HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Frank E. Schmidt Watts R. Webb Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Schmidt, F. E. Articles by Rozans, M. H. Search for Related Content PubMed PubMed Citation Articles by Schmidt, F. E. Articles by Rozans, M. H. Related Collections Lung - cancer

Ann Thorac Surg 2002;74:870-875
© 2002 The Society of Thoracic Surgeons

---

Original article: general thoracic

Sentinel nodal assessment in patients with carcinoma of the lung

^a Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
^b Veterans Affairs Medical Center, University Hospital, New Orleans, Louisiana, USA

* Address reprint requests to Dr Schmidt, Department of Surgery, Louisiana State University Health Sciences Center 1542 Tulane Ave, New Orleans, LA 70112 USA
e-mail: fschmi{at}lsuhsc.edu

Presented at the Forty-eighth Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 8–10, 2001.

	Abstract

Top Abstract Introduction Material and methods Results Comment Discussion References

 
Background. Assessment of sentinel nodes to predict metastases in a regional nodal basin is valuable for staging patients with melanoma and breast carcinoma. This study tested whether injection of isosulfan blue and technetium-99 could identify mediastinal sentinel nodes in patients with lung carcinoma and determine whether sentinel node histology predicts distal nodal metastases.

Methods. Isosulfan blue and technetium-99 were injected into the tumor and pulmonary resection performed. The hilum and mediastinum were assessed visually and with the gamma probe, and a mediastinal nodal dissection was performed.

Results. Thirty-one patients were evaluated. Three patients had positive sentinel nodes and positive distal mediastinal nodes. Twenty-two patients had negative sentinel nodes and negative distal nodes. No sentinel node was identified in 6 patients and 2 patients had two sentinel nodes.

Conclusions. These data demonstrate that this rapid, simple technique can identify sentinel nodes in the mediastinum and that the sentinel node is an accurate predictor of distal nodal metastases in patients with lung cancer.

	Introduction

Top Abstract Introduction Material and methods Results Comment Discussion References

 
Lung carcinoma causes the greatest number of cancer deaths in both men and women in the United States and more than 180,000 new cases are diagnosed each year. Surgical resection is the treatment of choice for patients with localized disease, and there is general agreement about the indications for and the extent of primary tumor resection [1]. Assessment of the mediastinal lymph nodes and the surgical management of nodal disease remains unclear [2–13].

The sentinel nodes are the nodes of first drainage in a lymphatic bed. Assessment of the sentinel node to predict metastases in the regional nodal basin has proven valuable in staging patients with melanoma and breast carcinoma [14–19]. The accuracy of sentinel node biopsy has been studied in patients with non-small cell lung carcinoma [20, 21]. In a study by Riquet and colleagues [22], 22%–25% of patients have direct lymphatic passages from the lung to mediastinal lymph nodes and other clinical studies [6, 23, 24] have shown a high incidence of metastases to mediastinal nodes (N2) with no evidence of metastases to intrapulmonary or hilar nodes (N1). This phenomenon is commonly called skip metastases. This study sought to determine whether sentinel nodal assessment is a reliable predictor of nodal metastases in the mediastinum.

We hypothesized that injecting isosulfan blue and technetium-99 (⁹⁹Tc) colloid into primary lung carcinomas would allow detection of mediastinal sentinel lymph nodes. We also hypothesized that mediastinal sentinel nodal histology would accurately predict distal lymphatic histology in these patients.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Discussion References

