1% lymphazurin vs 10% fluorescein for sentinel node mapping in colorectal tumors.

HYPOTHESIS: Ten percent fluorescein may be successfully used as an alternative to 1% Lymphazurin (1% isosulfan blue; US Surgical Corp, North Haven, Conn) in sentinel lymph node (SLN) mapping for the accurate staging of colorectal tumors. DESIGN: Review of prospectively gathered data. SETTING: University-affiliated regional medical center. PATIENTS: Sentinel lymph node mapping was performed in 120 consecutive patients with colorectal malignancies. INTERVENTIONS: The first 1 to 4 blue nodes detected within 5 minutes were designated as Lymphazurin-detected SLNs. The first 1 to 4 fluorescent nodes seen under the Wood light were designated as fluorescein-detected SLNs. Multilevel serial sections for hematoxylin-eosin and immunohistochemistry studies for cytokeratin were performed on all SLNs. MAIN OUTCOME MEASURES: Successful mapping, accuracy, skip metastasis, adverse reactions, occult micrometastases detection, and cost. RESULTS: Mapping was successful using Lymphazurin in 99% of the patients vs 97% of the patients using fluorescein (P =.89). The accuracy of predicting nodal metastases with each tracer was 95.8% vs 93.1%, respectively (P =.82). The skip metastases rate was 4.2% for Lymphazurin vs 6.9% for fluorescein (P =.37). The 5 patients in whom nodal disease was only identified as occult micrometastasis in the SLNs had a total of 5 SLNs, all of which were identified by both tracers. No adverse reactions occurred. The cost for Lymphazurin was $99.00, while the cost for fluorescein was $2.10. CONCLUSIONS: With the exception of cost, there were no statistically significant differences between the 2 dyes. While easy availability and lower cost remain distinct advantages of fluorescein, Lymphazurin remains the gold standard. In patients with known hypersensitivity to Lymphazurin and when availability and cost are an issue, fluorescein may be used effectively for SLN mapping in colorectal tumors.

CXC-chemokine regulation and neutrophil trafficking in hepatic ischemia-reperfusion injury in P-selectin/ICAM-1 deficient mice.

BACKGROUND: Neutrophil adhesion and migration are critical in hepatic ischemia and reperfusion injury (I/R). P-selectin and the intercellular adhesion molecule (ICAM)-1 can mediate neutrophil-endothelial cell interactions, neutrophil migration, and the interactions of neutrophils with hepatocytes in the liver. Despite very strong preclinical data, recent clinical trials failed to show a protective effect of anti-adhesion therapy in reperfusion injury, indicating that the length of injury might be a critical factor in neutrophil infiltration. Therefore, the aim of this study was to assess the role of P-selectin and ICAM-1 in neutrophil infiltration and liver injury during early and late phases of liver I/R. METHODS: Adult male wild-type and P-selectin/ICAM-1-deficient (P/I null) mice underwent 90 minutes of partial liver ischemia followed by various periods of reperfusion (6, 15 h, and a survival study). Liver injury was assessed by plasma level of alanine aminotransferase (ALT) and histopathology. The plasma cytokines, TNF-alpha, IL-6, MIP-2 and KC, were measured by ELISA. RESULTS: Reperfusion caused significant hepatocellular injury in both wild-type and P/I null mice as was determined by plasma ALT levels and liver histopathology. The injury was associated with a marked neutrophil infiltration into the ischemic livers of both wild-type and P/I null mice. Although the levels of ALT and neutrophil infiltration were slightly lower in the P/I null mice compared with the wild-type mice the differences were not statistically significant. The plasma cytokine data of TNF-alpha and IL-6 followed a similar pattern to ALT data, and no significant difference was found between the wild-type and P/I null groups. In contrast, a significant difference in KC and MIP-2 chemokine levels was observed between the wild-type and P/I null mice. Additionally, the survival study showed a trend towards increased survival in the P/I null group. CONCLUSION: While ICAM-1 and P-selectin does not appear to be critical for neutrophil infiltration and I/R injury in the liver, they may regulate CXC-chemokine production. Blockage of these adhesion molecules may improve survival and remote organ injury that often accompanies liver I/R injury, through chemokine regulation.

Comparative analysis of nodal upstaging between colon and rectal cancers by sentinel lymph node mapping: a prospective trial.

PURPOSE: Sentinel lymph node mapping accurately predicts nodal status in > 90 percent of melanoma and breast and colorectal cancers. However, because of anatomic differences, sentinel lymph node mapping of rectal cancers has been considered inaccurate and difficult relative to colon. A prospective study was undertaken to identify differences in sentinel lymph node mapping between patients with colon cancer and those with rectal cancer. METHODS: At operation 1 to 3 ml of 1 percent isosulfan blue dye was injected subserosally around colon cancers. The first to fourth blue-staining nodes seen within ten minutes of injection were marked as sentinel lymph nodes. For cancer of the mid-rectum to low rectum, the dye was injected submucosally via rigid scope and spinal needle. The mesorectum was dissected ex vivo to identify blue nodes nearest the tumor as sentinel lymph nodes. Multilevel microsections of sentinel lymph nodes were stained with hematoxylin and eosin and immunostained for cytokeratin, and standard examination of the entire specimen was performed. RESULTS: There were 407 consecutive patients (336 with colon and 71 rectum). The sentinel lymph nodes were identified in 99.1 percent of colon and 91.5 percent of rectal patients (P < 0.0001). Skip metastases were found in 3.6 percent of colon vs. 2.8 percent of rectal patients (P = 0.16). Occult micrometastases were found in 13.4 percent of colon vs. 7.0 percent of rectal patients (P = 0.24). Except for success rates, no other parameters were statistically different between colon and rectum. Lower success in sentinel lymph node identification in rectal cancer may have been related to neoadjuvant chemoradiation received in all six of the patients with sentinel lymph node mapping failures. CONCLUSION: Despite higher success rates in sentinel lymph node identification for colon patients, sentinel lymph node mapping was highly successful (91.5 percent) in rectal patients. Nodal upstaging, skip metastases, and occult metastases were similar.