Indocyanine Green Cannot Predict Malignancy in Partial Nephrectomy: Histopathologic Correlation with Fluorescence Pattern in 100 Patients

ArticleinJournal of endourology / Endourological Society 27(7) · February 2013with8 Reads
DOI: 10.1089/end.2012.0756 · Source: PubMed
Introduction: Indocyanine green (ICG) is emerging as a potential adjunct to robot-assisted partial nephrectomy by its ability to aid in the real-time identification of renal vasculature, renal masses, and the renal mass-parenchymal margin. The fluorescence patterns of renal masses have not been adequately described according to histology, and it remains unknown if fluorescence pattern can reliably predict histology or malignancy. We therefore describe the ICG fluorescence pattern of our first 100 robot-assisted partial nephrectomies (RAPN) and correlate with histology. Materials and methods: We reviewed our prospective RAPN database and categorized fluorescence pattern as isofluorescent (same as surrounding parenchyma), hypofluorescent (less than surrounding parenchyma, but with uptake), or afluorescent (no visible uptake of dye). Descriptive statistics were applied. Results: All 14 cystic lesions were afluorescent and comprised 9 malignant and 5 benign masses. Eighty-six lesions were solid, of which 3 were isofluorescent including two clear-cell and one translocation tumor. The remaining 83 solid lesions were hypofluorescent and included 65 malignant and 18 benign lesions. Clear-cell was the most common histology of which 96% were hypofluorescent and 4% isofluorescent. In determining malignant vs benign lesions, hypofluorescence had a positive predictive value of 87%, negative predictive value of 52%, sensitivity of 84%, and specificity of 57%. Conclusions: A three-grade classification of renal mass ICG fluorescence pattern is correlated with some histologic findings but unable to reliably predict malignant vs benign lesions.
    • "These studies show that ICG-assisted vascular identification specific to the tumor may allow either off clamp or selective clamping of the arterial supply, demonstrating short-term post-operative improvement in renal function. In an effort to assess whether ICG can predict malignancy in RPN patients, Manny et al. [13] reviewed the ICG fluorescence pattern in 100 patients undergoing RPN and correlated these findings to final tumor histology. The tumor fluorescent schema used included isofluorescent (the same amount as surrounding parenchyma), hypofluorescent (less than surrounding parenchyma, but with uptake), or afluorescent (no visible uptake of dye). "
    [Show abstract] [Hide abstract] ABSTRACT: The surgical management of small renal masses has continued to evolve, particularly with the advent of the robotic partial nephrectomy (RPN). Recent studies at high volume institutions utilizing near infrared imaging with indocyanine green (ICG) fluorescent dye to delineate renal tumor anatomy has generated interest among robotic surgeons for improving warm ischemia times and positive margin rate for RPN. To date, early studies suggest positive margin rate using ICG is comparable to traditional RPN, however this technology improves visualization of the renal vasculature allowing selective clamping or zero ischemia. The precise combination of fluorescent compound, dose, and optimal tumor anatomy for ICG RPN has yet to be elucidated.
    Full-text · Article · Jul 2014
  • [Show abstract] [Hide abstract] ABSTRACT: Purpose: Near infrared fluorescence allows the differentiation of tumors and normal parenchyma during robotic partial nephrectomy. This may facilitate tumor excision but requires proper dosing of indocyanine green. Under dosing causes inadequate fluorescence of peritumor parenchyma. Overdosing causes tumors to fluoresce inappropriately. Currently there are no described dosing strategies to our knowledge to optimize near infrared fluorescence and reported doses vary widely. We devised a dosing strategy and assessed the reliability of near infrared fluorescence for differential fluorescence. Materials and methods: Robotic partial nephrectomy with near infrared fluorescence was performed for 79 tumors. Dosing strategy involved at minimum 2 indocyanine green doses, including the test dose and the calibrated dose before resection. The test dose was deliberately low to avoid confounding over-fluorescence. The second dose was calibrated depending on the extent of differential fluorescence achieved with the test doses. Intraoperative assessment of tumor fluorescence was recorded before pathological assessment. Results: Mean tumor size was 3.5 cm (range 1.1 to 9.8) with a mean R.E.N.A.L. score of 8 (range 4 to 12). Median indocyanine green test dose and re-dose before clamping were 1.25 mg (range 0.625 to 2.5) and 1.875 mg (range 0.625 to 5), respectively. Differential fluorescence was achieved in 65 of 79 tumors (82%) that did not fluoresce. After 3 exclusions for the inability to assess fluorescence or indeterminate histology, 60 of 76 tumors were renal cell carcinoma. Of 60 renal cell carcinomas 55 behaved appropriately and did not fluoresce (92%). Overall 65 of 76 tumors behaved appropriately for an 86% agreement between histology and near infrared fluorescence behavior. Conclusions: With our dosing regimen near infrared fluorescence was highly reliable in achieving differential fluorescence of kidney and renal cell carcinomas. Standardized dosing is needed before deciding whether near infrared fluorescence improves robotic partial nephrectomy outcomes and additional studies may further improve reliability.
    Article · Apr 2013
  • [Show abstract] [Hide abstract] ABSTRACT: To present the initial clinical experience with robot-assisted partial adrenalectomy using indocyanine green dye with near-infrared fluorescence (ICG-NIRF) imaging. Three consecutive patients with solitary adrenal masses with worrisome features were referred for treatment. The preoperative workup included dedicated axial imaging and adrenal function studies. All patients underwent purely robotic partial adrenalectomy with ICG-NIRF guidance. Relevant steps of the technique included a transperitoneal approach, gross identification of the adrenal gland, administration of 5 mg intravenous ICG, and finally, mass resection guided by ICG-NIRF and white light visualization in an effort to completely excise the mass while sparing uninvolved adrenal tissue. Robotic partial adrenalectomy was successfully performed with negative margins in all patients. All masses were hypofluorescent relative to normal adrenal tissue with ICG-NIRF and included a pheochromocytoma, lipoadenoma, and follicular lymphoid hyperplasia. Robotic partial adrenalectomy with intraoperative ICG-NIRF is safe and feasible. The addition of ICG-NIRF may help mass identification, excision, and promote the use adrenal-sparing surgery.
    Article · Jul 2013
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