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ICG-gestützte Navigation bei der Chirurgie uteriner Malignome

Intraoperative Navigation with ICG in Surgery of Uterine Cancer

  • Gynäkologie aktuell
  • Published:
Der Gynäkologe Aims and scope

Zusammenfassung

Synopsis

Die uterine Applikation von Indocyaningrün (ICG) vor der Operation markiert die primären lymphatischen Netzwerke der Organ- (Sub-)Kompartimente und deren Verbindungen zu den primären Lymphbassins beim Endometrium- und Zervixkarzinom. Die Technik kann für die intraoperative Navigation ebenso wie für die chirurgische Qualitätskontrolle eingesetzt werden.

Hintergrund

Evaluation der Darstellbarkeit embryologisch determinierter Organkompartimente bei Zervix- und Endometriumkarzinom durch ICG-Markierung ihrer zugehörigen lymphatischen Netzwerke.

Methoden

Unmittelbar präoperativ wurden 36 Patientinnen mit Uteruskarzinom und klinisch unauffälligen Lymphknotenstationen 2,5 mg ICG-Lösung in die Zervix oder das Korpus injiziert. Die Grünfluoreszenz wurde intermittierend während der roboterassistierten Laparoskopie dargestellt (Firefly System®, Intuitve Surgical). Die Auswertung erfolgte im Hinblick auf das kompartimentale lymphatische Netzwerk sowie die Sammel- und Verbindungsgefäße zu den nachgeordneten Lymphbassins.

Resultate

Das Müller- (Sub-)Kompartiment und der Transport der Lymphflüssigkeit entlang der lymphatischen Sammel- und Verbindungsgefäße konnten bei allen Patientinnen dargestellt werden. Die Zervix wird entlang des ligamentären und des kaudalen Anteils des vaskulären Mesometriums, das Korpus entlang des kranialen Anteils des vaskulären Mesometrium und entlang des ovariellen Gefäßsystems im Lig. infundibulopelvicum drainiert.

Schlussfolgerung

Das lymphatische Netzwerk des uterinen Organkompartiments ist mit ICG darstellbar und lässt sich „down stream“ zu den nachgeordneten Lymphbassins verfolgen. Die Methode kann für die intraoperative Navigation entlang der Kompartimentgrenzen verwendet werden: im Rahmen der Ausbildung, zur intraoperativen Orientierung, aber auch für die Qualitätskontrolle. Sie scheint die kompartimentale Anordnung der Organsysteme im Becken und der nachgeschalteten Lymphknotenstationen zu bestätigen.

Abstract

Background and Objectives

To evaluate feasibility of intraoperative visualization of embryologically defined organ compartments and their drainage by ICG in uterine cancer.

Methods

Total of 2.5 mg of ICG have been injected into cervix or corpus in uterine cancer patients immediately prior to surgery. Green fluorescence was intermittently detected during robotically assisted laparoscopic surgery (Firefly System®, Intuitve Surgical Inc.). Total of 36 patients with uterine cancer without macroscopically suspicious nodes were evaluated with respect to their compartmental lymphatic network, collecting lymphatic vessels, and the connection to the postponed lymph basins.

Results

Müllerian (sub) compartment and transport of lymph fluid along the lymphatic collectors and connecting vessels to the postponed lymph basins could be visualized invariably in all patients. Cervix drained along the ligamentous and caudal part of vascular mesometria, whereas midcorporal and fundal drainage occurred along the upper part of vascular mesometria and along the mesonephric pathway along the ovarian vessels.

Conclusions

Visualization of lymphatic network and downstream flow of lymphatic fluid to the postponed lymph basins by ICG is feasible; it can be used to navigate along compartment boarders for education, intraoperative orientation, and quality control. It seems to confirm the compartmental order of pelvic organ systems and postponed lymph basins.

