Yonsei Med J.  2010 May;51(3):407-413. 10.3349/ymj.2010.51.3.407.

Preoperative Imaging of Sentinel Lymph Nodes in Gastric Cancer Using CT Lymphography

Affiliations
  • 1Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.
  • 2Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
  • 3Department of Radiology, Yonsei University College of Medicine, Seoul, Korea. jslim1@yuhs.ac
  • 4Insititute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea.
  • 5Brain Korea 21 Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea.

Abstract

PURPOSE
Preoperative identification of the sentinel lymph node (SLN) in gastric cancer (GC) patients may have great advantages for the minimally invasive treatment. This study was performed to evaluate the possibility of preoperative SLN detection using CT lymphography.
MATERIALS AND METHODS
Fourteen patients with early GC were enrolled. CT images were obtained before and at 1, 3, and 5 minutes after endoscopic submucosal peritumoral injection of 2 mL iopamidol. For patients with clearly identified SLNs, to make comparisons with the CT lymphography results, intraoperative SLN detection was performed using subserosally injected Indocyanine green (ICG) lymphography and ex vivo ICG and iopamidol lymphography using mammography was also performed.
RESULTS
CT lymphography clearly visualized draining lymphatics and SLNs in 4 (28.6%) out of 14 patients. All clearly visualized SLNs (one to three SLNs per patient) under preoperative imaging were detected in the same location by intraoperative ICG lymphography and ex vivo ICG and iopamidol lymphography using mammography. All preoperative SLN detections were observed with the primary tumors in the lower third of the stomach.
CONCLUSION
Although our study demonstrated a SLN detection rate of less than 30%, CT lymphography with radio-contrast showed potential as a method of preoperative SLN detection for GC.

Keyword

Gastric cancer; sentinel lymph nodes; preoperative imaging; lymphography

MeSH Terms

Adult
Aged
Female
Humans
Iopamidol/diagnostic use
Lymph Nodes/pathology/*radiography
Lymphography/*methods
Male
Middle Aged
Models, Biological
Preoperative Care
Sentinel Lymph Node Biopsy
Stomach Neoplasms/pathology/*radiography
Tomography, X-Ray Computed/*methods

Figure

  • Fig. 1 CT lymphography. (A) Upper endoscopy for peritumoral injection of iopamidol at the CT scanning table. (B) Successful preitumoral submucosal injection of iopamidol showing swelling of the lesion. (C) Axial CT image after iopamidol injection (long arrow: SLN, Short arrow: draining lymphatic). SLN, Sentinel lymph node.

  • Fig. 2 Intraoperative and ex vivo SLN detection. (A) Three-dimensional volume rendering image of CT lymphography. Contrast enhanced SLN (long arrow) and draining lymphatics (short arrow) well-visualized at station #6. Dense iopamidol uptake at the peritumoral area is seen (arrow head) with a related beam hardening artifact. (B) Intraoperative SLN navigation with surserosal injection of ICG. A green colored SLN (long arrow) and a draining lymphatic (short arrow) are well identified with subserosal site injection (arrow head). (C) Ex vivo sentinel lymph node navigation using subserosal injection of ICG. SLN with ICG uptake (long arrow) and peritumoral area (arrow head) are stained green. (D) X-ray mammography. Magnified view shows the draining lymphatic vessel (short arrow) by peritumoral iopamidol injection (arrowhead). SLN, Short arrow: draining lymphatic). SLN, Sentinel lymph node; ICG, Indoc yanine green.

  • Fig. 3 Results of CT lymphography with iopamidol according to the location of the primary lesion. Success refers to the primary lesion that SLNs were seen on CT lymphography. Failure refers to the primary lesion that SLNs were not seen on CT lymphography. *indicates primary lesions with ulcers. SLN, Sentinel lymph node.


