Targeted lymph node assessment in gastrointestinal neoplasms

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Presentation transcript:

Targeted lymph node assessment in gastrointestinal neoplasms Victoria O'Connor, MD, Yuko Kitagawa, MD, PhD, FACS, Alexander Stojadinovic, MD, FACS, Anton J. Bilchik, MD, PhD, FACS Current Problems in Surgery Volume 51, Issue 1, Pages 9-37 (January 2014) DOI: 10.1067/j.cpsurg.2013.09.001 Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 1 Ex vivo lymphatic mapping identifies sentinel nodes (arrows) in the mesentery. Injection of isosulfan blue dye is undertaken at a side table after the specimen has been removed. (Reprinted with permission from Wood et al.20) (Color version of figure is available online.) Current Problems in Surgery 2014 51, 9-37DOI: (10.1067/j.cpsurg.2013.09.001) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 2 Blue dye is injected subserosally around a tumor in the cecum, using a tuberculin syringe. (Reprinted with permission from Saha et al.21) (Color version of figure is available online.) Current Problems in Surgery 2014 51, 9-37DOI: (10.1067/j.cpsurg.2013.09.001) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 3 Blue-stained sentinel lymph nodes are tagged with sutures in the adjacent mesentery near the primary tumor. (Reprinted with permission from Saha et al.21) (Color version of figure is available online.) Current Problems in Surgery 2014 51, 9-37DOI: (10.1067/j.cpsurg.2013.09.001) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 4 Micrometastasis (<2mm) identified by pancytokeratin IHC staining of a sentinel node (left) is very difficult to detect in an adjacent section stained by H&E (right). (Reprinted with permission from Iddings and Bilchik.27) (Color version of figure is available online.) Current Problems in Surgery 2014 51, 9-37DOI: (10.1067/j.cpsurg.2013.09.001) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 5 Definition of sentinel node metastases (“upstaging”) not detected by standard pathologic techniques. (A and B) Tumor cell clusters <0.2mm (N0i+) and (C and D) micrometastases 0.2-2mm (N1mi). (Reprinted with permission from Bilchik et al.28) Current Problems in Surgery 2014 51, 9-37DOI: (10.1067/j.cpsurg.2013.09.001) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 6 Scatter plot illustrating the correlation between the sensitivity of the sentinel node procedure across studies and the number of identified sentinel nodes (Pearson correlation coefficient 0.37, P = 0.004). A fitted linear regression equation is shown with 95% confidence intervals. (Reprinted with permission from van der Zaag et al.8) (Color version of figure is available online.) Current Problems in Surgery 2014 51, 9-37DOI: (10.1067/j.cpsurg.2013.09.001) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 7 Kaplan-Meier curves for disease outcome according to detection of at least 1 qRT-PCR (qRT) marker in sentinel lymph nodes. (A) Overall survival by qRT-PCR(+) in sentinel lymph nodes (not significant). (B) Disease-free survival by qRT-PCR(+) in sentinel lymph nodes (P = 0.014). (Reprinted with permission from Koyanagi et al.30) Current Problems in Surgery 2014 51, 9-37DOI: (10.1067/j.cpsurg.2013.09.001) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 8 Kaplan-Meier curves: qRT-PCR marker detection in blood. Overall survival by qRT-PCR(+) in blood (P = 0.040). (Reprinted with permission from Koyanagi et al.30) Current Problems in Surgery 2014 51, 9-37DOI: (10.1067/j.cpsurg.2013.09.001) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 9 Gastric lymph node stations. Number key: 1, right paracardial; 2, left paracardial; 3a, left gastric vessels; 3b, right gastric vessels; 4sa, short gastric vessels; 4sb, left gastroepiploic vessels; 4d, right gastroepiploic vessels; 5, suprapyloric; 6, infrapyloric; 7, left gastric artery; 8a, common hepatic artery—anterosuperior group; 8p, common hepatic artery—posterior group; 9, celiac artery; 10, splenic hilum; 11p, proximal splenic artery; 11d, distal splenic artery; 12a, hepatoduodenal ligament—hepatic artery; 12b, hepatoduodenal ligament—bile duct; 12p, hepatoduodenal ligament—behind the portal vein; 13, posterior surface of the pancreatic head; 14v, superior