Preoperative computerized tomography-guided blue dye localiz
Case 1:

A 49-year-old woman diagnosed with ileocecal valve adenocarcinoma in October 2015 underwent right hemicolectomy with extended lymphadenectomy and subsequent chemotherapy. Pathologic analysis revealed American Joint Committee on Cancer (AJCC) 7th stage pT4aN2bM0. After 17 months of regular follow-up, CT imaging showed newly developed right internal iliac lymphadenopathy with a short axis diameter measuring up to 13 mm. Positron emission tomography (PET) revealed 18F-fluorodeoxyglucose uptake and nodal metastasis was strongly indicated. Considering that it would be difficult to identify and access the target lesion during laparoscopic surgery due to the overlying right psoas muscle, preoperative CT-guided blue dye localization was performed.

After local anesthesia and percutaneous puncture with a 22-gauge percutaneous transhepatic cholangiography needle (Hakko, Japan) via an anterior approach, 0.5 mL of pure PATENT BLUE V (Guerbet, France) was injected into the target node. However, the surgeon could not recognize the target node via the laparoscopic ports in the supra-umbilical, infra-umbilical, and left lower abdomen regions because the dye marker was mostly hidden underneath the psoas muscle. After placing an additional port site in the right groin area, a well-defined node with dye marker was identified. The size, shape and adjacent anatomical landmarks of the node corresponded to our measurement in preoperative CT. There was no other suspicious lesion in the intraoperative field. The target node was resected uneventfully. The pathology result showed metastatic adenocarcinoma, representing stage IV status. After 5 days of hospitalization, the patient was referred to another hospital for further chemotherapy.

Case 2:

A 55-year-old woman diagnosed with descending colon adenocarcinoma in January 2017 underwent left hemicolectomy with extended lymphadenectomy and subsequent chemotherapy. Pathologic analysis revealed AJCC 7th stage pT4aN1aM0. After 8 months of regular follow-up, the carcinoembryonic antigen level increased from 0.5 ng/mL to 5.9 ng/mL, and CT scan demonstrated suspicious local recurrence and 3 sites of peritoneal tumor implants with surrounding adhesion. The subsequent PET scan also suggested the impression. Believing that it would be difficult to identify the smallest tumor implant during laparoscopic surgery, preoperative CT-guided blue dye localization with 0.3 mL of pure PATENT BLUE V was performed. The target lesion was clearly identified with the dye marker during the surgery.

All tumor implants corresponded to preoperative CT in size and location were removed, along with the local recurrence. The pathology results all revealed adenocarcinoma. Her disease remained stable during the first 5 months of chemotherapy with folinic acid-fluorouracil-irinotecan (FOLFIRI) regimen. Small new growing implants were found in CT at 8-month follow-up. The treatment plan was changed to chemotherapy with FOLFIRI regimen plus targeted therapy with bevacizumab. Nevertheless, the treatment effect was limited and the latest CT showed disease progression in January 2019.

Source: Medicine: June 2019 - Volume 98 - Issue 25 - p e16159

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