Discussion
tumor
REGRESSION, TUMOR, RECURRENCE, REFLUX, PRIMARY TUMOR
This RCT aimed to evaluate the role of ICG in LN tracing during laparoscopic radical gastrectomy. Our study shows that laparoscopic ICG fluorescence imaging-guided lymphadenectomy can improve the long-term OS and DFS of patients with GC and reduce the cumulative recurrence rate compared with conventional lymphadenectomy. This finding provides further evidence of the effectiveness and importance of ICG fluorescence imaging-guided lymphadenectomy in the treatment of GC.Previous studies have shown that within the specified scope of dissection, the greater the number of LNs retrieved, the better the long-term survival of GC patientsThis clinical trial found that the 3-year DFS rate and 3-year OS rates in the ICG group were significantly better than those in the non-ICG group, which may be due to more extensive and complete LN dissection in the ICG group. The pN stage of resectable GC is directly related to the number of metastatic LNsPrevious studies have shown that LN dissection noncompliance, especially major LN dissection noncompliance, significantly affects the long-term survival of GC patientsIt should be noted that the fluorescent LNs can only indicate, with an accuracy of about 62.2%–97.2%, that the LN receives lymphatic reflux from the tumor, though it is not necessarily a metastatic LN. Nevertheless, it is possible to have false negatives in ICG fluorescence, that is, nonfluorescent LNs with metastatic LNs as observed by near-infrared (NIR) imaging, with an incidence of 46.4% to 60%The recent therapeutic effectiveness of robot-assisted gastrectomy guided by ICG has been reportedICG solution was injected into the submucosal layer of the four quadrants around the primary tumor via endoscopy 1 day preoperatively. Patients who have previously undergone gastrectomy (such as distal gastrectomy) or endoscopic submucosal dissection may experience an alteration in their gastric wall anatomy, physiological function, and lymphatic drainageWith the reporting of previous studiesThe previously reported safety resultsThe present study had several limitations. First, this study only included patients from a single center. Based on the findings of this RCT, the Chinese Laparoscopic Gastrointestinal Surgery Study (CLASS) group conducted a multicenter RCT (CLASS-11 trial; NCT04593615) to provide further evidence. Second, the study did not include patients receiving neoadjuvant therapy, and patients often had tumor and LN regression and fibrotic responses after neoadjuvant therapy, although previous studies have shown that ICG tracing can also improve the number of LNs retrieved in patients who received neoadjuvant chemotherapyIn conclusion, for patients with resectable GC, ICG fluorescence imaging-guided lymphadenectomy can not only significantly improve the total number of LNs retrieved in laparoscopic D2 radical gastrectomy for GC, but it also shows substantial long-term oncological efficacy compared with conventional lymphadenectomy. We suggest that ICG-guided laparoscopic radical lymphadenectomy for GC be routinely performed.