Intraoperative lymphatic mapping and sentinel lymph node biopsy using radioactive tracer in gastric cancer

doi:10.1016/j.surg.2005.04.014

Surgery

Volume 138, Issue 5, November 2005, Pages 899-904

https://doi.org/10.1016/j.surg.2005.04.014 Get rights and content

Background

Gastric cancer continues to be a significant health problem around the world. Surgical resection with a lymph node dissection remains the only potentially curative treatment with gastric cancer. Determination of the extent of lymph node dissection required on the basis of actual node involvement in patients with gastric cancer is important as less extensive dissection may reduce postoperative morbidity and mortality rates. The current study examines the feasibility and reliability of sentinel lymph node biopsy in gastric cancer.

Methods

A total of 32 patients who underwent gastrectomy with extended lymphadenectomy were enrolled in this study. A total volume of 148 MBq (2 mL) technetium-99m–radiolabeled, filtered sulphur colloid solution was injected into the primary lesion under gastroscopy 2 hours before the operation. Lymph nodes were examined as soon as possible by a hand-held gamma probe during the operation, without significant manipulation of the stomach or greater omentum. A sentinel lymph node (SLN) was defined by a level of radioactivity 10 times higher than the background.

Results

Thirty-one of 32 patients had succesful SLN biopsy, with a success rate of 97%. The sensitivity, specificity, positive predictive value, and negative predictive value of SLN biopsy were 100%, 95%, 90%, and 100%, respectively.

Conclusions

SLN biopsy using gamma probe in gastric cancer is a feasible procedure with high sensitivity and accuracy. This technique may be of a great benefit to surgeons in planning the extend of lymph node dissection in gastric cancer.

Section snippets

Methods

A total of 32 (6 female) patients who underwent gastrectomy with extended lymphadenectomy, including the sampling of paraaortic lymph nodes, at the Department of Surgery, Ankara Numune Teaching and Research Hospital, Ankara, Turkey, from April 1999 to March 2003 were enrolled in this study.

Results

The 32 gastric cancer patients with a median age of 58 years (range, 34-69 years) were included. The clinicopathologic characteristics of patients enrolled in the study are summarized in Table I. There were no unexpected toxicities or complications related to administration of radioactive tracer.

The operations were uneventful in all patients. There was no intraoperative or in-hospital death. Six patients had some minor complications including prolonged abdominal drainage, delayed gastric

Discussion

The rationale for extended lymph node dissection is that it may achieve an R0 resection attributed to clearance of the metastatic lymph nodes and better locoregional tumor control, which should improve patient survival.25, 26, 27 However, the efficacy of lymph node dissection in gastric cancer is still controversial, and is debated between Western groups and Japanese groups. Several Japanese studies25, 28, 29, 30 reported favorable results with extended lymphadenectomy with positive nodes:total

Conclusion

SLN biopsy using a gamma probe in gastric cancer is a feasible procedure with high sensitivity and accuracy. We believe that SLN biopsy can identify lymph node involvement without adding substantially to the time, cost, or morbidity of the primary surgical procedure. This technique may be of benefit to surgeons in planning the extent of lymph node dissection in gastric cancer.

