Minimally Invasive and Robotic Thoracic Surgery, Department of Surgical, Medical, Molecular Pathology and Critical Area, University Hospital of Pisa, 56124 Pisa, Italy.
Pathological Anatomy, Surgical, Medical, Molecular, and Critical Care Pathology Department, University Hospital of Pisa, 56124 Pisa, Italy.
Tomography. 2024 May 15;10(5):761-772. doi: 10.3390/tomography10050058.
Lymphadenectomy represents a fundamental step in the staging and treatment of non-small cell lung cancer (NSCLC). To date, the extension of lymphadenectomy in early-stage NSCLC is a debated topic due to its possible complications. The detection of sentinel lymph nodes (SLNs) is a strategy that can improve the selection of patients in which a more extended lymphadenectomy is necessary. This pilot study aimed to refine lymph nodal staging in early-stage NSCLC patients who underwent robotic lung resection through the application of innovative intraoperative sentinel lymph node (SLN) identification and the pathological evaluation using one-step nucleic acid amplification (OSNA). Clinical N0 NSCLC patients planning to undergo robotic lung resection were selected. The day before surgery, all patients underwent radionuclide computed tomography (CT)-guided marking of the primary lung lesion and subsequently Single Photon Emission Computed Tomography (SPECT) to identify tracer migration and, consequently, the area with higher radioactivity. On the day of surgery, the lymph nodal radioactivity was detected intraoperatively using a gamma camera. SLN was defined as the lymph node with the highest numerical value of radioactivity. The OSNA amplification, detecting the mRNA of CK19, was used for the detection of nodal metastases in the lymph nodes, including SLN. From March to July 2021, a total of 8 patients (3 female; 5 male), with a mean age of 66 years (range 48-77), were enrolled in the study. No complications relating to the CT-guided marking or preoperative SPECT were found. An average of 5.3 lymph nodal stations were examined (range 2-8). N2 positivity was found in 3 out of 8 patients (37.5%). Consequently, pathological examination of lymph nodes with OSNA resulted in three upstages from the clinical IB stage to pathological IIIA stage. Moreover, in 1 patient (18%) with nodal upstaging, a positive node was intraoperatively identified as SLN. Comparing this protocol to the usual practice, no difference was found in terms of the operating time, conversion rate, and complication rate. Our preliminary experience suggests that sentinel lymph node detection, in association with the accurate pathological staging of cN0 patients achieved using OSNA, is safe and effective in the identification of metastasis, which is usually undetected by standard diagnostic methods.
淋巴结切除术是非小细胞肺癌（NSCLC）分期和治疗的重要步骤。迄今为止，由于其可能的并发症，早期 NSCLC 淋巴结切除术的扩展仍然是一个有争议的话题。前哨淋巴结（SLN）的检测是一种可以改善需要更广泛淋巴结切除术的患者选择的策略。这项初步研究旨在通过应用创新的术中前哨淋巴结（SLN）识别和使用一步法核酸扩增（OSNA）进行的病理评估，改进早期 NSCLC 患者接受机器人肺切除术的淋巴结分期。选择计划接受机器人肺切除术的临床 N0 NSCLC 患者。手术前一天，所有患者均接受放射性核素 CT 引导下的原发性肺病变标记，随后进行单光子发射计算机断层扫描（SPECT）以识别示踪剂迁移，从而确定放射性较高的区域。手术当天，使用伽马相机术中检测淋巴结的淋巴结放射性。SLN 被定义为放射性计数最高的淋巴结。OSNA 扩增检测 CK19 的 mRNA，用于检测淋巴结中的淋巴结转移，包括 SLN。2021 年 3 月至 7 月，共有 8 名患者（3 名女性；5 名男性）入组，平均年龄为 66 岁（范围 48-77 岁）。未发现与 CT 引导标记或术前 SPECT 相关的并发症。平均检查了 5.3 个淋巴结站（范围 2-8）。8 名患者中有 3 名（37.5%）发现 N2 阳性。因此，OSNA 对淋巴结的病理检查导致 3 例从临床 IB 期到病理 IIIA 期的分期升级。此外，在 1 例（18%）淋巴结升级的患者中，术中识别的阳性淋巴结为 SLN。与常规实践相比，该方案在手术时间、转化率和并发症发生率方面没有差异。我们的初步经验表明，前哨淋巴结检测结合 OSNA 对 cN0 患者进行的准确病理分期，在识别通常无法通过标准诊断方法检测到的转移方面是安全有效的。
