NPR: She Survived Breast Cancer, But Says A Treatment Side Effect ‘Almost Killed’ Her
“After Virginia Harrod was diagnosed with stage 3 breast cancer in 2014, she had a double mastectomy. Surgeons also removed 16 lymph nodes from under her armpit and the area around her breast, to see how far the cancer had spread and to determine what further treatment might be needed. Then she underwent radiation therapy.
As it turned out, the removal of those lymph nodes, along with the radiation, put Harrod at risk for another disorder — lymphedema, a painful and debilitating swelling of the soft tissue of the arms or legs, and/or an increased vulnerability to infection.”
Neighmond, Patti. “She Survived Breast Cancer, But Says A Treatment Side Effect ‘Almost Killed’ Her.” 90.1 FM WABE, 19 Feb. 2018, www.wabe.org/she-survived-breast-cancer-but-says-a-treatment-side-effect-almost-killed-her/.
Intraoperative Parathyroid Localization with Near-Infrared Fluorescence Imaging Using Indocyanine Green during Total Parathyroidectomy for Secondary Hyperparathyroidism
The detection of all glands during total parathyroidectomy (TPTX) in secondary hyperparathyroidism (SHPT) patients is often difficult due to their variability in number and location. The objective of this study was to evaluate the feasibility of near-infrared fluorescence (NIRF) imaging using indocyanine green (ICG) for intraoperative parathyroid gland (PTG) localization in SHPT patients. Twenty-nine patients with SHPT were divided into two groups with or without intraoperative NIRF imaging. ICG was administered in patients undergoing intraoperative imaging, and the fluorescence of PTGs was assessed. Clinical and histopathologic variables were analyzed to determine factors associated with ICG uptake. Comparisons between NIRF and preoperative imaging, as well as differences between groups with or without NIRF imaging, were carried out to evaluate the efficacy of this technique. Most PTGs could be clearly identified, including one ectopic gland. The sensitivity of NIRF imaging is 91.1% in contrast to 81.82% for ultrasonography (US), 62.34% for 99mTc-MIBI and 85.71% for computed tomography (CT). In addition, intraoperative NIRF imaging can reduce the operation time and improve the complete resection rate compared with the group not using it. Intraoperative NIRF imaging using ICG during TPTX is technically feasible and reliable for assisting surgeons in detecting and confirming PTGs.
Cui, Le, et al. “Intraoperative Parathyroid Localization with Near-Infrared Fluorescence Imaging Using Indocyanine Green during Total Parathyroidectomy for Secondary Hyperparathyroidism.” Scientific Reports, vol. 7, no. 1, 2017, doi:10.1038/s41598-017-08347-6.
Parathyroid gland angiography with indocyanine green fluorescence to predict parathyroid function after thyroid surgery
Postoperative hypocalcaemia following total thyroidectomy is common, and may have a significant effect on quality of life. Transient hypocalcaemia is frequent and has been described in 15–30 per cent of patients, depending on the technical difficulty of the procedure and expertise of the surgeon. Permanent hypocalcaemia, defined as hypocalcaemia present for more than 6 months after thyroidectomy, has been reported in 1–3 per cent of patients1. Some authors have described rates of up to 10 per cent1, 2, which suggests a possible underestimation of the true prevalence of permanent hypocalcaemia after thyroid surgery.
The main cause of hypocalcaemia after total thyroidectomy is hypoparathyroidism due to intraoperative damage to the parathyroid glands by trauma, inadvertent parathyroid gland removal or devascularization. The extent of damage to the parathyroid glands is difficult to predict during surgery. It has been generally accepted that half of one normal parathyroid gland can produce sufficient parathyroid hormone (PTH)2, 3. To avoid postoperative hypocalcaemia, parathyroid autotransplantation can be performed, although the results have been controversial4, 5.
Accurate prediction of post‐thyroidectomy hypocalcaemia has the potential to influence management strategies and could possibly reduce the incidence of hypoparathyroidism if the precise mechanisms of this condition were to be elucidated. Among the newer techniques2, 6, 7, intraoperative parathyroid gland angiography during thyroidectomy might be used to evaluate parathyroid gland perfusion and function.
Initially used in the detection of macular degeneration8, the technique of angiography using indocyanine green (ICG) has been used to identify sentinel lymph nodes9, to determine the extent of oncological resections10 and to study hepatic function11. Recent studies have also demonstrated its usefulness in evaluating the vascular blood flow of intestinal anastomoses12.
The aim of this pilot study was to evaluate the use of ICG angiography in predicting parathyroid gland function and the absence of postoperative hypoparathyroidism in patients in whom good vascularization of at least one parathyroid gland could be demonstrated by the technique.
Fortuny, J. Vidal, et al. “Parathyroid gland angiography with indocyanine green fluorescence to predict parathyroid function after thyroid surgery.” British Journal of Surgery, vol. 103, no. 5, Nov. 2016, pp. 537–543., doi:10.1002/bjs.10101.
