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Principles and data for fluorecence imaging in cancer staging
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Near infrared light is routinely used in human oncology with autofluorescence, photodynamisation, and Indocyanine green. Autofluorescence is used to determine tumor margins. Photodynamisation has been mostly used for bladder and brain tumors detection and resection. 5 aminolevulinic acid (5ALA)is injected IV and NIR light is used to highlight the tumor that is accumulating the 5 aminolevulinic acids. 5ALA is broken down in a protoporphyrin that will become fluorescent under NIR. Near infrared light is used to induce fluorescence of indocyanine green (Figure 1).
Indocyanine green and near infrared light (NIR) have been used in human surgery to identify sentinel lymph nodes during resection of solid tumors. Indocyanine green after being injected in a tumor will diffuse in the lymphatic system and collect in the sentinel lymph node. Therefore the combination of the indocyanine green injected in the tumor and near infrared light allows the identification of sentinel lymph nodes (Figure 2).
This technology has been used in human patients for many years with very limited adverse effects. The main utilization has been for tissue perfusion after GI anasmotomosis and wound management, evaluation of bile duct anatomy during laparoscopy, and identification of sentinel lymph nodes. Different fluorescent markers can be used. However, Indocyane green is the marker of choice mainly because of its extremely low toxicity and its cost. Indocyanine green has been used in clinical patients to study blood flow in different organs after intravenous injection. Again the toxicity of indocyanine green has been very limited. The routine dosage is 0.1 to 0.5 mg/kg on indocyanine green in the tumor or IV and the toxic dose is 5 mg/kg/day IV.
This technology is now available to us. The NIR can be used during open surgery but also during laparoscopy or thoracoscopy.
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