Assessment of diagnostic value of fluorescent lymphography-guided lymphadenectomy for gastric cancer

Abstract

Background Indocyanine green fluorescent lymphography helps visualize the lymphatic drainage pattern in gastric cancer; however, it is unknown whether fluorescent lymphography visualizes all metastatic lymph nodes. This study aimed to evaluate the sensitivity of fluorescent lymphography to detect metastatic lymph node stations and lymph nodes and the risk of false-negative findings. Methods Patients with clinical T1-4a gastric cancer were included. Indocyanine green was peritumorally injected the day prior to surgery by endoscopy. Gastrectomy with systematic D1+ or D2 lymphadenectomy was performed. Stations and lymph nodes were retrieved at the back-table using near-infrared imaging and classified as "fluorescent" or "non-fluorescent" and later matched with histopathological findings. Results Among 592 patients who underwent minimally invasive gastrectomy from September 2013 until December 2016, lymph node metastases were present in 150. The sensitivity of fluorescent lymphography in detecting all metastatic lymph node stations was 95.3% (143/150 patients), with a false-negative rate of 4.7% (7/150 patients) and the sensitivity in detecting all metastatic lymph nodes was 81.3% (122/150 patients). The negative predictive value was 99.3% for non-fluorescent stations and 99.2% for non-fluorescent LNs. For detecting all metastatic LN stations, subgroup analysis revealed 100% sensitivity for pT1a, 96.8% for pT1b, 100% for pT2, 91.3% for pT3, and 93.6% for pT4a tumors. Conclusions Fluorescent lymphography-guided lymphadenectomy can be a useful method for radical lymphadenectomy by facilitating the complete dissection of all potentially positive LN stations. Fluorescent lymphography-guided lymphadenectomy appears to be a reasonable alternative to conventional systematic lymphadenectomy for gastric cancer.

Comparison of submucosal and subserosal approaches toward optimized indocyanine green tracer-guided laparoscopic lymphadenectomy for patients with gastric cancer (FUGES-019): a randomized controlled trial

“…Tajima et al [ 28 ] found that intraoperative subserosal injection was less accurate than preoperative submucosal injection of ICG for detecting sentinel LNs. Moreover, some retrospective studies [ 29 , 30 ] support the use of submucosal injection of ICG for fluorescence-guided lymphadenectomy the day before surgery. These inconsistent results may be explained by the selection bias inherent in retrospective investigations and varying injection sites, time, and concentrations of ICG used across studies.…”

Lymph Node Involvement in Advanced Gastric Cancer in the Era of Multimodal Treatment—Oncological and Surgical Perspective

“…Ongoing trials investigating the extent of lymphadenectomy after neoadjuvant therapy will allow to standardize the LN dissection from the multimodal therapy perspective (NCT02139605, NCT03961373). Fluorescence-guided lymphadenectomy is a new, feasible technique which allows to detect LN metastases within fluorescent LN stations [101,102] (Figure 1). Indocyanine green can improve the LN harvest and reduce LN noncompliance without increased complications in patients undergoing D2 lymphadenectomy [103].…”

Modern surgical therapy for gastric cancer–Robotics and beyond

“…76 The sensitivity of fluorescent lymphography to detect metastatic lymph nodes was 95.3%, and the negative predictive value of nonfluorescent lymph nodes to not contain metastasis lymph nodes was 99%. 76 Fluorescent image-guided gastrectomy can be useful for radical lymphadenectomy and individualized lymphadenectomy for gastric cancer. ing the aberrant left hepatic artery, deciding whether to preserve or ligate an aberrant left hepatic artery.…”

“…Despite the results of studies, whether fluorescent lymphography detects all potentially metastatic lymph nodes remains unclear. Recently, a study to evaluate the diagnostic value of fluorescent lymphography was conducted in Korea 76 . The sensitivity of fluorescent lymphography to detect metastatic lymph nodes was 95.3%, and the negative predictive value of nonfluorescent lymph nodes to not contain metastasis lymph nodes was 99% 76 .…”

“…Recently, a study to evaluate the diagnostic value of fluorescent lymphography was conducted in Korea 76 . The sensitivity of fluorescent lymphography to detect metastatic lymph nodes was 95.3%, and the negative predictive value of nonfluorescent lymph nodes to not contain metastasis lymph nodes was 99% 76 . Fluorescent image‐guided gastrectomy can be useful for radical lymphadenectomy and individualized lymphadenectomy for gastric cancer.…”