 
This study was approved by the Louisiana State University Medical Center Institutional Review Board. All patients studied had proven carcinoma of the lung or lesions thought likely to be carcinoma. No patient was included if preoperative evaluation by chest roentgenograms or computed tomographic scans, or by mediastinoscopy or thoracoscopy showed mediastinal adenopathy. Thirty-eight patients were entered into the study from July 1, 1998, through October 31, 2001. Seven patients were later excluded from the study: 3 whose lesions proved to be benign, 1 whose instability during operation precluded resection, 2 who had pulmonary resections for carcinomas, but who had no mediastinal nodal dissection because of instability during operation, and 1 patient who had an incomplete nodal dissection. Thirty-one patients were eligible for evaluation. Isosulfan blue (1 mL) and ⁹⁹Tc fresh-filtered sulfur colloid (0.5 mCi, 1.0 mL) were injected directly into the periphery of the tumor. In 3 patients, ⁹⁹Tc was injected through the bronchoscope, and in 28 the radiocolloid was injected at thoracotomy. Injections through the bronchoscope were made on the afternoon before operation, but the injections made at thoracotomy were made upon entering the chest. Four patients had only isosulfan blue injected, and 1 patient has only ⁹⁹Tc injected. Pulmonary resection was performed, after which the hilum and mediastinum were assessed both visually and with the gamma probe. The sentinel nodes were excised and submitted as separate specimens. Mediastinal nodal dissection was performed in all eligible patients. In patients with upper or middle lobar lesions, the superior mediastinal lymph nodes were dissected and excised beginning at the apex of the thorax, removing all of the areolar tissue containing the lymph nodes caudally to the pulmonary hilum, clearing the side of the trachea, the superior vena cava, and removing all of the tissue between the vagus and phrenic nerves and beneath the azygos vein. The azygos vein and vagus nerves were not routinely divided.

On the left, the areolar tissue and lymph nodes beneath the aortic arch were dissected and excised, as well as the tissue surrounding the ascending aorta and the arch itself. The tissue in the superior mediastinum between the phrenic and vagus nerves was also excised, beginning at the apex of the thorax and clearing the aorta. Dissection of the inferior mediastinal lymph nodes was begun at the diaphragm at the inferior pulmonary ligament, removing the areolar tissue containing lymph nodes up to a point above and posterior to the pulmonary hilum, exposing the esophagus and inferior pulmonary vein. Dissections of the superior mediastinum were done in each patient with tumors of the upper or middle lobes and the dissection was routinely carried into the posterior and inferior mediastinum. The inferior mediastinum was routinely dissected in each patient with tumors of the lower lobes and the superior mediastinum was not dissected routinely in these patients.

Reassessment of the mediastinum with the gamma probe after dissection was routinely performed. The sentinel node and the mediastinal nodes were studied histologically using standard histology protocols. Specimens were submitted in 10% formalin. After overnight fixation, the lymph nodes were examined grossly, and a representative section was submitted for paraffin embedding. Five-micron sections were obtained and stained with hematoxylin and eosin. No immunochemical stains or serial sections were performed.

The patients ranged in age from 47 to 78 years, 15 were white and 16 were black. Only two patients were women. The 31 tumors were located in the right upper lobe (13), left upper lobe (10), left lower lobe (4), right lower lobe (3), and right middle lobe (1), and the cell types were squamous cell carcinoma (11), adenocarcinoma (7), bronchoalveolar (5), undifferentiated (3), large cell undifferentiated (2), small cell undifferentiated (1), bronchoalveolar and squamous cell (10), and carcinoid (1). The pulmonary resections performed are as follows: lobectomy (27), segmental resection (2), pneumonectomy (1), and wedge excision (1).

	Results

Top Abstract Introduction Material and methods Results Comment Discussion References

 
In 4 patients no dye was observed in the sentinel node, although each of these nodes concentrated ⁹⁹Tc. Three patients had blue nodes that did not concentrate ⁹⁹Tc. No sentinel node was identified in 6 patients, and 2 patients had two sentinel nodes. In 1 of these patients, one sentinel node concentrated dye, but not isotope, whereas the other concentrated the isotope but not the blue dye. In the other patient, both nodes contained both the dye and the isotope. Three patients had sentinel nodes that demonstrated metastases. All 3 patients had additional positive mediastinal nodes on histologic examination. In 22 patients the sentinel node was histologically negative and the mediastinal nodes were also histologically negative. In 1 patient, repeat examination of the mediastinum after nodal dissection using the gamma probe identified a 2.5-cm lymph node deep in the mediastinum that had not been seen or palpated and contained metastatic carcinoma. One of the patients in whom no sentinel node was recognized had only the ⁹⁹Tc injected. Two patients with positive mediastinal sentinel nodes also had metastases to hilar lymph nodes. One patient with a positive mediastinal sentinel node and who had positive distal mediastinal nodes did not have metastases to hilar (N1) nodes, a "skip metastasis."