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The mean and median percentages for the sensitivity were 85.4% and 88.9% respectively with a wide range from 45.5% to 100%. Low sensitivity percentages of less than 90% were observed in 13/21 studies.10–12,14,17,20–26 In two of the 13 studies better sensitivity percentage of 90–100% was obtained by using the combination method, 9,24 while one showed a similar result with IREE.18
Gastric cancer is one of the main causes of cancer-related deaths around the world. The prevalence of early gastric cancer (EGC) among all gastric cancers of 45–51% in Japan, but only 7–28% in Western countries. The prevalence of EGC is growing partly because of better diagnostics and screening programmes. Possible treatment options for EGC treatment are expanded by the introduction of endoscopic mucosal resection and endoscopic submucosal dissection Therefore, detailed knowledge about nodal metastatic risk is warranted. We performed a systematic review of the literature concerning studies investigating the role of sentinel lymph node biopsy in EGCr and whether there is enough proof to introduce SLN as a part of treatment for EGC in the Netherlands. Several detection substances (dye or radiocolloid) and injection methods (submucosal or subserosal) are investigated. An overall sensitivity percentage of 85.4% was found. In comparison, high and clinically sufficient percentages were observed for specificity (98.2%), negative predictive value (90.7%) and accuracy (94%). Subgroup analyses showed that the combination of dye and radiocolloid detection substances is the best method for sentinel lymph node detection in early gastric cancer. However, the precise method of sentinel lymph node biopsy in EGC has to be determined further. Large, randomized series should be initiated in Europe to address this issue.
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Therefore, the detection of SN should be a great advantage for many patients with EGC, because the frequency of nodal metastasis is relatively low in EGC. Many feasibility studies have demonstrated promising results with respect to the detection rate and accuracy of SN in gastric cancer.5,12-18 However, there are still some practical problems in the clinical application of SN biopsy in EGC.
We assessed whether a mixture of hyaluronic acid (HA) and dye can facilitate dye-guided sentinel node (SN) mapping in gastric surgery. Although dye-guided, SN-navigated surgery is clinically applied for the treatment of early gastric cancer, there are still some practical problems. Because dyes are carried out from the SN within 20 to 30 minutes, it is sometimes difficult to detect SNs accurately, especially when they are located in a deep area in obese patients.
Patent blue or ferumoxides, superparamagnetic iron nanocolloids, with or without HA, were injected into the gastrointestinal tract of the pig, and the time course of dye transfer through the lymphatic system of the pig mesentery was assessed.
When a mixture of HA and patent blue at a volume ratio of 1:4 was injected into the submucosal layer, the time to stain the SN did not differ from that with patent blue alone; however, HA markedly prolonged the time the blue dye was retained in the SN. Patent blue alone stained the efferent lymphatics of the SN and spread to other lymph nodes within 20 minutes after submucosal injection. At the same time point, in contrast, blue stain was restricted to a part of the SN, and the efferent lymphatics were not stained for 2 hours when patent blue was mixed with HA. When a mixture of HA and ferumoxides was used as the tracer, the ferumoxides were still observed in the mesenteric SN even at 2 days after injection. Iron staining showed that Fe was trapped primarily in cells in the peripheral sinus of the SN, suggesting that the iron nanoparticles were mostly incorporated by phagocytic macrophages in the SN within a few hours.
Our data indicate that a mixture with HA prolongs the stay of a dye tracer in the SN and thus enables easy and accurate detection of the SN. HA may be a useful tool to develop a more sophisticated SN mapping technique.
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Original communicationIntraoperative lymphatic mapping and sentinel lymph node biopsy using radioactive tracer in gastric cancer

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Conclusion

J Am Coll Surg

Surg Clin North Am

Surgery

Am J Surg

Surgery

Prognostic factors for gastric cancer influencing clinical practice

World J Surg

Improving survival in gastric cancer: review of 5-year survival rates in English language publications from 1970

Br J Surg

Gastric cancer: a 25-year review

Br J Surg

Benefits of D2 lymph node dissection for patients with gastric cancer and pN0 and pN1 lymph node metastases

Br J Surg

Potential and futility of sentinel node detection for gastric cancer

Recent Results Cancer Res

Clinicopathological characteristics of stage 1 gastric cancer: comparison of macroscopic and microscopic findings

Hepatogastroenterology

Lymph node metastasis in early gastric cancer: how can surgeons perform limited surgery?

Int Surg

Gastric carcinoma: does lymph node dissection alter survival?

J Am Coll Surg

Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer:preliminary results of the MRC randomized controlled surgical trial

Lancet

Randomized comparison of R1 and R2 gastrectomy for gastric carcinoma

Br J Surg

A prospective randomized trial comparing R1 subtotal gastrectomy with R3 total gastrectomy for antral cancer

Ann Surg

Radio-guided sentinel node detection for gastric cancer

Br J Surg

Role of radiology in the diagnosis and staging of gastric malignancy

Endoscopy

Lymphatic mapping and sentinel node biopsy: is the method applicable to patients with colorectal and gastric cancer?

Eur J Surg

An approach for the treatment of penile carcinoma

Cancer

Lymphatic drainage of skin to a sentinel lymph node in a feline model

Ann Surg

Intraoperative identification of sentinel lymph node in patients with malignant melanoma

Br J Cancer

Original communication
Intraoperative lymphatic mapping and sentinel lymph node biopsy using radioactive tracer in gastric cancer