Indocyanine green (ICG) has been recently introduced in clinical practice as a fluorescent tracer. Lymphadenectomy is particularly challenging in gastric cancer surgery, owing to the complex anatomical drainage.
The primary outcomes of this study were the feasibility and usefulness of ICG-guided lymphadenectomy in gastric cancer surgery, considering both the success rate and improved understanding of the surgical anatomy of nodal basins. The secondary outcome was the diagnostic ability of ICG to predict the presence of nodal metastases.
Patients and methods
We conducted a single-center prospective trial comprising 13 patients with gastric cancer. ICG was injected the afternoon prior to surgery or intraoperatively via the submucosal or subserosal route. Standard lymphadenectomy was performed in all patients, according to patient age and tumor stage, as usual, but after standard lymphadenectomy the residual ICG + nodes were harvested and analyzed. Each nodal station and each dissected node was recorded and classified as ICG + or ICG− (both in vivo and back table evaluation was utilized for classification). After pathological analysis, each nodal station and each dissected node was recorded as metastatic or nonmetastatic (E&E staining).
The feasibility rate was 84.6% (11/13). The mean number of dissected lymph nodes per patient was 37.9. Focusing on the 11 patients in whom ICG-guided nodal navigation was successfully performed, 81 lymph node stations were removed, for a total of 417 lymph nodes. Sixty-six stations (81.48%), comprising a total of 336 lymph nodes, exhibited fluorescence. No IC− node was metastatic; all 54 metastatic nodes were ICG + . A total of 282 ICG + nodes were nonmetastatic. In two cases, some nodes outside D2 areas were harvested, being ICG + (1 case of metastatic node).
Fluorescence lymphography–guided lymphadenectomy is a promising new technique that combines a high feasibility rate with considerable ease of use. Regarding its diagnostic value, the key finding from this prospective series is that no metastatic nodes were found outside fluorescent lymph node stations. Further studies are needed to investigate whether this technique can help surgeons performing standard lymphadenectomy and selecting cases for D2 + lymphadenectomy.
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This study was supported by the University Hospital of Brescia (Spedali Civili di Brescia), Italy, the University of Brescia, and RicerChiAmo onlus (www.ricerchiamobrescia.it). The equipment used in this study was made available by Karl Storz and Stryker companies.
Conflict of interest
Prof. Baiocchi was the scientific organizer of two international workshops [“Intraoperative ICG Fluorescence Imaging in Hepatobiliary and Visceral Surgery: State of the Art and New Frontiers”, (Brescia, Italy, October 21, 2017); and “ICG 2.0. Intraoperative ICG Fluorescence Imaging in Abdominal Surgery: Prevention of Complications and Oncological Perspectives”, Milano, Italy, September 27–28, 2018) partly funded (travel expenses) by Karl Storz and Stryker companies. Prof. Baiocchi has a paid consultant relationship wit Stryker. Drs. B. Molteni, S. Molfino, G. Arcangeli, S. Manenti, L. Arru, F Gheza, Prof. M Botticini have no conflicts of interest or financial ties to disclose.
Research involving human participant and/or animals
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.
Informed consent was obtained from all individual participants included in the study.
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Baiocchi, G.L., Molfino, S., Molteni, B. et al. Fluorescence-guided lymphadenectomy in gastric cancer: a prospective western series. Updates Surg (2020). https://doi.org/10.1007/s13304-020-00836-0
- Fluorescence-guided surgery
- Indocyanine green
- Gastric cancer
- Navigation surgery