Author: Mariana-A
What is SWIR
Calling All Pathologists’ Assistants! Become a Founding Cision Vision Clinical Ambassador
If you love new technology, enjoy connecting with clinical teams, and want to be part of a movement innovating pathology workflows, this is your chance to get involved with Cision Vision.
We are officially launching our Clinical Ambassador program — and we’re looking for detail-oriented, go-getters to help shape the future of pathology in clinical practice.
As a Clinical Ambassador, you’ll serve in a contract-based, per-diem role where you’ll showcase our InVision device to staff at hospitals and medical centers in your area.
What you’ll do:
🔹 Showcase the InVision device to local hospital/medical center teams
🔹 Support real-world demonstrations and feedback
🔹 Represent Cision Vision as an early champion of digital and automated specimen imaging
🔹 Enjoy flexible, per-diem contract work that fits your schedule
Who we’re looking for:
Pathologists’ Assistants who are:
✔️ Credible, enthusiastic, and trusted voices in their local labs
✔️ Excited about elevating pathology through innovation
✔️ Ready to help introduce tools that improve accuracy, documentation, and workflow efficiency
Interested?
Please send:
📄 Your resume
📝 A short paragraph on why you’d like to work with Cision Vision and serve as a Clinical Ambassador
➡️ Email to: cvca@cisionvision.com
Let’s bring the future of pathology into the hands of the people who know it best. Looking forward to connecting with passionate PAs who want to be part of something groundbreaking.
Negative Lymph Node Count Is Associated With Survival of Colorectal Cancer Patients, Independent of Tumoral Molecular Alterations and Lymphocytic Reaction
Summarized by
Matthew Rosenbaum, MD
Beth Israel Deaconess Medical Center
Harvard School of Medicine
Background
The total number of lymph nodes examined during colorectal cancer (CRC) resection is often considered a quality metric. However, the number of negative lymph nodes (NLNs)—has emerged as a potential independent prognostic factor. This study aimed to determine whether NLN count predicts survival.
Methods
This analysis included 716 non-neoadjuvant CRC patients (stages I–IV) from the Nurses’ Health Study and Health Professionals Follow-Up Study cohorts. Molecular features assessed included microsatellite instability (MSI), CpG island methylator phenotype (CIMP), KRAS/BRAF mutations, p53 expression, LINE-1 methylation, and lymphocytic immune response. Patients were grouped by NLN count (0–3, 4–6, 7–12, ≥13), and outcomes were assessed using multivariate Cox proportional hazards models.
Key Findings:
A mean of 11.9 total lymph nodes were found (median:10, 25th %ile:6, 75th %tile: 15, range 0–55, highlighting a high degree of variability and general difficulty getting the prerequisite number of lymph nodes.
- Survival Association:
Higher NLN counts were significantly associated with improved overall and CRC-specific survival (p < 0.0001), even after adjusting for tumor stage, molecular markers, immune response, and a myriad of other clinical factors. Multivariate HR for all cause mortality was 0.46 in patients with greater than 13 LNs compared to those with 0-3 LNs.
- Stage-Specific Effect:
The survival benefit of increased NLNs was observed across all stages but was more pronounced in stages I–II than in stages III–IV (interaction p = 0.002).
- No Plateau Effect:
Spline analysis revealed no threshold beyond which additional NLNs ceased to confer survival benefit.
- Lymph Node Ratio (LNR):
Among stage III–IV patients, a lower LNR (lyph node ratio: positive/total nodes) also independently predicted better survival.
- Independent of Molecular Features:
The prognostic value of NLN count was independent of MSI, CIMP, BRAF, and LINE-1 methylation status, as well as lymphocytic inflammation.
- Study limitations:
Most CRC were diagnosed in the 1980s-1990s when the grossing standard was not as rigorous than it is today, although this gives us a real-world situation demonstrating the important of proper grossing in prognostication. Also not all data or tumors were able to be retrieved and analyzed but this did not appear to bias the data set.
Key Outcomes by Negative Lymph Node Count
Conclusion:
Negative lymph node count is a robust, independent prognostic factor for colorectal cancer survival. It remains significant after adjusting for known molecular, immune, and clinical predictors and may reflect tumor biology, host immune competence, surgical quality, or a combination of these.
Raising Standards in Pathology: The Case for Training and Oversight in Grossing
In pathology, every accurate diagnosis starts with a foundational step: the gross examination. Yet as Jennifer Hudson, MD, compellingly argues in The Pathologist, this critical stage is vulnerable—especially when gauntlets are handed to personnel without standardized training or proper oversight.
“Diagnosis begins at the gross bench. If that part of the process is not done correctly, the downstream effects can be catastrophic.”
