Bilateral Mediastinal Dissection Research Articles

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

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.

P1.06-030 Extended Lymph Node Dissection through Median Sternotomy in N3 Left NSCLC Surgical Results and Anatomical Findings

The role of surgical approach to stage IIIA or IIIB disease surgery has been considered not appropriate. Patients with mediastinal lymph node metastasis have a poor prognosis, especially for N3 (contra lateral lymph node metastases) diseases, and lung operation is not typically indicated. We performed bilateral mediastinal lymph node dissection by median sternotomy to resect lung cancer and dissect the bilateral mediastinal lymph nodes. An extended surgical approach to bilateral neck and mediastinal nodal dissection based on the knowledge about the pathways of lymph drainage, systematic neck and bilateral mediastinal nodal dissection through a median sternotomy, beyond the anatomical difficulties would bring some improvement on the survival of the patients with N3 left NSCLC without any preoperative treatments routinely. Patients with p- N3α and N3γ (neck lymph node metastases case) cases have poor prognosis, and lung operation is not normally indicated. We have performed neck and bilateral mediastinal lymph node dissection by median sternotomy to resect lung cancer and dissect the bilateral mediastinal lymph nodes. We have performed this operation in 289 patients with primary left lung cancer excluding small cell carcinoma and stage IV since 1987. 42 patients had p-N3 lymph node metastases. We will report the investigation of the prognoses of left NSCLC patients who underwent initially our extended neck and bilateral mediastinal dissection, focused on the patients with N3 disease. According to the macroscopic dissection procedure, dissection of the lymphatics from the lungs to the supraclavicular lymph nodes was performed by sequential removal of the related organs. We systematically compared and reviewed the route of lymphatic communications to the neck and contra lateral side with the anatomical significance of left-to-right lymphatic communications in the bilateral mediastinal lymph nodes. The 5-year survival rate （Kaplan-Meier method), including operative deaths and deaths due to unrelated diseases, was 48.8% in p-N3α, 35.8% in N3γ. We found various lymphatic metastases pattern such as between neck and mediastinal lymph nodes and around the trachea in terms of clinical and anatomical status. Our surgical approach suggest the importance of the extend dissection by median sternotomy.

Detection of micrometastases in lymph nodes underwent systematic bilateral mediastinal dissection (BMD) for lung cancer patients by using immunohistochemical method

Detection of micrometastases in lymph nodes underwent systematic bilateral mediastinal dissection (BMD) for lung cancer patients by using immunohistochemical method

373 The efficacy of systematic bilateral mediastinal dissection for survival and investigation into lymph node metastasis in patients of non small cell lung cancer (NSCLC)

373 The efficacy of systematic bilateral mediastinal dissection for survival and investigation into lymph node metastasis in patients of non small cell lung cancer (NSCLC)

Role of systematic mediastinal dissection in N2 non-small cell lung cancer patients

The surgical results in patients with non-small cell lung cancer staged as N2 disease were historically analyzed. Twenty-six patients were confirmed to have N2 disease on the basis of histologic study of suspicious nodes without systematic mediastinal dissection (PI group), 50 patients underwent systematic mediastinal dissection (R2 group), and 17 patients had bilateral mediastinal dissection, 4 of whom were N3 positive (R3+ group) and 13, N3 negative (R3− group). The difference in the 5-year survival rate between the PI and R2 groups (8% and 16.3%, respectively) was not significant. All 4 patients in the R3+ group died of recurrence within 14 months after operation. Several findings suggest that some patients with N2 disease, especially those with three or more N2-positive stations, actually have N3 disease: The 3-year survival rate was higher in the R3− group (51.3%) compared with the R2 (32.6%; p = not significant) and PI groups (24%; p = 0.01); in the R2 group, the survival rate was significantly ( p = 0.017) better for patients with N2 metastases in two stations or less than in patients with three or more N2-positive stations; and the rate of early postoperative death related to cancer correlated with the number of N2-positive stations. We conclude that accurate diagnosis of N2 and N3 disease, and therefore better evaluation of survival for patients with N2 disease, is possible by bilateral mediastinal dissection.