title: Sentinel lymph node biopsy using intraoperative indocyanine green fluorescence imaging navigated with preoperative CT lymphography for superficial esophageal cancer.
abstract: BACKGROUND
  The sentinel lymph node (SLN) concept has been gaining attention for gastrointestinal neoplasms but remains controversial for esophageal cancer. This study evaluated the feasibility of SLN identification using intraoperative indocyanine green (ICG) fluorescence imaging (IGFI) navigated by preoperative computed tomographic lymphography (CTLG) to treat superficial esophageal cancer.
  
  
  METHODS
  Subjects comprised 20 patients clinically diagnosed with superficial esophageal cancer. Five minutes after endoscopic submucosal injection of iopamidol around the primary lesion using a four-quadrant injection pattern with a 23-gauge endoscopic injection sclerotherapy needle, three-dimensional multidetector computed tomography was performed to identify SLNs and lymphatic routes. ICG solution was injected intraoperatively around the tumor. Fluorescence imaging was obtained by infrared ray electronic endoscopy. Thoracoscope-assisted standard radical esophagectomy with lymphadenectomy was performed to confirm fluorescent lymph nodes detected by CTLG.
  
  
  RESULTS
  Lymphatic vessels and SLNs were identified preoperatively using CTLG in all cases. Intraoperative detection rates were 100% using CTLG and 95% using IGFI. Lymph node metastases were found in four cases, including one false-negative case with SLNs occupied by bulky metastatic tumor that were not enhanced with both methods. The other 19 cases, including three cases of metastatic lymph nodes, were accurately identified by both procedures.
  
  
  CONCLUSIONS
  Preoperative CTLG visualized the correct number and site of SLNs in surrounding anatomy during routine computed tomography to evaluate distant metastases. Referring to CTLG, SLNs were identified using IGFI, resulting in successful SLN navigation and saving time and cost. This method appears clinically applicable as a less-invasive method for treating superficial esophageal cancer.
authors.affiliation: Department of Thoracic, Endocrine Surgery and Oncology, Institute of Health Bioscience, The University of Tokushima, Tokushima, Japan. yuasay0911@gmail.com
authors.forename: Yasuhiro
authors.initials: Y
authors.lastname: Yuasa
authors.forename: Junichi
authors.initials: J
authors.lastname: Seike
authors.forename: Takahiro
authors.initials: T
authors.lastname: Yoshida
authors.forename: Hirokazu
authors.initials: H
authors.lastname: Takechi
authors.forename: Hiromichi
authors.initials: H
authors.lastname: Yamai
authors.forename: Yota
authors.initials: Y
authors.lastname: Yamamoto
authors.forename: Yoshihito
authors.initials: Y
authors.lastname: Furukita
authors.forename: Masakazu
authors.initials: M
authors.lastname: Goto
authors.forename: Takuya
authors.initials: T
authors.lastname: Minato
authors.forename: Takeshi
authors.initials: T
authors.lastname: Nishino
authors.forename: Seiya
authors.initials: S
authors.lastname: Inoue
authors.forename: Satoshi
authors.initials: S
authors.lastname: Fujiwara
authors.forename: Akira
authors.initials: A
authors.lastname: Tangoku
mesh_terms: D000368:Aged; D004396:Coloring Agents; D004938:Esophageal Neoplasms / Q000473:pathology* / Q000601:surgery*; D016629:Esophagectomy; D005240:Feasibility Studies; D005453:Fluorescence; D005500:Follow-Up Studies; D006801:Humans; D007208:Indocyanine Green; D008197:Lymph Node Excision; D008198:Lymph Nodes / Q000473:pathology / Q000601:surgery; D008207:Lymphatic Metastasis; D008220:Lymphography; D008875:Middle Aged; D009367:Neoplasm Staging; D011379:Prognosis; D021701:Sentinel Lymph Node Biopsy; D015996:Survival Rate; D014057:Tomography, X-Ray Computed
chemical_list: D004396:Coloring Agents; D007208:Indocyanine Green