— Jennifer Hudson, The Pathologist
The Stakes: Who’s at the Bench Matters
Grossing was once the purview of pathologists and their residents. But mounting workloads prompted the adoption of pathologists’ assistants (PAs) and grossing technicians (GTs). While PAs emerge from accredited programs supplemented by robust hands-on experience, GTs often lack such rigorous education.
As pathology increasingly shifts toward digital diagnostics and complex analyses, the role and competency of the person at the gross bench matters more than ever.
Regulatory Gaps in a High-Stakes Role
Despite its complexity, grossing remains a high-complexity task under CLIA ’88. Yet in most U.S. states, requirements remain minimal—often just an associate degree in lab science. Only California has implemented tiered oversight, and a mere three states formally license PAs.
Such regulatory gaps are concerning, particularly when moderately or highly complex specimens—like cancer resections—are handled by underqualified staff.
AAPA’s POV: Define Roles. Elevate Training.
According to the American Association of Pathologists’ Assistants (AAPA), GTs should be limited to handling low-complexity specimens that don’t require selective sampling. PAs, by contrast, should graduate from NAACLS-accredited programs, pass the ASCP board certification exam, and handle moderate to high-complexity tasks—including selective sampling and frozen sections.
This role delineation allows pathologists to focus on microscopic diagnosis while ensuring grossing is done with the right level of training, ultimately protecting diagnostic integrity and workflows.
Conclusion
At Cision Vision, we believe that excellence in pathology starts at the gross bench. The article reinforces what we champion every day:
- Training matters: Only personnel with rigorous education and certification should handle complex specimens.
- Role clarity is critical: Clearly defined scopes ensure each team member works at the top of their competency.
- Regulations need updating: National standards should reflect modern diagnostic complexity.
By empowering pathology teams with both technology and defined training frameworks, we enable faster, safer, and more accurate diagnoses from the very first step.
From Grossing to Diagnosis: Time for a Pathology Revolution
In pathology, the awe-inspiring advances in diagnostics often grab headlines: molecular assays, digital AI analysis, augmented intelligence. But beneath these innovations lies a critical, yet underappreciated, foundation—grossing.
Every diagnosis begins with an older, overlooked step—grossing—where specimens are inspected, measured, and prepared for analysis. This process is vital, but it remains one of the most manual, inconsistent, and under-innovated parts of clinical care.
When grossing is slow or inaccurate, delays and errors can ripple downstream, impacting patient outcomes. As Soufiane Zakaria Azdad, MD, highlights in The Pathologist, it’s time to bring precision, consistency, and traceability to the bench.
Why Grossing Needs to Change
- High stakes: Even minor mistakes at this stage can affect diagnostic accuracy.
- Outdated methods: Many labs still rely on tools and workflows unchanged for decades.
- New possibilities: Automation, digital imaging, and AI can standardize processes and capture valuable data.
The Challenge: Antiquated Tools, High Stakes
Imagine using a tape measure to determine a tumor’s size—while a caliper would offer far greater precision. This was the stark realization of author Soufiane Azdad when he compared pathology’s traditional toolkit to the precision demanded in modern diagnostics. The Pathologist
The stakes couldn’t be higher: pathology error rates range from 1% to 43%, depending on the type and context. Even small mishaps during grossing can cascade into misdiagnoses with dire consequences. Yet, despite being the starting point of every diagnostic journey, grossing remains one of the most manual and variable steps. The Pathologist
The Opportunity: Digitize and Standardize
Modern pathology workflows are undergoing seismic shifts. Innovations like digital pathology systems, automated grossing stations, AI-powered analysis, and cloud-based platforms are showing what’s possible.
- Digital imaging and remote consultation tools can slash turnaround times by up to 30 percent P Market Research.
- Automation and robotics bring reproducibility and reduce human error when preparing samples P Market Research.
- AI models can detect anomalies with 95%+ accuracy—acting as powerful second eyes to pathologists P Market Research.
- Digital tracking and specimen traceability provide a level of oversight that today’s fast-food delivery apps offer—but for patient samples.
Why Now? The Imperative for Pathology Labs
- Patient Outcomes Depend on It: Every delay or misstep in grossing risks misdiagnosis.
- Efficiency Gains Are at Stake: Automated workflows save time, labor, and operational costs.
- Technology Has Arrived: From robotics to AI to digital twins, the tools exist to revolutionize pre-analytics. BioMed Central
- Global Need for Traceability: Many regions still lack robust systems for sample tracking and quality control. Google Patents
The Path Forward: A Vision for the Future
Revolutionizing grossing isn’t about replacing pathologists—it’s about equipping them with tools to do their best work faster and more accurately. Modernizing this foundational step will improve efficiency, protect quality, and, most importantly, lead to better patient outcomes.
