Long-term follow-up after near-infrared fluorescence-guided resection of colorectal liver metastases: A retrospective multicenter analysis

Abstract

BACKGROUND Several studies demonstrated that intraoperative near-infrared fluorescence (NIRF) imaging using indocyanine green (ICG) identifies (sub)capsular colorectal liver metastases (CRLM) missed by other techniques. It is unclear if this results in any survival benefit. This study evaluates long-term follow-up after NIRF-guided resection of CRLM using ICG. METHODS First, patients undergoing resection of CRLM with or without NIRF imaging were analyzed retrospectively. Perioperative details, liver-specific recurrence-free interval and overall survival were compared. Second, the prognosis of patients in whom additional metastases were identified solely by NIRF was studied. RESULTS Eighty-six patients underwent resection with NIRF imaging and 87 without. In significantly more patients of the NIRF imaging cohort additional metastases were identified during surgery (25% vs. 13%, p=0.04). Tumors identified solely by NIRF imaging were significantly smaller compared to additional metastases identified also by inspection, palpation or intraoperative ultrasound (3.2 ± 1.8 mm vs. 7.4 ± 2.6 mm, p<0.001). Liver-specific recurrence-free survival at 4 years was 47% with NIRF imaging and 39% without (hazard ratio at multivariate analysis 0.73, 95%CI 0.42–1.28, p=0.28). Overall survival at 4 years was 62% and 59%, respectively (p=0.79). No liver recurrences occurred within 3 years follow-up in 52% of patients in whom additional metastases were resected based on only NIRF imaging. CONCLUSIONS This study suggests that NIRF imaging identifies significantly more and smaller tumors during resection of CRLM, preventing recurrences in a subset of patients. Given its safety profile and low expense, routine use can be considered until tumor targeting fluorescent tracers are clinically available. Keywords: .

A practical guide for the use of indocyanine green and methylene blue in fluorescence‐guided abdominal surgery

“…Furthermore, ICG accumulates into well‐differentiated hepatocellular carcinoma (HCC), resulting in complete fluorescence signal rather than a dark center. In a retrospective cohort study in our institute it was shown that NIR fluorescence imaging of colorectal liver metastases was able to identify more and smaller tumors, resulting in reduced recurrences in a subset of patients . Twenty‐one studies evaluated the use of NIR fluorescence imaging with ICG for liver tumor detection, both primary tumors as metastatic spread of colorectal, uveal, breast, and pancreatic cancer …”

“…Dashed arrow: a preoperative suspected lesion could be recognised by its characterizing fluorescent rim. Reprinted by permission from Elsevier: European Journal of Surgical Oncology © 2017…”

Fluorescence‐guided surgery for liver tumors

“…Since the initial reports in 2009, more than 700 hepatectomy cases with the use of intraoperative fluorescence imaging for identification of liver tumors have been reported, with fairly high sensitivity (70% to 100% on liver surfaces or resected specimens; Table ) . For further clinical applications of the present technique, we need to establish a protocol of ICG administration and fluorescence imaging, although it seems to be difficult to optimize the dose and timing of ICG injection for liver tumor imaging in the centers where ICG should also be administered for preoperative liver function estimation.…”

Precise right hemihepatectomy for the treatment of hepatocellular carcinoma guided by fusion ICG fluorescence imaging

“…Time Region Case Male Lap Surgical Mean size(cm) Kaibori [11] 2011 Japan 52/50 76/26 0/0 5.3/5.0 Handgraaf [12] 2017 Netherlands 67/87 38/56 0/0 7.4/3.2 Nishino [6] 2017 Japan 23/29 19/17 0/0 -Aoki [13] 2018 Japan 25/72 15/44 25/72 2.9/2.22 Chen [14] 2019 China 12/12 9/10 12/12 5.03/4.62 Zhou [15] 2019 China 21/21 15/15 21/21 3.1/3.2 Zhang [16] 2019 China 13/11 8/9 13/11 -Yao [17] 2019 China 28/27 23/22 0/0 6/8 Xiao [18] 2019 Six studies reported perioperative bleeding, and three of the studies did not provide specific data, so the final study included seven studies and 516 patients. There was significant heterogeneity between the groups (I 2 =88%), so a random effects model was used.…”