Completeness of lung cancer surgery: is mediastinal dissection common practice?

Abstract

In patients with early-stage non-small cell lung cancer, surgery offers the best chance of cure when a complete resection, including mediastinal lymph node dissection, is performed. A definition for complete resection and guidelines for intra-operative lymph node staging have been published, but it is unclear whether these guidelines are followed in daily practice. The goal of this study was to evaluate the extent of mediastinal lymph node dissection routinely performed during lung cancer surgery, and hereby the completeness of resection according to the guidelines of the European Society of Thoracic Surgery (ESTS) for intra-operative lymph node staging. In a retrospective cohort study, the extent of mediastinal lymph node dissection was evaluated in 216 patients who underwent surgery for lung cancer with a curative intent in four different hospitals, three community hospitals and one university hospital. Data regarding clinical staging, the type of resection and extent of lymph node dissection were collected from both the patient's medical record and the surgical and pathology report. Based on histology, location and side of the primary tumour, the extent of mediastinal dissection was compared with the ESTS guidelines for intra-operative lymph node staging. According to the surgical report interlobar and hilar lymph nodes were dissected in one-third of patients. A mediastinal lymph node exploration was performed in 75% of patients; however, subcarinal lymph nodes were dissected in <50% of patients and at least three mediastinal lymph node stations were investigated in 36% of patients. In 35% of the mediastinal stations explored, lymph nodes were sampled instead of a complete dissection of the entire station. A complete lymph node dissection according to the guidelines of the ESTS was performed in 4% of patients. Despite an incomplete dissection unexpected mediastinal lymph nodes were found in 5% of patients. In daily practice, the intended curative resection for lung cancer cannot be considered complete in the majority of patients, because of an incomplete lymph node dissection according to the current guidelines of the ESTS.