- Build Awareness: Educate the pathology community on the hidden vulnerabilities of grossing.
- Deploy AI and Automation: Integrate data-driven tools into everyday grossing workflows.
- Prioritize Traceability: Ensure every specimen’s journey is recorded and verifiable.
- Enhance Training and Guidance: Provide real-time support with digital resources right at the grossing station.
The future of pathology starts at the bench. Let’s make it count.
Shortwave infrared imaging increases the number of lymph nodes and improves cancer staging: a 104-patient study
Introduction
Adequate lymph node staging is critically important for accurate cancer staging.1 It has been widely shown that the number of lymph nodes examined is correlated with overall improved prognosis, possibly because of increased accuracy in staging. This association has been reported in colon cancer,1 rectal cancer,2 gastric cancer,3 lung cancer,4 head and neck cancers,5 among others. As a result, different minimum numbers of lymph nodes have been proposed across many cancer types. The most well-known benchmark is a yield of at least 12 lymph nodes for colorectal cancer specimens.6
The task of finding lymph nodes is laborious, time-consuming, and produces inconsistent results.7-9 This problem has even become a common point of friction between pathology and surgery departments.10
Attempts have been made to improve the efficiency and accuracy of lymph node dissection over the past few decades. The most notable solution is a method in which the specimen is soaked in organic solvents, such as acetone,11 Carnoy’s solution,12 and GEWF solution.13 However, this procedure significantly extends turnaround time and requires a designated chemical handling protocol. As a result, it has not been adopted in many institutions for routine gross examination. Another alternative is to submit the specimens in entireties. This can be done for smaller specimens,14 but is not feasible for large cases. Even for small cases, it is an inefficient and wasteful process that results in processing greater numbers of cassettes and increased microscopic review time.14
Shortwave infrared (1000 – 2000 nm) imaging is a novel emerging field for pathological imaging. The unique property of this wavelength range is that water, while being transparent in the visible light (400 – 700 nm) and near-infrared (700 – 1000 nm) range, is highly absorbent of shortwave infrared light. Therefore, when shortwave infrared light is illuminated onto biological tissues, the tissue types that are rich in water, such as lymph node and lymphatic vessels, will absorb the light and appear as dark areas. The tissue types that are low in water content, such as fat, will reflect the shortwave infrared light and appear as bright areas.
Cision InVision™ is an imaging device based on shortwave infrared imaging. Surgical specimens can be placed on the glass window of the imaging device and a reflection-based shortwave infrared image will be displayed on its monitor in real time. (Figure 1A)
Figure. 1
(A) A prosector using the Cision InVision shortwave infrared imaging device on a surgical resection specimen for lymph node dissection. (B) Example case (Case H1-2) from a breast cancer axillary lymph node dissection in which the only positive lymph node was identified via shortwave infrared imaging. Metastatic carcinoma is located within lymph node parenchyma (circle) (B: H&E, 4×) and consists of cohesive cells with large, pleomorphic nuclei, prominent nucleoli and readily identifiable mitoses (arrow) (C: H&E, 20×).
The prosector can manually palpate the surgical specimen and dissect out the lymph node candidates on the glass window. The glass viewing window portion of the Cision InVision™ system can be treated as an extension of the prosector’s cutting board and thereby enhances the manual palpation experience without changing the workflow.
It is worth noting that the technique only displays a reflection image of shortwave infrared light highlighting the natural water content difference — it does not specifically highlight the lymph nodes for the prosectors. The prosector still needs to rely on one’s prior experience with lymph node grossing to determine whether the identified darker areas are lymph nodes, as opposed to vessels, or other structures that may display high relative water content. The purpose of this pilot study was to investigate the effectiveness of this novel imaging technology to improve lymph node yield and its impact on cancer staging.
Methods
Patients
The study included 104 patients with cancer from two hospitals, 37 cases from an academic hospital (Froedtert & Medical College of Wisconsin, Milwaukee, Wisconsin, USA) and 67 cases from a large community hospital (St. Dominic Hospital, Jackson, Mississippi, USA). The cancer types for these cases include colon (68 cases), rectum (17 cases), breast (3 cases), pancreas (8 cases), stomach (5 cases), skin (1 case) and small bowel (2 cases).
Pathologists and pathologists’ assistants
The gross examination procedures and the operation of the shortwave infrared imaging device were conducted by pathologists and board-certified pathologists’ assistants (PA) under the supervision of board-certified pathologists. Microscopic examinations of submitted lymph node candidates were confirmed by board-certified pathologists.
Study Procedure
To evaluate the effectiveness of shortwave infrared imaging in assisting lymph node searches compared with standard of care, the study is designed to have two steps:
In the first step, the gross examination for lymph nodes was performed with visual inspection and manual palpation. The lymph node candidates retrieved in this step were placed in the first batch of cassettes, batch A. This step is representative of the current standard of care.
