Sentinel Node Localization
Yolonda L. Colson, MD, PhD
Professor of Surgery, Harvard Medical School
Vice Chair for Surgical Innovation Executive Director, Center for Surgical
Innovation
Associate Administrative Chief, Division of Thoracic Surgery at BWH
Dana Farber Cancer Institute / Brigham & Women’s Cancer Center
NIR Image-guided Lymphatic Mapping in Lung Cancer
Disclosures• I have no equity, ownership, stock, options or
any interest in any company
• I do not consult for any company
•We gratefully acknowledge Novadaq for the generous loan of the Pinpoint system. There has been no data preview or monetary sponsorship for this collaboration• I have presented our NIH-funded data on NIR-
imaging at a Novadaq-sponsored conference but without honorarium
•Use of ICG for NIR-imaging of SLN is NOT FDA-approved
Why Consider SLN Mapping in Lung Cancer?
•Almost 30% of Clinical stage I NSCLC patients upstaged at surgery due to occult nodal disease
•Sites of Missed Nodal disease ▫Residual lymph nodes: only 50% of patients
undergo a complete lymphadenectomy.
▫Micrometastasis: 16-18% of “node negative” patients harbor positive LN disease with further histologic scrutiny.
▫Skip Metastases: ~20% of “first tumor-draining lymph nodes” (i.e. SLN) at N2 station.
Group Year Technique Success
Little et al 1999 Single Center Blue Dye 47%
Liptay et al 2000 Single Center Radioisotope 81%
Liptay et al 2009 Multi-Center Radioisotope 51%
Nomori et al 2007 Single Center Pre-op Radioisotope 81%
Schmidt et al 2002 Single Center Intra-operative Blue Dye/ Radioisotope
81%
Tiffet et al 2005 Single Center Intra-operative Blue Dye/ Radioisotope
54%
No Reliable SLN Technology for Lung Cancer
SLN Mapping in Lung Cancer
“Conventional Methods” Mixed Success▫Low Signal▫Anatomic Limitations
Lipid
NIR Window
Courtesy of J. Frangioni, BIDMC
Advantages of NIR Fluorescent Imaging
High signal-to-background ratio▫Low NIR Autoflourescence▫High Fluorophore Signal in
NIRInvisible to the human eye▫No alteration of Surgical
FieldIncreased Safety▫No radioactivity or laser
risk
Real-time visualization of target
during surgical dissection
Excitation of the Indocyanine Green (ICG) captured by a near-infrared camera
• Indocyanine Green (ICG) emission in NIR spectra: 750-950nm
• ICG signal detection via NIR videoscopic camera
• Visualization of merged and single channel images in real-time
Light Source
Surgical Field
NIRCame
ra
Color VideoCame
ra
Video of Real-time Merged Images
Courtesy of J. Frangioni, BIDMC.
How Does it Work?
Lesion Characteristics Dictate NIR Approach
How I Do It
0%
20%
40%
60%
80%
100%
Pathology of NIR+ SLN Predicts Overall Nodal
Status
Pathology of NIR+ SLN
% p
ts w
ith
an
y n
od
al
dis
ease
Pos. Neg.
Summary•32 SLN in 20 patients ▫ ICG Dose Dependent
▫Dose optimized at 2.5mg
▫N1 Stations – 21 LN▫N2 Stations – 11 LN
•No Adverse events •SLN status predictive
of nodal metastases in all patients
N=7 n=13
0%
Conclusion
•NIR guided lymphatic mapping appears to be a safe & feasible approach to identify SLN
•Learning curve is initially high
•May improve intraoperative staging with identification of micrometastatic disease in lung cancer patients
•Still an experimental approach and has not been evaluated for long-term safety or for SLN accuracy in a sufficient number of patients to be standard of care
•Large prospective clinical trial is needed
Funding & SupportNational Cancer Institute – R01-CA131044
American College of Surgeons Clowes AwardEdward M. Kennedy Award for Healthcare
InnovationCenter for Integration of Medicine & Innovative
Technology (CIMIT)
TalentHisashi Tsukada (BWH), John Frangioni
(BIDMC) Krista Hachey, Denis Gilmore, Onkar Khullar
Katie Armstrong, David Owens
Acknowledgments