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Feasibility of fluorescence lymph node imaging in colon cancer: FLICC

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Abstract

Background

In colon cancer, appropriate tumour excision and associated lymphadenectomy directly impact recurrence and survival outcomes. Currently, there is no standard for mesenteric lymphadenectomy, with a lymph node yield of 12 acting as a surrogate quality marker. Our goal was to determine the safety and feasibility of indocyanine green (ICG) fluorescence imaging to demonstrate lymphatic drainage in colon cancer in a dose-escalation study.

Methods

A prospective pilot study of colon cancer patients undergoing curative laparoscopic resection was performed. At surgery, peritumoural subserosal ICG injection was done to demonstrate lymphatic drainage of the tumour. A specialized fluorescence system excited the ICG and assessed lymphatics in real time. The primary outcome was the feasibility of ICG fluorescent lymphangiography for lymphatic drainage in colon cancer. Secondary outcomes were the optimal protocol for dose, injection site, and ICG lymphatic mapping timing.

Results

Ten consecutive patients were evaluated (six males, mean age 69.5 years). In all, lymphatic channels were seen around the tumour to a varying extent. Eight (80%) had drainage to the sentinel node. In all cases where the lymphatic map was seen, there was no further spread 10 min after injection. In 2 patients (20%), additional lymph nodes located outside of the proposed resection margins were demonstrated. In both cases the resection was extended to include the nodes and in both patients these nodes were positive on histopathology. Factors contributing to reduced lymphatic visualization were inadequate ICG concentrations, excess India ink blocking drainage, and inflammation from tattoo placement.

Conclusions

ICG can be safely injected into the peritumoural subserosal and demonstrate lymphatic drainage in colon cancer. This proof of concept and proposed standards for the procedure can lead to future studies to optimize the application of image-guided precision surgery in colon cancer. Furthermore, this technique may be of value in indicating the need for more extended lymphadenectomy.

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Authors and Affiliations

  1. Department of Surgery and Interventional Sciences, University College London Hospitals, NHS Foundation Trusts, GENIE Centre, University College London, Charles Bell House, 43 Foley Street, London, W1W 7TS, UK

    M. Chand, D. S. Keller & L. Devoto

  2. Department of Surgery and Interventional Sciences, University College London Hospitals, NHS Foundation Trusts, London, UK

    H. M. Joshi & R. Cohen

  3. Department of Pathology, University College London Hospitals, NHS Foundation Trusts, London, UK

    M. Rodriguez-Justo

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  1. M. Chand
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  2. D. S. Keller
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  3. H. M. Joshi
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  4. L. Devoto
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  5. M. Rodriguez-Justo
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  6. R. Cohen
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Corresponding author

Correspondence to M. Chand.

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Conflict of interest

Mr. Chand reports speaking fees for Novadaq, Inc., outside of the scope of this work. Dr. Keller, Dr. Joshi, Dr. Devoto, Dr. Rodriguez-Justo, and Mr. Cohen declare that they have no conflict of interest.

Ethical approval

This dose-escalation study received approval from the Joint Research Office, University College London Hospital.

Informed consent

All patients received and agreed to the Patient Information Sheet and Informed Consent for the study and procedure.

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Chand, M., Keller, D.S., Joshi, H.M. et al. Feasibility of fluorescence lymph node imaging in colon cancer: FLICC. Tech Coloproctol 22, 271–277 (2018). https://doi.org/10.1007/s10151-018-1773-6

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  • DOI: https://doi.org/10.1007/s10151-018-1773-6

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