Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-gu, Daegu, 41404, South Korea.
Department of Radiology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea.
Surg Endosc. 2020 Jan;34(1):469-476. doi: 10.1007/s00464-019-06830-x. Epub 2019 May 28.
Lateral pelvic lymph node dissection (LPND) is a technically demanding procedure. Consequently, there is a possibility of incomplete dissection of lateral pelvic lymph nodes (LPNs). We aimed to identify metastatic LPNs intraoperatively in real-time under dual guidance of fluorescence imaging and 3D lymphovascular reconstruction, and then to remove them completely.
Rectal cancer patients who were scheduled to undergo LPND after preoperative chemoradiotherapy (CRT) were prospectively enrolled. We traced changes in suspected metastatic LPNs during preoperative CRT and defined them as index LPNs on post-CRT imaging studies. For fluorescence imaging, indocyanine green (ICG) at a dose of 2.5 mg was injected transanally around the tumor before the operation. For 3D reconstruction images, each patient underwent preoperative axial CT scan with contrast (0.6 mm slice thickness). These images were then manipulated with OsiriX. Index LPNs and essential structures in the pelvic sidewall, such as the obturator nerve, were reconstructed with abdominal arteries from 3D volume rendering. All surgical procedures were performed via laparoscopic or robotic approach.
From March to July 2017, ten rectal cancer patients underwent total mesorectal excision with LPND after preoperative CRT under dual image guidance. Bilateral LPND was performed in five patients. All index LPNs among ICG-bearing lymph nodes were clearly identified intraoperatively by matching with their corresponding 3D images. Pathologic LPN metastasis was confirmed in four patients (40.0%) and in five of the 15 dissected pelvic sidewalls (33.0%). All metastatic LPNs were identified among index LPNs. Four (80.0%) of the five metastatic LPNs were located in the internal iliac area.
Index LPNs among ICG-bearing lymph nodes in pelvic sidewall were clearly identified and completely removed by matching with their corresponding 3D reconstruction images. Further studies and long-term oncologic outcomes are required to determine the real impact of dual image guidance in LPND.
侧方盆腔淋巴结清扫术（LPND）是一项技术要求很高的手术。因此，存在侧方盆腔淋巴结（LPN）清扫不彻底的可能。我们旨在通过荧光成像和 3D 淋巴血管重建的双重引导，术中实时识别转移性 LPN，并将其完全切除。
前瞻性纳入接受术前放化疗（CRT）后行 LPND 的直肠癌患者。我们追踪术前 CRT 期间疑似转移性 LPN 的变化，并在 CRT 后影像学研究中定义为指数 LPN。对于荧光成像，在手术前经肛门周围注射吲哚菁绿（ICG）2.5mg。对于 3D 重建图像，每位患者在术前均进行轴向 CT 扫描（0.6mm 层厚）。然后用 OsiriX 处理这些图像。用腹部动脉从 3D 容积渲染重建指数 LPN 和盆腔侧壁的重要结构，如闭孔神经。所有手术均通过腹腔镜或机器人进行。
2017 年 3 月至 7 月，10 例直肠癌患者在术前 CRT 下行全直肠系膜切除术加 LPND，采用双图像引导。5 例患者行双侧 LPND。通过与相应的 3D 图像匹配，术中清晰识别出所有 ICG 阳性淋巴结中的指数 LPN。4 例（40.0%）患者和 5 例（33.0%）解剖的盆腔侧壁证实存在病理性 LPN 转移。所有转移性 LPN 均在指数 LPN 中发现。5 个转移性 LPN 中有 4 个（80.0%）位于髂内区。
通过与相应的 3D 重建图像匹配，可清晰识别盆腔侧壁 ICG 阳性淋巴结中的指数 LPN，并将其完全切除。需要进一步的研究和长期的肿瘤学结果来确定双图像引导在 LPND 中的实际影响。