A reappraisal of vascular anatomy of the parathyroid gland based on fluorescence techniques
Identification of the parathyroid glands (PGs) during thyroid surgery may prevent their inadvertent surgical removal and prevent postoperative hypoparathyroidism. However, identification of the PGs does not guarantee their function, and their vascular supply needs to be preserved as well. The recent introduction of intraoperative indocyanine green (ICG) fluorescent angiography of the PGs during thyroid surgery allows for the appraisal of the vascular anatomy and evaluation of PG function. The use of this tool could lead to a significant reduction in the rate of postoperative hypoparathyroidism, as it allows surgeons to adapt their surgical technique for the preservation of the PGs. ICG fluorescent angiography is currently the only available real-time tool to assess the vascular blood supply of each individual PG intraoperatively and can thus assist surgeons in their decision-making. Herein, we review the relevant literature.
Sadowski, Samira Mercedes, et al. “A reappraisal of vascular anatomy of the parathyroid gland based on fluorescence techniques.” Gland Surgery, vol. 6, no. S1, 2017, doi:10.21037/gs.2017.07.10.
Role of Indocyanine Green in Fluorescence Imaging with Near-Infrared Light to Identify Sentinel Lymph Nodes, Lymphatic Vessels and Pathways Prior to Surgery – A Critical Evaluation of Options
Modern surgical strategies aim to reduce trauma by using functional imaging to improve surgical outcomes. This reviews considers and evaluates the importance of the fluorescent dye indocyanine green (ICG) to visualize lymph nodes, lymphatic pathways and vessels and tissue borders in an interdisciplinary setting. The work is based on a selective search of the literature in PubMed, Scopus, and Google Scholar and the authorsʼ own clinical experience. Because of its simple, radiation-free and uncomplicated application, ICG has become an important clinical indicator in recent years. In oncologic surgery ICG is used extensively to identify sentinel lymph nodes with promising results. In some studies, the detection rates with ICG have been better than the rates obtained with established procedures. When ICG is used for visualization and the quantification of tissue perfusion, it can lead to fewer cases of anastomotic insufficiency or transplant necrosis. The use of ICG for the imaging of organ borders, flap plasty borders and postoperative vascularization has also been scientifically evaluated. Combining the easily applied ICG dye with technical options for intraoperative and interventional visualization has the potential to create new functional imaging procedures which, in future, could expand or even replace existing established surgical techniques, particularly the techniques used for sentinel lymph node and anastomosis imaging.
Using ICG in medicine is simple, radiation-free and safe, and ICG has been shown to be an excellent marker after both interstitial and intravascular administration. The detection rates of ICG-dyed sentinel lymph nodes are at least as good as those reported for established techniques and sometimes even superior. Moreover, using ICG to detect sentinel lymph nodes is less expensive and logistically simpler than protocols which use technetium colloid ( 99mTc) the day before surgery, when it is administered by nuclear medicine specialists in accordance with radiation protection regulations 19 , 20 .
Hackethal, Andreas, et al. “Role of Indocyanine Green in Fluorescence Imaging with Near-Infrared Light to Identify Sentinel Lymph Nodes, Lymphatic Vessels and Pathways Prior to Surgery – A Critical Evaluation of Options.” Geburtshilfe und Frauenheilkunde, vol. 78, no. 01, 2018, pp. 54–62., doi:10.1055/s-0043-123937.
Validity of Sentinel Lymph Node Biopsy by ICG Fluorescence for Early Head and Neck Cancer
This study was designed to assess the validity of sentinel lymph node (SLN) biopsy using either the combination of indocyanine green (ICG) fluorescence and radioisotope (RI) or ICG-alone in SLN mapping for early head and neck cancer patients. Patients and Methods: Nineteen patients received SLN biopsy with the following method. Thirteen patients received SLN biopsy with only RI, 2 patients with only ICG and 4 patients with the combination of ICG and RI. Detection time for each method of SLN biopsy was measured to evaluate the validity of SLN with the combination of ICG and RI. Results: A total of 41 SLNs were identified by RI or ICG. All SLNs identified by ICG could be localized intraoperatively. The number of SLNs identified by the combination of ICG and RI was greater than that of SLNs identified by RI-alone. One of the patients who underwent SLN biopsy by RI-alone was diagnosed with a metastatic lymph node one year later, then underwent neck dissection. Mean detection time for SLN biopsy with ICG or with the combination of ICG and RI tended to be shorter than that of RI-alone. Conclusion: SLN biopsy with the combination of ICG and RI enabled us to identify SLNs more easily and rapidly than by using RI alone.
Yamauchi, Kohichi, et al. “Diagnostic evaluation of sentinel lymph node biopsy in early head and neck squamous cell carcinoma: A meta-Analysis.” Head & Neck, vol. 37, no. 1, 2014, pp. 127–133., doi:10.1002/hed.23526.
Use of Indocyanine Green for Sentinel Lymph Node Biopsy: Case Series and Methods Comparison
Sentinel lymph node biopsy is indicated for patients with biopsy-proven thickness melanoma greater than 1.0 mm. Use of lymphoscintigraphy along with vital blue dyes is the gold standard for identifying sentinel lymph nodes intraoperatively. Indocyanine green (ICG) has recently been used as a method of identifying sentinel lymph nodes. We herein describe a case series of patients who have successfully undergone ICG-assisted sentinel lymph node biopsy for melanoma. We compare 2 imaging systems that are used for ICG-assisted sentinel lymph node biopsy.
Mcgregor, Andrew, et al. “Use of Indocyanine Green for Sentinel Lymph Node Biopsy.” Plastic and Reconstructive Surgery – Global Open, vol. 5, no. 11, 2017, doi:10.1097/gox.0000000000001566.