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 technique for sentinel node identification is real-time in the operating room, allowing surgeons to control injection location (intratumoral vs. four quadrants, dermal vs. subdermal)

ICG visualization of sentinel nodes occurs over 45-75 seconds after injection

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

ICG enables laparoscopic sentinel node identification in paratesticular cases by injecting directly into spermatic cord and visualizing lymphatic channels

For paratesticular rhabdomyosarcoma, full ipsilateral lymph node clearance is required over age 10, but sentinel node biopsy may be sufficient under age 10

Indocyanine green has been FDA approved since the 1960s as a safe, harmless fluorescent contrast for all adult and pediatric applications

ICG is exclusively cleared by the biliary system

For hepatic metastases in the chest, administering ICG the day before thoracotomy allows only the hepatic tissue to retain fluorescence by the time of surgery

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

Other sarcomas require much higher ICG dosage than hepatoblastoma and are not as specific

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

At thoracotomy for hepatic metastases, ICG given the day before reveals additional spots beyond what visual inspection and palpation can detect

Infrared-emitting ureteral stents allow ureter visualization through centimeters of tissue during pelvic tumor resection

A renally-cleared fluorophore is in testing that could enable ureter identification without stent placement, administered 15 minutes before visualization

ICG is used extensively in biliary atresia for bile duct plate dissection

In Wilms tumor partial nephrectomies, ICG can map kidney vasculature

ICG in cholecystectomy can identify accessory cystic ducts by showing separate fluorescence of the artery, main cystic duct, and common bile duct/hepatic duct junction