Annals of Surgical Oncology

, Volume 17, Issue 1, pp 144–151 | Cite as

Feasibility of a Lateral Region Sentinel Node Biopsy of Lower Rectal Cancer Guided by Indocyanine Green Using a Near-Infrared Camera System

  • Shingo Noura
  • Masayuki OhueEmail author
  • Yosuke Seki
  • Koji Tanaka
  • Masaaki Motoori
  • Kentaro Kishi
  • Isao Miyashiro
  • Hiroaki Ohigashi
  • Masahiko Yano
  • Osamu Ishikawa
  • Yasuhide Miyamoto
Colorectal Cancer



A lateral pelvic lymph node dissection (LPLD) for lower rectal cancer may be beneficial for a limited number of patients. If sentinel node (SN) navigation surgery could be applied to lower rectal cancer, then unnecessary LPLDs could be avoided. The aim of this study was to investigate the feasibility of lateral region SN biopsy by means of indocyanine green (ICG) visualized with a near-infrared camera system (Photodynamic Eye, PDE).


This study investigated the existence of a lateral region SN in 25 patients with lower rectal cancer. ICG was injected around the tumor, and the lateral pelvic region was observed with PDE.


With PDE, the lymph nodes and lymph vessels that received ICG appeared as shining fluorescent spots and streams in the fluorescence image. This allowed the detection of not only tumor-negative SNs but also tumor-positive SNs as shining spots. The lateral SNs were detected in 6 of 6 T1 and T2 diseases and 17 of 19 T3 diseases. The lateral SNs were successfully identified in 23 (92%) of the 25 patients. The mean number of lateral SNs per patients was 2.1. Of the 23 patients, 6 patients underwent LPLD. Of the 3 patients who had a tumor-negative SN, all dissected lateral non-SNs were negative in all 3 cases.


We could detect the lateral SNs, not only in T1 and T2 disease, but also in T3 disease. Although this is only a preliminary study, the detection of lateral SNs in lower rectal cancer by means of the ICG fluorescence imaging system is considered to be a promising technique that may be used for determining the indications for performing LPLD.


Rectal Cancer Sentinel Node Total Mesorectal Excision Lower Rectal Cancer Lateral Lymph Node Metastasis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



This study was supported in part by the Public Trust Surgery Research Fund.


