Update Course 2023 - Updates in the use of ICG

Well, good afternoon from Cleveland. I'm Tom Isch and I'll be the moderator today and we'll, uh, introduce our guest of honor, Seth Goldstein, associate professor of surgery, uh, formerly assistant professor, as the slides say, um, who is our, our one of our resident experts on endocyanin green and fluorescence, uh, guided surgery. So, Seth, tell us about this new technique. OK, thanks. Uh, you know, and I think, I think this will maybe throw a little bit of a curveball at you all because, I mean, my understanding was that this distinguished course had already taken on ICG in some of its better known uses, namely organ. Angiography and expatic biliary tree identification. So I was asked to take a little bit of an approach for how, how, how would you use it for pediatric surgical oncology. And so I'm bringing to you an experience that I developed with our director of surgical oncology, Tim Lutz and also uh an ICG aficionado. I'm gonna try to. Show you a little bit of our experience and some tips and tricks. Let me get you to the. First pole. OK, does anyone do sentinel node biopsies? It comes up, it comes up. 10 year old boy, right gluteal biopsy confirmed alveolar rhabdo. You've been asked for sentinel node biopsy at the time of port placement. This is pretty much standard of care. It, it dictates to some extent the drug regimen. It'll, it'll indicate radiation to the lymph node basin if it's positive. And so my question for you all is, what is your preferred primary marker for sentinel node identification? Blue dye that could be the methylene blue or the lymphozurin radio tracer, that's the, that's the radio labeled technetium or ICG preferred primary marker. And while people are getting their thoughts in on this, and let me see a show of hands, who are the surgical oncologists in the room here at the live event? We have, uh, maybe 4. OK, 5. Perfect. OK then, victims, well, what do you, what do you think? We don't, we're buying an ICG machine right now and I've seen the technique, but I'm, I'm, I'm not sure about the, the results. Sure, you like using the technicium? Yeah, yeah, it has, I think it has pretty high yield of finding the, the correct lymph node. What, what's your sense, Doctor Petrosian? Give that man a microphone. I think the machine is pretty expensive, so it takes a buy-in from oncologists and the surgeons to purchase the machine. Second of all, it takes, at least in our institution, it takes a group to coordinate the tracer injection. In the same day operations, so it takes a lot of Has to be involved in one procedure that's not that common. And, but the tracer worked great. I've used it and it's, it's good. I mean, I, I think that's fair, right? Both those things are true. It works, but isn't it hard for surgeons to cede control of where is it injected and how and when and the extra time and energy and expense, and you can probably see where I'm going with some of this. Can we show the poll results? OK, here we go. Hey, that's a. That's an interesting, even, even thirds. I'm actually surprised to see so much ICG because what I want to tell you. Is that pediatric surgeons can, uh, I'm not yet to the point of saying should, but can consider use of ICG as an adjunct to the sentinel node identification, so. Yeah, it's for the um. For the adult breast and cervical cancers where sentinel nodes are very frequent and and already standard of care, this, this interest in bringing back the, not just the control to the surgeons in terms of, well, what if there's a biopsy scar in the way or is this something that you want injected intratumoral or in 4 quadrants around it, dermal, subdermal. You can either spend a lot of time and energy training your radiologists and fretting about it, or you can take charge because the ICG technique is real-time in the operating room. And so, of course, the main point is to find the node that is your first sentinel drainage, and that's ever so important, but ICG can do that. So here's that boy. Here's the gluteal, um, upper left panel, head to the left, feet to the right in the operating room with. With equipment, you all that you either either have or are about to have standard in all your laparoscopic towers, OK? So, not, not something that you've gotta get a nuclear medicine license to use. And so in the cyanin injection into the tumor. And then look at that right below it, the, the, um, with, with the lights off contrast you can, you can just watch over the course of 45, 60, 75 seconds, um, the ICG head to the sentinel node and then this, this right hand panel is OK, we've seen that we prep and drape the area. You're holding the camera right there. You've made a little skin incision. Heat map leads you right to the sentinel node. So, Seth, just, uh, technically speaking, you know, if it's in the tower, is it, are you using this, you know, laparoscopic camera? Are you using a handheld that's a little bit friendlier to an open case? Yeah, I mean this one is with a system that has an open field camera, but it is not unusual to, to take a short laparoscope and, and use it in the same way. It, it depends what vendor you're using and what equipment you have, um. You've, you've got it. You've got it or are going to have it soon. So Todd, we're gonna turn to you. Any prohibitions about mentioning specific, uh, manufacturers and so forth. Uh, this, this is with the, with the Stryker 1688 Sy Fi system. I mean, the Stort's Rubina, as I was saying, it only comes in the, in the endoscopic camera form and so you hook it up to the short camera and Tina can, you can call Tina, she'll teach you how to do that at a moment's notice and do essentially practically the same thing. We're at a junction where we are using the ICG as the