Multimodal surgical guidance towards the sentinel node in vulvar cancer

• Published in: Gynecologic oncology 2013-12, Vol.131 (3), p.720-725
• Main Authors: Mathéron, H.M, van den Berg, N.S, Brouwer, O.R, KleinJan, G.H, van Driel, W.J, Trum, J.W, Vegt, E, Kenter, G, van Leeuwen, F.W.B, Valdés Olmos, R.A
• Format: Article
• Language: English
• Subjects: Adult; Aged; Aged, 80 and over; Female; Fluorescence imaging; Hematology, Oncology and Palliative Medicine; Humans; Indocyanine Green; Lymph Nodes - diagnostic imaging; Lymph Nodes - pathology; Lymph Nodes - surgery; Middle Aged; Multimodal; Multimodal Imaging; Neoplasm Staging; Obstetrics and Gynecology; Radioactivity; Radiopharmaceuticals; Sentinel (lymph) node; Sentinel Lymph Node Biopsy - methods; Technetium Tc 99m Aggregated Albumin; Tomography, Emission-Computed, Single-Photon; Tomography, X-Ray Computed; Vulvar cancer; Vulvar Neoplasms - diagnostic imaging; Vulvar Neoplasms - pathology; Vulvar Neoplasms - surgery; Young Adult
• ISSN: 0090-8258; 1095-6859
• DOI: 10.1016/j.ygyno.2013.09.007

Abstract Introduction Conventional sentinel node (SN) mapping is performed by injecting a radiocolloid followed by lymphoscintigraphy (and SPECT/CT imaging). An extra intraoperative injection with blue dye can then allow for optical identification of the SN. In order to improve the current clinical standard, the hybrid tracer indocyanine green (ICG)-99m Tc-nanocolloid was introduced, a tracer that is both radioactive and fluorescent. This feasibility study aimed to evaluate the value of a multimodal-based SN biopsy in vulvar cancer. Materials and methods Fifteen patients with vulvar cancer (29 groins) scheduled for SN biopsy were peritumorally injected with ICG-99m Tc-nanocolloid followed by lymphoscintigraphy and SPECT/CT imaging to identify the SNs. In thirteen patients, shortly before the start of the operation, blue dye was intradermally injected around the lesion. SNs were harvested using a combination of radiotracing, fluorescence imaging, and optical blue dye detection. A portable gamma camera was used before and after SN excision to confirm excision of the preoperatively defined SNs. Results Preoperative lymphoscintigraphy and SPECT/CT imaging visualized drainage to 39 SNs in 28 groins. During the operation, 98% ( ex vivo 100%) of the SNs were radioactive. With fluorescence imaging 96% of the SNs ( ex vivo 100%) could be visualized. Only 65% of the SNs had stained blue at the time of excision. Conclusion ICG-99m Tc-nanocolloid can be used for preoperative SN identification and enables multimodal (radioactive and fluorescent) surgical guidance in patients with vulvar cancer. The addition of fluorescence-based optical guidance offers more effective SN visualization compared to blue dye.