Abstract
Background
This study evaluated the safety, effectiveness, and feasibility of indocyanine green (ICG) tracing in guiding lymph-node (LN) dissection during laparoscopic D2 radical gastrectomy in patients with advanced gastric cancer (AGC) after neoadjuvant chemotherapy (NAC).
Method
We retrospectively analyzed data on 313 patients with clinical stage of cT1-4N0-3M0 who underwent laparoscopic radical gastrectomy after NAC between February 2010 and October 2020 from two hospitals in China. Grouped according to whether ICG was injected. For the ICG group (n = 102) and non-ICG group (n = 211), 1:1 propensity matching analysis was used.
Results
After matching, there was no significant difference in the general clinical pathological data between the two groups (ICG vs. non-ICG: 94 vs. 94). The average number of total LN dissections was significantly higher in the ICG group and lower LN non-compliance rate than in the non-ICG group. Subgroup analysis showed that among patients with LN and tumor did not shrink after NAC, the number of LN dissections was significantly more and LN non-compliance rate was lower in the ICG group than in the non-ICG group. Intraoperative blood loss was significantly lesser in the ICG group than in the non-ICG group, while the recovery and complications of the two groups were similar.
Conclusion
For patients with poor NAC outcomes, ICG tracing can increase the number of LN dissections during laparoscopic radical gastrectomy, reduce the rate of LN non-compliance, and reduce intraoperative bleeding. Patients with AGC should routinely undergo ICG-guided laparoscopic radical gastrectomy.
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Introduction
Gastric cancer is the fifth most common malignant tumor worldwide and the third highest cause of cancer mortality. Although the 5-year survival rate of patients with early gastric cancer exceeds 90%, for patients with locally advanced gastric cancer (AGC), the 5-year survival rate is low even with radical surgery [1,2,3,4]. In 1994, Kitano et al. [5] reported laparoscopic radical gastrectomy, with the development of minimally invasive equipment and technology, the safety and effectiveness of laparoscopic radical gastrectomy are gradually being recognized [6]. Since the MAGIC trial in 2006, which proved for the first time that preoperative neoadjuvant chemotherapy (NAC) combined with surgery can significantly improve the 5-year overall survival rate of patients with AGC [7], NAC has gradually become an indispensable part of treatment for AGC patients. However, for patients receiving NAC, fibrosis of lymphatic tissue caused by NAC and loss of normal anatomical planes caused by cytotoxicity are technical challenges for laparoscopic lymph-node (LN) dissection [8,9,10]. Although studies have confirmed the safety and feasibility of laparoscopic distal gastrectomy for patients with neoadjuvant gastric cancer, for more technically difficult whole-stomach resections and for inexperienced surgeons, neoadjuvant standard gastric cancer radical resection after chemotherapy is a challenge. In contrast, Taylor et al. [11] found that, due to reasons including tumor downgrading, patients receiving NAC require more LN dissections to truly reflect the prognosis of patients. Therefore, for patients with gastric cancer who have undergone NAC and plan to undergo laparoscopic surgery, surgeons should focus on how to safely complete the operation and complete the standardized and precise LN dissection.
Indocyanine green (ICG) near-infrared light imaging technology, as a new surgical navigation technology, has achieved relatively positive results in sentinel LN dissection and in detecting the location of tumors such as breast cancer and non-small cell lung cancer [11,12,13,14]. Furthermore, in gastric cancer research, prospective studies have reported that ICG can significantly increase the number of LN dissections during laparoscopic radical gastrectomy [28,29,30,31]. However, in neoadjuvant patients with AGC, fibrosis reaction or cytotoxicity caused by chemotherapy can cause loss of the normal tissue plane. However, evidence regarding whether it will affect LN visualization or tissue discrimination by ICG in these patients is lacking. This study included patients with AGC who underwent laparoscopic radical resection after NAC in two centers in China and analyzed the relationship between ICG injection and the number of LNs dissected and LN non-compliance in detail. Our study shows that ICG can reduce intraoperative blood loss without increasing the operation time and number of complications, and it can guide the surgeon to dissected more LNs during laparoscopic radical gastrectomy after neoadjuvant therapy and reduce the LN non-compliance rate. In particular, for surgical patients with poor chemotherapy effects, the effect is obvious.
The total number of LNs dissected and the LN non-compliance rate are of great significance in radical gastrectomy. Previous studies have confirmed that, regardless of whether the dissected LNs are metastasized, the perigastric LNs are thoroughly dissected during surgery, the number of LNs is detected, and the rate of LN non-conformance is reduced. Accurate staging, selection of appropriate subsequent treatment options, and improvement in prognoses are of great significance. Studies have proven that patients with NAC need more LN dissections to truly reflect the tumor stage and prognosis of patients [11]. Among patients with gastric cancer who did not receive NAC, our center concluded through randomized-controlled trial research that, in the early stage of disease, ICG can guide the surgeon to dissect more LNs and LNs during laparoscopic radical gastrectomy without increasing the operation time and complications, effectively reducing LN inconsistencies in patients undergoing total gastrectomy [ Huang CM and Yan S had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Ahn HS, Lee HJ, Hahn S, Kim WH, Lee KU, Sano T, et al. Evaluation of the seventh American Joint Committee on Cancer/International Union Against Cancer Classification of gastric adenocarcinoma in comparison with the sixth classification. Cancer. 2010;116:5592–8. Sobin LH, Wittekind CH. TNM Classification of Malignant Tumors (6th edn). New York: Wiley-Liss; 2002. Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. 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JAMA Surg. 2019;154(2):150–8. https://doi.org/10.1001/jamasurg.2018.4267. Hu X. Zhonghua wei chang wai ke za zhi. Chinese J Gastrointest Surg. 2013;16(6):509–12. Gioux S, et al. Image-guided surgery using invisible near-infrared light: fundamentals of clinical translation. Mol Imaging. 2010;9:237–55. Schaafsma BE, et al. The clinical use of indocyanine green as a near-infrared fluorescent contrast agent for image-guided oncologic surgery. J Surg Oncol. 2011;104:323–32. This work was supported by scientific and technological innovation joint capital projects of Fujian province (2017Y9011, 2017Y9004, and 2018Y9041) and the general project of Startup Fund of Fujian Medical University (2019QH1033). Conception and design: Ze-Ning Huang, Cheng-Hao Liu, Wen-Wu Qiu, Su-Yan, and Changming Huang. Provision of study materials or patients: all authors. Collection and assembly of data: all authors. Data analysis and interpretation: Ze-Ning Huang, Cheng-Hao Liu, Wen-Wu Qiu, Su-Yan, Chao-Hui Zheng, and ** Li. Manuscript writing: all authors. Final approval of manuscript: all authors. Accountable for all aspects of the work: all authors. There are no conflicts of interest or financial ties to disclose from any of author. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions. Informed consent or a substitute for it was obtained from all patients for inclusion in the study. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Below is the link to the electronic supplementary material. Supplementary file7 (WMV 82843 KB) Huang, ZN., Su-Yan, Qiu, WW. et al. Assessment of indocyanine green tracer-guided lymphadenectomy in laparoscopic gastrectomy after neoadjuvant chemotherapy for locally advanced gastric cancer: results from a multicenter analysis based on propensity matching.
Gastric Cancer 24, 1355–1364 (2021). https://doi.org/10.1007/s10120-021-01211-7 Received: Accepted: Published: Issue Date: DOI: https://doi.org/10.1007/s10120-021-01211-7Data accessibility statement
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