Invited commentary

Abstract

Systematic nodal dissection (SND) has become standard practice when undertaking pulmonary resection for lung cancer with curative intent. It is accepted by the International Association for the Study of Lung Cancer (IASLC) as an important step in the intrathoracic staging of lung cancer. In practice it has two component steps; the first to excise all mediastinal fat and the nodes contained therein, submitted for histological analysis labeled in accordance with an internationally accepted nodal chart, and the second step to extend this evaluation to the hilar, interlobar, lobar and segmental nodes in a centrifugal manner until the extent of resection has been determined. SND will demonstrate “unexpected” N2 disease in up to 25% of cases and ensures that complete resection has been performed with the minimum resection of lung parenchyma.As the resection of pulmonary metastases has become established for the curative treatment of selected patients with varied primary tumors in most parts of the body surgeons have experienced the occasional unpleasant surprise when “unexpected” involved nodes have been found at thoracotomy. Undoubtedly earlier estimates of the incidence of nodal deposits have been an underestimate as nodal dissection has not been “systematic.” We all should therefore be grateful to Dr Loehe and colleagues for doing the study many felt was necessary but no one else was prepared to undertake. Their study, published in this issue of The Annals of Thoracic Surgery provides the answer to the question as to whether SND should be routine at pulmonary metastasectomy. The answer is a definite yes, with “unexpected” nodal disease being identified in N1 and N2 stations in 1 in 7 patients (14.3%).No doubt the debate will now follow the same lines as that over SND in lung cancer. Does SND contribute to our attempts at cure, or is it an investigation that merely gives insight into the prospects for cure? Should the findings influence decisions regarding adjuvant therapy, and will this improve the cure rate? Is there increased morbidity with this extension to the surgical procedure? Can nodal dissection be applied selectively according to cell-type, number, size and site of metastases? Is this another argument against the resection of pulmonary metastases by video-assisted techniques? Loehe and colleagues have established that SND is necessary and it is for the thoracic surgical community to respond with further evidence to answer these questions. Systematic nodal dissection (SND) has become standard practice when undertaking pulmonary resection for lung cancer with curative intent. It is accepted by the International Association for the Study of Lung Cancer (IASLC) as an important step in the intrathoracic staging of lung cancer. In practice it has two component steps; the first to excise all mediastinal fat and the nodes contained therein, submitted for histological analysis labeled in accordance with an internationally accepted nodal chart, and the second step to extend this evaluation to the hilar, interlobar, lobar and segmental nodes in a centrifugal manner until the extent of resection has been determined. SND will demonstrate “unexpected” N2 disease in up to 25% of cases and ensures that complete resection has been performed with the minimum resection of lung parenchyma. As the resection of pulmonary metastases has become established for the curative treatment of selected patients with varied primary tumors in most parts of the body surgeons have experienced the occasional unpleasant surprise when “unexpected” involved nodes have been found at thoracotomy. Undoubtedly earlier estimates of the incidence of nodal deposits have been an underestimate as nodal dissection has not been “systematic.” We all should therefore be grateful to Dr Loehe and colleagues for doing the study many felt was necessary but no one else was prepared to undertake. Their study, published in this issue of The Annals of Thoracic Surgery provides the answer to the question as to whether SND should be routine at pulmonary metastasectomy. The answer is a definite yes, with “unexpected” nodal disease being identified in N1 and N2 stations in 1 in 7 patients (14.3%). No doubt the debate will now follow the same lines as that over SND in lung cancer. Does SND contribute to our attempts at cure, or is it an investigation that merely gives insight into the prospects for cure? Should the findings influence decisions regarding adjuvant therapy, and will this improve the cure rate? Is there increased morbidity with this extension to the surgical procedure? Can nodal dissection be applied selectively according to cell-type, number, size and site of metastases? Is this another argument against the resection of pulmonary metastases by video-assisted techniques? Loehe and colleagues have established that SND is necessary and it is for the thoracic surgical community to respond with further evidence to answer these questions.