title: Laparoscopic detection and resection of occult liver tumors of multiple cancer types using real-time near-infrared fluorescence guidance.
abstract: Tumor recurrence after radical resection of hepatic tumors is not uncommon, suggesting that malignant lesions are missed during surgery. Intraoperative navigation using fluorescence guidance is an innovative technique enabling real-time identification of (sub)capsular liver tumors. The objective of the current study was to compare fluorescence imaging (FI) and conventional imaging modalities for laparoscopic detection of both primary and metastatic tumors in the liver.
  
  
  
  Patients undergoing laparoscopic resection of a malignant hepatic tumor were eligible for inclusion. Patients received standard of care, including preoperative CT and/or MRI. In addition, 10 mg indocyanine green was intravenously administered 1 day prior to surgery. After introduction of the laparoscope, inspection, FI, and laparoscopic ultrasonography (LUS) were performed. Histopathological examination of resected suspect tissue was considered the gold standard.
  
  
  
  Twenty-two patients suspected of having hepatocellular carcinoma (n = 4), cholangiocarcinoma (n = 2) or liver metastases from colorectal carcinoma (n = 12), uveal melanoma (n = 2), and breast cancer (n = 2) were included. Two patients were excluded because their surgery was unexpectedly postponed several days. Twenty-six malignancies were resected in the remaining 20 patients. Sensitivity for various modalities was 80 % (CT), 84 % (MRI), 62 % (inspection), 86 % (LUS), and 92 % (FI), respectively. Three metastases (12 %) were identified solely by FI. All 26 malignancies could be detected by combining LUS and FI (100 % sensitivity).
  
  
  
  This study demonstrates added value of FI during laparoscopic resections of several hepatic tumors. Although larger series will be needed to confirm long-term patient outcome, the technology already aids the surgeon by providing real-time fluorescence guidance.
authors.affiliation: Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
authors.forename: Leonora S F
authors.initials: LS
authors.lastname: Boogerd
authors.affiliation: Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
authors.forename: Henricus J M
authors.initials: HJ
authors.lastname: Handgraaf
authors.affiliation: Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
authors.forename: Hwai-Ding
authors.initials: HD
authors.lastname: Lam
authors.affiliation: Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
authors.forename: Volkert A L
authors.initials: VA
authors.lastname: Huurman
authors.affiliation: Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Arantza
authors.initials: A
authors.lastname: Farina-Sarasqueta
authors.affiliation: Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.|Curadel, LLC, Worcester, MA, USA.|Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
authors.forename: John V
authors.initials: JV
authors.lastname: Frangioni
authors.affiliation: Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
authors.forename: Cornelis J H
authors.initials: CJ
authors.lastname: van de Velde
authors.affiliation: Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
authors.forename: Andries E
authors.initials: AE
authors.lastname: Braat
authors.affiliation: Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands. a.l.vahrmeijer@lumc.nl.
authors.forename: Alexander L
authors.initials: AL
authors.lastname: Vahrmeijer
mesh_terms: D000328:Adult; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000175:diagnosis* / Q000556:secondary / Q000601:surgery; D018281:Cholangiocarcinoma / Q000175:diagnosis / Q000556:secondary / Q000601:surgery; D005260:Female; D005453:Fluorescence; D006801:Humans; D007208:Indocyanine Green / Q000378:metabolism; D010535:Laparoscopy / Q000379:methods; D008113:Liver Neoplasms / Q000175:diagnosis* / Q000473:pathology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009362:Neoplasm Metastasis; D009364:Neoplasm Recurrence, Local / Q000175:diagnosis* / Q000473:pathology / Q000601:surgery; D012680:Sensitivity and Specificity; D019265:Spectroscopy, Near-Infrared; D025321:Surgery, Computer-Assisted
chemical_list: D007208:Indocyanine Green
keywords: Fluorescence imaging; Hepatic metastases; Indocyanine green; Intraoperative guidance; Surgical navigation; Tumor imaging