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Literatur

  1. Kimmig R, Aktas B, Buderath P, Rusch P, Heubner M (2016) Intraoperative navigation in robotically assisted compartmental surgery of uterine cancer by visualisation of embryologically derived lymphatic networks with indocyanine-green (ICG). J Surg Oncol : doi:10.1002/jso.24174

    Google Scholar 

  2. Wolpert L (1969) Positional information and spatial pattern of cellular differentiation. J Theor Biol 25:1–47

    Article  CAS  PubMed  Google Scholar 

  3. Dahmann C, Oates AC, Brand M (2011) Boundary formation and maintenance in tissue development. Nat Rev Genet 12:43–55

    Article  CAS  PubMed  Google Scholar 

  4. Höckel M (2015) Morphogenetic fields of embryonic development in locoregional cancer spread. Lancet Oncol 16(3):e148–e151. doi:10.1016/S1470-2045(14)71028-9

    Article  PubMed  Google Scholar 

  5. Höckel M, Hentschel B, Horn LC (2014) Association between developmental steps in the organogenesis of the uterine cervix and locoregional progression of cervical cancer: a prospective clinicopathological analysis. Lancet Oncol 15(4):445–456. doi:10.1016/S1470-2045(14)70060-9.

    Article  PubMed  Google Scholar 

  6. Ribatti D, Crivellato E (2010) The embryonic origins of lymphatic vessels: an historical review. Br J Haematol 149:669–674

    Article  PubMed  Google Scholar 

  7. Yang Y, Oliver G (2015) Development of the mammalian lymphatic vasculature. J Clin Invest 124:888–897

    Article  Google Scholar 

  8. Höckel M (2012) Cancer permeates locally within ontogenetic compartments: clinical evidence and implications for cancer surgery. Future Oncol 8(1):29–36. doi:10.2217/fon.11.128

    Article  PubMed  Google Scholar 

  9. Xiong L, Gazyakan E, Yang W et al (2014) Indocyanine green fluorescence-guided sentinel node biopsy: a meta-analysis on detection rate and diagnostic performance. Eur J Surg Oncol 40:843–849

    Article  CAS  PubMed  Google Scholar 

  10. Verbeek FP, Troyan SL, Mieog JS et al (2014) Near-infrared fluorescence sentinel lymph node mapping in breast cancer: a multicentre experience. Breast Cancer Res Treat 143:333–342

    Article  PubMed  PubMed Central  Google Scholar 

  11. Rossi EC, Ivanova A, Boggess JF (2012) Robotically assisted fluorescence-guided lymph node mapping with ICG for gynecologic malignancies: a feasibility study. Gynecol Oncol 124(1):78–82. doi:10.1016/j.ygyno.2011.09.025.

    Article  PubMed  Google Scholar 

  12. Jewell EL, Huang JJ, Abu-Rustum NR et al (2014) Detection of sentinel lymph nodes in minimally invasive surgery using indocyanine green and near-infrared fluorescence imaging for uterine and cervical malignancies. Gynecol Oncol 133(2):274–277. doi:10.1016/j.ygyno.2014.02.028.

    Article  PubMed  Google Scholar 

  13. Plante M, Touhami O, Trinh XB et al (2015) Sentinel node mapping with indocyanine green and endoscopic near-infrared fluorescence imaging in endometrial cancer. A pilot study and review of the literature. Gynecol Oncol : doi:10.1016/j.ygyno.2015.03.004.

    Google Scholar 

  14. Kimmig R, Iannaccone A, Buderath P et al (2013) Definition of compartment based radical surgery in uterine cancer-part I: therapeutic pelvic and Periaortic Lymphadenectomy by michael Höckel translated to Robotic surgery. ISRN Obstet Gynecol 2013:297921 doi:10.1155/2013/297921

    PubMed  PubMed Central  Google Scholar 

  15. Kimmig R, Wimberger P, Buderath P et al (2013) Definition of compartment-based radical surgery in uterine cancer: radical hysterectomy in cervical cancer as „total mesometrial resection (TMMR)“ by Michael Höckel translated to robotic surgery (rTMMR). World J Surg Oncol 11(1):211

    Article  PubMed  PubMed Central  Google Scholar 

  16. Kimmig R, Aktas B, Buderath P et al (2013) Definition of compartment-based radical surgery in uterine cancer: modified radical hysterectomy in intermediate/high-risk endometrial cancer using peritoneal mesometrial resection (PMMR) by M Höckel translated to robotic surgery. World J Surg Oncol 11(1):198

