ICG-Guided Lymphadenectomy during Surgery for Colon and Rectal Cancer-Interim Analysis of the GREENLIGHT Trial.

Dario Ribero,Giuseppe Spinoglio,Valentina Sega,Alfredo Mellano,Federica Mento,Domenico Lo Conte

doi:10.3390/biomedicines10030541

Dario Ribero, Giuseppe Spinoglio + Show 4 more

Open Access

https://doi.org/10.3390/biomedicines10030541

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Journal: Biomedicines	Publication Date: Feb 24, 2022
Citations: 15	License type: CC BY 4.0

Affiliation: MultiMedica, Candiolo Cancer Institute

Abstract

Lymphadenectomy is crucial for an optimal oncologic resection of colon and rectal cancers. However, without a direct visualization, an aberrant route of lymph node (LN) diffusion might remain unresected. Indocyanine-green (ICG) lymphatic mapping permits a real-time LNs visualization. We designed the GREENLIGHT trial to explore in 100 patients undergoing robotic colorectal resection the clinical significance of a D3 ICG-guided lymphadenectomy. The primary endpoint was the number of patients in whom ICG changed the extent of lymphadenectomy. We report herein the interim analysis on the first 70 patients. After endoscopic ICG injection 24 h (n = 49) or 72 h (n = 21) ahead, 19, 20, and 31 patients underwent right colectomy, left colectomy, and anterior rectal resection. The extent of lymphadenectomy changed in 35 (50%) patients, mostly (29 (41.4%)) for the identification of LNs (median two) outside the standard draining basin. Identification of such LNs was less frequent in rectal tumors that had undergone chemoradiotherapy (26.3%) (p > 0.05). A non-significant correlation between time-to-ICG injection and identification of aberrant LNs was observed (48.9% at 24 h vs. 23.8% at 72 h). The presence of LN metastases did not affect a proper fluorescent mapping. These data indicate that ICG lymphatic mapping provides relevant information in 50% of patients, thus increasing the accuracy of potentially curative resections.

Highlights

In colon and rectal cancer care, surgery remains the mainstay of the potentially curative treatment of non-metastatic disease
While the principles of a proper oncologic resection have been refined over the years, the importance of a regional lymphadenectomy is a concept that has been recognized since 1908, when Moynihan, discussing the surgical approach to these tumors, affirmed that “The surgery of malignant disease is not the surgery of organs, it is the anatomy of the lymphatic system” [1]
The interim analysis of the first 70 cases showed that ICG lymphatic mapping modifies in up to 50% of patients the extension of the D3 lymphadenectomy that would have been performed based on anatomical landmarks under white light vision

Summary

Introduction

In colon and rectal cancer care, surgery remains the mainstay of the potentially curative treatment of non-metastatic disease. While the principles of a proper oncologic resection have been refined over the years, the importance of a regional lymphadenectomy is a concept that has been recognized since 1908, when Moynihan, discussing the surgical approach to these tumors, affirmed that “The surgery of malignant disease is not the surgery of organs, it is the anatomy of the lymphatic system” [1]. Individual unpredictable variations of the lymphatic draining basin, with possible extramesocolic diffusion, have been observed in all colonic segments, in particular in tumors of the hepatic and splenic flexures [11,12,13]. The boundaries of the lymphatic area to dissect, in particular the D3 area, are Biomedicines 2022, 10, 541.

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