Occult micrometastases can be missed by routine pathological analysis. Mapping of the pulmonary lymphatic system by near-infrared (NIR) fluorescence imaging can identify the first lymph node relay. This sentinel lymph node (SLN) can be analyzed by immunohistochemistry (IHC), which may increase micrometastasis detection and improve staging. This study analyzed the feasibility and safety of identifying SLNs in thoracic surgery by NIR fluorescence imaging in non-small cell lung cancer (NSCLC). This was a prospective, observational, single-center study. Eighty adult patients with suspected localized stage NSCLC (IA1 to IIA) were included between December 2020 and May 2022. All patients received an intraoperative injection of indocyanine green (ICG) directly in the peri tumoural area or by electromagnetic navigational bronchoscopy (ENB). The SLN was then assessed using an infrared fluorescence camera. SLN was identified in 60 patients (75%). Among them, 36 SLNs associated with a primary lung tumor were analyzed by IHC. Four of them were invaded by micrometastases (11.1%). In the case of pN0 SLN, the rest of the lymphadenectomy was cancer free. The identification of SLNs in thoracic surgery by NIR fluorescence imaging seems to be a feasible technique for improving pathological staging.
IntroductionThe place of segmentectomy in the management of lung cancer is shifting following the inspiring results of the Japanese JCOG0802 trial. I n this study, authors suggested that performing segmentectomy would require in an optimal way an intraoperative confirmation of pN0 tumor with a frozen section. Our objective was to determine whether the proposed technique, i.e. adjacent lymph node analysis, is consistent with the results of our study on sentinel lymph node (SLN) detection using fluorescence.MethodsThis is a retrospective, observational, single center study. Eighty-one patients with suspected localized stage NSCLC (IA to IIA) were included between December 2020 and March 2022. All patients received an intra-operative injection of indocyanine green (ICG) directly in the peritumoral area or by electromagnetic navigational bronchoscopy (ENB). The SLN was then assessed by using an infrared fluorescence camera.ResultsIn our cohort, SLN was identified in 60/81 patients (74.1%). In 15/60 patients with identified SLN (25%), NIR-guided SLN was concordant with the suggestions of JCOG0802 study. A retrospective SLN pathological analysis was performed in 43 patients/60 cases with identified SLN (71.2%), including 37 cases of malignant disease. Occult micro-metastases were found in 4 patients out of 37 SLN analyzed, leading to a 10.8% upstaging with NIR-guided SLN analysis.DicussionAt the time of segmentectomies, ICG technique allowed the identification of the SLN in a high percent of cases and in some areas usually out of the recommended stations for lymph node dissection.
To the Editor Dr Bhatnagar and colleagues 1 examined the effect of thoracoscopic talc poudrage vs talc slurry on pleurodesis in individuals with malignant pleural effusions and found no significant differences between the procedures. We have a number of concerns about the study.The term thoracoscopic talc poudrage usually refers to video-assisted thoracoscopic surgery and not to medical thoracoscopy, as described in the study, which may be confusing for readers. Furthermore, the type of procedure performed by the authors was not clearly described in the Methods section, suggesting that a range of techniques was used (including rigid, semi-rigid, and flexible medical thoracoscopy) with variation in efficiency. 2 This hypothesis is reinforced by the multi-institutional design of the study and could lead to possible bias.Although there are no published data comparing the efficiency of video-assisted thoracoscopic surgery vs medical thoracoscopy talc pleurodesis, it is largely accepted by most surgical teams that video-assisted thoracoscopic surgery leads to better results regarding recurrence of pleural effusion. Videoassisted thoracoscopic surgery allows for more efficient drainage of loculated effusions trapped in dense fibrous bands and distribution of talc throughout the pleural cavity, whereas medical thoracoscopy, as well as the slurry technique, do not allow adhesiolysis and only permit application of talc in a few parts of the pleural cavity. Hence, it would have been interesting to know the proportion of loculated effusions managed in both groups.In addition, the flowchart (Figure 1 in the article 1 ) indicated that 5 patients were excluded from the analysis in both groups after 90 days, although the primary outcome at 90 days was achieved. Was this a mistake? Most studies focus on 30 days after talc pleurodesis as the first date of assessment. 3 The authors should clarify why they used 90 days as the end point for the primary outcome.Additional studies should be conducted to compare medical vs surgical thoracoscopy to define the treatment algorithm for malignant pleural effusions.
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