Near-infrared fluorescence imaging using Indocyanine Green (ICG) to guide laparoscopic lymph node biopsy by highlighting lymphatic tissue
Target Population
Adult patients (≥18 years) with suspected abdominal lymphoma requiring lymph node biopsy and no accessible superficial pathological lymph nodes
Care Setting
Minimally invasive laparoscopic surgery in specialized surgical centers
Key Highlights
FLABILY is a multicenter observational study investigating fluorescence-guided laparoscopic lymph node biopsy (FGLLB) using ICG in abdominal lymphoma diagnosis.
ICG demonstrates elective tropism for lymph nodes, potentially simplifying identification and biopsy site selection in lymphoproliferative disease.
Injection site, dosage, and timing of ICG administration vary by lymph node anatomical location to optimize fluorescence visualization.
Guideline-Based Recommendations
Diagnosis
Use preoperative PET/CT to localize pathological lymph nodes and assess standardized uptake value (SUV) to target biopsy site.
Consider laparoscopic lymph node biopsy over needle biopsy for adequate tissue sampling and histologic evaluation in abdominal lymphoma.
Management
Administer ICG intradermally in inguinal regions and intra-nodally (if possible) for sub-mesocolic lymph nodes 30 minutes to several hours before surgery.
Inject ICG intraoperatively into the peritoneum near pathological lymph nodes for supra-mesocolic lymph nodes.
Use dedicated infrared endoscopic systems to visualize fluorescence during laparoscopic biopsy.
Monitoring & Follow-up
Monitor operative time, blood loss, surgical conversions, additional trocar use, drain placement, hospital stay length, and postoperative complications per Clavien–Dindo classification.
Risks
Exclude patients with known iodide allergies, coagulopathy, or pregnancy due to contraindications for ICG use.
Obtain informed consent for both the surgical procedure and use of fluorescent dye.
Patient & Prescribing Data
Adults undergoing laparoscopic biopsy for abdominal lymphadenopathy suspicious for lymphoma without accessible superficial nodes
ICG dosing ranges from 3.75 to 5 mg per side for sub-mesocolic nodes and 2 ml intraoperative injection for supra-mesocolic nodes; timing and injection site tailored to lymph node location to maximize fluorescence detection.
Clinical Best Practices
Target biopsy to lymph nodes with highest SUV on PET/CT to improve diagnostic yield.
Use fluorescence guidance to identify viable lymphatic tissue and optimize biopsy site selection.
Tailor ICG administration route and timing based on anatomical lymph node location to enhance fluorescence visualization.
Employ minimally invasive laparoscopic techniques to reduce morbidity compared to open or needle biopsy.
Collect comprehensive intra- and postoperative data to monitor safety and efficacy outcomes.
by Marco Casaccia, Giovanni Alemanno, Paolo Prosperi, Graziano Ceccarelli, Stefano Olmi, Alberto Oldani, Mauro Santarelli, Roberta Tutino, Franco De Cian
