Update Course 2023 - Updates in the use of ICG

Sentinel node biopsy in pediatric rhabdomyosarcoma is standard of care and dictates drug regimen and indicates radiation to lymph node basin if positive

ICG can be used as an adjunct to sentinel node identification in pediatric surgical oncology

ICG technique allows real-time intraoperative control of injection location (intratumoral vs. four quadrants, dermal vs. subdermal) by surgeons rather than radiologists

ICG fluorescence visualization occurs over 45-75 seconds after injection, allowing direct observation of lymphatic drainage to sentinel node

Near-infrared fluorescence penetrates approximately 1-2 centimeters through soft tissue

ICG enables laparoscopic sentinel node identification in paratesticular rhabdomyosarcoma, which is not feasible with radiotracer methods

In children under 10 years old with paratesticular rhabdomyosarcoma, sentinel node biopsy may be performed instead of full ipsilateral lymph node clearance

Indocyanine green was developed by Kodak company after World War II and has been FDA approved since the 1960s

ICG is approved for all adult and pediatric applications with no on-label or off-label concerns

ICG is exclusively cleared through the biliary system

For hepatic metastases in the chest, ICG administered 24 hours preoperatively will be retained only in liver tissue by the time of thoracotomy, enabling metastasis localization

ICG technique for hepatic metastases is successful for hepatoblastoma but has not been successful for Wilms tumor

Sarcomas other than hepatic primaries require much higher ICG dosage and are less specific

Wilms tumor metastases in the lungs are avid for ICG, though the primary kidney tumor is not

ICG fluorescence identifies additional pulmonary metastases beyond what visual inspection and palpation detect during thoracotomy

Infrared ureteral stents emit light that travels through centimeters of tissue and can be detected by standard fluorescence imaging systems

A renally-cleared fluorophore is under investigation that could enable ureteral identification without stent placement

ICG is used for vascular mapping in partial nephrectomy for Wilms tumor

ICG can identify accessory cystic ducts during cholecystectomy by showing separate fluorescence of the accessory duct, main cystic duct, and common bile duct