Radical systematic mediastinal lymphadenectomy in non-small cell lung cancer

Abstract

The extent of lymphadenectomy in the treatment of non-small cell lung cancer (NSCLC) is still a matter of controversy. While some centers perform mediastinal lymph node sampling (LS) with resection of only suspicious lymph nodes, others recommend a radical, systematic mediastinal lymphadenectomy (LA) in order to improve survival and to achieve a better staging. Herein we report on the impact of LA on intra- and postoperative morbidity and mortality, on tumor staging and on the prognosis of patients with operable NSCLC in a controlled prospective randomized clinical trial comparing LS and LA in a total of 182 patients. Comparison of short-term results revealed a significantly longer operation time in the LA group, but overall-morbidity and mortality were comparable in both groups. However, there were LA-associated complications like prolonged air leak and hemorrhage. Regardless of the type of lymphadenectomy performed, the percentage of patients with pN1 or pN2 disease was very similar in both groups, indicating that systematic radical lymphadenectomy is not an essential prerequisite to determine the N stage of a patient. In contrast, the number of patients detected to have lymph node involvement at multiple levels was significantly increased by LA. In the LS group only 4 out of 23 patients (17.4%) with N2 disease were found to have more than one lymph node level involved, while LA results in the detection of excessive N2 disease in 12 out of 21 patients (57.2%, p=0.007). After a median follow-up of 26.8 months there was no significant influence of LA on local recurrence-free interval, metastasis-free interval, or cancer-related survival. Radical systematic lymphadenectomy is a safe operation and results in a more detailed staging of the N2 region. The prognostic benefit of LA is questionable.