Daniel Skubleny, MD, Jerry T Dang, MD, Samuel Skulsky, Noah J Switzer, MD, MPH, Chunhong Tian, MSc, Xinzhe Shi, MSc, Christopher de Gara, MD, FRCSC, Daniel W Birch, MD, FRCSC, Shahzeer Karmali, MD, FRCSC. University of Alberta
OBJECTIVE OF THE STUDY: Sentinel node navigation surgery (SNNS) in gastric cancer has been investigated for almost two decades in an effort to reduce operative morbidity. Indocyanine green (ICG) with enhanced infrared visualization is one technique with increasing evidence for clinical use. We are the first to systematically review and perform meta-analysis to assess the diagnostic utility of ICG and infrared electronic endoscopy (IREE) or near infrared fluorescent imaging (NIFI) for SNNS exclusively in gastric cancer.
METHODS AND PROCEDURES: A search of electronic databases MEDLINE, EMBASE, SCOPUS, Web of Science and the Cochrane Library using search terms “gastric/stomach” AND “tumor/carcinoma/cancer/neoplasm/adenocarcinoma/malignancy” AND “indocyanine green” was completed in May 2017. All human, English language randomized control trials, non-randomized studies, and case series were evaluated. Articles were selected by two independent reviewers based on the following major inclusion criteria: (1) diagnostic accuracy study design; (2) indocyanine green was injected at tumor site; (3) IREE or NIFI was used for intraoperative visualization. The primary outcomes of interest were identification rate, sensitivity and specificity. 327 titles or abstracts were screened after removing duplicates. The quality of all included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2.
RESULTS: Ten full text studies were selected for meta-analysis. A total of 643 patients were identified with the majority of patients possessing T1 tumors (79.8%). Pooled identification rate, diagnostic odds ratio, sensitivity and specificity was 0.99 (0.97 – 1.0), 380.0 (68.71 – 2101), 0.87 (0.80 – 0.93) and 1.00 (0.99 – 1.00) respectively. The summary receiver operator characteristic for ICG + IREE/NIFI demonstrated a test accuracy of 98.3%. Subgroup analysis found improved test performance for studies with low risk QUADAS-2 scores, studies published after 2010 and submucosal ICG injection. IREE had improved diagnostic odds ratio, sensitivity and identification rate compared to NIFI. Heterogeneity among studies ranged from low (I2 <25%) to high (I2 >75%).
CONCLUSIONS: The idea of SNNS in gastric cancer is intriguing because of the potential to limit operative morbidity. We found encouraging results regarding the accuracy, diagnostic odds ratio and specificity of the test. The sensitivity was not optimal but may be improved by a carefully planned and strict protocol to augment the technique. Given the limited number and heterogeneity of studies, our results must be viewed with caution.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87989
Program Number: P677
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster