Complete Mediastinal Lymph Node Dissection Research Articles

Robot-assisted esophagectomy with robot-sewn intrathoracic anastomosis (Ivor Lewis): surgical technique and early results.

Esophagectomy is the selected treatment for nonmetastatic esophageal and esophagogastric junction cancer, although high perioperative morbidity and mortality incur. Robot-assisted minimally invasive esophagectomy (RAMIE) effectively reduces cardiopulmonary complications compared to open esophagectomy and offers a technical advantage, especially for lymph node dissection and intrathoracic anastomosis. This article aims at describing our initial experience of Ivor Lewis RAMIE, focusing on the technique's main steps and robotic-sewn esophagogastrostomy. Prospectively collected data from all consecutive patients who underwent Ivor Lewis RAMIE for cancer was reviewed. Reconstruction was performed with a gastric conduit pull-up and a robotic-sewn intrathoracic anastomosis. Intraoperative and postoperative complications were recorded as prescribed by the Esophagectomy Complications Consensus Group (ECCG). Thirty patients underwent Ivor Lewis RAMIE with complete mediastinal lymph node dissection and robot-sewn anastomosis. No intraoperative complications nor conversion occurred. Pulmonary complications totaled 26.7%. Anastomotic leakage (ECCG, type III) and conduit necrosis (ECCG, type III) both occurred in one patient (3.3%). Chylothorax appeared in 2 patients (6.7%) (ECCG, Type IIA). Anastomotic stricture, successfully treated with endoscopic dilatations, occurred in 8 cases (26.7%). Median overall postoperative stay was 11days (range, 6-51days). 30day and 90day mortality was 0%. R0 resection was performed in 96.7% of patients with a median number of 47 retrieved lymph nodes. RAMIE with robot-sewn intrathoracic anastomosis appears to be feasible, safe and effective, with favorable perioperative results. Nevertheless, further high-quality studies are needed to define the best anastomotic technique for Ivor Lewis RAMIE.

Continuous vagal intraoperative neuromonitoring during video-assisted thoracoscopic surgery for left lung cancer: its efficacy in preventing permanent vocal cord paralysis.

We investigated the safety and efficacy of continuous intraoperative neuromonitoring (CIONM) during video-assisted thoracoscopic lobectomy for left lung cancer in preventing recurrent laryngeal nerve injury. From August 2015 to March 2020, 22 patients with left lung cancer without CIONM (unmonitored) and 20 patients with left lung cancer with CIONM underwent thoracoscopic lobectomy with complete mediastinal lymph node dissection including 4L dissection. Clinical outcomes from these 2 groups were compared. The incidence of 4L metastasis was 7.14% (3 patients). There was no significant difference in the total number of dissected 4L lymph nodes between the 2 groups (3.23 ± 2.2 in the unmonitored group, 3.95 ± 2.0 in the CIONM group). CIONM was successful in all of the cases. There was no significant difference in the incidence of postoperative vocal cord palsy (22.7% in the unmonitored group, 20% in the CIONM group, P = 1.000). All of the 5 patients (100%) had permanent vocal cord palsy in the unmonitored group. Although statistically insignificant, 75% (3 patients) had total recovery of the vocal cord function, with only 1 patient remaining in permanent vocal cord palsy in the CIONM group. CIONM was safe and efficient. CIONM might be helpful to avoid permanent vocal cord palsy by immediately warning the surgeon about impending nerve injury, so the surgeon can stop delivering further injury to the recurrent laryngeal nerve.

172. THE MEDIASTINOSCOPIC RADICAL ESOPHAGECTOMY WITH A TRANS-BICERVICAL APPROACH USING INTRAOPERATIVE NERVE MONITORING (IOMN)