Ten of the 13 patients with primary tumors in the right upper lobe had sentinel nodes identified: all were located in nodal station 4. All 10 patients with primary tumors of the left upper lobe had sentinel nodes identified. One node was in position 3, five were in position 4, two in position 5, two in position 6, and one in position 8. The sentinel node in the one patient with a middle lobe lesion was in position 4. Two patients with lesions of the right lower lobe had sentinel nodes identified and both were in position 9 (the inferior pulmonary ligament). Two of the 4 patients with primary tumors of the left lower lobe had sentinel nodes identified: 1 patient had two sentinel nodes, one in position 4 and one in position 5. The second patient had a sentinel node in position 8.

Nine of the 13 patients who had mediastinal nodal dissections after right upper lobectomy for carcinoma had the number of lymph nodes reported by the pathologist. The number ranged from 6 to 19 and the average number was 10.7. Eight of the 10 patients who had nodal dissections after left upper lobectomy had the number of nodes counted; the range was from 6 to 11 and the average was 7.3. Two of the patients with inferior mediastinal dissections after right lower lobectomy had the number of nodes stated: it was six in 1 patient and nine in the other. Two of the patients who had inferior mediastinal nodal dissections after left lower lobectomy for carcinoma had no nodal count reported. The 2 patients with left lower lobe primary tumors in whom the lymph nodes in the specimens were counted had three and eight lymph nodes, respectively. Of the 31 patients analyzed in this study, the number of lymph nodes removed from the mediastinal dissection was counted in 22 patients (Table 1).

	Comment

Top Abstract Introduction Material and methods Results Comment Discussion References

 
These findings demonstrate that direct injection of both dye and ⁹⁹Tc will accurately identify mediastinal sentinel nodes. Analysis of these data suggests that using both isosulfan blue and ⁹⁹Tc improves the sensitivity to detect mediastinal sentinel nodes. Despite the small number of subjects in this study, the fact that several patients concentrated enough blue dye for identification of the sentinel node yet insufficient ⁹⁹Tc, whereas others concentrated sufficient ⁹⁹Tc but insufficient blue dye strongly suggests that using both agents increases the sensitivity of this technique. In 6 subjects in this study no sentinel nodes were identified. One of these patients had only ⁹⁹Tc injected.

This study demonstrates that the sentinel node is a reliable predictor of the presence or absence of metastases in other mediastinal nodes. This is the key to accuracy of this technique. In all 3 patients with positive sentinel lymph nodes, the distal mediastinal lymphatic basin was found to contain lymph nodes positive for metastases, a true positive rate of 100%. In none of the 22 patients with sentinel lymph nodes negative for metastases, were lymph nodes positive for metastases found in the distal nodal basin of the mediastinum. Thus, the true negative rate of this technique as demonstrated in this study is 100%. The most significant point of sentinel nodal biopsy is to identify negative sentinel nodes and be assured that the distal nodal basin is also negative. Its significance is that a negative sentinel node will not indicate or demand a mediastinal nodal dissection, whereas a positive node makes this dissection mandatory. Thus, the critical concept is that a negative sentinel node reflects a node negative mediastinum. In all 22 patients with negative sentinel nodes these results were in concordance.

