Preoperative Imaging of Sentinel Lymph Nodes in Gastric Cancer Using CT Lymphography

형우진,김용수,김명진,노성훈,김기황,임준석 연세대학교의과대학 2010 Yonsei medical journal Vol.51 No.3

Purpose: Preoperative identification of the sentinel lymph node (SLN) in gastric cancer (GC) patients may have great advantages for the minimally invasive treatment. This study was performed to evaluate the possibility of preoperative SLN detection using CT lymphography. Materials and Methods: Fourteen patients with early GC were enrolled. CT images were obtained before and at 1, 3, and 5 minutes after endoscopic submucosal peritumoral injection of 2 mL iopamidol. For patients with clearly identified SLNs, to make comparisons with the CT lymphography results, intraoperative SLN detection was performed using subserosally injected Indocyanine green (ICG) lymphography and ex vivo ICG and iopamidol lymphography using mammography was also performed. Results: CT lymphography clearly visualized draining lymphatics and SLNs in 4 (28.6%) out of 14 patients. All clearly visualized SLNs (one to three SLNs per patient) under preoperative imaging were detected in the same location by intraoperative ICG lymphography and ex vivo ICG and iopamidol lymphography using mammography. All preoperative SLN detections were observed with the primary tumors in the lower third of the stomach. Conclusion: Although our study demonstrated a SLN detection rate of less than 30%, CT lymphography with radio-contrast showed potential as a method of preoperative SLN detection for GC.

Three-dimensional analysis of dermal backflow in cancer-related lymphedema using photoacoustic lymphangiography

Anna Oh,Hiroki Kajita,Nobuaki Imanishi,Hisashi Sakuma,Yoshifumi Takatsume,Keisuke Okabe,Sadakazu Aiso,Kazuo Kishi 대한성형외과학회 2022 Archives of Plastic Surgery Vol.49 No.1

Background Dermal backflow (DBF), which refers to lymphatic reflux due to lymphatic valve insufficiency, is a diagnostic finding in lymphedema. However, the three-dimensional structure of DBF remains unknown. Photoacoustic lymphangiography (PAL) is a new technique that enables the visualization of the distribution of light-absorbing molecules, such as hemoglobin or indocyanine green (ICG), and can provide three-dimensional images of superficial lymphatic vessels and the venous system. This study reports the use of PAL to visualize DBF structures in the extremities of patients with lymphedema after cancer surgery. Methods Patients with a clinical or lymphographic diagnosis of lymphedema who previously underwent surgery for cancer at one of two participating hospitals were included in this study. PAL was performed using the PAI-05 system. ICG was administered subcutaneously in the affected hand or foot, and ICG fluorescence lymphography was performed using a near-infrared camera system prior to PAL. Results Between April 2018 and January 2019, 21 patients were enrolled and examined using PAL. The DBF was composed of dense, interconnecting, three-dimensional lymphatic vessels. It was classified into three patterns according to the composition of the lymphatic vessels: a linear structure of lymphatic collectors (pattern 1), a network of lymphatic capillaries and lymphatic collectors in an underlying layer (pattern 2), and lymphatic capillaries and precollectors with no lymphatic collectors (pattern 3). Conclusions PAL showed the structure of DBF more precisely than ICG fluorescence lymphography. The use of PAL to visualize DBF assists in understanding the pathophysiology and assessing the severity of cancer-related lymphedema.

Fluorescent Lymphography–guided Lymphadenectomy During Minimally Invasive Completion Total Gastrectomy for Remnant Gastric Cancer Patients

NASSER Alrashidi,Woo Jin Hyung 대한외과학회 2021 대한외과학회 학술대회 초록집 Vol.2021 No.11

Local tissue reaction after injection of contrast media on gastric wall of mouse

Sun-Hwi Hwang,Hyung-Ho Kim,Do Joong Park,Ye-Seob Jee,Kyoung Ho Lee,Young Hoon Kim,Hye Seung Lee,Hyuk-Joon Lee,Han-Kwang Yang 대한외과학회 2012 Annals of Surgical Treatment and Research(ASRT) Vol.82 No.2