  1. 1.
    Gerota D. Die Lymphgefaesse des Rectums und des Anus. Arch Anat Physiol Anat Abt. 1895:240–56.Google Scholar
  2. 2.
    Blair JB, Holyoke EA, Best RR. A note on the lymphatics of the middle and lower rectum and anus. Anat Rec. 1950;108:635–44.CrossRefPubMedGoogle Scholar
  3. 3.
    Stearns MW Jr, Deddish MR. Five-year results of abdominopelvic lymph node dissection for carcinoma of the rectum. Dis Colon Rectum. 1959;2:169–72.CrossRefPubMedGoogle Scholar
  4. 4.
    Suzuki K, Muto T, Sawada T. Prevention of local recurrence by extended lymphadenectomy for rectal cancer. Surg Today. 1995;25:795–801.CrossRefPubMedGoogle Scholar
  5. 5.
    Moriya Y, Sugihara K, Akasu T, Fujita S. Patterns of recurrence after nerve-sparing surgery for rectal adenocarcinoma with special reference to loco-regional recurrence. Dis Colon Rectum. 1995;38:1162–8.CrossRefPubMedGoogle Scholar
  6. 6.
    Mori T, Takahashi K, Yasuno M. Radical resection with autonomic nerve preservation and lymph node dissection techniques in lower rectal cancer surgery and its results: the impact of lateral lymph node dissection. Langenbecks Arch Surg. 1998;383:409–15.CrossRefPubMedGoogle Scholar
  7. 7.
    Moriya Y, Hojo K, Sawada T, Koyama Y. Significance of lateral node dissection for advanced rectal carcinoma at or below the peritoneal reflection. Dis Colon Rectum. 1989;32:307–15.CrossRefPubMedGoogle Scholar
  8. 8.
    Fujita S, Yamamoto S, Akasu T, Moriya Y. Lateral pelvic lymph node dissection for advanced lower rectal cancer. Br J Surg. 2003;90:1580–5.CrossRefPubMedGoogle Scholar
  9. 9.
    Ueno H, Mochizuki H, Hashiguchi Y, et al. Potential prognostic benefit of lateral pelvic node dissection for rectal cancer located below the peritoneal reflection. Ann Surg. 2007;245:80–7.CrossRefPubMedGoogle Scholar
  10. 10.
    Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg. 1994;220:391–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Veronesi U, Paganelli G, Galimberti V, et al. Sentinel-node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph-nodes. Lancet. 1997;349(9069):1864–7.CrossRefPubMedGoogle Scholar
  12. 12.
    Hiratsuka M, Miyashiro I, Ishikawa O, et al. Application of sentinel node biopsy to gastric cancer surgery. Surgery. 2001;129:335–40.CrossRefPubMedGoogle Scholar
  13. 13.
    Saha S, Wiese D, Badin J, et al. Technical details of sentinel lymph node mapping in colorectal cancer and its impact on staging. Ann Surg Oncol. 2000;7:120–4.CrossRefPubMedGoogle Scholar
  14. 14.
    Joosten JJ, Strobbe LJ, Wauters CA, et al. Intraoperative lymphatic mapping and the sentinel node concept in colorectal carcinoma. Br J Surg. 1999;86:482–6.CrossRefPubMedGoogle Scholar
  15. 15.
    Kitagawa Y, Fujii H, Kumai K, et al. Recent advances in sentinel node navigation for gastric cancer: a paradigm shift of surgical management. J Surg Oncol. 2005;90:147–51.CrossRefPubMedGoogle Scholar
  16. 16.
    Saha S, Dan AG, Bilchik AJ, et al. Historical review of lymphatic mapping in gastrointestinal malignancies. Ann Surg Oncol. 2004;11(3 Suppl):245S–9S.PubMedGoogle Scholar
  17. 17.
    Miyashiro I, Miyoshi N, Hiratsuka M, et al. Detection of sentinel node in gastric cancer surgery by indocyanine green fluorescence imaging: comparison with infrared imaging. Ann Surg Oncol. 2008;15:1640–3.CrossRefPubMedGoogle Scholar
  18. 18.
    Tajima Y, Yamazaki K, Masuda Y, et al. Sentinel node mapping guided by indocyanine green fluorescence imaging in gastric cancer. Ann Surg. 2009;249:58–62.CrossRefPubMedGoogle Scholar
  19. 19.
    Sobin LH, Wittekind C. TNM classification of malignant tumors. 6th edn. New York: Wiley-Liss; 2002.Google Scholar
  20. 20.
    Japanese Society for Cancer of the Colon and Rectum. Japanese classification of colorectal carcinoma. First English edn. Tokyo: Kanehara; 1997.Google Scholar
  21. 21.
    Pilipshen SJ, Heilweil M, Quan SH, et al. Patterns of pelvic recurrence following definitive resections of rectal cancer. Cancer. 1984;53:1354–62.CrossRefPubMedGoogle Scholar
  22. 22.
    Kobayashi H, Mochizuki H, Sugihara K, et al. Characteristics of recurrence and surveillance tools after curative resection for colorectal cancer: a multicenter study. Surgery. 2007;141:67–75.CrossRefPubMedGoogle Scholar
  23. 23.
