Intraoperative lymphatic mapping for non-small cell lung cancer: the sentinel node technique.

BACKGROUND: The purpose of the study was to determine the accuracy and role of the sentinel node technique in patients with non-small cell lung cancer. METHODS: This study was carried out on 36 consecutive patients undergoing lung resection. Peritumoral tissue was infiltrated with isosulfan blue dye and the first lymph node to stain was identified as a sentinel node. Sensitivity and specificity of the sentinel node in predicting the status of other lymph node stations were determined. RESULTS: Seventeen patients had sentinel lymph nodes. In 9 of these 17 cases neither the sentinel node nor any other lymph node contained metastatic carcinoma. In 5 cases the sentinel node was in the mediastinum and documented unexpected N2 disease. In 19 patients no sentinel node was found. Final lymph node statuses were N0 in 13 patients, N1 in 5, and N2 in 1. CONCLUSIONS: The use of isosulfan blue for intraoperative lymphatic mapping is feasible. The specificity in our experience was good; 9 of 9 patients with negative sentinel nodes were found to be N0 on the final pathology report. Unexpected N2 disease was found in 5 patients. The accumulation of further experience will determine the role of the sentinel node technique in patients with non-small cell lung cancer.

Bronchiolitis obliterans organizing pneumonia (BOOP) in lung transplant recipients.

We reviewed all tissue specimens from 163 transplant patients (108 double lung transplant [DLT], 55 single lung transplant [SLT]) between November 1983 and January 1994 for abnormalities indicating bronchiolitis obliterans organizing pneumonia (BOOP) and found 17 cases (14 DLT and 3 SLT). Of the three SLTs, BOOP was diagnosed by open lung biopsy (OLB) in two and one was found at autopsy. Of the 14 DLTs, BOOP was diagnosed by transbronchial biopsy (TBB) specimens (9), OLB specimens (2), autopsy (1), TBB and OLB specimens (1), and OLB specimens and autopsy (1). BOOP was found between 1 and 43 months posttransplantation; time of survival from diagnosis was between 2 and 36 months with 9 patients presently alive. Concurrent pathologic diagnosis at the time of BOOP findings were as follows: acute rejection (7) (grade 1 [4] and grade 2 [3]), BO and grade 1 rejection (2), BO and grade 2 rejection (2), BO and Aspergillus infection (1), acute alveolar injury (1), acute alveolar injury and pulmonary embolus (1), acute rejection (grade 1) and Burkholderia cepacia pneumonia (1). No other pathologic diagnosis was found in 1 patient. In total, 11 of 17 patients (65%) had associated acute rejection. Of the 17 patients, 7 subsequently developed BO and 3 had BO before the finding of BOOP. Death occurred in 8 patients (5 DLT and the 3 SLT) between 2 and 6 months after the diagnosis. We conclude that BOOP is an important complication after lung transplantation; it was present in 13% of DLTs and 5% of SLTs. BOOP was most often associated with acute rejection.

An evaluation of the role of omentopexy and of early perioperative corticosteroid administration in clinical lung transplantation. The University of Toronto and Washington University Lung Transplant Programs.

Early success in clinical lung transplantation was believed due in part to the technique of bronchial anastomosis, routine bronchial omentopexy, and avoidance of early postoperative corticosteroid therapy. A recent 16-month consecutive experience at the University of Toronto and Washington University with single or bilateral lung transplantation was compared to study the current short-term effect of these perioperative strategies. At the University of Toronto, of 37 patients undergoing lung transplantation, 30 (group I) had telescoped bronchial anastomoses, coverage of the bronchus with local tissue only (no omentopexy), and routine perioperative corticosteroid administration. At Washington University, of 50 patients having lung transplantation, 44 (group II) had end-to-end bronchial anastomoses wrapped in omentum and received no routine perioperative corticosteroid. In group I, septic lung disease was the most frequent indication (14 of 29 patients), whereas in group II obstructive lung disease was the most frequently encountered condition (24 of 44 patients). Sepsis accounted for three of five early deaths in group I (all due to resistant Pseudomonas cepacia infection in recipients who had cystic fibrosis) and for two of four perioperative deaths in group II (one Pseudomonas, and Candida). In group I, cytomegalovirus prophylaxis was administered to all patients except recipients negative for cytomegalovirus receiving grafts from donors also negative for cytomegalovirus. Cytomegalovirus infection requiring treatment was encountered in 5 of 30 patients in group I in comparison with 23 of 44 recipients in group II where only D+ and R- mismatches received prophylaxis. Routine omentopexy is not essential for successful lung transplantation. Early postoperative corticosteroids do not impair airway healing, but neither do these agents appear to protect against acute rejection episodes. While routine corticosteroids do not predispose the recipient to cytomegalovirus infection, their use may increase the likelihood of postoperative bacterial sepsis.