Fluorescence-Image Guided Paraaortic Sentinel Lymph Node Sampling in Early Ovarian Cancer

Study Objective

To describe stepwise techniques for fluorescence image-guided paraaortic sentinel lymph node (SLN) sampling in early ovarian cancer.

Design

Single port laparoscopic ovarian lymphatic flow mapping technique with narrated video.

Setting

Tertiary referral hospital.

Patients or Participants

A 48-year-old female with an 8 cm sized right ovarian cystic tumor with internal solid nodules was transferred to Yonsei Cancer Center. Preoperative serum CA 125 and CA19-9 levels were 23.9 U/mL and 24.7 U/mL, respectively. The right ovarian mass was suspected to be a malignant ovarian epithelial tumor on pelvic MRI and PET-CT.

Interventions

Single port laparoscopy was performed. Right salpingo-oophorectomy with total laparoscopic hysterectomy was performed. The solid tumor component of right ovarian mass was submitted for frozen section and the pathologic finding was ovarian nonepithelial tumor (such as germ cell or sex cord/stromal cell origin). As ovarian malignancy could not be excluded in this patient, subsequent single port laparoscopic surgical staging with SLN sampling was planned. Through the single port, diluted indocyanine green (ICG, 1.25 mg/mL) was directly injected into the right infundibulopelvic (IP) ligament stump. Fluorescent lymphatic channels of right IP ligament were visualized using endoscopic fluorescence imaging system.

Measurements and Main Results

After 7 minutes, the ICG drained from the right IP ligament to the right aortocaval lymph nodes. The paraaortic lymphatic drainage of the ovary appeared to branch along the ovarian vessels. After 15 minutes, the ICG drained to inframesenteric interaortocaval lymph nodes (L3M) and supramesenteric interaortocaval lymph node (L4M). There were no detected fluorescent lymph nodes between the right IP ligament and the right paracaval area. In this patient, the right ovarian SLNs were detected at the L3M and L4M. The patient was diagnosed with stage 1A clear cell ovarian cancer in permanent section pathology.

Conclusion

This stepwise technique of paraaortic SLN sampling in early ovarian cancer allows further utilization of this surgical method.