切除,保留负显影不染色的甲状旁腺。ICG+CN组（n=37）,结合上述两组方法,利用双方的优势,双示踪、双识别,在腔镜下保留甲状旁腺,切除中央区淋巴结。比较三组患者的临床资料、手术相关指标、术后相关并发症等。结果:ICG+CN组较单纯ICG组及CN组在手术时间、清扫中央区淋巴结个数及中央区淋巴结转移个数方面表现更优,具有统计学差异（P＜0.05）;而ICG+CN组、单纯ICG组在暂时性甲状旁腺功能减退方面均优于单纯CN组,具有统计学差异（P＜0.05）。结论:通过外周静脉注射ICG和腺体内注射CN两者相结合的双示踪技术指导腔镜PTC手术,取得了较满意的临床疗效,还为临床实践提供了理论依据。     

A feasibility study (ICG-10) of indocyanine green (ICG) fluorescence mapping for sentinel lymph node detection in early breast cancer

Background

There is now increasing evidence to support the use of indocyanine green (ICG) for sentinel lymph node (SLN) detection in early breast cancer. The primary objective of this feasibility study (ICG-10) was to determine the sensitivity and safety of ICG fluorescence imaging in sentinel lymph node identification when combined with blue dye and radiocolloid.

Methods

One hundred women with clinically node negative breast cancer (95 unilateral; 5 bilateral) had sentinel lymph node (SLN) biopsy using blue dye, radioisotope and ICG. One patient was excluded from analysis and sensitivity, or detection rate, of ICG alone, and in combination with blue dye and/or radioisotope, was calculated for the remaining 104 procedures in 99 patients.

Results

Transcutaneous fluorescent lymphography was visible in all 104 procedures. All 202 true SLNs, defined as blue and/or radioactive, were also fluorescent with ICG. Detection rates were: ICG alone 100%, ICG & blue dye 95.0%, ICG & radioisotope 77.2%, ICG & blue dye & radioisotope 73.1%. Metastases were found in 25 of 201 SLNs (12.4%) and all positive nodes were fluorescent, blue and radioactive. The procedural node positivity rate was 17.3%.

Conclusion

The results of this study confirm the high sensitivity of ICG fluorescence for SLN detection in early breast cancer. The combination of ICG and blue dye had the highest nodal sensitivity at 95.0% defining a dual approach to SLN biopsy that avoids the need for radioisotope.