In the second step, the same PA, under the supervision of a pathologist, used the Cision InVision™ Pathology Imaging System to search for additional lymph nodes in residual specimens after the first step. The lymph node candidates that were retrieved in this step were placed in the second batch of cassettes, batch B.
Batch A and B cassettes were processed via standard histological protocols. Microscopic review was performed by board-certified pathologists to confirm the total numbers of lymph nodes and the numbers of positive lymph nodes in batches A and B.
Statistics
Table 1 and Table 2 include all the data from individual cases that were collected in this study. Poisson regression was used to test the hypotheses that 1 the number of lymph nodes identified by shortwave infrared imaging was significantly different than zero and 2 the number of positive lymph nodes identified by shortwave infrared imaging was significantly different than zero.
This statistical technique was used to test the hypotheses where the outcome scale was counted data. The two hypothesis outcomes comprised distinct counts of total lymph nodes detected and distinct counts of positive lymph nodes detected. Statistical significance was concluded with Wald χ2 p values <0.05. Analysis was run using the GENMOD procedure in SAS 9.4 (Cary, North Carolina, USA), with the Poisson distribution and the log-linear regression model specifications.
Results
The columns represent the study case numbers, the disease types, the number of lymph nodes retrieved via traditional palpation, the number of positive lymph nodes retrieved via traditional palpation, the number of lymph nodes retrieved in residual tissue assisted by shortwave infrared imaging, the number of lymph nodes retrieved in residual tissue assisted by shortwave infrared, the percentage improvement in lymph node counts, whether the lymph node count improvement affected cancer staging results and whether the lymph node count improvement affected the compliance, that is, the requirement to examine at least 12 lymph nodes for colorectal cases. N, no; N/A, not available; Y, yes.
The columns represent the study case numbers, the disease types, the number of lymph nodes retrieved via traditional palpation, the number of positive lymph nodes retrieved via traditional palpation, the number of lymph nodes retrieved in residual tissue assisted by shortwave infrared imaging, the number of lymph nodes retrieved in residual tissue assisted by shortwave infrared, the percentage improvement in lymph node counts, whether the lymph node count improvement affected cancer staging results and whether the lymph node count improvement affected the compliance, that is, the requirement to examine at least 12 lymph nodes for colorectal cases. N,no;Y,yes.
Improvement in lymph node counts
As shown in Table 3, gross examination assisted by shortwave infrared imaging identified a significant number (non-zero) of positive lymph nodes in samples discarded after standard of care lymph node dissection, b=−2.01, x2= 56.30, p<0.0001.
*Shortwave infrared imaging helped a significant number of positive nodes after traditional grossing, b=−2.01, = 56.30, p<0.0001. †Mean case total % improvement=mean of (lymph nodes count identified in batch B per case/lymph node count identified in batch A per case). ‡Shortwave infrared imaging helped identify a significant number of nodes after traditional grossing, b=1.57, = 1232.79, p<0.0001.
As shown in Table 4, in 4 of the 37 cases (10.8%) in hospital 1 and 7 of the 67 cases (10.4%) in hospital 2, additional positive lymph nodes were identified with the assistance of shortwave infrared imaging. Overall, in 11 of the 104 cases (10.6%), additional lymph nodes were identified with the assistance of shortwave infrared imaging.
*Lymph node compliance means the requirement of a minimum of 12 lymph nodes examined for colorectal cancer cases.
Improvement in positive lymph node counts
As shown in Table 3, gross examination assisted by shortwave infrared imaging identified a significant number (non-zero) of positive lymph nodes in samples discarded after standard of care lymph node dissection, b=−2.01, x2= 56.30, p<0.0001.
As shown in Table 4, in 4 of the 37 cases (10.8%) in hospital 1 and 7 of the 67 cases (10.4%) in hospital 2, additional positive lymph nodes were identified with the assistance of shortwave infrared imaging. Overall, in 11 of the 104 cases (10.6%), additional lymph nodes were identified with the assistance of shortwave infrared imaging.
There were 31 lymph node positive cases in total (8 from hospital 1 and 23 from hospital 2). In four of these positive cases (12.9%), the positive lymph nodes were only discovered by shortwave infrared imaging, with no positive lymph nodes being identified through the standard of care visual and manual dissection. These four positive cases would have been wrongly staged as lymph node negative in the absence of shortwave infrared imaging support. An example where the only positive lymph node was identified with the help of shortwave infrared imaging was depicted in Figure 1(B) and (C).
Also, in 11 of the 31 lymph node-positive cases (35.5%), additional lymph nodes were identified with the assistance of shortwave infrared imaging.
