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Fluorescence-based sentinel lymph node map** and lymphography evaluation: results from the IHU-IRCAD-EAES EURO-FIGS registry

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Abstract

Background

The identification of metastatic lymph nodes is one of the most important prognostic factors in gastrointestinal (GI) cancers. Near-infrared fluorescence (NIRF) imaging has been successfully used in GI tumors to detect the lymphatic pathway and the sentinel lymph node (SLN), facilitating fluorescence image-guided surgery (FIGS) with the purpose to achieve a correct nodal staging. The aim of this study was to analyze the current results of NIRF SLN navigation and lymphography through data collected in the EURO-FIGS registry.

Methods

Prospectively collected data regarding patients and ICG-guided lymphadenectomies were analyzed. Additional analyses were performed to identify predictors of metastatic SLN and determinants of fluorescence positivity and nodal metastases outside the boundaries of standard lymphadenectomies.

Results

Overall, 188 patients were included by 18 surgeons from 10 different centers. Colorectal cancer was the most reported pathology (77.7%), followed by gastric (19.1%) and esophageal tumors (3.2%). ICG was injected with higher doses (p < 0.001) via extraparietal side (63.3%), and with higher volumes (p < 0.001) via endoluminal side (36.7%). Overall, NIRF SLN navigation was positive in 75.5% of all cases and 95.5% of positive SLNs were retrieved, with a metastatic rate of 14.7%. NIRF identification of lymph nodes outside standard lymphatic stations occurred in 52.1% of all cases, 43.8% of which were positive for metastatic involvement. Positive NIRF SLN identification was an independent predictor of metastasis outside standard lymphatic stations (OR = 4.392, p = 0.029), while BMI independently predicted metastasis in retrieved SLNs (OR = 1.187, p = 0.013). Lower doses of ICG were protective against NIRF identification outside standard of care lymphadenectomy (OR = 0.596, p = 0.006), while higher volumes of ICG were predictive of metastatic involvement outside standard of care lymphadenectomy (OR = 1.597, p = 0.001).

Conclusions

SLN map** helps identifying potentially metastatic lymph nodes outside the boundaries of standard lymphadenectomies. The EURO-FIGS registry is a valuable tool to share and analyze European surgeons’ practices.

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Acknowledgements

The authors would like to thank: Guy Temporal and Christopher Burel, professionals in medical English proofreading, for their valuable assistance.

Funding

The EURO-FIGS registry is funded by a grant from the ARC Foundation for Cancer Research (9, rue Guy Môquet, 94803 Villejuif Cedex, France, https://www.fondation-arc.org), within the framework of the ELIOS (Endoscopic Luminescent Imaging for precision Oncologic Surgery) project.

Author information

Author notes

  1. Andrea Picchetto and Lorenzo Cinelli share the first authorship.

Authors and Affiliations

  1. Department of General Surgery and Surgical Specialties “Paride Stefanini”, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy

    Andrea Picchetto, Giancarlo D’Ambrosio, Alessandro M. Paganini & Silvia Quaresima

  2. Research Institute Against Digestive Cancer (IRCAD), Strasbourg, France

    Lorenzo Cinelli, Elisa Bannone, Jacques Marescaux & Michele Diana

  3. IRCCS San Raffaele Scientific Institute, Milan, Italy

    Lorenzo Cinelli

  4. Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy

    Elisa Bannone

  5. Department of Pancreatic Surgery, Verona University, Verona, Italy

    Elisa Bannone

  6. Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy

    Gian Luca Baiocchi

  7. Unit of Innovation in Minimally Invasive Surgery, Department of General Surgery, University Hospital Virgen del Rocío, University of Sevilla, Seville, Spain

    Salvador Morales-Conde

  8. General and Digestive Unit, Hospital Quironsalud Sagrado Corazon, Seville, Spain

    Salvador Morales-Conde

  9. Ospedale di Vaio, Fidenza, Italy

    Lorenzo Casali, Christian Franzini, Caterina Santi, Alessio Rollo, Paolo Detullio, Tartamella Luciano & Giorgio Bianchi

