Validation Study of Radio-Guided Sentinel Lymph Node Navigation in Esophageal Cancer

Abstract Background Minimally invasive approach to esophageal cancer has been accepted as the standard of care in many centers. Nontheless, some technical difficulties are encountered during surgery. A proper vascularization of the gastric tube is mandatory to avoid the dreadful complication of a leak or of gastric conduit necrosis. On the other hand, there is controversy on the identification of sentinel lymph node in early esophageal cancer and on the extent of lymphadenectomy in locally advanced tumours. Indocyanine green (ICG) is a sterile, anionic, water-soluble but relatively hydrophobic, tricarbocyanine molecule, which is bound to plasma proteins when intravenously injected. It is extracted by the liver appearing in the bile around 8 minutes after injection. When injected outside the blood vessels, ICG reaches the nearest lymph node within 15 minutes and after 1 to 2 hours it binds to the regional lymph nodes. The usual dose of ICG is 0.1 - 0.5mg/mL/kg. ICG becomes fluorescent once excited with near-infrared (NIR) light at about 820 nm. The fluorescence released by ICG may be detected using specially developed cameras. Methods A systematic review of the literature of ICG in esophageal surgery was carried on February 2018 using the following terms: esophagus, indocyanine green, ICG, surgery, angiography, lymph node, and combinations of the above. Results The technique of ICG angiography for vascular assessment of the gastroepiploic arcade and gastric conduit is explained and the published results are review. The use of ICG for the evaluation of sentinel lymph node in early esophageal cancer and of lymph node mapping for regional lymph nodes is explained and current evidence is reviewed. Conclusion ICG use in esophageal surgery is still a novel and promising technique. It could help to reduce anastomotic leak by means of vascular assessment of the gastric conduit, locate lymph nodes out of the usual fields of lymphadenectomy and locate the sentinel lymph node in early esophageal cancer Disclosure All authors have declared no conflicts of interest.

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Sentinel lymph node mapping for T1 esophageal cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.4_suppl.7 ◽

2012 ◽

Vol 30 (4_suppl) ◽

pp. 7-7

Author(s):

Hiroya Takeuchi ◽

Hirofumi Kawakubo ◽

Yoshiro Saikawa ◽

Tadaki Nakahara ◽

Tai Omori ◽

...

Keyword(s):

Esophageal Cancer ◽

Lymph Node ◽

Sentinel Lymph Node ◽

Lymph Node Metastasis ◽

Standard Procedure ◽

Gamma Probe ◽

Early Esophageal Cancer ◽

Radical Esophagectomy ◽

Primary Tumors ◽

Node Metastasis

7 Background: Extended radical esophagectomy with three-field lymph node dissection has been recognized as the standard procedure for thoracic esophageal cancer in Japan, even for clinically T1N0 cases. However, to eliminate the uniform application of the highly invasive surgery, we hypothesized that sentinel lymph node (SLN) mapping would play a key role to obtain individual information and allows modification of the surgical procedure for early esophageal cancer. Methods: We have established radio-guided method to detect SLNs in patient with early esophageal cancer using endoscopic injection of technetium-99m tin colloid. Preoperative lymphoscintigraphy and intra-operative use of hand held gamma probe were reliable to locate the radioactive SLNs. Intra-operative gamma probing was also feasible in thoracoscopic or laparoscopic surgery using a special gamma detector which is introducible from trocar ports. Results: SLN mapping has been performed for 70 patients with clinically N0 and early (pT1) esophageal cancer in our institute since 1999. Detection rate of hot node using our procedure was 94% (66/70). The mean number of sentinel nodes per case was 4.6. Twenty-one of 23 cases (91%) with lymph node metastasis showed positive SLNs. Accuracy of metastatic status based on SLN was 97% (64/66). SLNs widely spread from cervical to abdominal areas. In more than 80% of the cases, at least one SLN was located in the 2nd or 3rd compartment of regional lymph nodes. However, 56 (85%) of 66 patients had no lymph node metastasis or metastasis (+) only in SLNs. Conclusions: Our results suggest that SLN concept for clinically N0 and T1 esophageal cancer could be validated. Theoretically more than 80% of patients with pT1b esophageal cancer may be controlled by local treatments such as surgery and chemoradiotherapy targeting primary tumors plus their SLNs. Individualized selective and modified lymphadenectomy targeted on SLN basins for clinically N0 early esophageal cancer should become feasible and clinically useful as less invasive surgical procedures.

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