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

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.

Keywords: ICG; ICG-guided lymphadenectomy; colorectal cancer; lymphatic mapping; robotic surgery.

Figure 1

Sketch of the operative field (A) and corresponding intraoperative pictures under white (B) and NIR (C) light of a male patient (#GLTr 69) undergoing robotic left colectomy for a sigmoid cancer. With NIR light, a fluorescent node is visualized on the left side of the aorta below the Gerota’s fascia. Enlarged lymph nodes at the origin of the IMA were harvested and left attached to the distal IMA stump (IMA: inferior mesenteric artery; Inf LSG: inferior branch of the left spermatic ganglion).

Figure 2

Sketch of the surgical field (A) and corresponding intraoperative pictures under white (B) and NIR (C) light of a female patient (#GLTr 7) undergoing robotic right colectomy with complete mesocolic excision and D3 lymphadenectomy with a bottom-to-up approach for a cancer of the ascending colon. With NIR light, a fluorescent node is visualized on the right gastroepiploic vessels (ICV: ileocolic vessels; GTH: gastroduodenal trunk of Henle; RGEV: right gastroepiploic vein; RGEA: right gastroepiploic artery; ASPDA: anterior superior pancreaticoduodenal artery; GEA: gastroduodenal artery).