Cabanas introduced in 1977 the concept and the term sentinel node in a series of patients with carcinoma of the penis [25]. The technique revived interest in Halsted’s notion of sequential lymphatic dissemination. However, it is now known that more than one lymphatic channel may drain from a primary tumor and that "skip areas" are sometimes found. Riquet and associates [22] found direct passages in the pulmonary lymphatics to the mediastinum in 22.2% to 25% of subjects. Okada and colleagues found skip metastases in 37.5% of 141 patients with mediastinal nodal metastases (N2) from lung cancer [6].

Morton and colleagues [26] applied the concept to melanoma using vital blue dye. Since then numerous investigators [27–29] have used sentinel nodal mapping as an aid in evaluating lymphatic basins in several types of cancers. Some researchers have used radioactive isotopes, some vital dyes, and some combinations of both. Morton and co-workers [26] defined the sentinel node as being the "first lymph node that receives afferent lymphatic drainage from a primary tumor." This appears to be the best definition, but it must be recognized that there may be more than one sentinel node and that it may not have the highest concentration of dye or of the radioactive isotope [29]. However, one must recognize the node that receives most directly the afferent lymphatic drainage from a tumor as the sentinel node [30].

In the mediastinum this requires some degree of flexibility and subjectivity. Because of the proximity of the primary tumor to the hilum in many patients, the "shining through" phenomenon sometimes interfered with use of the gamma probe in the hilar region. The present study assessed only mediastinal nodes outside of the pleural envelope. Hilar nodes and nodes within the pleural envelope were not assessed. Because of nodal anthracosis, recognition of staining with isosulfan blue was sometimes difficult and required considerable judgment on the part of the surgeon. We found, as did Liptay and colleagues [21], that the ⁹⁹Tc colloid traversed the lymphatics into the mediastinum within an hour, and that the isosulfan blue traveled within minutes. When we began the study we did not know how long this interval would be and we injected the first 3 patients transbronchially using 1 mCi of the ⁹⁹Tc on the afternoon before operation. We soon realized that this interval was unduly long and that we could inject the isotope at the time of thoracotomy directly around the tumor and use only 0.5 mCi of ⁹⁹Tc. All of the isosulfan blue was injected at the operating table. We found that this technique was easily accomplished in the operating room and added no more than 15 minutes to the time of operation. Finally, using the gamma probe to reassess the mediastinum after completion of the dissection was helpful in 1 patient in identifying an additional "hot" lymph node.

Allergic reactions to isosulfan blue and the sulfur colloid have been reported, but are estimated to occur in less than 1% of patients [31]. We did not encounter any adverse drug effects in this group of patients.

In conclusion, 38 patients with lung carcinoma were entered into this study using isosulfan blue and ⁹⁹Tc colloid. The study sought to test the hypothesis that this technique could identify sentinel lymph nodes within the mediastinum. We also set out to determine whether the sentinel node histology would be an accurate predictor of the presence of nodal metastases in the remainder of the nodal basin in the mediastinum. In the 25 patients in whom a sentinel node was identified, the sentinel node was negative in 22 and no metastases were found in the mediastinal nodes (22 of 22 patients, 100%). In the 3 patients in whom the sentinel node was positive, all were found to have metastases in the mediastinum (3 of 3 patients, 100%). Thus, sentinel node evaluation appears to be an accurate way to stage the mediastinal nodal basin. One of the 3 patients with positive sentinel nodes had a skip metastasis, but the metastases in the distal mediastinum were accurately predicted by the sentinel node. Sentinel nodal assessment in the mediastinum using visual and gamma probe interrogation is feasible and does not add significantly to operative time. Identification of the sentinel node and its assessment should prove valuable in staging patients with lung carcinoma at operation.

	Discussion

Top Abstract Introduction Material and methods Results Comment Discussion References

 
DR DARRYL S. WEIMAN (Memphis, TN): It seems that with only 3 patients in the series having positive mediastinal nodes, coming to those conclusions might be a little bit too overreaching.