Seven different types of specimens were included in this study. Among them, colorectal cases were the most common with 85 cases. In these colorectal cases, the mean lymph node count for after manual palpation was 11.6, and the mean lymph node count found with the assistance of shortwave infrared imaging in the residual tissue was 5.0. The percentage improvement was 42.5. This percentage is lower than the mean percentage improvement of 79.6% for all cases because of the higher denominator number, that is, lymph node counts through manual palpation for colorectal cases. The numbers for other types of specimens are too low in this study to draw any meaningful comparison.
DISCUSSION
The main purpose of this study was to evaluate the effectiveness of shortwave infrared imaging in (1) increasing lymph node counts and (2) identifying additional positive lymph nodes. As shown in the ‘Results’ section, both hypotheses were strongly supported.
In addition to supporting these two main hypotheses, we also investigated the effectiveness of shortwave infrared imaging for improving compliance of gross examination of colorectal cancer cases. Established guidelines in the USA dictate that colorectal cancer cases yield a minimum of 12 lymph nodes. Failure in reaching 12 lymph nodes after the first round of gross examination results in re-examination of residual adipose tissue, which is time-consuming, labour intensive and economically costly.15 This problem is particularly common for cases that had been previously treated with radiation or chemotherapy.2 Lymph nodes often become smaller and are thus more challenging to retrieve after such treatments, with reassessment of the gross specimen multiple times being common for such cases. In this study, only 34.1% (29/85) of colorectal cancer cases achieved the required number of 12 lymph nodes after the first round of grossing. If it was not the use of the Cision InVision device, the rest of the cases will need to be regrossed potentially for multiple rounds, incurring substantial time delays and processing costs. Shortwave infrared imaging brought 35.7% (20/56) of the non-compliant cases into compliance, obviating the need to return to the specimen in over a third of these cases.
The data provide compelling evidence for the benefit of shortwave infrared imaging in lymph node dissection in the surgical pathology laboratory. However, as a first large-scale multicentre pilot study of this emerging technology, there are several limitations to this study. The prosectors were not blinded, and the study was performed in a two-step approach, which was not representative of the practical workflow using this technology.
Other potential benefits that shortwave infrared imaging can have that were not investigated in this study are (1) time saving in lymph node searches and (2) cost saving for reducing the number of cassettes submitted for histological processing. Future studies need to be conducted to evaluate these potential benefits.
In conclusion, this two-centre, 104-patient large-scale pilot study demonstrated that shortwave infrared imaging helps not only find additional lymph nodes, but also additional positive lymph nodes. Future studies will need to be conducted to overcome the limitations of this study and investigate other potential benefits of shortwave infrared imaging.
Conclusion:
Shortwave infrared imaging may increase the number of lymph nodes identified and has the potential to improve cancer staging accuracy.
Further validation in larger, randomised or prospective studies is warranted.
Authors
Julie M Jorns, MD
Medical College of Wisconsin
Milwaukee, WI
Randall S Smith, MD
St Dominic Memorial Hospital
Jackson, MS, United States
Dennis Strenk, PA(ASCP)
Wisconsin Diagnostic Laboratories LLC
Milwaukee, WI
Greg Stauble, PA(ASCP)
St Dominic Memorial Hospital
Jackson, MS
Sihem Khelifa, MD
Cision Vision Inc
Mountain View, CA
Ryan Seltzer, MD
Cision Vision Inc.
Mountain View, CA
John Manuel, PA(ASCP)
Cision Vision Inc.
Mountain View, CA
Matthew Rosenbaum, MD
Cision Vision Inc.
Mountain View, CA
James Almas, MD
Cision Vision Inc.
Mountain View, CA
Jeremy Li, PhD
Cision Vision Inc.
Mountain View, CA
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Google Scholar
Evaluation of a novel “gross room” device aiming to increase lymph node yield in colorectal cancer specimens: Preliminary results
Background:
Colorectal cancer is the second most common cause of cancer-related death in the US. Staging is crucial to assess prognosis and treatment options. According to AJCC guidelines, at least 12 lymph nodes are required for nodal staging. However, previous studies showed the importance of retrieving as many lymph nodes as possible. Herein, we evaluated a novel, optical imaging-based device using infrared light a.k.a. CisionVision (Cision Vision, Mountain View, CA; Fig. 1) to increase lymph node yield in colorectal cancer specimens.
Design:
The CisionVision device has increased the lymph node yield significantly in all categories except low-anterior resection (Tab. 1). This result is likely due to a small number of subjects. The increase in lymph node yield was significant when all subjects were included in the analysis (average increase of 53%). The size of the lymph nodes was compared in each case separately, also categorically. This increase was particularly notable for smaller lymph nodes (<3 mm; Fig 2). In 19 cases, lymph nodes found by the device were significantly smaller, however in three cases, there was no significant difference. In the entire study, a total of 21 metastatic lymph nodes were harvested from 7 nodal positive cases; 20 by conventional grossing and 1 by CisionVision device where a patient was upstaged from T1 N1a M0 to T1 N1b M0.
