Abstract：
OBJECTIVE: The effectiveness of sentinel lymph node (SLN) biopsy has been validated by 2 prospective trials, GROINS VI and GOG 173 [1,2]. According to the European Society of Gynaecological Oncology guideline in patients with unifocal tumors with a diameter of <4 cm, in the absence of suspected inguinal lymph nodes, SLN biopsy is recommended. The use of a radioactive tracer is mandatory [2]. Using indocyanine green (ICG) increases the detection of the vulvar sentinel node from 89.7% to 100% [3]. This video aimed to share our experience about the feasibility, safety, and usefulness of the surgical identification of SLN in vulvar cancer using real-time fluorescent ICG with 99m-technetium (Tc) nanocolloid.
METHODS: A stepwise demonstration of the technique with narrated video footage.
METHODS: Tertiary level hospital \"IRCCS Istituto Nazionale dei Tumori,\" Milano, Italy.
METHODS: A 50-year-old woman was diagnosed as having vulvar cancer on biopsy of 1.5 cm size vulvar lesion under the clitoris area and referred to our operative unit. F-18 fluorodeoxyglucose positron emission tomography computed tomography showed no extravulvar disease. The patient was scheduled for radical vulvectomy and bilateral inguinal SLN biopsy. (Video still 1) In this video, the surgical procedure involved double location of SLN, first with the 99m-Tc detector followed by ICG identification. We used an ICG dilution of 2.5 mg/mL in sterile water and injected 4 mL around the tumor 5 to 10 minutes before visualization. First a handheld gamma probe used to identify the location of the SLNs with 99m-Tc. The fluorescence imaging was performed by the quest imaging system (FLUOPTICS, Middenmeer, The Netherlands) that combines autofluorescence and fluorescence perfusion imaging (Video Still 2). Second, we performed the SLN biopsy using a dark mode procedure to identify the IGC tracer (Video Still 3). The fluorescence imaging enables the detection of these markers through some millimeters of tissue, and ICG has the advantage that is visible through the skin [4].
CONCLUSIONS: This video shows a successful combined 99m-Tc and ICG fluorescence image-guided bilateral SLN biopsy in a vulvar cancer patient using a near-infrared optical imaging system (FLUOPTICS). ICG for SLN mapping seems to be safe in women with vulvar cancer with a satisfactory detection rate. This may help in retaining surgical radicality while minimizing operative complications.
METHODS: A stepwise demonstration of the technique with narrated video footage.
METHODS: Tertiary level hospital \"IRCCS Istituto Nazionale dei Tumori,\" Milano, Italy.
METHODS: A 50-year-old woman was diagnosed as having vulvar cancer on biopsy of 1.5 cm size vulvar lesion under the clitoris area and referred to our operative unit. F-18 fluorodeoxyglucose positron emission tomography computed tomography showed no extravulvar disease. The patient was scheduled for radical vulvectomy and bilateral inguinal SLN biopsy. (Video still 1) In this video, the surgical procedure involved double location of SLN, first with the 99m-Tc detector followed by ICG identification. We used an ICG dilution of 2.5 mg/mL in sterile water and injected 4 mL around the tumor 5 to 10 minutes before visualization. First a handheld gamma probe used to identify the location of the SLNs with 99m-Tc. The fluorescence imaging was performed by the quest imaging system (FLUOPTICS, Middenmeer, The Netherlands) that combines autofluorescence and fluorescence perfusion imaging (Video Still 2). Second, we performed the SLN biopsy using a dark mode procedure to identify the IGC tracer (Video Still 3). The fluorescence imaging enables the detection of these markers through some millimeters of tissue, and ICG has the advantage that is visible through the skin [4].
CONCLUSIONS: This video shows a successful combined 99m-Tc and ICG fluorescence image-guided bilateral SLN biopsy in a vulvar cancer patient using a near-infrared optical imaging system (FLUOPTICS). ICG for SLN mapping seems to be safe in women with vulvar cancer with a satisfactory detection rate. This may help in retaining surgical radicality while minimizing operative complications.