DR SCHMIDT: Well, what we found is what we found, and we realize that this is a small series, but we believe that the data are reliable.

DR WEIMAN: If you are going to do a mediastinal resection anyway, how will this change your plan?

DR SCHMIDT: Well, we think that we will learn a great deal about lung carcinoma from using the sentinel node technique, and it may be that complete mediastinal nodal dissection could be avoided by identifying patients with a negative sentinel node if this technique continues to prove a reliable guide.

DR WILLIAM A. COOK (North Andover, MA): I had two questions that I wanted to ask you. One is, I assume, although I do not think you stated, that these patients did not have preliminary mediastinoscopy or mediastinoscopy.

DR SCHMIDT: No, sir, they did not.

DR COOK: And the other is, do you have access to positron emission tomography (PET) scanning in your institution and did you, by any chance, PET scan any of these patients and find that they had positive nodes by PET scan in an area that was subsequently identified as your sentinel node?

DR SCHMIDT: We do have PET scanning available now, but during the period of this study it was not available for much of the time, and none of these patients were studied preoperatively with PET scans.

DR ROBERT J. CERFOLIO (Birmingham, AL): I want to thank Dr Schmidt for asking me to critique his article and for giving me the manuscript before the meeting. It is very well written and your presentation was excellent.

My first question is what would you say to the people out there who subscribe to the theory that complete thoracic lymph node dissection leads to increased survival for patients with non-small cell lung cancer? If we were to buy this argument—and the ACOSOG Z-30 study will hopefully tell us this soon—is the sentinel node important? Although there is a "risk" to thoracic lymphadenectomy—possible chylothoraces or nerve injuries—these are exceedingly rare—would you not agree that complete dissection then should be done on all patients?

And the other question I would like for you to talk a little bit about skip metastases. Also, are you really sure with this intraoperative Geiger counter—what is a signal for a N2 node versus an N1 node—is it that accurate? I think it may be difficult to tell where exactly (which node) is the sentinel lymph node.

And finally, if you took your idea one further step and you were able to inject a tumor preoperatively, could it theoretically help you with some sort of preoperative staging technique, like a nuclear scan, PET scan, or computed tomographic-PET scan. Could it help to more accurately stage a patient with or without N1 or N2 disease and avoid surgical staging procedures like mediastinoscopy, Chamberlin, or video assisted thoracoscopic lymph nodes biopsy? Is there any offshoot of this method or idea of yours in this direction?

DR SCHMIDT: Thank you very much. To answer the last question first, to do preoperative injection of the tumors through the bronchoscope and obtain PET scans might be very helpful. When we initiated this study, we did inject the first 3 patients through the bronchoscope, because we did not realize that we can inject directly at the operating table. Although bronchoscopic injection worked satisfactorily, the interval was too long, and we found it very difficult logistically to accomplish the injection. However, it may be worth further study.

As to the question about nodal dissection, we are very aggressive about complete mediastinal nodal dissection also. However, we believe that it may be worth further study. If the sentinel node continues to prove a reliable predictor of the distal nodal basin, it could be that many of these patients in whom we are now doing routine mediastinal dissections really would not benefit and we could omit that procedure. My colleagues and I wish to thank the association for the privilege of presenting these data.

	References

Top Abstract Introduction Material and methods Results Comment Discussion References

 