Purpose: Computed tomography (CT) lymphography is a simple technique of sentinel node navigation but tissue reaction after injection of contrast media has not been reported yet. Methods: Ninety mice used in this study were divided into three groups: lipiodol, iopamidol, and normal saline. The test compounds were given by submucosal injection to the gastric wall of anesthetized mice. The specimens were subjected to histopathological examination. Results: The mean grades of acute inflammatory response after iopamidol and lipiodol injection were significantly higher than control group. However, there was no significant difference between iopamidol and lipiodol injection. The mean grade of chronic inflammatory response and fibrosis showed no differences between groups. The presence or absence of fibrinoid necrosis and mesothelial hyperplasia showed no statistical differences at each time point between groups. The foam cell, which is similar to human signet ring cell carcinoma, were not identified in normal saline and iopamidol group, but were detected by postoperative day 7 in lipiodol group. Conclusion: We conclude that iopamidol and lipiodol when used as a contrast media of CT lymphography is an available material for preoperative sentinel node navigation surgery for gastric cancer with an acceptable incidence of pathological alterations in a mouse model. Our results are potentially useful to clinical (human) application.

Lower extremity lymphatic leakage and lymphedema secondary to punch biopsy

( Chang Min Kim ),( Bo Young Kim ),( Jung Jin Shin ),( Jae Beom Park ),( Deok Woo Kim ),( Yoo Chan Kim ),( Hwa Jung Ryu ),( Il Hwan Kim ) 대한피부과학회 2016 대한피부과학회 학술발표대회집 Vol.68 No.1

Punch biopsy is a relatively safe procedure compared with other biopsy methods, so there has been very low incidence of complications after punch biopsy. Lymphatic leakage and secondary lymphedema can be one of those complications. ICG lymphography is one of the popular methods to diagnose lymphedema, recently. A 60-year-old female patient presented with asymptomatic crusted erythematous macule with continuous clear discharge on left lower leg after punch biopsy, which was done 50 days prior to the visit. Under the initial impression of lymphatic leakage due to trauma, indocyanine green(ICG) lymphography was performed to examine blockage of lymphatic drainage. During the ICG lymphography, Dermal backflow(DB) pattern was found on the left lower leg. Under the final diagnosis of secondary lymphedema and lymphatic leakage, lymphatic vessel ligation was performed on department of plastic surgery. No recurrence of lymphatic leakage or lymphedema has been reported till now. Although secondary lymphedema due to sentinel lymph node biopsy has been reported a few times, there was no report of simple skin punch biopsy induced secondary lymphedema and lymphatic leakage. Herein we report a rare case of secondary lymphedema and lymphatic leakage, the complication induced by punch biopsy.

Sentinel Node Mapping of VX2 Carcinoma in Rabbit Thigh with CT Lymphography Using Ethiodized Oil

이윤진,김영훈,이경호,박지훈,이혜승,정승채,주승문 대한영상의학회 2014 Korean Journal of Radiology Vol.15 No.1

Objective: To assess the feasibility of computed tomography (CT) lymphography using ethiodized oil for sentinel node mapping in experimentally induced VX2 carcinoma in the rabbit thigh. Materials and Methods: This experiment received approval from the institutional animal use and care administrative advisory committee. Twenty-three rabbits with VX2 carcinoma in the thigh underwent CT before and after (1 hour, 2 hour) peritumoral injection of 2 mL ethiodized oil. After the CT examination, sentinel nodes were identified by peritumoral injection of methylene blue and subsequently removed. The retrieved sentinel and non-sentinel lymph nodes were investigated with radiographic and pathologic examinations. Based on the comparison of CT findings with those of radiographic and pathologic examinations, the diagnostic performance of CT for sentinel node identification was assessed. Results: All 23 rabbits showed 53 ethiodized oil retention nodes on post-injection CT and specimen radiography, and 52 methylene blue-stained nodes at the right femoroiliac area. Of the 52 blue-stained sentinel nodes, 50 nodes demonstrated ethiodized oil retention. Thus, the sentinel node detection rate of CT was 96% (50 of 52). On pathologic examination, 28 sentinel nodes in 17 rabbits (nodes/rabbit, mean ± standard deviation, 1.7 ± 0.6) harbored metastasis. Twenty seven of the 28 metastatic sentinel nodes were found to have ethiodized oil retention. Conclusion: Computed tomography lymphography using ethiodized oil may be feasible for sentinel node mapping in experimentally induced VX2 carcinoma in the rabbit thigh.