    Article  PubMed  PubMed Central  Google Scholar 

  17. Kimmig R, Iannaccone A, Aktas B et al (2015) Embryologically based radical hysterectomy as peritoneal mesometrial resection (PMMR) with pelvic/paraaortic lymphadenectomy for loco-regional tumour control in endometrial cancer – first evidence for efficacy. Arch Gynecol Obstet : doi:10.1007/s00404-015-3956-y

    Google Scholar 

  18. Crane LM, Themelis G, Buddingh KT et al (2010) Multispectral real-time fluorescence imaging for intraoperative detection of the sentinel lymph node in gynecologic oncology. J Vis Exp : doi:10.3791/2225

    Google Scholar 

  19. Alitalo A, Detmar M (2012) Interaction of tumor cells and lymphatic vessels in cancer progression. Oncogene 201(31):4499–4508

    Article  Google Scholar 

  20. Quirke P, Dixon MF, Durdey P et al (1986) Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Lancet 2:996–998

    Article  CAS  PubMed  Google Scholar 

  21. Höckel M, Horn L‑C, Manthey N et al (2009) Resection of the embryologically defined uterovaginal (Müllerian) compartment and pelvic control in patients with cervical cancer: a prospective analysis. Lancet Oncol 10:683–692

    Article  PubMed  Google Scholar 

  22. Höckel M, Schmidt K, Bornmann et al (2010) Vulvar field resection: Novel approach to the surgical treatment of vulvar cancer based on ontogenetic anatomy. Gynecol Oncol 119:106–113

    Article  PubMed  Google Scholar 

  23. Höckel M, Horn LC, Illig R et al (2011) Ontogenetic anatomy of the distal vagina: Relevance for local tumor spread and implications for cancer surgery. Gynecol Oncol 122:313–318

    Article  PubMed  Google Scholar 

  24. Rossi EC, Jackson A, Ivanova A et al (2013) Detection of sentinel nodes for endometrial cancer with robotic assisted fluorescence imaging: cervical versus hysteroscopic injection. Int J Gynecol Cancer 23(9):1704–1711. doi:10.1097/IGC.0b013e3182a616f6

    Article  PubMed  Google Scholar 

  25. Cibula D, Oonk MH, Abu-Rustum NR (2015) Sentinel lymph node biopsy in the management of gynecologic cancer. Curr Opin Obstet Gynecol 27(1):66–72. doi:10.1097/GCO.0000000000000133

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Westdeutsches Tumorzentrum, Klinik für Frauenheilkunde und Geburtshilfe, Universität Duisburg-Essen, Hufelandstr. 55, 45133, Essen, Deutschland

    Rainer Kimmig, Bahriye Aktas, Paul Buderath, Peter Rusch & Martin Heubner

Authors
  1. Rainer Kimmig
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  2. Bahriye Aktas
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  3. Paul Buderath
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  4. Peter Rusch
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  5. Martin Heubner
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Corresponding author

Correspondence to Rainer Kimmig.

Ethics declarations

Interessenkonflikt

R. Kimmig erhielt Honorare und Reisekostenerstattungen von Intuitive Surgical Inc. für Vorträge und Proctoring in Bezug auf „robotic surgery“ in Europa. B. Aktas, P. Buderath, P. Rusch und M. Heubner geben an, dass kein Interessenkonflikt besteht.

Alle Patientinnen wurden präoperativ sorgfältig aufgeklärt und gaben ihren „informed consent“.

Additional information

Redaktion

W. Janni, Ulm

R. Kimmig, Essen

N. Maass, Kiel

Deutsche Version der englischen Open-Access-Publikation

Kimmig R, Aktas B, Buderath P, Rusch P, Heubner M (2016) Intraoperative navigation in robotically assisted compartmental surgery of uterine cancer by visualisation of embryologically derived lymphatic networks with indocyanine-green (ICG). J Surg Oncol. doi:10.1002/jso.24174. (Epub ahead of print; Jan 21). (Mit freundl. Genehmigung der Autoren und von John Wiley and Sons, alle Rechte vorbehalten). Das englische Abstract wurde unverändert übernommen.

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Kimmig, R., Aktas, B., Buderath, P. et al. ICG-gestützte Navigation bei der Chirurgie uteriner Malignome. Gynäkologe 49, 373–380 (2016). https://doi.org/10.1007/s00129-016-3857-6

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