Karol Polom

Current Trends and Emerging Future of Indocyanine Green Usage in Surgery and Oncology

Ever since Kitai first performed fluorescent navigation of sentinel lymph nodes (SLNs) using indocyanine green (ICG) dye with a charge‐couple device and light emitting diodes, the intraoperative use of near infrared fluorescence has served a critical role in increasing our understanding in various fields of surgical oncology. Here the authors review the emerging role of the ICG fluorophore in the development of our comprehension of the lymphatic system and its use in SLN mapping and biopsy in various cancers. In addition, they introduce the novel role of ICG‐guided video angiography as a new intraoperative method of assessing microvascular circulation. The authors attempt to discuss the promising potential in addition to assessing several challenges and limitations in the context of specific surgical procedures and ICG as a whole. PubMed and Medline literature databases were searched for ICG use in clinical surgical settings. Despite ICGs significant impact in various fields of surgical oncology, ICG is still in its nascent stages, and more in‐depth studies need to be carried out to fully evaluate its potential and limitations. Cancer 2011;.

Breast cancer sentinel lymph node mapping using near infrared guided indocyanine green and indocyanine green–human serum albumin in comparison with gamma emitting radioactive colloid tracer

AIMS Recently, a novel method of using near infrared (NIR) guided indocyanine green (ICG) and ICG conjugated with human serum albumin (ICG:HSA) for sentinel lymph node biopsy (SLNB) of breast cancer patients has shown true potential. The aim of this study was to compare the usefulness of NIR guided ICG and ICG:HSA against the gamma emitting radiocolloid (RC). METHODS A group of 49 consecutive breast cancer patients underwent SLNB using RC. From this group, the first 28 patients were compared against ICG, while the next 21 patients were compared against ICG:HSA. The number of patients with visible fluorescent path was recorded. Furthermore, the number of SLNs detected by fluorophores percutaneously and total number of intraoperative SLNs detected by fluorophores and/or RC was noted. RESULTS NIR guided real time lymphatic flow was observed in 47/49 patients (96%). In all cases except one, SLNs detected by the RC tracer were also detected by their respective fluorophore. Additionally, ICG detected 10 additional SLNs in 8 patients, while 3 additional SLNs were detected by ICG:HSA in 3 patients. Statistical analysis revealed no difference between the number of SLNs detected between ICG versus ICG:HSA and RC versus ICG:HSA. However, a significant statistical difference was observed between RC and ICG (p=0.0117), as well as between the combined NIR guided and RC method (p=0.0033). CONCLUSIONS In conclusion, the use of either ICG or ICG:HSA with RC to obtain SLNB seems to be an effective alternative. Compared to RC alone, the use of ICG:HSA, more so than ICG alone, may provide additional benefits.

Multimodal treatment of gastric cancer in the west: Where are we going?

The incidence of gastric cancer (GC) is decreasing worldwide, especially for intestinal histotype of the distal third of the stomach. On the contrary, proximal location and diffuse Lauren histotype have been reported to be generally stable over time. In the west, no clear improvement in long-term results was observed in clinical and population-based studies. Results of treatment in these neoplasms are strictly dependent on tumor stage. Adequate surgery and extended lymphadenectomy are associated with good long-term outcome in early-stage cancer; however, results are still unsatisfactory for advanced stages (III and IV), for which additional treatments could provide a survival benefit. This implies a tailored approach to GC. The aim of this review was to summarize the main multimodal treatment options in advanced resectable GC. Perioperative or postoperative treatments, including chemotherapy, chemoradiotherapy, targeted therapies, and hyperthermic intraperitoneal chemotherapy have been reviewed, and the main ongoing and completed trials have been analyzed. An original tailored multimodal approach to non-cardia GC has been also proposed.

Surgical management of advanced gastric cancer: An evolving issue

Worldwide, gastric cancer represents the fifth most common cancer and the third leading cause of cancer deaths. Although the overall 5-year survival for resectable disease was more than 70% in Japan due to the implementation of screening programs resulting in detection of disease at earlier stages, in Western countries more than two thirds of gastric cancers are usually diagnosed in advanced stages reporting a 5-year survival rate of only 25.7%. Anyway surgical resection with extended lymph node dissection remains the only curative therapy for non-metastatic advanced gastric cancer, while neoadjuvant and adjuvant chemotherapies can improve the outcomes aimed at the reduction of recurrence and extension of survival. High-quality research and advances in technologies have contributed to well define the oncological outcomes and have stimulated many clinical studies testing multimodality managements in the advanced disease setting. This review article aims to outline and discuss open issues in current surgical management of advanced gastric cancer.

Breast cancer: Actual methods of treatment and future trends.

The recent ten to twenty years have seen a substantial progress in the diagnosis and treatment of breast cancer. A rapid development of various curative options has led to the improvement of treatment outcomes, while paying more and more attention to the aspects of quality of life and cosmetic effect. In our publication, we wish to outline certain trends in the development of modern treatment of breast cancer. Among topics discussed are new forms of molecular diagnostics, new approach to the idea of sentinel node biopsy, as well as new techniques for delivery of medical procedures, the increasing use of nomograms, progress in the techniques of breast conservative treatment, modern approach to occult breast lesions, the increasing use of neoadjuvant treatment and intraoperative radiotherapy.