1. Ginsberg R.J., Rubinstein L.V. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Ann Thorac Surg 1995;60:615-623.[Abstract/Free Full Text]
2. Patterson G.A., Piazza D., Pearson F.G., et al. Significance of metastatic disease in subaortic lymph nodes. Ann Thorac Surg 1987;43:155-159.[Abstract]
3. Fernando H.C., Goldstraw P. The accuracy of clinical evaluative intrathoracic staging in lung cancer as assessed by postsurgical pathologic staging. Cancer 1990;65:2503-2506.[Medline]
4. Ishida T., Yano T., Maeda K., Kaneko S., Tateishi M., Sugimachi K. Strategy for lymphadenectomy in lung cancer three centimeters or less in diameter. Ann Thorac Surg 1990;50:703-713.
5. Bollen E.C.M., van Duin C.J., Theunissen P.H.M.H., v.’t Hof-Grootenboer B.E., Blijham G.H. Mediastinal lymph node dissection in resected lung cancer morbidity, and accuracy of staging. Ann Thorac Surg 1993;55:961-966.[Abstract]
6. Okada M., Tsubota N., Yoshimura M., Miyamoto Y. Proposal for reasonable mediastinal lymphadenectomy in bronchogenic carcinomas. Role of subcarinal nodes in selective dissection. J Thorac Cardiovasc Surg 1998;116:949-953.[Abstract/Free Full Text]
7. Izbicki J.R., Thetter O., Habekost M., et al. Radical systematic mediastinal lymphadenectomy in non-small cell lung cancer. A randomized controlled trial. Br J Surg 1994;81:229-235.[Medline]
8. Graham A.N.J., Chan K.J.M., Pastorino U., Goldstraw P. Systematic nodal dissection in the intrathoracic staging of patients with non-small cell lung cancer. J Thorac Cardiovasc Surg 1999;117:246-251.[Abstract/Free Full Text]
9. Roberts J.R., Blum M.G., Arildsen R., et al. Prospective comparison of radiologic, thoracoscopic, and pathologic staging in patients with early non-small cell lung cancer. Ann Thorac Surg 1999;68:1154-1158.[Abstract/Free Full Text]
10. Kernstine K.H., Stanford W., Mullan B.F., et al. PET, CT, and MRI with combidex for mediastinal staging in non-small cell lung carcinoma. Ann Thorac Surg 1999;68:1022-1028.[Abstract/Free Full Text]
11. Okada M., Tsubota N., Yoshimura M., Miyamoto Y., Matsuoka H. Prognosis of completely resected pN2 non-small cell lung carcinomas: what is the significant node that affects survival?. J Thorac Cardiovasc Surg 1999;118:270-275.[Abstract/Free Full Text]
12. Izbicki J.R., Passlick B., Hosch S.B., et al. Mode of spread in the early phase of lymphatic metastasis in non-small-cell lung cancer. Significance of nodal micrometastasis. J Thorac Cardiovasc Surg 1996;112:623-630.[Abstract/Free Full Text]
13. Martini N., Flehninger B.J., Zaman M.B., Beattie E.J. Results of resection in non-oat cell carcinoma of the lung with mediastinal lymph node metastases. Ann Surg 1983;198:386-397.[Medline]
14. Cox C.E., Pendas S., Cox J.M., et al. Guidelines for sentinel node biopsy and lymphatic mapping of patients with breast cancer. Ann Surg 1998;227:645-653.[Medline]
15. Krag D., Weaver D., Ashikaga T., et al. The sentinel node in breast cancer: a multicenter validation study. N Engl J Med 1998;339:941-946.[Abstract/Free Full Text]
16. Rahusen F.D., Torrenga H., van Diest P.J., et al. Predictive factors for metastatic involvement of nonsentinel nodes in patients with breast cancer. Arch Surg 2001;136:1059-1063.[Abstract/Free Full Text]
17. Wincherster D.J., Sener S.T., Wincherster D.P., et al. Sentinel lymphadenectomy for breast cancer: experience with 180 consecutive patients. Efficacy of filtered technetium 99m sulfur colloid with overnight migration time. J Am Coll Surg 1999;188:597-603.[Medline]
18. Gershenwald J.E., Thompson W., Mansfield P.F., et al. Multi-institutional melanoma lymphatic mapping experience: the prognostic value of sentinel lymph node status in 612 stage I or II melanoma patients. J Clin Oncol 1999;17:976-983.[Abstract/Free Full Text]
19. Balch C.M., Lange J.R. lymphatic mapping, and sentinel nodal lymphadenectomy for cancer: an overview. Ann Surg Oncol 2001;95:1-4.
20. Little A.G., DeHoyos A., Kirgan D., et al. Intraoperative lymphatic mapping for non- small cell lung cancer: the sentinel node technique. J Thorac Cardiovasc Surg 1999;117:20-24.
21. Liptay M.J., Masters G.A., Winchester D.J., et al. Intraoperative radioisotope sentinel lymph node mapping in non-small cell lung cancer. Ann Thorac Surg 2000;70:384-390.[Abstract/Free Full Text]
22. Riquet M., Hidden G., Debesse B. Direct lymphatic drainage of lung segments to the mediastinal nodes. J Thorac Cardiovas Surg 1989;97:623-632.[Abstract]
23. Yoshino I., Yokoyama H., Yano T. Skip metastasis to the mediastinal lymph nodes in non-small cell lung cancer. Ann Thorac Surg 1996;62:1021-1025.[Abstract/Free Full Text]
24. Bonner J.A., Garces Y.I., Sawyer T.E., et al. Frequency of noncontiguous lymph node involvement in patients with respectable nonsmall cell lung carcinoma. Cancer 1999;86:1159-1164.[Medline]
25. Cabanas R.M. An approach for the treatment of penile carcinoma. Cancer 1977;39:456-466.[Medline]
26. Morton D.L., Wen D., Wong J., et al. Technical details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg 1992;127:392-399.[Abstract/Free Full Text]
27. Tsioulias GJ, Wood TF, Morton DL, et al. Lymphatic mapping and focused analysis of sentinel lymph nodes upstage gastrointestinal neoplasm. Arch Surg 200;135:926–32.
28. Aikou T., Higashi H., Natsugoe S., et al. Can sentinel node navigation surgery reduce the extent of lymph node dissection in gastric cancer?. Ann Surg Oncol 2001;8:90-93.
29. Mozzilo N., Chiesa F., Botti G., et al. Sentinel node biopsy in head and neck cancer. Ann Surg Oncol 2001;8:103-105.
30. Nieweg O.E., Tanis P.J., Kroon B.R.B. The definition of a sentinel node. Ann Surg Oncol 2001;8:538-541.[Medline]
31. Leong S.P.L., Donegan E., Heffernon W., et al. Adverse reactions to isosulfan blue during selective sentinel lymph node dissection in melanoma. Ann Surg Oncol 2000;7:361-366.[Medline]