mesenteric vein; 14a, superior mesenteric artery; 17, anterior surface of the pancreas head; 18, inferior margin on the pancreas. (Reprinted with permission from the Japanese Gastric Cancer Association.56) (Color version of figure is available online.) Current Problems in Surgery 2014 51, 9-37DOI: (10.1067/j.cpsurg.2013.09.001) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 10 Indocyanine green infrared imaging using infrared ray electronic endoscopy for laparoscopic sentinel node biopsy. (A) Normal light and (B) infrared ray electronic endoscopy. Infrared ray electronic endoscopy can visualize even tiny sentinel nodes and thin lymphatics. (Reprinted with permission from Takeuchi and Kitagawa.22) (Color version of figure is available online.) Current Problems in Surgery 2014 51, 9-37DOI: (10.1067/j.cpsurg.2013.09.001) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 11 Prevalence and location of metastatic lymph node involvement based on depth of penetration of esophageal adenocarcinoma. (Reprinted with permission from Feith et al.79) Current Problems in Surgery 2014 51, 9-37DOI: (10.1067/j.cpsurg.2013.09.001) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 12 Prevalence and location of lymph node metastases in 42 patients with esophageal adenocarcinoma and single node metastases. (Reprinted with permission from Feith et al.79) Current Problems in Surgery 2014 51, 9-37DOI: (10.1067/j.cpsurg.2013.09.001) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 13 Tumor infiltration and lymph node metastatic rate of T1 esophageal cancer. Early esophageal cancers are in situ lesions (carcinoma in situ) or T1 tumors. T1 tumors are subcategorized as T1a or T1b depending on the depth of invasion. T1a: M1 or SSM, intraepithelial cancer; M2 or LPM, cancer with invasion into the lamina propria mucosae; M3 or DMM, cancer reaching to the muscularis mucosae. T1b: SM1, cancer with invasion into one-third of the submucosa; SM2, cancer with invasion into the middle third of the submucosa; SM3, cancer with invasion into the lower third of the submucosa. (Reprinted with permission from Tangoku et al.83) Current Problems in Surgery 2014 51, 9-37DOI: (10.1067/j.cpsurg.2013.09.001) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 14 Fluorescent navigation after injection of indocyanine green dye into the submucosal layer beside the tumor. (A) Lymph flow (arrows) and a sentinel node in the right recurrent nerve (arrow head) are visualized with an infrared endoscopic camera system. (B) The sentinel node (arrow head) and right recurrent nerve (arrows) are retrieved. (C) The fluorescent camera clearly shows the sentinel node in the right recurrent nerve (arrow head) and the lymph flow (arrows). (Reprinted with permission from Tangoku et al.83) (Color version of figure is available online.) Current Problems in Surgery 2014 51, 9-37DOI: (10.1067/j.cpsurg.2013.09.001) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 15 Preoperative lymphoscintigraphy of esophageal cancer. (Reprinted with permission from Aikou et al.65) Current Problems in Surgery 2014 51, 9-37DOI: (10.1067/j.cpsurg.2013.09.001) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 16 Preoperative lymphoscintigraphy for thoracic esophageal cancer. SLN, sentinel lymph node. (Reprinted with permission from Takeuchi et al.74) (Color version of figure is available online.) Current Problems in Surgery 2014 51, 9-37DOI: (10.1067/j.cpsurg.2013.09.001) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 17 Intraoperative findings in the upper mediastinum during thoracoscopic surgery. (A) A radioactive (hot) node along the right recurrent laryngeal nerve is identified using a hand-held gamma probe. (B) This sentinel node is harvested using a vessel-sealing device. (C) The harvested sentinel node is placed on the gamma probe. The intensity of radioactivity in the sentinel node is shown by the scintillation counter. (D) Dual-tracer method identifies a hot and blue-stained sentinel node along the left gastric artery. (Reprinted with permission from Takeuchi et al.74) (Color version of figure is available online.) Current Problems in Surgery 2014 51, 9-37DOI: (10.1067/j.cpsurg.2013.09.001) Copyright © 2014 Elsevier Inc. Terms and Conditions