Sentinel Node Mapping in Non-small Cell Lung Cancer Using an Intraoperative Radiotracer Technique

Document Type: Original Article

Authors

1 Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

2 Lung Disease Research Center, Emam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

3 Cancer Biology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

4 Thoracic Surgeon, Department of General Surgery, 5 Azar Hospital, Golestan University of Medical Science, Gorgan, Iran

5 Lung Disease Research Center, Faculty of Medicine Mashhad University of Medicine Sciences, Mashhad, Iran

Abstract

 Objective(s): Lymph node metastases are the most significant prognostic factor in localized non-small cell lung cancer (NSCLC). Identification of the first nodal drainage site (sentinel node) may improve detection of metastatic nodes. Extended surgeries, such as lobectomy or pneumonectomy with lymph node dissection, are among the therapeutic options of higher acceptability. Sentinel node biopsy can be an alternative approach to less invasive surgeries. The current study was conducted to evaluate the accuracy of sentinel node mapping in patients with NSCLC using an intraoperative radiotracer techniques.
Methods: This prospective study was conducted on 21 patients with biopsy-proven NSCLC who were candidates for sentinel node mapping during 2012-2014. All patients underwent thoracoabdominal computed tomography, based on which they had no lymph node involvement. Immediately after thoracotomy and before mobilizing the tumor, peritumoral injection of 2mCi/0.4 mL Tc-99m- phytate was performed in 4 corners of tumor. After mobilization of the tumoral tissues, the sentinel nodes were searched for in the hillar and mediastinal areas using hand-held gamma probe . Any lymph node with in vivo count twice the background was considered as sentinel node and removed and sent for frozen section evaluation. All dissected nodes were evaluated by step sectioning and hematoxylin and eosin staining (H&E).The recorded data included age, gender, kind of pathology, site of lesion, number of dissected sentinel nodes, number of sentinel nodes, and site of sentinel nodes. Data analysis was performed in SPSS software (version 22).
Results: The mean age of the patients was 58.52±11.46 years with a male to female ratio of 15/6. The left lower lobe was the most commonly affected site (30.09%). Squamous cell carcinoma and adenocarcinoma were detected in 11 and 10 subjects, respectively. A total of 120 lymph nodes were harvested with the mean number of 5.71±2.9 lymph nodes per patient. At least one sentinel node was identified in each patient, resulting in a detection rate of 95.2%. The mean number of sentinel nodes per patient was 3.61±2. Frozen section results showed 100% concordance with the results of hematoxylin and eosin staining.
Conclusion: Based on the findings, sentinel node mapping can be considered feasible and accurate for lymph node staging and NSCLC treatment.

Keywords

Main Subjects


1. Somi MH, Farhang S, Mirinezhad SK, Naghashi S, Seif-Farshad M, Golzari M. Cancer in East Azerbaijan, Iran: results of a population-based cancer registry. Asian Pac J Cancer Prev. 2008;9(2):327-30.

2. Taghizadeh Kermani A, Bagheri R, Tehranian S, Shojaee P, Sadeghi R, Krag DN. Accuracy of sentinel node biopsy in the staging of non-small cell lung carcinomas: systematic review and meta-analysis of the literature. Lung Cancer. 2013;80(1):5-14.

3. Nomori H, Watanabe K, Ohtsuka T, Naruke T, Suemasu K. In vivo identification of sentinel lymph nodes for clinical stage I non-small cell lung cancer for abbreviation of mediastinal lymph node dissection. Lung Cancer. 2004;46(1):49-55.

4. Naruke T, Tsuchiya R, Kondo H, Nakayama H, Asamura H. Lymph node sampling in lung cancer: how should it be done? Eur J Cardio Thorac Surg. 1999;16(Suppl 1):S17-24.

5. Liptay MJ, Masters GA, Winchester DJ, Edelman BL, Garrido BJ, Hirschtritt TR, et al. Intraoperative radioisotope sentinel lymph node mapping in non–small cell lung cancer. Ann Thorac Surg. 2000;70(2):384-9.

6. Abdollahi A, Jangjoo A, Dabbagh Kakhki VR, Rasoul Zakavi S, Memar B, Naser Forghani M, et al. Factors affecting sentinel lymph node detection failure in breast cancer patients using intradermal injection of the tracer. Rev Esp Med Nucl. 2010;29(2):73-7.

7. Sadeghi R, Forghani MN, Memar B, Abdollahi A, Zakavi SR, Mashhadi MT, et al. Comparison of pre-operative lymphoscintigraphy with inter-operative gamma probe and dye technique regarding the number of detected sentinel lymph nodes. Hell J Nucl Med. 2009;12(1):30-2.

8. Hassanzade M, Attaran M, Treglia G, Yousefi Z, Sadeghi R. Lymphatic mapping and sentinel node biopsy in squamous cell carcinoma of the vulva: systematic review and meta-analysis of the literature. Gynecol Oncol. 2013;130(1):237-45.

9. Sadeghi R, Gholami H, Zakavi SR, Kakhki VR, Tabasi KT, Horenblas S. Accuracy of sentinel lymph node biopsy for inguinal lymph node staging of penile squamous cell carcinoma: systematic review and meta-analysis of the literature. J Urol. 2012;187(1):25-31.

10. Dabbagh Kakhki VR, Bagheri R, Tehranian S, Shojaei P, Gholami H, Sadeghi R, et al. Accuracy of sentinel node biopsy in esophageal carcinoma: a systematic review and meta-analysis of the pertinent literature. Surg Today. 2014;44(4):607-19.

