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      A Review of Indocyanine Green Fluorescent Imaging in Surgery

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          Abstract

          The purpose of this paper is to give an overview of the recent surgical intraoperational applications of indocyanine green fluorescence imaging methods, the basics of the technology, and instrumentation used. Well over 200 papers describing this technique in clinical setting are reviewed. In addition to the surgical applications, other recent medical applications of ICG are briefly examined.

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          The clinical use of indocyanine green as a near-infrared fluorescent contrast agent for image-guided oncologic surgery.

          Optical imaging using near-infrared (NIR) fluorescence provides new prospects for general and oncologic surgery. ICG is currently utilised in NIR fluorescence cancer-related surgery for three indications: sentinel lymph node (SLN) mapping, intraoperative identification of solid tumours, and angiography during reconstructive surgery. Therefore, understanding its advantages and limitations is of significant importance. Although non-targeted and non-conjugatable, ICG appears to be laying the foundation for more widespread use of NIR fluorescence-guided surgery. Copyright © 2011 Wiley-Liss, Inc.
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            Real-time identification of liver cancers by using indocyanine green fluorescent imaging.

            We have often encountered difficulties in identifying small liver cancers during surgery. Fluorescent imaging using indocyanine green (ICG) has the potential to detect liver cancers through the visualization of the disordered biliary excretion of ICG in cancer tissues and noncancerous liver tissues compressed by the tumor. ICG had been intravenously injected for a routine liver function test in 37 patients with hepatocellular carcinoma (HCC) and 12 patients with metastasis of colorectal carcinoma (CRC) before liver resection. Surgical specimens were investigated using a near-infrared light camera system. Among the 49 subjects, the 26 patients examined during the latter period of the study (20 with HCC and 6 with metastasis) underwent ICG-fluorescent imaging of the liver surfaces before resection. ICG-fluorescent imaging identified all of the microscopically confirmed HCCs (n = 63) and CRC metastases (n = 28) in surgical specimens. Among the 63 HCCs, 8 tumors (13%, including 5 early HCCs) were not evident grossly unless observed by ICG-fluorescent imaging. Five false-positive nodules (4 large regenerative nodules and 1 bile duct proliferation) were identified among the fluorescent lesions. Well-differentiated HCCs appeared as uniformly fluorescing lesions with higher lesion-to-liver contrast than that of moderately or poorly differentiated HCCs (162.6 [71.1-218.2] per pixel vs 67.7 [-6.3-211.2] per pixel, P < .001), while CRC metastases were delineated as rim-fluorescing lesions. Fluorescent microscopy confirmed that fluorescence originated in the cytoplasm and pseudoglands of HCC cells and in the noncancerous liver parenchyma surrounding metastases. ICG-fluorescent imaging before resection identified 21 of the 41 HCCs (51%) and all of the 16 metastases that were examined. ICG-fluorescent imaging enables the highly sensitive identification of small and grossly unidentifiable liver cancers in real time, enhancing the accuracy of liver resection and operative staging. (c) 2009 American Cancer Society.
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              New technologies for human cancer imaging.

              Despite technical advances in many areas of diagnostic radiology, the detection and imaging of human cancer remains poor. A meaningful impact on cancer screening, staging, and treatment is unlikely to occur until the tumor-to-background ratio improves by three to four orders of magnitude (ie, 10(3)- to 10(4)-fold), which in turn will require proportional improvements in sensitivity and contrast agent targeting. This review analyzes the physics and chemistry of cancer imaging and highlights the fundamental principles underlying the detection of malignant cells within a background of normal cells. The use of various contrast agents and radiotracers for cancer imaging is reviewed, as are the current limitations of ultrasound, x-ray imaging, magnetic resonance imaging (MRI), single-photon emission computed tomography, positron emission tomography (PET), and optical imaging. Innovative technologies are emerging that hold great promise for patients, such as positron emission mammography of the breast and spectroscopy-enhanced colonoscopy for cancer screening, hyperpolarization MRI and time-of-flight PET for staging, and ion beam-induced PET scanning and near-infrared fluorescence-guided surgery for cancer treatment. This review explores these emerging technologies and considers their potential impact on clinical care. Finally, those cancers that are currently difficult to image and quantify, such as ovarian cancer and acute leukemia, are discussed.
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                Author and article information

                Journal
                Int J Biomed Imaging
                Int J Biomed Imaging
                IJBI
                International Journal of Biomedical Imaging
                Hindawi Publishing Corporation
                1687-4188
                1687-4196
                2012
                22 April 2012
                : 2012
                : 940585
                Affiliations
                1Department of Electrical Engineering and Energy Technology, University of Vaasa, Vaasa, Finland
                2Department of Hand Surgery, Tampere University Hospital, 33680 Tampere, Finland
                3Department of Neurosurgery, Helsinki University Central Hospital (HUCH), Helsinki, Finland
                4Department of Cardiosurgery, Helsinki University Central Hospital, Helsinki, Finland
                5Department of Equine and Small Animal Medicine, University of Helsinki, Helsinki, Finland
                6Saratov State University, Saratov 410012, Russia
                7Institute of Precise Mechanics and Control, Russian Academy of Sciences, Saratov 410028, Russia
                8University of Oulu, Oulu, Finland
                9Clinic of Angiosurgery, Helsinki University Central Hospital, Helsinki, Finland
                Author notes

                Academic Editor: Guowei Wei

                Article
                10.1155/2012/940585
                3346977
                22577366
                9e543ba4-8719-438a-8747-5940446274a1
                Copyright © 2012 Jarmo T. Alander et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 1 September 2011
                : 1 February 2012
                Categories
                Review Article

                Radiology & Imaging
                Radiology & Imaging

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