Reference

1. Noh SH, Hyung WJ, Cheong JH. Minimally invasive treatment for gastric cancer: approaches and selection process. J Surg Oncol. 2005. 90:188–193.
Article
2. Kitano S, Shiraishi N. Minimally invasive surgery for gastric tumors. Surg Clin North Am. 2005. 85:151–164.
3. Sano T, Katai H, Sasako M, Maruyama K. The management of early gastric cancer. Surg Oncol. 2000. 9:17–22.
Article
4. Hiki N, Kaminishi M. Pylorus-preserving gastrectomy in gastric cancer surgery--open and laparoscopic approaches. Langenbecks Arch Surg. 2005. 390:442–447.
Article
5. Otani Y, Furukawa T, Kitagawa Y, Yoshida M, Saikawa Y, Kubota T, et al. New method of laparoscopy-assisted function-preserving surgery for early gastric cancer: vagus-sparing segmental gastrectomy under sentinel node navigation. J Am Coll Surg. 2004. 198:1026–1031.
Article
6. Ishikawa K, Arita T, Ninomiya S, Bandoh T, Shiraishi N, Kitano S. Outcome of segmental gastrectomy versus distal gastrectomy for early gastric cancer. World J Surg. 2007. 31:2204–2207.
7. Park do J, Lee HJ, Jung HC, Kim WH, Lee KU, Yang HK. Clinical outcome of pylorus-preserving gastrectomy in gastric cancer in comparison with conventional distal gastrectomy with Billroth I anastomosis. World J Surg. 2008. 32:1029–1036.
Article
8. Katai H, Sano T, Fukagawa T, Shinohara H, Sasako M. Prospective study of proximal gastrectomy for early gastric cancer in the upper third of the stomach. Br J Surg. 2003. 90:850–853.
Article
9. Kitano S, Shiraishi N, Fujii K, Yasuda K, Inomata M, Adachi Y. A randomized controlled trial comparing open vs laparoscopy-assisted distal gastrectomy for the treatment of early gastric cancer: an interim report. Surgery. 2002. 131:1 Suppl. S306–S311.
Article
10. Kim YW, Baik YH, Yun YH, Nam BH, Kim DH, Choi IJ, et al. Improved quality of life outcomes after laparoscopy-assisted distal gastrectomy for early gastric cancer: results of a prospective randomized clinical trial. Ann Surg. 2008. 248:721–727.
Article
11. Kunisaki C, Shimada H, Nomura M, Akiyama H. Appropriate lymph node dissection for early gastric cancer based on lymph node metastases. Surgery. 2001. 129:153–157.
12. Hyung WJ, Cheong JH, Kim J, Chen J, Choi SH, Noh SH. Application of minimally invasive treatment for early gastric cancer. J Surg Oncol. 2004. 85:181–185.
13. Aikou T, Higashi H, Natsugoe S, Hokita S, Baba M, Tako S. Can sentinel node navigation surgery reduce the extent of lymph node dissection in gastric cancer? Ann Surg Oncol. 2001. 8:9 Suppl. 90S–93S.
14. Kitagawa Y, Fujii H, Mukai M, Kubo A, Kitajima M. Current status and future prospects of sentinel node navigational surgery for gastrointestinal cancers. Ann Surg Oncol. 2004. 11:3 Suppl. 242S–244S.
15. Bembenek A, Gretschel S, Schlag PM. Sentinel lymph node biopsy for gastrointestinal cancers. J Surg Oncol. 2007. 96:342–352.
16. Suga K, Yuan Y, Ueda K, Kaneda Y, Kawakami Y, Zaki M, et al. Computed tomography lymphography with intrapulmonary injection of iopamidol for sentinel lymph node localization. Invest Radiol. 2004. 39:313–324.
Article
17. Japanese Gastric Cancer Association. Japanese Classification of Gastric Carcinoma - 2nd English Edition. Gastric Cancer. 1998. 1:10–24.
18. Kim MC, Kim HH, Jung GJ, Lee JH, Choi SR, Kang DY, et al. Lymphatic mapping and sentinel node biopsy using 99mTc tin colloid in gastric cancer. Ann Surg. 2004. 239:383–387.
Article
19. Lee JH, Ryu KW, Kim CG, Kim SK, Lee JS, Kook MC, et al. Sentinel node biopsy using dye and isotope double tracers in early gastric cancer. Ann Surg Oncol. 2006. 13:1168–1174.
Article
20. Lee JH, Ryu KW, Kook MC, Lee JY, Kim CG, Choi IJ, et al. Feasibility of laparoscopic sentinel basin dissection for limited resection in early gastric cancer. J Surg Oncol. 2008. 98:331–335.
Article
21. Hayashi H, Tangoku A, Suga K, Shimizu K, Ueda K, Yoshino S, et al. CT lymphography-navigated sentinel lymph node biopsy in patients with superficial esophageal cancer. Surgery. 2006. 139:224–235.
22. Suga K, Shimizu K, Kawakami Y, Tangoku A, Zaki M, Matsunaga N, et al. Lymphatic drainage from esophagogastric tract: feasibility of endoscopic CT lymphography for direct visualization of pathways. Radiology. 2005. 237:952–960.
Article
23. Tangoku A, Yamamoto S, Suga K, Ueda K, Nagashima Y, Hida M, et al. Sentinel lymph node biopsy using computed tomography-lymphography in patients with breast cancer. Surgery. 2004. 135:258–265.
24. Amersi F, Morton DL. The role of sentinel lymph node biopsy in the management of melanoma. Adv Surg. 2007. 41:241–256.
Article
25. Maruyama K, Sasako M, Kinoshita T, Sano T, Katai H. Can sentinel node biopsy indicate rational extent of lymphadenectomy in gastric cancer surgery? Fundamental and new information on lymph-node dissection. Langenbecks Arch Surg. 1999. 384:149–157.
26. Soetikno R, Kaltenbach T, Yeh R, Gotoda T. Endoscopic mucosal resection for early cancers of the upper gastrointestinal tract. J Clin Oncol. 2005. 23:4490–4498.
Article
27. Abe N, Mori T, Takeuchi H, Yoshida T, Ohki A, Ueki H, et al. Laparoscopic lymph node dissection after endoscopic submucosal dissection: a novel and minimally invasive approach to treating early-stage gastric cancer. Am J Surg. 2005. 190:496–503.
Article
28. Wisner ER, Katzberg RW, Griffey SM, Drake CM, Haley PJ, Vessey AR. Indirect computed tomography lymphography using iodinated nanoparticles: time and dose response in normal canine lymph nodes. Acad Radiol. 1995. 2:985–993.
Article
29. Ryu KW, Lee JH, Kim HS, Kim YW, Choi IJ, Bae JM. Prediction of lymph nodes metastasis by sentinel node biopsy in gastric cancer. Eur J Surg Oncol. 2003. 29:895–899.
Article
30. Nakahara T, Kitagawa Y, Yakeuchi H, Fujii H, Suzuki T, Mukai M, et al. Preoperative lymphoscintigraphy for detection of sentinel lymph node in patients with gastric cancer--initial experience. Ann Surg Oncol. 2008. 15:1447–1453.
Article
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