Results:
The CisionVision device has increased the lymph node yield significantly in all categories except low-anterior resection (Tab. 1). This result is likely due to a small number of subjects. The increase in lymph node yield was significant when all subjects were included in the analysis (average increase of 53%). The size of the lymph nodes was compared in each case separately, also categorically. This increase was particularly notable for smaller lymph nodes (<3 mm; Fig 2). In 19 cases, lymph nodes found by the device were significantly smaller, however in three cases, there was no significant difference. In the entire study, a total of 21 metastatic lymph nodes were harvested from 7 nodal positive cases; 20 by conventional grossing and 1 by CisionVision device where a patient was upstaged from T1 N1a M0 to T1 N1b M0.
Results Table:
Conclusion:
The CisionVision device significantly increases lymph node yield, especially for smaller nodes, leading to potential stage changes in some cases (4.5%). While further research is needed to address limitations and explore broader clinical implications, our preliminary findings highlight its potential value in colorectal cancer pathology.
Authors
Kadir Isidan, MD, MS
University of Chicago Medical Center/NorthShore University HealthSystem
Chicago, IL, United States
Hussein Alnajar, Alnajar, MD
NorthShore University HealthSystem
Chicago, IL, United States
Alicia Huber, PA (ASCP)
NorthShore University HealthSystem
Chicago, IL, United States
Zitlali Montiel-Martinez, PA (ASCP)
NorthShore University HealthSystem
Franklin Park, IL, United States
John V. Groth, MD
NorthShore University HealthSystem
Libertyville, IL, United States
Enhanced Lymph Node Detection in Pancreatic Resection Cases Using CisionVision: An Institutional Study
Background:
Accurate staging and prognosis of pancreatic adenocarcinoma rely on the precise identification of regional lymph nodes (LNs). The AJCC 8th edition classifies LNs into N1 & N2 stages based on the number of LNs involved, making LN identification critical. A smaller number of LNs carries the risk of under-staging the patient while reevaluating LNs and submitting fat fragments risks overcounting LNs and upstaging the patient. CisionVision (Cision Vision, CA) (CV) is a real-time shortwave infrared imaging device to locate lymph nodes by highlighting water content contrast (Fig. 1). This study explores the utility of CV in increasing LN detection and minimizing fat submission in pancreatic resection cases.
Design:
We prospectively enrolled 8 pancreatic resection cases (4 Whipple & 4 distal pancreatectomy) from June to September 2023. Primary grossers (PG) with varying levels of expertise identified LNs manually. Subsequently, a single secondary grosser (SG) utilized CV to extract additional LNs, and the remaining fat was submitted for evaluation (Fig. 2). The average number of LNs for manual extraction, remaining fat, intended LN cassettes, and fat cassettes were calculated. Incidental LNs found microscopically were included in PGs’ LN count.
Results:
The CisionVision device has increased the lymph node yield significantly in all categories except low-anterior resection (Tab. 1). This result is likely due to a small number of subjects. The increase in lymph node yield was significant when all subjects were included in the analysis (average increase of 53%). The size of the lymph nodes was compared in each case separately, also categorically. This increase was particularly notable for smaller lymph nodes (<3 mm; Fig 2). In 19 cases, lymph nodes found by the device were significantly smaller, however in three cases, there was no significant difference. In the entire study, a total of 21 metastatic lymph nodes were harvested from 7 nodal positive cases; 20 by conventional grossing and 1 by CisionVision device where a patient was upstaged from T1 N1a M0 to T1 N1b M0.
Results Table:
Conclusion:
In our Our experience, CV use in pancreatic resection cases demonstrated a 79% increase in LN extraction and a 66% reduction in LN detection in remaining fat. This improvement has the potential to eliminate the need for remaining fat submission, leading to reduced costs, improved grosser accuracy, and ultimately better patient outcomes by more precise staging, and tailored treatment approaches. However, we acknowledge the small sample size of the study, further large-scale validation using CV at the time of initial grossing is underway, recruiting more cases and various organ resections.
