SLN mapping in cervical cancer
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1 Gynecoogic Cancer InterGroup Cervix Cancer Research Network SLN mapping in cervica cancer Dr Marie Pante Gynecoogic Oncoogist L Hôte-Dieu de Québec Lava University Cervix Cancer Education Symposium, January 2017, Mexico
2 LN status Part of the surgica staging of a soid tumors One of the most important prognostic factor Predictor of outcome Need for adjuvant treatment
3 LN dissection Pevic LND Para-aortic LND
4 LN dissection Morbidity of the LN dissection Nerve / vesses damage Lymphoedema, ymphocee Increased OR time Obese / edery patient popuation
5 SLN mapping Logica / inteigent compromise Between no nodes at a and compete LND
6 No fase negative resuts were observed in the 104 patients (76.5%) in whom SLN were identified biateray No fase-negative
7
8 Node negative BPLND: 1078 BSLNB : 110
9 NCCN guideines
10 NCCN guideines
11 NCCN guideines
12 SLN mapping Tracers Bue dye Tc-99 ICG
13 Bue Dye?
14 Bue Dye
15 Bue Dye
16 Sentine node mapping
17 Sentine node mapping Right Ureter Uterine Artery
18 Sentine node mapping
19 Bue Dye Cheap and easy to inject Rapid transit to nodes Leakage Bood ess dissection Less reiabe in obese patients Aergic reaction (1-2%)
20 Technetium - 99 Intracervica injection 2 cc, 3 and 9 o cock - In nucear medicine - The morning of surgery - Lymphoscintigram min ater
21 Technetium - 99
22 Technetium - 99 Semi-quantitative method (count) Ex-vivo confirmation Preop LSG pictures Probaby the god standard method But
23 Technetium - 99 Patients concerns vs radioactive agent Avaiabiity of Tc-99 Coordinating injection times in nucear medicine suite vs OR sate Wait time for the LSG Need for gamma probe and gamma counter Costy
24 IndoCyanine Green (ICG) Deveoped by KODAK (1950) Protein-bound (abumin) Hepato-biiary excretion Laser iumination (803 nm)
25 Fuorescence imaging (ICG) Variety of appications Vascuar anatomy Anastomosis integrity Pastic reconstructive surgery Wound care Acute care surgery/trauma injuries Oncoogy SLN mapping
26 ICG preparation
27 ICG injection Intraoperative cervica injection 2cc, at 3 and 9 o cock 25-gauge spina neede
28 ICG SLN mapping
29 Endoscopy Unit
30 Endoscopy Unit 0 or 30 o scope pinpoint button activates NIR mode
31 ICG SLN mapping Norma mode Spy mode NIR mode
32 ICG SLN mapping Maintains norma tissue coor Can switch mode as often as needed
33 ICG SLN mapping
34 ICG SLN mapping ICG does not tend to eak out Detection rate much better in obese patients
35 ICG SLN mapping Detection rate much better in boody surgica fied
36 Lymphatic drainage Pevic nodes Paraaortic nodes Pent and Friedman, 1971
37
38 ICG SLN ocaisation
39
40 ICG SLN ocaisation
41 ICG SLN mapping: pitfas Lymph nodes or swoen ymphatics?? Smear effect
42 Lymph nodes vs. swoen ymphatics
43 Lymph nodes vs. swoen ymphatics SPY mode - NIR mode
44 Smear effect
45 ICG Coor Segmented Fuorescence
46 ICG Coor Segmented Fuorescence
47 ICG Coor Segmented Fuorescence
48 CSF mode
49 ICG SLN mapping Different appications of the endoscopic pinpoint system Laparoscopy Prior to robotic surgery Combined with robotic surgery Laparotomy
50 Pinpoint combined with robotic sx
51 Pinpoint combined with robotic sx
52 Pinpoint and aparotomy
53 Pinpoint and aparotomy
54 IndoCyanine Green (ICG) Safety Aergy to iodides May contain < 5% iodides Risk of anaphyactic reaction VERY ow
55 VIDEOs
56 Left side
57 Right side
58 Left side - boody
59 SLN mapping ICG currenty not FDA approved for interstitia injection Lymphatic mapping
60 FILM Study A Randomized, Prospective, Open Labe, Muticenter Study Assessing the Safety and Utiity of PINPOINT Near Infrared Fuorescence Imaging in the Identification of Lymph Nodes in Subjects with Uterine and Cervica Maignancies who are Undergoing Lymph Node Mapping Bue Dye ICG
61 The FILM study Study design randomized prospective, open abe, muticenter study a non-inferiority within-patient comparison study to determine the effectiveness of ICG in the identification of LNs compared to LNs identified with Bue dye Approximatey 150 subjects
62 FILM study
63 FILM study
64 J Minim Invasive Gyneco Feb 1;23(2):
65 N=513 (pooed data) Detection rate: 96% Sensitivity: 87% Specificity: 100% Eur J Surg Onco Ju;40(7):843-9
66 ICG - Pinpoint system Advantages Exceent safety profie Maintains norma coored anatomy Switch on/off NIR mode easiy CSF mode very usefu System is versatie Laparoscopic, robotic and open surgery
67 Concusion SLN mapping using endoscopic NIR fuorescence imaging with ICG Simpe, easy to earn High overa / biatera detection rate Cervica injection works we Most practica approach for arge scae wordwide impementation
68
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