The role of sentinel node biopsy in ductal carcinoma in situ of the breast

AIM Sentinel node biopsy (SNB) is an accepted alternative to lymphadenectomy in the case of invasive breast carcinoma, although the sentinel nodes role in ductal carcinoma in situ (DCIS) diagnosed on core needle biopsy has not been well defined nevertheless guidelines recommend this procedure. The purpose of this study was to determine the diagnostic value of sentinel nodes in female patients with primary DCIS using core needle stereotactic biopsy. MATERIAL AND METHODS Between the years 2000 and 2005, 261 patients were diagnosed with DCIS by core needle biopsy. In this group, 183 patients underwent SNB to determine lymph node involvement. Those patients with metastases to the sentinel node underwent axillary lymphadenectomy. RESULTS In the group of 183 patients that underwent SNB, 10 patients (5.5%) showed metastases to the sentinel lymph node. Histopathological studies of the primary lesions of these 10 patients revealed invasive ductal carcinoma in 6 cases (3.5%) and 1 case (0.5%) of invasive lobular carcinoma. Only 3 of the patients (1.5%) were given a final diagnosis of DCIS with metastases to sentinel lymph nodes, of which 2 cases were DCIS and 1 case was DCIS with microinvasion. Axillary lymphadenectomy performed on patients with abnormal SNB showed involvement of other axillary lymph nodes in 4 patients. CONCLUSIONS SNB as a diagnostic tool in DCIS remains controversial as the number of cases of axillary lymph node metastases is minuscule. The biggest clinical challenge in this situation is a group of patients with primary diagnosis of DCIS in which invasive components are seen by mammotomic biopsy.

Gastric cancer: Current status of lymph node dissection

D2 procedure has been accepted in Far East as the standard treatment for both early (EGC) and advanced gastric cancer (AGC) for many decades. Recently EGC has been successfully treated with endoscopy by endoscopic mucosal resection or endoscopic submucosal dissection, when restricted or extended Gotodas criteria can be applied and D1+ surgery is offered only to patients not fitted for less invasive treatment. Furthermore, two randomised controlled trials (RCTs) have been demonstrating the non inferiority of minimally invasive technique as compared to standard open surgery for the treatment of early cases and recently the feasibility of adequate D1+ dissection has been demonstrated also for the robot assisted technique. In case of AGC the debate on the extent of nodal dissection has been open for many decades. While D2 gastrectomy was performed as the standard procedure in eastern countries, mostly based on observational and retrospective studies, in the west the Medical Research Council (MRC), Dutch and Italian RCTs have been conducted to show a survival benefit of D2 over D1 with evidence based medicine. Unfortunately both the MRC and the Dutch trials failed to show a survival benefit after the D2 procedure, mostly due to the significant increase of postoperative morbidity and mortality, which was referred to splenopancreatectomy. Only 15 years after the conclusion of its accrual, the Dutch trial could report a significant decrease of recurrence after D2 procedure. Recently the long term survival analysis of the Italian RCT could demonstrate a benefit for patients with positive nodes treated with D2 gastrectomy without splenopancreatectomy. As nowadays also in western countries D2 procedure can be done safely with pancreas preserving technique and without preventive splenectomy, it has been suggested in several national guidelines as the recommended procedure for patients with AGC.

Indocyanine green angiography for evaluation of gastric conduit perfusion during esophagectomy--first experience.

Abstract Background : A complication of esophageal surgery is leakage at the anastomosis site and one of the factors involved in this complication is poor blood flow in the distal portion of the tube. The aim of this study was to evaluate the feasibility of indocyanine green fluorescence imaging as a method of determining the perfusion of the gastric conduit after esophagectomy. Methods : We analysed 15 consecutive patients who underwent transhiatal esophagectomy (THE) due to cancer. All of the patients had reconstruction of the gastrointestinal tract using the gastric conduit. Before performing the anastomosis, the blood flow in the area of the tube was evaluated using intravenous indocyanine green and observing its vascular flow with a camera equipped with an infrared laser. Results : In all cases it was possible to visualize the vascular flow of indocyanine green within the region of the gastric tube. The fluorescence imaging system showed vascular insufficiency of the distal gastric conduit in 4 patients - in all of these patients the anastomosis was performed end-to-side and there was no subsequent leak. Leakage at the anastomosis site was observed in 1 patient (6,66%). The leak was observed in the 9th postoperative day, despite visualization of a good vascular supply of the tube. Conclusions : Indocyanine green fluorescence imaging of gastric tube allows for intraoperative modifications, but it must be noted that the patient’s comorbidities and general health may also increase the risk of anastomosis leakage.

Apatinib: A novel receptor tyrosine kinase inhibitor for the treatment of gastric cancer

Metastatic gastric cancer is a lethal disease characterized by a very short overall survival, underlining a critical need of new therapeutic options. Unfortunately, although several molecular targets have been investigated, only very few recently approved agents, such as trastuzumab in the HER2-positive setting and ramucirumab, led to a clinical improvement in the outcome of metastatic gastric cancer patients. VEGF (vascular endothelial growth factor) is one of the most potent angiogenic factors and is a signalling molecule secreted by many solid tumours. Since high VEGF expression is one of the characteristic features of gastric carcinomas, targeting VEGF is therefore considered as a promising therapeutic strategy for gastric cancer. In the scenario of possible new target therapies with particular regard to angiogenesis, apatinib is a novel receptor tyrosine kinase inhibitor selectively targeting VEGFR-2. It is an orally-bioavailable agent currently being studied in several solid tumour types showing a promising activity in gastric cancer. Due to the recent positive results as a third line of treatment for metastatic gastric cancer patients, apatinib may be an interesting and novel type of targeted treatment for metastatic gastric cancer in several lines of therapy. In this review, we summarize the available data of apatinib, mainly focused on the clinical aspect, in advanced/metastatic gastric cancer.

Meta‐analysis of microsatellite instability in relation to clinicopathological characteristics and overall survival in gastric cancer

Several associations between microsatellite instability (MSI) and other clinicopathological factors have been reported in gastric cancer, but the results have been ambiguous. This systematic review and meta‐analysis investigated the relationship between MSI and overall survival and clinicopathological characteristics of patients with gastric cancer.