The use of indocyanine green and near-infrared fluorescence in the detection of metastatic lymph nodes during oesophageal and gastric cancer resection: a systematic review and meta-analysis
File(s)
Published version
Author(s)
Slim, Naim
Anbu, Deepika
Darzi, Ara
Elson, Daniel S
Peters, Christopher J
Type
Journal Article
Abstract
Background
Lymph node status is one of the most important prognosticating factors for patients afflicted by oesophageal cancer (OC) and gastric cancer (GC), and lymphadenectomy during surgery is therefore an essential step to ensure complete oncological resection and accurate disease staging. Intraoperative lymph node visualisation using near-infrared fluorescence (NIRF) and indocyanine green (ICG) tracing has been postulated to improve the overall lymph node yield, and to ensure the appropriate radicality, but its usefulness in the detection of metastatic lymph nodes remains unclear.
Methods
We conducted a systematic review and meta-analysis of the relevant literature to ascertain the accuracy of ICG-guided lymphadenectomy in the detection of metastatic nodes in OC and GC. The primary outcomes were the sensitivity, specificity and diagnostic odds ratio of ICG-guided lymphadenectomy. Secondary outcomes included measurement of the effect of prior neoadjuvant chemotherapy (NAC), tumour characteristics and method of ICG administration. Summary receiver operator characteristic (SROC) curves were built to illustrate the relationship between the sensitivity of ICG and false positive rate.
Results
From an initial search of 6,302 articles, 15 studies met the criteria for inclusion, incorporating 4,004 patients. The pooled sensitivity for metastatic node detection was 69.1% (95% CI 56.5–79.3%), specificity 47.4% (38.0–56.9%), and DOR 2.02 (1.40–2.92). The SROC curve for diagnostic test accuracy yielded an area under the curve of 0.60. The use of NAC adversely affected the sensitivity of ICG 74.7% [59.2–85.8%] without NAC; 52.8% [43.6–61.9%] with NAC, p = 0.018). No significant difference in efficacy was demonstrated between pathological ‘T’ stage, or ICG administration method.
Conclusion
Our findings suggest that the oncological benefits of NIRF and ICG in the context of lymphadenectomy in OC and GC are limited, and that surgeons risk omitting a significant proportion of metastatic nodes if this technique is solely relied upon.
Lymph node status is one of the most important prognosticating factors for patients afflicted by oesophageal cancer (OC) and gastric cancer (GC), and lymphadenectomy during surgery is therefore an essential step to ensure complete oncological resection and accurate disease staging. Intraoperative lymph node visualisation using near-infrared fluorescence (NIRF) and indocyanine green (ICG) tracing has been postulated to improve the overall lymph node yield, and to ensure the appropriate radicality, but its usefulness in the detection of metastatic lymph nodes remains unclear.
Methods
We conducted a systematic review and meta-analysis of the relevant literature to ascertain the accuracy of ICG-guided lymphadenectomy in the detection of metastatic nodes in OC and GC. The primary outcomes were the sensitivity, specificity and diagnostic odds ratio of ICG-guided lymphadenectomy. Secondary outcomes included measurement of the effect of prior neoadjuvant chemotherapy (NAC), tumour characteristics and method of ICG administration. Summary receiver operator characteristic (SROC) curves were built to illustrate the relationship between the sensitivity of ICG and false positive rate.
Results
From an initial search of 6,302 articles, 15 studies met the criteria for inclusion, incorporating 4,004 patients. The pooled sensitivity for metastatic node detection was 69.1% (95% CI 56.5–79.3%), specificity 47.4% (38.0–56.9%), and DOR 2.02 (1.40–2.92). The SROC curve for diagnostic test accuracy yielded an area under the curve of 0.60. The use of NAC adversely affected the sensitivity of ICG 74.7% [59.2–85.8%] without NAC; 52.8% [43.6–61.9%] with NAC, p = 0.018). No significant difference in efficacy was demonstrated between pathological ‘T’ stage, or ICG administration method.
Conclusion
Our findings suggest that the oncological benefits of NIRF and ICG in the context of lymphadenectomy in OC and GC are limited, and that surgeons risk omitting a significant proportion of metastatic nodes if this technique is solely relied upon.
Date Issued
2025-06-01
Date Acceptance
2025-03-30
Citation
Surgical Endoscopy: surgical and interventional techniques, 2025, 39 (6), pp.3525-3538
ISSN
0930-2794
Publisher
Springer
Start Page
3525
End Page
3538
Journal / Book Title
Surgical Endoscopy: surgical and interventional techniques
Volume
39
Issue
6
Copyright Statement
© The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
License URL
Identifier
10.1007/s00464-025-11703-7
Subjects
ICG
Near-infrared fluorescence
Image-guided surgery
Lymph nodes
Gastric cancer
Oesophageal cancer
Publication Status
Published
Date Publish Online
2025-04-18