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. 2014 Dec;110(7):845-50.
doi: 10.1002/jso.23740. Epub 2014 Aug 11.

Optimization of sentinel lymph node mapping in bladder cancer using near-infrared fluorescence imaging

B E Schaafsma  1 , F P R Verbeek, H W Elzevier, Q R J G Tummers, J R van der Vorst, J V Frangioni, C J H van de Velde, R C M Pelger, A L Vahrmeijer
Affiliations

Optimization of sentinel lymph node mapping in bladder cancer using near-infrared fluorescence imaging

B E Schaafsma et al. J Surg Oncol. 2014 Dec.

Abstract

Background and objectives: Unlike other cancers, the Sentinel Lymph Node (SLN) procedure in bladder cancer requires special attention to the injection technique. The aim of this study was to assess feasibility and to optimize tracer injection technique for SLN mapping in bladder cancer patients using NIR fluorescence imaging.

Methods: Twenty patients with invasive bladder cancer scheduled for radical cystectomy were prospectively enrolled. Indocyanine green (ICG) bound to human serum albumin (complex ICG:HSA; 500 µM) was injected peritumourally to permit SLN mapping. ICG:HSA was first administrated serosally (n = 5), and subsequently mucosally by cystoscopic injection (n = 15). In the last cohort of 12 patients treated with cystoscopic injection, the bladder was kept filled with saline for at least 15 min.

Results: Fluorescent lymph nodes were observed only in the patient group with cystoscopic injection of ICG:HSA. Filling of the bladder post-injection was of added value to promote drainage of ICG:HSA to the lymph nodes, and in 11 of these 12 patients (92%) one or more NIR fluorescent lymph nodes were identified.

Conclusions: The current study demonstrates proof-of-principle of using NIR fluorescence imaging for SLN identification in bladder cancer. Cystoscopic injection with distension of the bladder appears optimal for SLN mapping.

Keywords: Bladder Cancer; Fluorescence Imaging; Image-Guided Surgery; Indocyanine Green; Sentinel Lymph Node.

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Conflict of interest statement

Conflict of interest statement: Dr. Schaafsma, Verbeek, Elzevier, Tummers, van der Vorst, van de Velde, Pelger and Vahrmeijer have no conflict of interest to declare.

Dr. Frangioni: FLARE™ technology is owned by Beth Israel Deaconess Medical Centre, a teaching hospital of Harvard Medical School. It has been licensed to the FLARE™ Foundation, a non-profit organization focused on promoting the dissemination of medical imaging technology for research and clinical use. Dr. Frangioni is the founder and chairman of the FLARE™ Foundation. The Beth Israel Deaconess Medical Centre will receive royalties for sale of FLARE™ Technology. Dr. Frangioni has waived post-market royalties, and has decided to donate pre-market proceeds to the FLARE™ Foundation.

Figures

Figure 1
Figure 1. Clinical Trial Protocol
1. The tracer ICG:HSA is administered either serosally after laparotomy or cystoscopically into the mucosa. In one cohort of patients, the bladder was distended with saline after cystoscopic injection of ICG:HSA. 2. During lymphadenectomy, the Mini-FLARE imaging system was used for in vivo identification of NIR fluorescent lymphatic vessels and lymph nodes. 3. After resection of NIR fluorescent lymph nodes (SLN) and further lymph node dissection (LND), all tissue was assessed ex vivo using Mini-FLARE to identify possible additional NIR fluorescent lymph nodes. 4. Fluorescent nodes and the lymphadenectomy specimen were sent separately for pathological examination.
Figure 2
Figure 2. Intraoperative and ex vivo detection of fluorescent lymph nodes
Shown are colour video (left), NIR fluorescence (middle), and a pseudo-coloured merge of the two (right). The upper row shows the intraoperative detection of two NIR fluorescent lymph nodes (arrowheads) along the left external iliac vein. In the lower row, the two NIR fluorescent lymph nodes are clearly identified using NIR fluorescence imaging after excision. Excitation fluence rate was 7.7 mW/cm2. Camera exposure times were 10 ms (upper row) and 15 ms (bottom row). Scale bar = 1 cm.
Figure 3
Figure 3. NIR fluorescent identification of lymphatic vessels
Shown are colour video (left), NIR fluorescence (middle), and a pseudo- coloured merge of the two (right). After exploration, the lymphatic vessel (arrow) draining to the SLN (arrowhead) is clearly identified using NIR fluorescence after injection of ICG:HSA. Excitation fluence rate was 7.7 mW/cm2. Camera exposure times were 10 ms.
See this image and copyright information in PMC

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