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Finding The True "N0" Cohort: Technical Aspects Of Near-infrared Sentinel Lymph Node Mapping In Non-Small Cell Lung Cancer
*William W Phillips1, *Kathleen D Weiss2, *Christopher S Digesu2, *Emanuele Mazzola3, *Lana Y Schumacher1, Yolonda L Colson1
1Massachusetts General Hospital, Boston, MA;2Brigham and Women's Hospital, Boston, MA;3Dana-Farber Cancer Institute, Boston, MA

Objectives: Missed nodal disease correlates with recurrence in early stage non-small cell lung cancer (NSCLC). Sentinel lymph node (SLN) mapping using near-infrared (NIR) guidance was examined in NSCLC for the potential to improve staging and outcomes through identification of occult nodal disease.
Methods: Retrospective analysis of two phase 1 clinical trials investigating NIR-guided SLN mapping utilizing indocyanine green (ICG) in patients with surgically resectable NSCLC. Method of injection, successful identification of NIR-positive SLNs, disease concordance between SLNs and lymphadenectomy specimen, disease free (DFS) and overall survival (OS) were evaluated.
Results: Between 2009 and 2018, 66 patients underwent intraoperative NIR-guided SLN mapping and lymphadenectomy following peritumoral ICG injection. For dose optimized injections, at least one NIR-positive SLN was identified following transpleural injection in 15 of 26 (57.7%) patients vs. 11 of 14 (78.5%) after transbronchial injection via navigational bronchoscopy. NIR-positive SLNs were identified in 13 of 25 wedge resections (52%) and 13 of 15 anatomic resections (86.7%). SLNs were 100% predictive of overall nodal status with 4 SLNs identifying occult nodal disease not found elsewhere in the lymphadenectomy specimen. Of 58 NSCLC patients eligible for outcome analysis, DFS and OS were 100% in the pN0 SLN group (n=25) compared to 63.6% (P=0.02) and 73.6% (P=0.01) in the pN0 non-SLN group (n=22).
Conclusions: NIR-positive SLNs are more reliably identified with transbronchial ICG injection and anatomic resections. To date, NIR SLN mapping is the only approach for identifying occult nodal disease associated with decreased recurrence and improved survival after surgery for NSCLC.


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