Authors
Payu Raval, MD
University of Chicago NorthShore
Des Plaines, IL, United States
John V. Groth, MD
NorthShore University HealthSystem
Libertyville, IL, United States
Hussein Alnajar, Alnajar, MD
NorthShore University HealthSystem
Chicago, IL, United States
The Effectiveness of InVision, an Optical Imaging Device, in Assisting with Lymph Node Retrieval
Abstract
This colorectal case study was part of a joint study conducted by Wisconsin Diagnostic Laboratories, Rosalind Franklin University, and Cision Vision Inc. InVision is an optical device that provides enhanced contrast between lymph nodes and surrounding adipose tissue based upon differing chemical compositions in real-time without the use of radiation or contrast media.1
Through use of Cision Vision’s innovative technology, InVision (Fig. 1), lymph node yield drastically improved. Consequently, with the increase in lymph node yield, the pN (N-regional lymph node) category of the American Joint Committee on Cancer (AJCC) Tumor, Node, Metastasis (TNM) staging system was impacted.
Introduction
Lymph node retrieval in surgically excised specimens is one of the most challenging tasks completed in anatomic pathology. It can take a prosector multiple hours to finish a single lymph node search. When such searches are inadequate and the established minimums for lymph node count are not met, re-grossing is required which prolongs turnaround time for a case. Lymph node yield is of significant clinical consequence for cancer patients. Decades of clinical evidence has shown a strong correlation between the number of lymph nodes examined and patient survival.2 Therefore, prosectors are encouraged to find all the lymph nodes in each relevant specimen regardless of the time it takes and challenges it creates. This problem has also been exacerbated by the recent advent of neoadjuvant chemotherapy which shrinks the size of lymph nodes making them more difficult to find, particularly for colorectal cancer cases.
Cision Vision’s InVision product is a novel imaging device that depicts lymph nodes in high contrast against the surrounding adipose tissue.1 This is done in real-time without the need for injections or radiation. The technology was developed at the Massachusetts Institute of Technology (MIT) by Drs. Angela Belcher and Jeremy Li. It utilizes shortwave infrared light that exploits the natural water content differences which exist between lymph nodes and fat.3 Lymph nodes are high in water content. Therefore, they absorb the shortwave infrared light and appear dark on imaging. This is in contrast to adipose tissue which has a low water content and reflects light, appearing bright on imaging. Aided by the real-time visualization of lymph nodes, a prosector can palpate and dissect the tissue directly on top of the InVision imaging platform. Therefore, the prosector’s tactile skills are reinforced by the real-time visual feedback provided by the InVision device.
In this case study, the effectiveness of the InVision device was evaluated by comparing it to the results of manual palpation from a Pathologists’ Assistant (PA) with 20 years of grossing experience. The PA manually palpated the specimen and searched for lymph nodes. The lymph nodes retrieved during this step were gathered and labeled as the first batch. The PA then went through the remaining adipose tissue scanning it with use of the InVision device to see if there were additional lymph nodes that were missed during the initial, manual palpation step. If lymph nodes were found by scanning with the InVision device, these lymph nodes were submitted as a second batch. The numbers of lymph nodes in both batches are confirmed through routine histologic examination. Comparison of the lymph node counts between the two batches provided insight into the effectiveness of the InVision device for lymph node retrieval.
Case History
A 46-year-old Caucasian male presented to his general practitioner (GP) with complaints of persistent, nonspecific pelvic pain. Family history was unremarkable for rectal cancer and no associated risk factors were reported. Subsequently, the patient was referred for MRI which revealed suspected adenocarcinoma of the rectum that was clinically staged as IVA (cT3, cN1b, cM1). The primary mass was circumferential, 2.1 cm on imaging, and located 6 cm from the anal verge with mesorectal fascia involvement (MRF+), and suspicious mesorectal and presacral lymph nodes. A solitary liver mass was also present, measuring 1.5 cm in greatest dimension. Biopsies were taken of the both the rectal and liver masses. The rectal mass biopsy revealed moderately differentiated adenocarcinoma and the liver mass biopsy revealed adenocarcinoma compatible with a rectal primary. After initial diagnosis, the patient received combination neoadjuvant therapy which consisted of FOLFIRINOX+Avastin and short course radiation over 4 consecutive days. Upon completion of the aforementioned therapy, the patient underwent a low anterior resection (Fig. 2) in conjunction with a hepatic wedge excision of segments 7 and 8.
Pathologic examination of the low anterior resection was completed via use of the Quirke method. This method of prosection allows for thorough visualization of the tumor in relation to the mesorectal/circumferential radial margin (CRM) by leaving the specimen intact within the area of the mass. This area is serially sectioned from proximal to distal at 3 to 5 mm intervals and the corresponding sections are subsequently referred to as levels. Sectioning of this case revealed a 2.5 x 1.3 x 0.3 cm centrally ulcerated, endophytic, tan mass within levels 2-5 (Fig. 3). The mass measured 0.6 cm from the distal margin, 18.5 cm from the proximal margin, 0.8 cm from the anterior mesorectal margin and extended below the peritoneal reflection with focal infiltration into the muscularis propria.