摘要：
目的：前哨淋巴结（SLN）活检的有效性已通过两项前瞻性试验得到验证，第六组和GOG1731-2。根据ESGO指南，对于直径<4cm的单灶性肿瘤患者，在没有可疑腹股沟淋巴结的情况下，建议进行SLN活检。必须使用放射性示踪剂。2使用吲哚菁绿（ICG）将外阴前哨淋巴结的检出量从89.7增加到100％3。这个视频的目的是分享我们关于可行性的经验，使用99m-tech纳米胶体的实时荧光吲哚菁绿在外阴癌中手术鉴定SLN的安全性和有效性。
方法：用叙述的视频片段逐步演示该技术。
方法：三级医院\“IRCCSIstitutoNazionaledeiTumori\”，米兰,意大利。
方法：一名50岁女性在阴蒂区域下1.5cm大小的外阴病灶活检时被诊断为外阴癌，并转诊到我们的手术单位。F-18氟脱氧葡萄糖正电子发射断层扫描计算机断层扫描（PET）未显示外阴疾病。患者计划进行根治性外阴切除术和双侧腹股沟前哨淋巴结活检（SLN）。在此视频中，外科手术涉及SLN的双重位置，首先使用99mtech探测器，然后进行ICG识别。我们在无菌水中使用2.5mg/mL的ICG稀释液，并在可视化前5-10分钟在肿瘤周围注射4mL。首先使用手持式伽马探针来识别具有99m-tech的SLN的位置。荧光成像由任务成像系统(FLUOPTICS©，Middenmeer,荷兰）结合了自发荧光和荧光灌注成像。第二,我们使用黑暗情绪程序进行了SLN活检,以鉴定IGC示踪剂.荧光成像使得能够通过几毫米的组织检测这些标记物,并且ICG具有通过皮肤可见的优点4。
结论：该视频显示了使用近红外（NIR）光学成像系统（FLUOPTICS©）在外阴癌患者中成功的99m-tech和ICG荧光图像引导的双侧SLN活检。用于SLN作图的ICG在患有外阴癌的女性中似乎是安全的，具有令人满意的检出率。这可能有助于保持手术的积极性，同时最大程度地减少手术并发症。
方法：用叙述的视频片段逐步演示该技术。
方法：三级医院\“IRCCSIstitutoNazionaledeiTumori\”，米兰,意大利。
方法：一名50岁女性在阴蒂区域下1.5cm大小的外阴病灶活检时被诊断为外阴癌，并转诊到我们的手术单位。F-18氟脱氧葡萄糖正电子发射断层扫描计算机断层扫描（PET）未显示外阴疾病。患者计划进行根治性外阴切除术和双侧腹股沟前哨淋巴结活检（SLN）。在此视频中，外科手术涉及SLN的双重位置，首先使用99mtech探测器，然后进行ICG识别。我们在无菌水中使用2.5mg/mL的ICG稀释液，并在可视化前5-10分钟在肿瘤周围注射4mL。首先使用手持式伽马探针来识别具有99m-tech的SLN的位置。荧光成像由任务成像系统(FLUOPTICS©，Middenmeer,荷兰）结合了自发荧光和荧光灌注成像。第二,我们使用黑暗情绪程序进行了SLN活检,以鉴定IGC示踪剂.荧光成像使得能够通过几毫米的组织检测这些标记物,并且ICG具有通过皮肤可见的优点4。
结论：该视频显示了使用近红外（NIR）光学成像系统（FLUOPTICS©）在外阴癌患者中成功的99m-tech和ICG荧光图像引导的双侧SLN活检。用于SLN作图的ICG在患有外阴癌的女性中似乎是安全的，具有令人满意的检出率。这可能有助于保持手术的积极性，同时最大程度地减少手术并发症。