  10. Candiolo Cancer Institute IRCCS, Candiolo, Italy

    Giuseppe Spinoglio

  11. Ponderas Academic Hospital, Bucharest, Romania

    Catalin Copaescu

  12. UOC of General and Minimally Invasive Surgery, Hospital “San Paolo”, Largo Donatori del Sangue 1, 00053, Rome, Civitavecchia, Italy

    Andrea Balla & Pasquale Lepiane

  13. GF Ingrassia, Catania, Italy

    Antonio Pesce

  14. University of Strasbourg, Strasbourg, France

    Michele Diana

  15. Department of General, Digestive, and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France

    Michele Diana

  16. ICube Laboratory, Photonics for Health, University of Strasbourg, Strasbourg, France

    Michele Diana

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  1. Andrea Picchetto
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Correspondence to Andrea Picchetto.

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Disclosures

Michele Diana is the PI and the recipient of the ELIOS grant from the ARC Foundation and a member of the Advisory Board of Diagnostic Green. Salvador Morales-Conde reports grants and other relationships with Medtronic, BD Bard, Ethicon, Olympus, Karl Storz, Stryker, Dipro, Baxter, and B. Braun, outside the submitted work. Gian Luca Baiocchi is consultant of Stryker. Jacques Marescaux is the President of the IRCAD, which is partly funded by Karl Storz and Medtronic. Andrea Picchetto, Lorenzo Cinelli, Elisa Bannone, Lorenzo Casali, Giuseppe Spinoglio, Christian Franzini, Caterina Santi, Giancarlo D’Ambrosio, Catalin Copaescu, Alessio Rollo, Andrea Balla, Pasquale Lepiane, Alessandro M. Paganini, Paolo Detullio, Silvia Quaresima, Antonio Pesce, Tartamella Luciano, Giorgio Bianchi have no conflicts of interest or financial ties to disclose.

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Appendices

Appendix A: List of items registered

  • Patient’s gender

  • Patient’s age

  • Patient’s BMI

  • Diagnosis (Esophageal cancer; Gastric cancer; ColoRectal cancer)

  • Surgical Procedure (Esophageal surgery, Gastric surgery, Colorectal surgery)

  • Camera type

  • Injection site

  • Dose of fluorophore (mg/mL)

  • How many mM injected?

  • ICG dose (mg/mL)

  • Adverse events of ICG administration?

  • Sentinel node(S) identification?

  • Sentinel node(S) retrieval?

  • Was the pathology positive for metastatic sentinel lymph node?

  • Did you visualize any fluorescent node(s) outside the boundaries of a standard of care lymphadenectomy?

  • Did you retrieve them?

  • Was the pathology positive for metastases in the other extra lymph nodes visualized?

  • Do you have any other comment(s)?

Appendix B: Contributing centers

University Hospital Virgen del Rocio

35

AOU Policlinico Umberto I, Sapienza University of Rome

17

Department of Clinical and Experimental Sciences, Brescia University—Italy

36

Department of Medical and Surgical Sciences and Advanced Technologies “G.F. Ingrassia”—University of Catania

1

Hospital Álvaro Cunqueiro

7

Hospital Vithas Nuestra Señora de Fátima

2

IEO (European Institute of Oncology), Milan, Italy

22

Metabolic and Bariatric Surgery Center—Ponderas Acdemic Hospital

4

Ospedale di Fidenza, AUSL Parma, Italy

63

Ponderas Academic Hospital

1

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Picchetto, A., Cinelli, L., Bannone, E. et al. Fluorescence-based sentinel lymph node map** and lymphography evaluation: results from the IHU-IRCAD-EAES EURO-FIGS registry. Surg Endosc 37, 5472–5481 (2023). https://doi.org/10.1007/s00464-023-10043-8

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