This article has been cited by other articles:

				M. J. Liptay Sentinel Node Mapping in Lung Cancer: The Holy Grail? Ann. Thorac. Surg., February 1, 2008; 85(2): S778 - S779. [Full Text] [PDF]

				Y. Minamiya, M. Ito, Y. Hosono, H. Kawai, H. Saito, Y. Katayose, S. Motoyama, and J.-i. Ogawa Subpleural injection of tracer improves detection of mediastinal sentinel lymph nodes in non-small cell lung cancer Eur. J. Cardiothorac. Surg., November 1, 2007; 32(5): 770 - 775. [Abstract] [Full Text] [PDF]

				H. Nomori, K. Ikeda, T. Mori, S. Shiraishi, H. Kobayashi, K. Iwatani, K. Kawanaka, and T. Kobayashi Sentinel node identification in clinical stage Ia non-small cell lung cancer by a combined single photon emission computed tomography/computed tomography system J. Thorac. Cardiovasc. Surg., July 1, 2007; 134(1): 182 - 187. [Abstract] [Full Text] [PDF]

				S. L. Chen, D. M. Iddings, R. P. Scheri, and A. J. Bilchik Lymphatic Mapping and Sentinel Node Analysis: Current Concepts and Applications CA Cancer J Clin, September 1, 2006; 56(5): 292 - 309. [Abstract] [Full Text] [PDF]

