Gregor Alexander, Sata Yuki, Hiraishi Yoshihisa, Ishiwata Tsukasa, Aragaki Masato, Kitazawa Shinsuke, Koga Takamasa, Ogawa Hiroyuki, Bernards Nicholas, Yasufuku Kazuhiro
Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
J Thorac Cardiovasc Surg. 2023 Jan;165(1):337-350.e2. doi: 10.1016/j.jtcvs.2022.08.031. Epub 2022 Sep 12.
Lung sentinel lymph node mapping, where peritumorally injected material is tracked through the lymphatics, aims to find the first potential sites of nodal metastasis. We sought to evaluate the preclinical feasibility of bronchoscopic fluorescence-guided sentinel lymph node mapping.
Healthy Yorkshire pigs were used; sentinel lymph node mapping was performed with indocyanine green. The primary fluorescence imaging method was an ultrathin composite fiberscope placed in the bronchoscope working channel. Secondary methods used a fluorescence thoracoscope placed in the trachea (rigid bronchoscopy) and pretracheal fascial plane (mediastinoscopy) to validate ultrathin composite fiberscope settings for sentinel lymph node detection. A tracheostomy was created, and the pig was placed in a lateral decubitus position. Transbronchial intraparenchymal indocyanine green injection was performed primarily in the right lower lobe. Ultrathin composite fiberscope and rigid bronchoscopy were performed with (n = 6) or without (n = 2) mediastinoscopy, with the former group guiding dose and ultrathin composite fiberscope optimization. Fluorescent targets were interrogated by endobronchial ultrasound before ultrathin composite fiberscope-guided transbronchial needle aspiration. Specimen fluorescence was documented before creating cytological smears. Pigs were killed postprocedure for nodal dissection.
A total of 100 μL of 10 mg/mL indocyanine green generated strong transbronchial fluorescence with low risk of indocyanine green contamination. Fluorescence was detectable by 10 minutes postinjection. There was concordance among ultrathin composite fiberscope, rigid bronchoscopy, and mediastinoscopy. Except for 1 pig with airway contamination, ultrathin composite fiberscope-guided endobronchial ultrasound transbronchial needle aspiration obtained fluorescent material in all pigs. Specimen fluorescence was associated with specimen adequacy.
Bronchoscopic fluorescence-guided sentinel lymph node mapping was feasible, with specimen fluorescence providing real-time feedback on sentinel lymph node biopsy success. If translated to clinical practice, attention must be paid to minimizing indocyanine green leakage.
肺前哨淋巴结 mapping，即通过淋巴管追踪瘤周注射的物质，旨在找到淋巴结转移的首个潜在部位。我们试图评估支气管镜荧光引导下前哨淋巴结 mapping 的临床前可行性。
使用健康的约克夏猪；用吲哚菁绿进行前哨淋巴结 mapping。主要的荧光成像方法是将超薄复合纤维镜置于支气管镜工作通道内。辅助方法是将荧光胸腔镜置于气管内（硬质支气管镜检查）和气管前筋膜平面（纵隔镜检查），以验证用于前哨淋巴结检测的超薄复合纤维镜设置。建立气管造口术，将猪置于侧卧位。主要在右下叶进行经支气管实质内吲哚菁绿注射。超薄复合纤维镜和硬质支气管镜检查在有（n = 6）或无（n = 2）纵隔镜检查的情况下进行，前一组用于指导剂量和超薄复合纤维镜优化。在超薄复合纤维镜引导下经支气管针吸活检前，通过支气管内超声询问荧光靶点。在制作细胞学涂片之前记录标本荧光。术后处死猪进行淋巴结解剖。
总共 100 μL 的 10 mg/mL 吲哚菁绿产生强烈的经支气管荧光，吲哚菁绿污染风险低。注射后 10 分钟可检测到荧光。超薄复合纤维镜、硬质支气管镜检查和纵隔镜检查结果一致。除 1 只猪有气道污染外，超薄复合纤维镜引导下的支气管内超声经支气管针吸活检在所有猪中均获得了荧光物质。标本荧光与标本充足性相关。
支气管镜荧光引导下前哨淋巴结 mapping 是可行的，标本荧光可为前哨淋巴结活检成功提供实时反馈。如果转化为临床实践，必须注意尽量减少吲哚菁绿渗漏。