primary localizer of the sentinel node. And still confirming with the technician. OK, so we took out this node, make sure it had the counts because we're still in our experience to be able to confidently say that yes, we are, it is guiding us right to the promised land, but I'm pretty sure that's where we're headed based on the experience in breast and adult GYN cervical cancer. Yeah, right here. What, what about the depth because the fluorescence only, it's emitted like 1 centimeter and you're gonna talk about finding meta metastasis later but it looks like this would be a very superficial node. Sounds like a good time to get into the biology of it. Well, yeah, I mean, OK, so it's a, it's a, it's a, it's a fair point. Now you've got a limitation of the near infrared fluorescence for about 1 centimeter or two through soft tissue. By the way, that exists with the radio tracer, yes, I mean, to, to, to some degree. And so, yeah, it's some combination of, of maybe in some thicker tissue cases needing to know where to have your incision. I don't know if it'll let me go back to the groin, but that groin where we'd already planned the incision and, and you can see it, but so often are those skin and soft tissue basins are sufficiently superficial, axillary inguinal that you're gonna be able to see them pretty easily in children anyway, but it's funny that you, you suggest that. You know, ICG might limit your visualization cause what about the stuff you can't do with technicium like laparoscopy? OK, so this is parasticular rhabdo with ICG being injected directly into the spermatic cord. So, you know, over 10 and you've got to do a full ipsilateral clearance, but under 10, you might just want a sentinel node. So look at this with the, with, you know, your standard laparoscope and ICG capabilities, you're, you're watching the, watching those lymphatic channels come right up the inguinal chain and then if I can get it to advance once more, OK, so these are, these are images, um. The, the pure white lights in the upper left, so, um, uh, umbo trochar view of the iliac and ureter and so you'd be hard pressed that you could do the full clearance, you'd be hard pressed to know where the sentinel node is, but you turn on that fluorescence. You know you've injected it into the, into the lymphatic chain. So I guess I would argue that all things considered, you're more likely than not gonna find things throughout the body with ICG than with the radio label spend 10 seconds from people in the audience around the world asking what ICG is. I would love to do so and that's an omission to assume that everyone understands in cyanin green, so. Into cyanin green was this neat dye that uh that the, the post World War II Kodak company found because it's got really forget the green on the screen. I mean, to your eye it is green and it's sort of a pleasant green you could develop photos with it, but what's so remarkable about ICG is it's potent fluorescence in the near infrared. So now you think outside the visible and, and you look at that image in the black, so that's just a. A bulb that is essentially night vision and then a detector, so uh. Night vision heat vision detector, it fluoresces in the infrared and so it's, it's been FDA approved since the 1960s. It's a safe, harmless fluorescent contrast. So, uh, you know, there, there's no need for concern for on or off label. It's essentially approved for all things adult and pediatric and. It, it falls into the bucket that, that, that I call augmenting the surgeon's visual field so there's what you can see with your own eyes and then there's everything ICG can show you if you understand the capabilities and limitations of the very safe fluorescent contrast. Is that a, is that an adequate 30 seconds? We got a, we, we got a 5 minute warning. I'm doing fine if you all are. OK, next scenario, 16 year old girl, unresectable hepatocellular carcinoma. Wants a liver transplant, needs clearance of the lung meds. OK? We've got some oncologists shaking their heads, this has come up before. There's a question coming. At the time of your thoracotomy, what's your most sensitive and specific method of localization of these two numerous to count hepatic metastases. You can talk about it for 2 minutes, but we cannot show the results for 2 minutes. No sweat, yeah. Or ask people here, so, and you, you know, this is, this is a trick of understanding ICG which is exclusively biliary cleared. So it's hard when you're in and around the liver, but what if you've got liver tissue in another organ space, then instead of giving it when you want it, you give it the day before, it's the only thing left in the chest by the time you get there the next day, Mira. Absolutely, I think for hepatoblastoma, you, we've not seen it be successful for Wilms, have you? All the other sarcomas in the world require a much higher dosage and aren't as specific. There's a future where we have disease-specific agents, but right now the only thing you can leverage is the, is the, the hepatic clearance of ICG. I, I love it too. I use it too, but I was gonna ask about, I trialed it for neuroblastoma just as a concept, uh, to see if it, it didn't work. I wonder if there's a, I did the wrong dose. I'll share with you our cheat sheet, it's a pretty ultra high dose for all I mean, but again I think you're for anything other than hepatic primaries you're hoping for the best until we develop this catalog of future fluorophores, an active source of of research. Any other thoughts about visual tactile or fluorescence because I want to show you some pictures of this. Can we show the poll? Just ever so briefly, I won't leave it up for two minutes. Back to Meir's question for a minute. I, I'm not a surgical oncologist, but I stayed in the Holiday Inn