Feasibility and Accuracy of Sentinel Lymph Node Identification Using Indocyanine Green in Esophageal and Esophagogastric Junction Adenocarcinoma

Background Nodal metastasis is a predictor of survival in patients with esophageal and esophagogastric junction (EGJ) adenocarcinoma. However, clinical staging is unreliable. Extensive lymphadenectomy during esophagectomy is crucial for staging and is associated with a lower risk of recurrence and improved survival. The identification and biopsy of the primary draining, or sentinel, lymph node (SLN) to guide the extent of lymphadenectomy has been established in other cancers. We conducted a prospective study to evaluate the feasibility of SLN identification in esophageal and EGJ adenocarcinoma and to determine whether the SLN concept is applicable to this disease. Methods This was a prospective, single-arm prospective study conducted between 2020–2024 involving patients undergoing esophagectomy for resectable clinical stage I-IVA esophageal and EGJ adenocarcinoma. Following approval by our institutional IRB and informed consent, eligible patients underwent intraoperative sentinel lymph node (SLN) mapping using near-infrared imaging with indocyanine green (ICG) injected via endoscopy prior to esophagectomy. Lymphatic drainage patterns were documented, and the first identified nodes (SLNs) were harvested separately for pathological analysis. Standard esophagectomy and lymphadenectomy were then performed. SLN status was compared with the overall nodal status. Results Overall, 90 patients were enrolled, with 77 undergoing ICG mapping; this was successful in 83% (64/77) of cases. Among those, 73% (47/64) received neoadjuvant therapy (Table 1). Most patients (62/64) had a single SLN station identified; this was most commonly along the left gastric artery (43%), followed by paracardial (24%) and periesophageal (20%) stations. Seven patients had a positive SLN. In one case, only the SLN was positive, whereas the other 6 patients had additional positive nodes in other stations. Among patients with negative SLNs, 11/57 (19.3%) had metastatic nodes elsewhere. The negative predictive value of SLN assessment was 80.7%. Conclusion SLN mapping with ICG during esophagectomy is feasible in most cases. However, its ability to reliably predict the absence of nodal disease when the SLN biopsy is negative remains limited. Further analysis of untreated patients is ongoing. In the future, this technique may help guide additional surgical management in patients treated with endoscopic therapy alone. However, its use in this setting should be approached with caution until more data are available.