title: Real-time lymphography by indocyanine green fluorescence: improved navigation for regional lymph node staging.
abstract: OBJECTIVE
  Lymphatic imaging is an important step for the identification of lymphonodal positive disease in solid malignancies. Various methods have been established to detect positive lymph nodes, but the available diagnostic tools leave some inherent drawbacks. The aim of this study was to validate the indocyanine green (ICG) guided approach for transcutaneous and transmesenterial navigation with accurate lymph vessel and node identification for regional lymph node staging in solid malignancies.
  
  
  METHODS
  After institutional review board approval, a planar fluorescence imaging system was applied for lymphography and lymph node detection using ICG. A total of 96 patients were recruited and subject to fluorescence navigation for axillary (n = 46), inguinal (n = 16), and mesenterial (n = 34) visualization to analyze technical and clinical feasibility of the method after regional lymph node dissection and the applicability.
  
  
  RESULTS
  Overall fluorescence imaging identified lymphatic vessels and the SLN in 92 out of 96 patients (detection rate: 96%) after a mean injection of 7 mg ICG. Sensitivity based on fluorescent emission of ICG navigation was 95.6% in 65 out of 68 patients with lymph node dissection. All solid tumors were feasible for fluorescence-guided navigation with a broad spectrum.
  
  
  CONCLUSIONS
  Fluorescence-guided real-time lymphography with navigation to regional lymph nodes enables accurate visualization for a broad spectrum of different solid tumors with potential lymphonodal spread. In addition, the technique can be applied for lymphography in non-malignant diseases. With reference to the broad application spectrum, institutional investment in camera equipment can be justified.
authors.affiliation: From the *Department of Hand, Plastic, and Reconstructive Surgery, Trauma Centre Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany; †Department of General Surgery and Surgical Oncology, Helios Hospital Berlin-Buch, Berlin, Germany; and ‡Department of Radiology, Helios Hospital Berlin-Buch, Berlin, Germany.
authors.forename: Christoph
authors.initials: C
authors.lastname: Hirche
authors.forename: Holger
authors.initials: H
authors.lastname: Engel
authors.forename: Zarah
authors.initials: Z
authors.lastname: Hirche
authors.forename: Sergiu
authors.initials: S
authors.lastname: Doniga
authors.forename: Thomas
authors.initials: T
authors.lastname: Herold
authors.forename: Ulrich
authors.initials: U
authors.lastname: Kneser
authors.forename: Marcus
authors.initials: M
authors.lastname: Lehnhardt
authors.forename: Michael
authors.initials: M
authors.lastname: Hünerbein
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001365:Axilla; D005188:False Negative Reactions; D005240:Feasibility Studies; D005456:Fluorescent Dyes; D006801:Humans; D007208:Indocyanine Green; D007264:Inguinal Canal; D007430:Intraoperative Care; D008198:Lymph Nodes; D008207:Lymphatic Metastasis / Q000175:diagnosis*; D008643:Mesentery; D008875:Middle Aged; D009367:Neoplasm Staging; D061848:Optical Imaging / Q000379:methods*; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D019265:Spectroscopy, Near-Infrared / Q000379:methods*; D055815:Young Adult
chemical_list: D005456:Fluorescent Dyes; D007208:Indocyanine Green