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ICG-Lymphknoten-Mapping in der Tumorchirurgie des oberen Gastrointestinaltrakts

ICG lymph node mapping in cancer surgery of the upper gastrointestinal tract

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Zusammenfassung

Die Wichtigkeit der Beurteilung des N‑Status beim Magenkarzinom, bei Tumoren des gastroösophagealen Übergangs sowie beim Ösophaguskarzinom ist unumstritten. Bis dato gibt es jedoch keine international validierte Methode zum Lymphknoten-Mapping beim Ösophagus- und Magenkarzinom. Nahinfrarot-Fluoreszenz-Bildgebung (NIR) ist eine innovative Technik aus dem Bereich der Schwingungsspektroskopien, welche in Kombination mit dem Fluoreszenz-Farbstoff Indocyaningrün (ICG) die intraoperative Darstellung von Strukturen in Echtzeit erlaubt. Für ICG finden sich im Bereich der onkologischen Chirurgie aktuell 4 Anwendungsgebiete: intraoperative Echtzeit-Angiographie zur Darstellung der Perfusion, Lymphographie zur Darstellung der Lymphgefäße, Darstellung solider Tumoren sowie (Wächter‑)Lymphknoten-Mapping. Für die Darstellung des Lymphabflussgebiets und somit der konsekutiven Lymphkoten muss die ICG-Injektion peritumoral erfolgen. Verschiedene Studien haben die Machbarkeit der peritumoralen Injektion von ICG 15 min bis 3 Tage präoperativ mit konsekutiver Darstellung der Lymphknoten intraoperativ bewiesen. Bislang fehlen prospektiv-randomisierte Studien zur Validierung der Methodik. Die Anwendung von ICG zum Lymphknoten-Mapping und Darstellung von Wächterlymphknoten beim Magenkarzinom hingegen ist an großen Kohorten sowie prospektiv-randomisierten Studien erforscht. Bis heute fehlen für die Anwendung des ICG-gesteuerten Lymphknoten-Mappings in der Chirurgie des oberen Gastrointestinaltrakts multizentrische Studien. Methoden der künstlichen Intelligenz (KI) können in Zukunft helfen, diese Techniken automatisiert auszuwerten sowie intraoperative Entscheidungen zu unterstützen und somit die chirurgisch-onkologische Qualität zu verbessern.

Abstract

The importance of the assessment of the N‑status in gastric carcinoma, tumors of the gastroesophageal junction and esophageal cancer is undisputed; however, there is currently no internationally validated method for lymph node mapping in esophageal and gastric cancer. Near-infrared fluorescence imaging (NIR) is an innovative technique from the field of vibrational spectroscopy, which in combination with the fluorescent dye indocyanine green (ICG) enables intraoperative real-time visualization of anatomical structures. The ICG currently has four fields of application in oncological surgery: intraoperative real-time angiography for visualization of perfusion, lymphography for visualization of lymphatic vessels, visualization of solid tumors, and (sentinel) lymph node mapping. For imaging of the lymph drainage area and therefore the consecutive lymph nodes, peritumoral injection of ICG must be performed. Several studies have demonstrated the feasibility of peritumoral injection of ICG administered 15 min to 3 days preoperatively with subsequent intraoperative visualization of the lymph nodes. So far prospective randomized studies on the validation of the method are still lacking. In contrast, the use of ICG for lymph node mapping and visualization of sentinel lymph nodes in gastric cancer has been performed in large cohorts as well as in prospective randomized settings. Up to now, multicenter studies for ICG-guided lymph node mapping during oncological surgery of the upper gastrointestinal tract are lacking. Artificial intelligence methods can help to evaluate these techniques in an automated manner in the future as well as to support intraoperative decision making and therefore to improve the quality of oncological surgery.

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  1. Klinik und Poliklinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Uniklinik Köln (AöR), Kerpener Str. 62, 50937, Köln, Deutschland

    Dolores Müller, Raphael Stier, Jennifer Straatman, Benjamin Babic, Lars Schiffmann, Jennifer Eckhoff, Thomas Schmidt, Christiane Bruns &  Hans F. Fuchs

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Correspondence to Hans F. Fuchs.

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Interessenkonflikt

H.F. Fuchs: Intuitive Surgical, ESOMAP trial (educational grant), Active Surgical; Advisory Board Medtronic; Advisory Board Stryker; Advisory Board DistalMotion; Advisory Board Fortimedix Surgical; stock options. D. Müller, R. Stier, J. Straatman, B. Babic, L. Schiffmann, J. Eckhoff, T. Schmidt und C. Bruns und geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Müller, D., Stier, R., Straatman, J. et al. ICG-Lymphknoten-Mapping in der Tumorchirurgie des oberen Gastrointestinaltrakts. Chirurgie 93, 925–933 (2022). https://doi.org/10.1007/s00104-022-01659-y

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