    Nagawa H, Muto T, Sunouchi K, et al. Randomized, controlled trial of lateral node dissection vs. nerve-preserving resection in patients with rectal cancer after preoperative radiotherapy. Dis Colon Rectum. 2001;44:1274–80.CrossRefPubMedGoogle Scholar
  24. 24.
    Watanabe T, Tsurita G, Muto T, et al. Extended lymphadenectomy and preoperative radiotherapy for lower rectal cancers. Surgery. 2002;132:27–33.CrossRefPubMedGoogle Scholar
  25. 25.
    Kusters M, Beets GL, van de Velde CJ, et al. A comparison between the treatment of low rectal cancer in Japan and the Netherlands, focusing on the patterns of local recurrence. Ann Surg. 2009;249:229–35.CrossRefPubMedGoogle Scholar
  26. 26.
    Kim JC, Takahashi K, Yu CS, et al. Comparative outcome between chemoradiotherapy and lateral pelvic lymph node dissection following total mesorectal excision in rectal cancer. Ann Surg. 2007;246:754–62.CrossRefPubMedGoogle Scholar
  27. 27.
    Kim TH, Jeong SY, Choi DH, et al. Lateral lymph node metastasis is a major cause of locoregional recurrence in rectal cancer treated with preoperative chemoradiotherapy and curative resection. Ann Surg Oncol. 2008;15:729–37.CrossRefPubMedGoogle Scholar
  28. 28.
    Nelson H, Petrelli N, Carlin A, et al. Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst. 2001;93:583–96.CrossRefPubMedGoogle Scholar
  29. 29.
    Caesar J, Shaldon S, Chiandussi L, et al. The use of indocyanine green in the measurement of hepatic blood flow and as a test of hepatic function. Clin Sci. 1961;21:43–57.PubMedGoogle Scholar
  30. 30.
    Cherrick GR, Stein SW, Leevy CM, Davidson CS. Indocyanine green: observations on its physical properties, plasma decay, and hepatic extraction. J Clin Invest. 1960;39:592–600.CrossRefPubMedGoogle Scholar
  31. 31.
    Unno N, Inuzuka K, Suzuki M, et al. Preliminary experience with a novel fluorescence lymphography using indocyanine green in patients with secondary lymphedema. J Vasc Surg. 2007;45:1016–21.CrossRefPubMedGoogle Scholar
  32. 32.
    Unno N, Suzuki M, Yamamoto N, et al. Indocyanine green fluorescence angiography for intraoperative assessment of blood flow: a feasibility study. Eur J Vasc Endovasc Surg. 2008;35:205–7.CrossRefPubMedGoogle Scholar
  33. 33.
    Motomura K, Inaji H, Komoike Y, et al. Sentinel node biopsy guided by indocyanine green dye in breast cancer patients. Jpn J Clin Oncol. 1999;29:604–7.CrossRefPubMedGoogle Scholar
  34. 34.
    Saha S, Nora D, Wong JH, Weise D. Sentinel lymph node mapping in colorectal cancer—a review. Surg Clin North Am. 2000;80:1811–9.CrossRefPubMedGoogle Scholar
  35. 35.
    Kawahara H, Nimura H, Watanabe K, et al. Where does the first lateral pelvic lymph node receive drainage from? Dig Surg. 2007;24:413–7.CrossRefPubMedGoogle Scholar
  36. 36.
    Nimura H, Narimiya N, Mitsumori N, et al. Infrared ray electronic endoscopy combined with indocyanine green injection for detection of sentinel nodes of patients with gastric cancer. Br J Surg. 2004;91:575–9.CrossRefPubMedGoogle Scholar
  37. 37.
    Ishikawa K, Yasuda K, Shiromizu A, et al. Laparoscopic sentinel node navigation achieved by infrared ray electronic endoscopy system in patients with gastric cancer. Surg Endosc. 2007;21:1131–4.CrossRefPubMedGoogle Scholar
  38. 38.
    Kitai T, Inomoto T, Miwa M, Shikayama T. Fluorescence navigation with indocyanine green for detecting sentinel lymph nodes in breast cancer. Breast Cancer. 2005;12:211–5.CrossRefPubMedGoogle Scholar
  39. 39.
    Noura S, Ohue M, Seki Y, et al. Evaluation of the lateral sentinel node by indocyanine green for rectal cancer based on micrometastasis determined by reverse transcriptase–polymerase chain reaction. Oncol Rep. 2008;20:745–50.PubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2009

Authors and Affiliations

  • Shingo Noura
    • 1
  • Masayuki Ohue
    • 1
    Email author
  • Yosuke Seki
    • 1
  • Koji Tanaka
    • 1
  • Masaaki Motoori
    • 1
  • Kentaro Kishi
    • 1
  • Isao Miyashiro
    • 1
  • Hiroaki Ohigashi
    • 1
  • Masahiko Yano
    • 1
  • Osamu Ishikawa
    • 1
  • Yasuhide Miyamoto
    • 2
  1. 1.Department of SurgeryOsaka Medical Center for Cancer and Cardiovascular DiseasesOsakaJapan
  2. 2.Department of ImmunologyOsaka Medical Center for Cancer and Cardiovascular DiseasesOsakaJapan

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