What is the appropriate “first lymph node” in the era of segmentectomy for non-small cell lung cancer?

Abstract

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.

Clinicopathological factors associated with sentinel lymph node detection in non-small-cell lung cancer

“…By guiding lymph node dissection, SLN mapping could help reduce postoperative morbidity, which is rare but can occur due to hemorrhage, recurrent nerve paralysis, esophageal wounds, chylothorax, worsening of bronchial congestion by pulmonary denervation, and bronchial fistula by devascularization of the stump [ 27 ]. Moreover, as we have found [ 18 ], station 11 LN is not always the first relay. Hence, SLN mapping could be helpful in the era of segmentectomy in the future.…”

“…Since PET has been described as a predictive tool for SLN identification [ 13 ], we included PET data. The [ 18 ]F-fluorodeoxyglucose positron emission tomography results were reviewed by two attending nuclear medicine physicians. The PET image parameter we used was the mean maximum standardized uptake value (SUVmax) of the lesion.…”

“…Based on their method, we recently conducted a study to assess the safety and feasibility of an intraoperative near-infrared (NIR)–guided SLN approach to lymphatic mapping in patients with lung cancer. We found that NIR lymphatic mapping was feasible, safe and good at identifying regional lymph nodes [ 17 , 18 ]. Why SLN detection fails in some patients has not yet been evaluated.…”