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:
Among the 8 cases, 3 had intraductal papillary mucinous neoplasm, and 5 had ductal adenocarcinoma, including 2 post-neoadjuvant cases. Upon implementation of CV, the average number of LNs extracted increased from 17.2 to 28.1. The accuracy of LN detection by SG with the use of CV (3.1 LNs/intended LN cassette) was improved compared to PG (1.7 LNs/intended LN cassette). Reciprocal to increase in LN yield with CV use, the average number of LNs in the remaining fat dropped from 15.9 to 5.0, and LN detection per fat cassette was reduced from 1.2 to 0.3 (Tab. 1).
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.