Pilot-study on the feasibility of sentinel node navigation surgery in combination with thoracolaparoscopic lymphadenectomy without esophagectomy in early esophageal adenocarcinoma patients

Abstract

High-risk submucosal esophageal adenocarcinoma's might be treated curatively by means of radical endoscopic resection, followed by thoracolaparoscopic lymphadenectomy without concomitant esophagectomy. A preclinical study has shown the feasibility and safety of this approach; however, no studies are performed in a clinical setting. In addition, sentinel node navigation surgery could be valuable in tailoring the extent of the lymphadenectomy. This study aimed to evaluate the feasibility and safety of thoracolaparoscopic lymphadenectomy without esophagectomy (phase I) and sentinel node navigation surgery (phase II) in patients with early esophageal adenocarcinoma. Patients with T1N0M0 early esophageal adenocarcinoma scheduled for esophagectomy without neoadjuvant therapy were included. Phase I: Two-field, esophagus preserving, thoracolaparoscopic lymphadenectomy was performed, followed by esophagectomy in the same session. Primary outcome parameters were the number of lymph nodes resected, and number of retained lymph nodes in the esophagectomy specimen. Phase II: A radioactive tracer was injected endoscopically the day before surgery. Static imaging was performed 15 and 120 minutes after injection. The day of surgery, sentinel node navigation surgery followed by esophagectomy was performed. Primary outcome parameters were the percentage of patients with a detectable sentinel node, and the concordance between static imaging and probe-based detection of sentinel node. Phase I: Five patients were included, and a median of 30 (IQR: 25-46) lymph nodes was resected. A median of 6 (IQR: 2-9) retained lymph nodes was found in the esophagectomy specimen. No acute adverse events occurred, but near the end of lymphadenectomy esophageal discoloration was observed, possibly indicating ischemia. Phase II: In all five included patients sentinel nodes could be visualized and resected, at a median of 3 (IQR: 2-5) locations. There was a high concordance between imaging and probe-based detection of sentinel nodes. In conclusion, sentinel node navigation surgery followed by lymphadenectomy without concomitant esophagectomy seems feasible in patients with high-risk submucosal early esophageal adenocarcinoma. More evidence is however needed before applying this technique in clinical practice.

Sentinel node navigation surgery in esophageal cancer

“…To date, fewer studies have shown the feasibility and validity of the SN concept in esophageal cancer compared with studies on gastric cancer (Table ). However, a number of single institution studies have indicated acceptable outcomes of SN mapping and biopsy for early‐stage esophageal cancer .…”

Robot-assisted minimally invasive esophagectomy (RAMIE) improves perioperative outcomes: a review

“…The extent of nodal dissection can be further improved by near-infrared (NIR) fluorescent imaging modalities that are standardly integrated into the latest robotic platforms. This visual support can identify lymph nodes when a patient's tumor is injected preoperatively with labeled colloid or also preoperatively with indocyanine green (ICG) dye (47). Of course, it should be mentioned that conventional minimally invasive cameras are also available with NIR fluorescent imaging modes.…”

The evolution of surgical approach for esophageal cancer

“…The newest robotic systems offer technological improvements that will further enhance the surgeon's capabilities. Fluorescence cameras are now standard features on these systems and will allow visualization of the vascularization of the gastric conduit but possibly also help us to improve lymph node dissection and target sentinel nodes . Furthermore, a robotic 45‐mm stapler (EndoWrist® Stapler System, Intuitive Surgical, Sunnyvale, CA) was recently developed for use with the da Vinci Xi® Surgical System.…”

“…Fluorescence cameras are now standard features on these systems and will allow visualization of the vascularization of the gastric conduit but possibly also help us to improve lymph node dissection and target sentinel nodes. 46,47 Furthermore, a robotic 45-mm stapler (EndoWrist R Stapler System, Intuitive Surgical, Sunnyvale, CA) was recently developed for use with the da Vinci Xi R Surgical System. This stapler offers extended articulation (108°total side-to-side and 54°total up and down), and is equipped with force feedback.…”