P2.18-08 The Necessity and Technique of the Upper Zone Lymph Node Dissection for Non-Small-Cell Carcinoma of the Left Upper Lobe

Abstract

The removal of the whole regional lymphatic system together with primary tumor is one of the important rules in oncological surgery. According to the study of regional lymphatic drainage, we considered reasonable lymphadenectomy contributes the post-operative survival of the Left lung cancer patients with mediastinal lymph node metastasis. Due to anatomical limitations imposed by arch of aorta, it is difficult to perform complete dissection of upper zone mediastinal lymph nodes through the left thoracotomy in the left lung cancer. We had devised Systematic extended bilateral mediastinal dissection through a median sternotomy (ND3 operation) for patient with NSCLC of the left lung. This report aimed to introduce procedure of our operation and investigate the prognostic impact of Upper zone lymph node dissection for left upper lobe NSCLC. The our operative procedure is as follows. In the supine position, made a median sternotomy. We dissect the meidastinal nodes before pulmonary resection. The dissection is started on the highest area. Tape the right and left recurrent laryngeal nerve and dissect the highest paratracheal lymph nodes in the thoracic inlet. After making the pericardiotomy, the ascending aorta is retracted to the left. Remove the whole upper zone tissue lying in front of the trachea. And dissect the pre and paratracheal nodes, together with bilateral highest nodes. Then, dissect the subcarinal nodes. Tie off the blood vessels (arteries and veins) and airways leading to the affected lobe, and then remove the lobe. We retrospectively studied 213 patients [157 male and 61 female, mean ages 60.4 years (range, 29-75)], underwent ND3 operation due to NSCLC of the left upper lobe, from January 1990 till December 2017. The patients with NSCLC who are estimated to be able to conventional radical operation and aged 75 year-old or less becomes the adaptation of our operation. Overall 5-year survival rate in the 218 patients of left upper lung primary was 65.1%. Operative mortality in 218 patients was 2.8%. Lymph node metastasis to the mediastinum was confirmed in 70 (32.1%) patients (pN2 was 43, pN3α was 18, pN3γ was 9). According to pathological stages, five-year survival rate was 92.7% in stage IA ,80.1% in stage IB, 53.8% in stage IIA, 66.7% in stageIIB, 51.7% in stageIIIA, 38.4% in stageIIIB. And it was 52.1% in pN2 cases, and 55.0% in pN3α cases. Five-year disease free survival rate was was 85.6% in p-stage IA ,74.0% in p-stage IB,49.7% in p-stage IIA, 49.4% in p-stageIIB, 33.3% in p-stageIIIA, 19.4% in p-stageIIIB, 32.6% in pN2 cases, and 27.8% in pN3α cases. In this nonrandomized comrarision, the post-operative survival of patients with pN2 and pN3α NSCLC of the left upper lung primary would be remarkably improved by our Systematic Bilateral Mediastinal Dissection. And better local tumor control by our operation does not increase mortality. When faced with a patient with resectable mediastinal lymph node metastasis, we should consider Extended bilateral mediastinal lymph node dissection through a median sternotomy. To improve survival rate, it is important to perform curative operation with upper zone mediastinal dissection.