건강한 아시아인들의 하지 림프관 주행 분석

이유환,김형규,유희진,김덕우 대한수부외과학회 2020 대한수부외과학회지 Vol.25 No.3

Purpose: Intraoperative indocyanine green (ICG) lymphography is an effective tool to obtain real-time video images of functioning lymph vessels in edematous limbs. However, it is difficult to identify the course of lymph vessels in obese patients or patients with large dermal backflow. Without the image, surgeons have to rely on their experience when performing the skin incision to locate the lymphatic vessels. This study focused on elucidating lymphatic vessel flow patterns in healthy lower extremities in an Asian population to refer these findings for lymphedema treatment. Methods: ICG fluorescence lymphography was performed by injecting 0.2 mL of ICG into the first web space of the foot. After 4 hours, fluorescence images of lymphatic vessels were obtained and the lymphatic vessels were marked. Three landmarks were designated; the medial malleolus, the medial patellar border, and the groin femoral artery. Straight lines connecting the points were drawn, and the distance between the connected lines and the marked lymphatic vessels was measured in eight points. Results: Fifteen subjects with healthy lower extremities (15 right and 15 left) were included. The average course of the main lymph vessels passed 26.2±18.0 mm dorsally to the medial malleolus, 53.7±35.7 mm medially to the medial patellar border, and 25.5±19.2 mm medially to the three-quarters point of the upper landmark line. Conclusion: The main functioning lymphatic vessel largely follows the great saphenous vein course, passes in front of the medial malleolus, runs over the posterior border of the medial epicondyle at the knee level, and travels anteriorly toward the inguinal lymph nodes. 목적: 수술 중 인도시아닌 그린(indocyanine green, ICG) 림프 조영술을 사용한 실시간 영상 촬영은 림프 부종 환자들의 림프관을 관찰하는 데 효과적인 방법이다. 하지만 비대하거나 어느 정도 진행된 림프 부종 환자들에서 이와 같은 방법으로 림프관 주행을 파악하는 것은 어려운 일이다. 영상이 없으면 외과의사들은 감에만 의존하여 절개를 해야 한다. 본 논문은 건강한 아시아인들의 하지 림프관 주행을 연구하여 위와 같이 영상을 얻을 수 없는 림프 부종 치료 시 참고할 수 있게 하고자 한다. 방법: 발의 첫 번째 지간 사이에 0.2 mL의 ICG를 주입한 후 ICG 형광(fluorescence) 림프 조영술을 실행하였다. 4시간 후, fluorescence image를 촬영하여 림프관 주행을 표시하였다. 세 부위의 랜드마크를 지정하였고 직선으로 그 점들을 연결하였다. 점들을 연결한 직선의 길이와 표시된 림프관들은 8가지 points로 측정하였다. 결과: 15명의 건강한 아시아인들의 하지(우측 15개, 좌측 15개)를 연구하였다. 평균적으로 림프관은 내측과의 배측 26.2±18.0 mm을 지나 슬개골 경계의 내측 53.7±35.7 mm을 지난 후 상단 랜드마크 라인의 3분의 4지점의 내측 25.5±19.2 mm을 지났다. 결론: 주 림프관은 대복재정맥의 주행을 따랐다. 내측과 앞을 지나, 무릎 높이에서 내측 상과의 뒷부분을 지나, 서혜부 림프절들로 이어졌다.

Lymphatic vessel mapping in the upper extremities of a healthy Korean population

이윤환,Soo-Hyun Lee,Hi-Jin You,Jae-A Jung,Eul-Sik Yoon,Deok-Woo Kim 대한성형외과학회 2018 Archives of Plastic Surgery Vol.45 No.2