				W. Rzyman, O. M. Hagen, R. Dziadziuszko, G. Kobierska-Gulida, A. Karmolinski, I. M. Lothe, A. Babovic, M. Murawski, W. Paleczka, T. Jastrzebski, et al. Intraoperative, radio-guided sentinel lymph node mapping in 110 nonsmall cell lung cancer patients. Ann. Thorac. Surg., July 1, 2006; 82(1): 237 - 242. [Abstract] [Full Text] [PDF]

				T. Yoshimasu, S. Miyoshi, S. Oura, I. Hirai, Y. Kokawa, and Y. Okamura Limited mediastinal lymph node dissection for non-small cell lung cancer according to intraoperative histologic examinations J. Thorac. Cardiovasc. Surg., August 1, 2005; 130(2): 433 - 437. [Abstract] [Full Text] [PDF]

				O. Tiffet, A. G. Nicholson, A. Khaddage, N. Prevot, G. Ladas, F. Dubois, and P. Goldstraw Feasibility of the Detection of the Sentinel Lymph Node in Peripheral Non-small Cell Lung Cancer With Radio Isotopic and Blue Dye Techniques Chest, February 1, 2005; 127(2): 443 - 448. [Abstract] [Full Text] [PDF]

				E. G. Soltesz, S. Kim, R. G. Laurence, A. M. DeGrand, C. P. Parungo, D. M. Dor, L. H. Cohn, M. G. Bawendi, J. V. Frangioni, and T. Mihaljevic Intraoperative Sentinel Lymph Node Mapping of the Lung Using Near-Infrared Fluorescent Quantum Dots Ann. Thorac. Surg., January 1, 2005; 79(1): 269 - 277. [Abstract] [Full Text] [PDF]

				F. Puma Isolated mediastinal skip metastasis in lung cancer: Is it real N2 disease? J. Thorac. Cardiovasc. Surg., January 1, 2005; 129(1): 235 - 235. [Full Text] [PDF]

				M. B. Faries, R. J. Bleicher, X. Ye, R. Essner, and D. L. Morton Lymphatic Mapping and Sentinel Lymphadenectomy for Primary and Metastatic Pulmonary Malignant Neoplasms Arch Surg, August 1, 2004; 139(8): 870 - 877. [Abstract] [Full Text] [PDF]

				K. Ueda, K. Suga, Y. Kaneda, T.-S. Li, K. Ueda, and K. Hamano Preoperative imaging of the lung sentinel lymphatic basin with computed tomographic lymphography: a preliminary study Ann. Thorac. Surg., March 1, 2004; 77(3): 1033 - 1037. [Abstract] [Full Text] [PDF]

				K. Ueda, K. Suga, Y. Kaneda, H. Sakano, T. Tanaka, M. Hayashi, T.-S. Li, and K. Hamano Radioisotope lymph node mapping in nonsmall cell lung cancer: can it be applicable for sentinel node biopsy? Ann. Thorac. Surg., February 1, 2004; 77(2): 426 - 430. [Abstract] [Full Text] [PDF]

				K. Sugi, Y. Kaneda, M. Sudoh, H. Sakano, and K. Hamano Effect of radioisotope sentinel node mapping in patients with cT1 N0 M0 lung cancer J. Thorac. Cardiovasc. Surg., August 1, 2003; 126(2): 568 - 573. [Abstract] [Full Text] [PDF]

				D. Lardinois, T. Brack, A. Gaspert, T. Spahr, D. Schneiter, H.C. Steinert, and W. Weder Bronchoscopic radioisotope injection for sentinel lymph-node mapping in potentially resectable non-small-cell lung cancer Eur. J. Cardiothorac. Surg., May 1, 2003; 23(5): 824 - 827. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Frank E. Schmidt Watts R. Webb Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Schmidt, F. E. Articles by Rozans, M. H. Search for Related Content PubMed PubMed Citation Articles by Schmidt, F. E. Articles by Rozans, M. H. Related Collections Lung - cancer