Invited Commentary

Abstract

The question posed by Riquet and colleagues [1Riquet M. Berna P. Brian E. et al.Intrathoracic lymph node metastases from extrathoracic carcinoma: the place for surgery.Ann Thorac Surg. 2009; 88: 200-205Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar] and the basis for this article was the role of surgical intervention in patients with isolated, intrathoracic hilar/mediastinal lymph node metastases from extrathoracic malignancies. Of 565 such patients reviewed, 37 had a history of extrathoracic malignancies, and 11 were excluded when a biopsy specimen showed unrelated pathology. Of the remaining 26 patients, operations were done for diagnostic purposes in 15 patients who had breast, prostate, kidney, and laryngeal cancers, and melanoma. That left 11 patients with six different extrathoracic primaries who underwent lymphadenectomy as a curative procedure. Multiple stations were removed in 5 patients and single stations in 6, with genitourinary tract lesions accounting for the most cases. The authors correctly point out that the mechanism of spread of disease into the thorax from extrathoracic tumors is poorly understood for the most part, except for pelvic and renal lesions. Their 5-year survival rate was 41.6%, but 6 of the 11 died after an average of 21.6 months. This difference could be explained by selection bias, because the resected patients had more limited disease. In fact, the only long-term survivors, at 134 and 110 months, were 2 patients with testicular cancers, both of which were noted to have “evolved into mature tissue” after resection. The patient with breast cancer survived for 61 months, but it is quite possible that the same outcome could have been obtained with chemotherapy. Perhaps the major concern with this article is that the authors compared 11 patients who met criteria and who had resectable disease with 15 patients who did not, which is not a valid comparison. They concluded that, “these metastatic lesions may be isolated and that resection can be done safely with benefits to selected patients.” It is not possible to make a strong case for surgical intervention because the authors have not established that patients with resectable disease could not have had the same survival without an operation by using other forms of adjuvant therapy. To begin with, the number for the entire group is too small. The authors cover the literature well for these rare lesions, but unfortunately, the information provided here cannot be generalized over a broad spectrum of extrathoracic lesions. Not enough patients were included, and the successful cases reported are largely anecdotal, or even worse, if one considers the skew imposed by the 2 patients with testicular cancer. Therefore, the original intent of elucidating the role of surgical intervention in these patients, unfortunately, remains unanswered. Surgeons should exercise extreme caution when recommending a surgical procedure and decide each case on its merits. Intrathoracic Lymph Node Metastases From Extrathoracic Carcinoma: The Place for SurgeryThe Annals of Thoracic SurgeryVol. 88Issue 1PreviewIntrathoracic hilar or mediastinal lymph node metastases (HMLNMs) of extrathoracic carcinomas are infrequent. Their treatment strategy is not established and their prognosis poorly known. We reviewed the place of surgical intervention in their management. Full-Text PDF