last night. I, I, I did read, you know, Wilms actually in the chest, in the lungs is actually uh avid for ICG, not in the kidney itself, but in the lungs. Maybe we won't get our pole. You can show them. These are folks just flattering me. I, I'm not sure that that, but, but in truth, let, let me come back to my slides and let me show you some things. So at the, at the time of um. At the time of thoracotomies such as these, I mean you can spend the requisite time feeling and looking, and then when you're done, if you've given ICG the day before, you'll find more. And so I think it's just, it's just so provocative when used for the right disease you run out of steam, you've, you've used everything your eyes and hands can find and because of that trick of the kinetics, you will find more spots. This is, you know, data that we will show you in time when we can tell you a little bit more about sensitivity and specificity, but spots like these that we then wedge out are also positive on histology. So I'm gonna ask um for the, for you or anyone, there's indications that you have used this for or if you're wondering if it's used for in the chat because people are starting to write that I think there's a million use cases so it would be great for you to be looking at these and giving the thumbs up, thumbs down if you've tried it before. You want a rapid fire or have me come back to the chat later. We could if that's how you want to end because we have to end. So let's see, we have 2 minutes. So how do you want no problem. I wanna tell you that that injectable ICG is not the only future for fluorescence. Think about pelvic tumors, and my query to you all was going to be how you like to protect the ureter, so. You got to protect the ureter. You wanna do a hard pelvic tumor. Careful scrutiny, that's fine. Cystoscopy and stent placement. Cystoscopy with a lit or an infrared stent. So let me show you a video. I do not wanna run out of time. So a right lower quadrant port looking at at the end of a of a debulking with aortic bifurcation on the screen, right? and how look how the ureter has been kept out of harm's way. And allowed, here's now umbo port looking down into the pelvis, a case that I'm quite sure would have needed to be done open because of the ureterral proximity to the clearly sticky tumor that you can pull off and, and it's just that sense that, OK, that was standard cystoscopy and stent placement, but when the stent is emitting an infrared light that gets picked up by your system and you know that that travels through centimeters of tissue. It, it's clear as day. So it's about augmenting the surgeon's visual field and making things safer and better for us. And real quick, this future is bright. I'm understanding with the more specific, this is pretty non-specific, hits liver tumors, but you're gonna, well, these slides are a new flurofore we are testing that is renally cleared. So what if you could do that without a stent? You just, you know, you give ICG and let it be liver cleared for the expatic biliary tree. If you can give the the the renally cleared floor 4 and do your ureter, do your ureteral identification for any perf dappy or anything you want, just 15 minutes later, as soon as you say. So this is something we're testing. This goes further into research than innovation and isn't practice ready, but it's coming, and I don't know if I've left 15 seconds for rapid fire. You can cut me off. I think if, if someone wants, we can do really quick because we're at end, but uh, I just wanted to mention that. Seth and his colleagues have a paper in the Journal of Pediatric Surgery this month. It's one of the 3 featured articles on the use of fluoresce guided pediatric surgery. Awesome. Thanks for saying that. These are ideas we are trying to share. I think it's the work you're doing is great. The idea of image guided surgery and, and constantly looking. I saw a technology last week of using. Uh, AR and being in the operating room, you can actually see the overlay of the CAT scanner. So I think the fact that you're constantly looking for not just ICG but all of the things available for image guidance is so cool. So, um, I would say if anyone has things, I know I've used it for different things that we can talk about, so I'll text it in here. If anyone else has other things, I'll do the same because in the, in the robot you have the, the function as well. It works, it works great. It's, it's perfect. Anyone else? Thoracic duct leaks. What else? Yeah, I was gonna say, and we've used it extensively in biliary atresia, and I, I, you know, I'm curious if the long-term data, if we can pull some stuff together to see if you do a better plate dissection. For That that's what uh and in Wilms, not, not for the main tumor resection, but for partial nephrectomies, you can actually find out about the vasculature of the kidney much better. This is awesome. And then we most commonly use it with gallbladders and in one case, we've seen an accessory cystic duct that my partners were out of town at the time for, um, called in an adult surgeon to take a look at it too, but with the ICG we could see it fluorescing, see the artery separately, the main cystic duct separately. And so we ended up dissecting gallbladder all the way up. Uh, we could see the The common bile duct, hepatic duct split well separately, see the, the main cystic duct coming down and joining it. And so then we ended up clipping that rather than probably would have just bovied it if hadn't had the, the additional ICG view. We've used it to inject, um, ICG in the ureteral stents for colon cases to use it for parathyroid identification as well. That was awesome. All right, well, thank you. We'll take a quick break and then we'll come back with 2 more sessions.