11. Bagheri R, Naghavi F, Kakhki VR, Zakavi SR, Fattahi AS, Jafarian AH, et al. Sentinel node mapping in esophageal squamous cell carcinoma using intra-operative combined blue dye and radiotracer techniques. Esophagus. 2013;10(4):211-6.

12. Nomori H, Horio H, Naruke T, Orikasa H, Yamazaki K, Suemasu K. Use of technetium-99m tin colloid for sentinel lymph node identification in non– small cell lung cancer. J Thorac Cardiovasc Surg. 2002;124(3):486-92.

13. Jangjoo A, Forghani MN, Mehrabibahar M, Sadeghi R. Anaphylaxis reaction of a breast cancer patient to methylene blue during breast surgery with sentinel node mapping. Acta Oncol. 2010;49(6):877-8.

14. Little AG, DeHoyos A, Kirgan DM, Arcomano TR, Murray KD. Intraoperative lymphatic mapping for non–small cell lung cancer: the sentinel node technique. J Thorac Cardiovasc Surg. 1999; 117(2):220-4.

15. Sadeghi R, Alesheikh G, Zakavi SR, Fattahi A, Abdollahi A, Assadi M, et al. Added value of blue dye injection in sentinel node biopsy of breast cancer patients: do all patients need blue dye? Int J Surg. 2014;12(4):325-8.

16. Aliakbarian M, Memar B, Jangjoo A, Zakavi SR, Reza Dabbagh Kakhki V, Aryana K, et al. Factors influencing the time of sentinel node visualization in breast cancer patients using intradermal injection of the radiotracer. Am J Surg. 2011;202(2):199-202.

17. Sadeghi R, Forghani MN, Memar B, Rajabi Mashhadi MT, Dabbagh Kakhki VR, Abdollahi A, et al. How long the lymphoscintigraphy imaging should be continued for sentinel lymph node mapping? Ann Nucl Med. 2009;23(6):507-10.

18. Liptay MJ, Grondin SC, Fry WA, Pozdol C, Carson D, Knop C, et al. Intraoperative sentinel lymph node mapping in non-small-cell lung cancer improves detection of micrometastases. J Clin Oncol. 2002; 20(8):1984-8.

19. Bluemel C, Herrmann K, Kubler A, Buck AK, Geissinger E, Wild V, et al. Intraoperative 3-D imaging improves sentinel lymph node biopsy in oral cancer. Eur J Nucl Med Mol Imaging. 2014;41(12):2257-64.

20. Bluemel C, Herrmann K, Muller-Richter U, Lapa C, Higuchi T, Wild V, et al. Freehand SPECT-guided sentinel lymph node biopsy in early oral squamous cell carcinoma. Head Neck. 2014;36(11):E112-6.

21. Sugi K, Fukuda M, Nakamura H, Kaneda Y. Comparison of three tracers for detecting sentinel lymph nodes in patients with clinical N0 lung cancer. Lung Cancer. 2003;39(1):37-40.

22. Salhab M, Al Sarakbi W, Mokbel K. Skin and fat necrosis of the breast following methylene blue dye injection for sentinel node biopsy in a patient with breast cancer. Int Semin Surg Oncol. 2005;2:26.

23. Ramin S, Azar FP, Malihe H. Methylene blue as the safest blue dye for sentinel node mapping: emphasis on anaphylaxis reaction. Acta Oncol. 2011;50(5):729-31.

24. Rzyman W, Hagen OM, Dziadziuszko R, Kobierska- Gulida G, Karmolinski A, Lothe IM, et al. Intraoperative, radio-guided sentinel lymph node mapping in 110 nonsmall cell lung cancer patients. Ann Thorac Surg. 2006;82(1):237-42.

25. Hashemzadeh SM. Epidemiological study of lung cancer in East Azerbaijan, Iran. J Cardiovasc Thorac Res. 2009;1(4):7-12.

26. Memar B, Sadeghi R, Ayati NK, Aledavood SA, Tghizadeh A, Naseri S, et al. The value of touch imprint cytology and frozen section for intra-operative evaluation of axillary sentinel lymph nodes. Pol J Pathol. 2010;61(3):161-5.

27. Takizawa H, Sakiyama S, Tsuboi M, Tangoku A. Demonstration of the skip metastasis pathway for N2 non-small cell lung cancer. J Thorac Cardiovasc Surg. 2014;147(4):e50-2.

28. Komatsu H, Mizuguchi S, Izumi N, Chung K, Hanada S, Inoue H, et al. Sialyl Lewis X as a predictor of skip N2 metastasis in clinical stage IA non-small cell lung cancer. World J Surg Oncol. 2013;11:309.

29. Atinkaya C, Ozlem Kucuk N, Koparal H, Aras G, Sak SD, Ozdemir N. Mediastinal intraoperative radioisotope sentinel lymph node mapping in non-small-cell lung cancer. Nucl Med Communs. 2005;26(8):717-20.

30. Ueda K, Suga K, Kaneda Y, Sakano H, Tanaka T, Hayashi M, et al. Radioisotope lymph node mapping in nonsmall cell lung cancer: can it be applicable for sentinel node biopsy? Ann Thorac Surg. 2004;77(2):426-30.

31. Lardinois D, Brack T, Gaspert A, Spahr T, Schneiter D, Steinert HC, et al. Bronchoscopic radioisotope injection for sentinel lymph-node mapping in potentially resectable non-small-cell lung cancer. Eur J Cardiothorac Surg. 2003;23(5):824-7.