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We present images from a 71-year-old prostate cancer patient who underwent a robot-assisted radical prostatectomy and extended pelvic lymph node dissection (ePLND) complemented with experimental sentinel node (SN) resection [1]. Additional intraoperative lymphangiography was performed to highlight lymphatic structures that should ideally be spared. This concept is part of a prospective trial wherein we aim to use the presented approach to reduce the 20% complication rate associated with ePLND procedures [2].
For SN identification, the bimodal/hybrid tracer ICG-99mTc-nanoscan (218 MBq in 2 ml) was used, which has replaced the well-known ICG-99mTc-nanocolloid [3]. Preoperative (lymphoscintigraphy and SPECT/CT) and intraoperative SN imaging (gamma and fluorescence imaging) were performed after intraprostatic tracer injection. Previous work indicates that the hybrid tracer and the visible-dye fluorescein both stain lymphatic structures, but with different kinetics [4]. It is also known that multi-color fluorescence imaging can be used to differentiate between lymphatics of different organs [5, 6]. With this first-in-human implementation (see Scheme), we underscore that lymphatic ducts draining the left upper leg can be made visible using fluorescein (80 mg in 4 ml; yellow, dotted triangle) and that this drainage can be distinguished from the SNs visualized with ICG-99mTc-nanoscan (blue, dotted circle). With that, the former can act as “red-flag” to highlight tissues that should be spared, while the latter provides a ”green-flag” for tissues that should be resected. As such, the presented three-way multiplexing approach may help preserve the oncological benefit of ePLND + SN [3], while providing a handle to reduce complication rates.
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This work was financially supported by an NWO-TTW-VICI (TTW BGT16141) grant.
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All authors contributed to the study conceptualization and design. Material preparation was performed by ACB, FvL, and TB. Data collection and analysis were performed by ACB, TB, MNvO, LS, and HGvdP. All authors read and approved the final manuscript.
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All procedures performed in this study were in accordance with the ethical standards of the local ethics committee of The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital (NL78523.031.21, N21SPL, NCT05120973) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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The presented data were part of the study registered under NL78523.031.21/NCT05120973.
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Berrens, AC., van Oosterom, M.N., Slof, L.J. et al. Three-way multiplexing in prostate cancer patients — combining a bimodal sentinel node tracer with multicolor fluorescence imaging. Eur J Nucl Med Mol Imaging 50, 1262–1263 (2023). https://doi.org/10.1007/s00259-022-06034-x
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DOI: https://doi.org/10.1007/s00259-022-06034-x