Firefly Fluorescence Imaging Helps Surgeons Identify Sentinel Lymph Nodes During Robotic Endometrial Cancer Surgery

Endometrial cancer, which occurs in the lining of the uterus, is the most common gynecological cancer in the U.S. According to estimates from the American Cancer Society, more than 65,000 new endometrial cancer cases are expected to be diagnosed in 2020. 

Surgery is usually the first line of treatment for endometrial cancer and most often involves a total hysterectomy, including removing the ovaries, fallopian tubes, uterus, and cervix. The gynecological cancer care specialists at Hackensack Meridian Hackensack University Medical Center often perform this procedure using the da Vinci robotic surgical system, which involves only a few small incisions in the abdomen. 

In addition to state-of-the-art da Vinci robotic surgical technology, our women’s robotic reproductive and gynecological surgery specialists use a near-infrared imaging system called Firefly to assess sentinel lymph nodes and improve quality of life for patients after endometrial cancer surgery. 

Benefits of Firefly 

The da Vinci robotic surgical system is equipped with three robotic arms that hold surgical instruments and one robotic arm with a small camera. During surgery, the instruments and camera are inserted into the patient’s abdomen through several small incisions. The camera projects a 3D video image of the surgical area onto a screen on the specialized surgical console, allowing the surgeon to precisely guide the surgical instruments. 

The small incisions and smaller surgical instruments used during robotic surgery — plus the enhanced surgical visibility — are often associated with patient benefits such as shorter recovery, less pain, a lower risk of complications, and reduced scarring. 

But according to Ami P. Vaidya, M.D., vice-chair of the Department of Obstetrics & Gynecology; co-chief of the Division of Gynecologic Oncology; and director of the Minimally Invasive and Robotic Gynecologic Surgery, Firefly allows surgeons to provide patients with benefits that continue even after healing is complete. 

“Firefly allows us to assess the patient’s pelvic lymph nodes to find the sentinel lymph nodes, or the first lymph nodes to receive lymphatic drainage from a tumor,” said Dr. Vaidya. “By removing only the sentinel lymph nodes instead of performing a complete lymphadenectomy to remove all of the lymph nodes in the tumor area, we can lower the patient’s risk of developing lymphedema.” 

Lymphedema is a complication that can occur anywhere between a few days and a few years after surgery to remove lymph nodes. The more lymph nodes that are removed, the higher the risk of developing lymphedema. Patients who develop lymphedema after endometrial cancer surgery experience uncomfortable, chronic leg swelling due to a buildup of lymph fluid that cannot drain. In some cases, lymphedema requires additional surgical treatment. 

“Lymphedema after surgery can significantly impair a patient’s quality of life,” said Dr. Vaidya. “When it comes to endometrial cancer, we not only have to think about a cure, but we always have to look for ways to improve quality of life after curative surgery.”

How Firefly Works

Hackensack University Medical Center received approval from the National Comprehensive Cancer Network (NCCN) to use Firefly in conjunction with surgery to treat Stage 1 endometrial cancer in patients with a low or high risk of sentinel lymph node involvement. 

At the beginning of the surgery, the surgeon injects a fluorescent dye called ICG into the patient’s cervix and uterus. The dye is taken up by the patient’s lymphatic channels and makes its way into the sentinel lymph nodes.

Hackensack University Medical Center’s da Vinci robotic surgical systems are specially equipped with near-infrared technology that triggers the injected dye to fluoresce. When the surgeon switches the da Vinci surgical system’s camera to “Firefly mode” from the surgical console, the sentinel lymph nodes appear green — making them easier to see and accurately remove. 

“Not every hospital that has a da Vinci robotic surgical system has Firefly, so we are privileged to be able to use this technology when caring for our patients,” said Dr. Vaidya. 

Study Shows Excellent Outcomes

Mira Hellmann, M.D., along with gynecologic oncology colleagues Dr. Vaidya and Merieme Klobocista, M.D., conducted an internal study of 128 patients who had robotic endometrial cancer surgery with sentinel lymph node identification using Firefly. The study showed that Firefly technology was effective in helping to accurately identify and remove sentinel lymph nodes. 

“We want our patients to know that we are committed to quality surgical care, and that means taking the time to demonstrate the success of new technology through research,” said Dr. Vaidya.