Background Intraoperative indocyanine green (ICG) lymphography can effectively detect functioning lymph vessels in edematous limbs. However, it is sometimes difficult to clearly identify their course in later-stage edematous limbs. For this reason, many surgeons rely on experience when they decide where to make the skin incision to locate the lymphatic vessels. The purpose of this study was to elucidate lymphatic vessel flow patterns in healthy upper extremities in a Korean population and to use these findings as a reference for lymphedema treatment. Methods ICG fluorescence lymphography was performed by injecting 1 mL of ICG into the second web space of the hand. After 4 hours, fluorescence images of lymphatic vessels were obtained with a near-infrared camera, and the lymphatic vessels were marked. Three landmarks were designated: the radial styloid process, the mid-portion of the cubital fossa, and the lower border of the deltopectoral groove. A straight line connecting the points was drawn, and the distance between the connected lines and the marked lymphatic vessels was measured at 8 points. Results There were 30 healthy upper extremities (15 right and 15 left). The average course of the main lymph vessels passed 26.0±11.6 mm dorsal to the styloid process, 5.7±40.7 mm medial to the mid-cubital fossa, and 31.3±26.1 mm medial to the three-quarters point of the upper landmark line. Conclusions The main functioning lymphatic vessel follows the course of the cephalic vein at the forearm level, crosses the mid-cubital point, and travels medially toward the mid-axilla.

The relationship between lymphedema severity and awareness of lymphedema surgery

Lee, Hyun Seung,Bae, Yong Chan,Nam, Su Bong,Yi, Chang Ryul,Yoon, Jin A,Kim, Joo Hyoung Korean Society of Plastic and Reconstructive Surge 2021 Archives of Plastic Surgery Vol.48 No.5

Background During the early stages of lymphedema, active physiologic surgical treatment can be applied. However, lymphedema patients often have limited knowledge and misconceptions regarding lymphedema and surgical treatment. We analyzed the correlations between lymphedema severity and surgical technique according to patients' awareness of surgical treatment for secondary upper extremity lymphedema (UEL). Methods Patients with UEL diagnosed between December 2017 and December 2019 were retrospectively evaluated. At the time of their presentation to our hospital for the treatment of lymphedema, they were administered a questionnaire about lymphedema and lymphedema surgery. Based on the results, patients were classified as being aware or unaware of surgical treatment. Lymphedema severity was classified according to the arm dermal backflow (ADB) stage and the MD Anderson Cancer Center (MDACC) stage based on indocyanine green lymphography conducted at presentation. Surgical techniques were compared between the two groups. Results Patients who were aware of surgical treatment had significantly lower initial ADB and MDACC stages (P<0.05) and more frequently underwent physiologic procedures than excisional procedures (P=0.003). Conclusions If patients are actively educated regarding surgical treatment of lymphedema, physiologic procedures may be performed during the early stages of UEL.

Lymphatic vessel mapping in the upper extremities of a healthy Korean population

Lee, Yun-Whan,Lee, Soo-Hyun,You, Hi-Jin,Jung, Jae-A,Yoon, Eul-Sik,Kim, Deok-Woo Korean Society of Plastic and Reconstructive Surge 2018 Archives of Plastic Surgery Vol.45 No.2

Background Intraoperative indocyanine green (ICG) lymphography can effectively detect functioning lymph vessels in edematous limbs. However, it is sometimes difficult to clearly identify their course in later-stage edematous limbs. For this reason, many surgeons rely on experience when they decide where to make the skin incision to locate the lymphatic vessels. The purpose of this study was to elucidate lymphatic vessel flow patterns in healthy upper extremities in a Korean population and to use these findings as a reference for lymphedema treatment. Methods ICG fluorescence lymphography was performed by injecting 1 mL of ICG into the second web space of the hand. After 4 hours, fluorescence images of lymphatic vessels were obtained with a near-infrared camera, and the lymphatic vessels were marked. Three landmarks were designated: the radial styloid process, the mid-portion of the cubital fossa, and the lower border of the deltopectoral groove. A straight line connecting the points was drawn, and the distance between the connected lines and the marked lymphatic vessels was measured at 8 points. Results There were 30 healthy upper extremities (15 right and 15 left). The average course of the main lymph vessels passed $26.0{\pm}11.6mm$ dorsal to the styloid process, $5.7{\pm}40.7mm$ medial to the mid-cubital fossa, and $31.3{\pm}26.1mm$ medial to the three-quarters point of the upper landmark line. Conclusions The main functioning lymphatic vessel follows the course of the cephalic vein at the forearm level, crosses the mid-cubital point, and travels medially toward the mid-axilla.