As for the lymph node search, 19 lymph nodes were identified in total, 8 via use of traditional manual palpation by the prosector and 11 via use of the InVision device. Two out of eight lymph nodes found were microscopically positive for metastatic adenocarcinoma from the manual palpation batch;
1 out of 11 nodes were microscopically positive from the batch retrieved with assistance from the InVision device.
As for the lymph node search, 19 lymph nodes were identified in total, 8 via use of traditional manual palpation by the prosector and 11 via use of the InVision device. Two out of eight lymph nodes found were microscopically positive for metastatic adenocarcinoma from the manual palpation batch;
1 out of 11 nodes were microscopically positive from the batch retrieved with assistance from the InVision device.
Due to the fact that only 8 lymph nodes were found through the traditional manual palpation method, which falls short of the established minimum of 12 stipulated by AJCC and the College of American Pathologists (CAP), this case would be subject to re-grossing.
With the assistance of InVision, the total number was increased to 19, a 137.5% increase in lymph node count, bringing it into compliance with lymph node yield requirements. More importantly, because one additional positive lymph node was found, the patient’s N category was upstaged from ypN1a to ypN1b (Fig. 4).2 The final diagnosis was residual invasive moderately differentiated adenocarcinoma of the rectum without involvement of the margins and metastatic adenocarcinoma with extensive liver necrosis, consistent with metastasis from a rectal primary. The pathologic stage was reported as ypT2 pN1b PM1a.
Fig. 4 AJCC TNM staging for colorectal carcinoma with specific information related to N categorization.
Discussion
Colorectal cancer staging utilizes the TNM system established by AJCC. Pre-fix “p” designates pathologic stage while “c” denotes clinical stage. Cases staged subsequent to use of neoadjuvant therapy utilize the pre-fix “yp”. These designations are important for QA/QC purposes across professions. As with any cancer, as the stage increases, patient prognosis inevitably decreases.
A minimum number of regional nodes is needed for accurate N category staging and is recommended by the National Comprehensive Cancer Network (NCCN) and accepted by the AJCC and CAP (Fig. 4).4 The minimum number of lymph nodes determined to be adequate for accurate colorectal cancer staging is 12. For reasons unknown, an association has been found between examination of 12 or more lymph nodes and improved patient survival.4
Additionally, as outlined in the Intergroup Trial INT – 0089, conducted by Le Voyer TE, Sigurdson ER, Hanlon AL, et al., an increase in the number of lymph nodes examined correlated with an increase in survival in patients with node negative and node positive disease.5 These findings highlight the importance of lymph node yield for accurate N category staging and predictions related to patient survival.
Use of the novel InVision device, in this instance, upstaged the patient from ypN1a to ypN1b and improved lymph node yield by 137.5%. By doing so, correlation within the N category between clinical and pathologic staging was achieved. In this particular case, the minor staging change does not alter the patient’s treatment regimen. However, it is reasonable to assume that there might be instances where InVision can potentially assist prosectors in finding positive lymph nodes that could have been missed through use of manual palpation techniques alone; therefore, rendering consequential changes to staging and treatment options. Larger studies need to be completed to have a more thorough and accurate assessment of the effectiveness of InVision.
Conclusion:
Use of InVision improved lymph node retrieval by allowing the institution to meet the NCCN recommendation. It also impacted staging within the N category and decreased turnaround time through elimination of the need for re-grossing. While this is a single example of the value the innovative device provided, larger studies are being conducted to determine the impact on patient care and subsequent treatment decisions.
Authors
Mary L. Mattes, MS, PA(ASCP)CM
Rosalind Franklin University
Chicago, IL, United States
Dennis Strenk, PA(ASCP)CM
Wisconsin Diagnostic Laboratories
Milwaukee, WI, United States
Jeremy Li, PhD
Cision Vision Inc.
Mountain View, CA, United States
References
- Cision Vision Inc. https://cisionvision.com. Accessed May 2023.
- Amin MB, Edge SB, Greene FL, et al. AJCC Cancer Staging Manual 8th ed. Springer, 2018. Print.
- Li, Z., Huang, S., He, Y., et al. bioRxiv 2023.01.13.523938; doi: https://doi org/10.1101/2023.01.13.523938.
- National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology – Colon Cancer. Version 3.2022.
https://www.nccn.org/professionals/physician_gls/pdf/colon.pdf. Accessed March 2023. - Le Voyer TE, Sigurdson ER, Hanlon AL, et al. Colon cancer survival is associated with increasing number of lymph nodes analyzed: a secondary survey of intergroup trial INT-0089. J Clin Oncol 2003;21:29122919. Available at: http://www.ncbi.nlm.nih.gov/pubmed/12885809.