Near infrared fluorescence-guided lymphadenectomy during esophagectomy for esophageal squamous cell carcinoma.

Abstract

Lymph node metastasis is a crucial prognostic factor for esophageal squamous cell carcinoma. This study evaluated the role of near-infrared fluorescence imaging-guided lymphadenectomy during minimally invasive esophagectomy after a peritumoral indocyanine green injection. A prospective cohort of 30 patients with esophageal squamous cell carcinoma who underwent minimally invasive esophagectomy with 2-field lymphadenectomy between January 2023 and December 2024 was evaluated. Preoperatively, indocyanine green dye (0.5 mL, 2.5 mg) was injected peritumoral in 4 quadrants. During lymphadenectomy, all indocyanine green-positive and -negative lymph nodes were retrieved and documented station-wise. On histopathology, the total number of lymph nodes retrieved was recorded, and indocyanine green positivity was correlated with histopathologic positivity as the primary endpoint. The median age of the cohort was 51 years (interquartile range: 45-61 years). The commonest location of esophageal squamous cell carcinoma was lower thoracic (14 of 30, 47%), and all patients received neoadjuvant chemoradiotherapy, followed by minimally invasive esophagectomy. A total of 678 lymph nodes were retrieved, with a median of 23.5 lymph nodes per patient (interquartile range: 9-40). Overall, 56 of 678 lymph nodes (8.3%) were indocyanine green positive, of which 16 (28.6%) were positive for malignancy on histopathology. Among the 678 lymph nodes harvested, 20 (2.9%) were positive on histopathology, with 80% (16 of 20) being indocyanine green fluorescence positive. The indocyanine green positivity in lymph nodes had an 80% sensitivity, a 93% specificity, a 28.3% positive predictive value, and a 99.4% negative predictive value for accurately detecting histopathology-positive lymph nodes. Esophagectomy with indocyanine green fluorescence-guided lymphadenectomy can serve as a complementary mapping tool to enhance the clearance of histopathology-positive lymph nodes. Indocyanine green-negative nodes showed a high negative predictive value but do not replace standard anatomic lymphadenectomy.