Non–small cell lung cancer (NSCLC) prognosis is linked to lymphatic spread of disease, but localizing metastatic disease within locoregional lymphatics to accurately stage and guide therapy represents a clinical challenge. This challenge is evident in the nearly 30% recurrence rate and suboptimal overall survival among patients thought to have early-stage disease.1 Complex thoracic lymphatic pathways and variable surgeon practices result in inadequate nodal analysis in nearly 50% of patients with lung cancer undergoing surgery.2 Furthermore, the current practice of hematoxylin and eosin staining of sampled nodes misses metastatic disease in up to 22% of patients.3 Sentinel lymph node (SLN) mapping allows surgeons to target the first tumor-draining lymph node for sampling and for in-depth pathologic analysis. Previous applications of SLN mapping in NSCLC have been met with variable success. However, recent advances in image-guided surgery, specifically near-infrared (NIR) imaging, have led to renewed interest in the diagnostic and therapeutic benefits of SLN mapping. Two phase 1, single-institution clinical trials examined real-time NIR SLN mapping after peritumoral injection of the NIR fluorescent dye indocyanine green in patients with NSCLC. These trials resulted in a greater than 80% detection of NIR-positive SLN(s) without adverse events and identified metastatic disease exclusively within the SLN in several patients.4,5 The fluorescence itself is physiologically independent of disease status and is intended to function as an anatomical indicator of the most clinically relevant node (ie, the first tumor-draining lymph node). To reach tumors of varying sizes and locations, several approaches have been developed for peritumoral indocyanine green injection, including transthoracic injection for palpable tumors and navigational bronchoscopy–guided (Figure) or intraoperative computed tomography–guided injections for small, ill-defined early-stage tumors.
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Digesu CS, Weiss KD, Colson YL. Near-Infrared Sentinel Lymph Node Identification in Non–Small Cell Lung Cancer. JAMA Surg. 2018;153(5):487–488. doi:10.1001/jamasurg.2017.5928
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