Abstract We developed ‘mediastinoscopic esophagectomy with lymph node dissection’ (MELD), performed under pneumomediastinum via a trans-bicervical and transhiatal approach using cadavers. A clinical trial on the feasibility and safety of MELD showed it to be useful for complete mediastinal lymph node dissection. We report the indications and novel aspects of MELD. MELD was indicated for patients of thoracic esophageal cancer without bulky primary lesions or lymph node metastases. MELD was performed in 16 patients. First, 101R and part of the 106recR lymph nodes were dissected in open surgery. After attaching an APS electrode for intraoperative nerve monitoring (IOMN) to the right vagus nerve, open surgery was changed to the pneumomediastinal method. The dorsal side of the esophagus was dissected along the visceral sheath. The 106tbL lymph nodes and the106recR lymph nodes were dissected using a right trans-cervical pneumomediastinal approach. The 106recL lymph nodes were dissected using a left trans-cervical pneumomediastinal approach. The median pneumomediastinal operation time was 320 minutes. The median amount of bleeding was 230 mL, and the median postoperative hospital stay was 16 days. Regarding complications, eight patients developed recurrent laryngeal nerve palsy (right, n = 3; left, n = 2; bilateral, n = 3), but no patients required conversion to thoracotomy, and no leakage, pneumonia, or operative deaths occurred. After incorporating the use of IOMN, the incidence of recurrent laryngeal nerve palsy was drastically reduced recurrent laryngeal nerve palsy was drastically decrease. Previous clinical trials shown that MELD can retrieve the mediastinal lymph nodes at the same level as thoracoscopic esophagectomy. The incidence of recurrent laryngeal nerve palsy was reduced by IONM; thus, MELD is considered a feasible procedure for radical esophagectomy.

Treatment for Early-Stage Lung Cancer Should Never Be “Just a Wedge”

Anatomic resection with lobectomy and complete mediastinal lymph node dissection has been considered the gold-standard early-stage lung cancer surgery since the Lung Cancer Study Group showed a higher risk of local-regional recurrence for sublobar resections.1 Nevertheless, evidence guiding lung cancer surgery has evolved since that study was published, possibly from increased radiology study use that has shifted the presentation of early-stage lung cancer such that patients are generally discovered with smaller tumors.

Is Adjuvant Radiochemotherapy Always Mandatory in Patients with Resected N2 Non-Small Cell Lung Cancer?

In patients with non-small cell lung cancer (NSCLC), the pathologic union for international cancer control (UICC) stage IIIA is a heterogeneous entity, with different forms of N2-lymph node involvement representing different prognoses. Although a multimodality treatment approach, including surgery, systemic therapy, and/or radiotherapy, is almost always recommended, in this retrospective observational study, we sought to determine whether long-term survival might be possible in selected patients who are treated with complete surgical resection alone. Between 2013 and 2018, we retrospectively identified 24 patients with NSCLC (16 men and 8 women), who were found to have pathologic N2-lymph node involvement, and were treated with complete surgical lung resection and systematic mediastinal and hilar lymph node dissection but no neoadjuvant or adjuvant treatment. The most frequent reason (n = 14) for forgoing adjuvant treatment was patient refusal. The mean overall survival (OS) was 34.5 months (interquartile range [IQR]: 15.5-53.5 months). The mean disease-free survival (DFS) was 18 months (IQR: 4.75-46.75 months). We identified five patients who survived at least 5 years without recurrence (21%). In each of these cases, the nodal metastases were restricted to a single level and no extracapsular lymph node involvement were detected. Additionally, worse DFS was associated with pT3/4 (vs. a lower T-stage), as well as microscopic lymphovascular invasion. Although the small sample size precludes any definitive conclusions, it was possible to demonstrate that long-term survival without neoadjuvant and adjuvant treatment is possible in some patients if complete tumor and nodal resection is performed.

The CARDIA-trial protocol: a multinational, prospective, randomized, clinical trial comparing transthoracic esophagectomy with transhiatal extended gastrectomy in adenocarcinoma of the gastroesophageal junction (GEJ) type II

BackgroundAdenocarcinoma of the gastroesophageal junction (GEJ) Siewert type II can be resected by transthoracic esophagectomy or transhiatal extended gastrectomy. Both allow for a complete tumor resection, yet there is an ongoing controversy about which surgical approach is superior with regards to quality of life, oncological outcomes and survival. While some studies suggest a better oncological outcome after transthoracic esophagectomy, others favor transhiatal extended gastrectomy for a better postoperative quality of life. To date, only retrospective studies are available, showing ambiguous results.MethodsThis study is a multinational, multicenter, randomized, clinical superiority trial. Patients (n = 262) with a GEJ type II tumor resectable by both transthoracic esophagectomy and transhiatal extended gastrectomy will be enrolled in the trial. Type II tumors are defined as tumors with their midpoint between ≤1 cm proximal and ≤ 2 cm distal of the top of gastric folds on preoperative endoscopy. Patients will be included in one of the participating European sites and are randomized to either transthoracic esophagectomy or transhiatal extended gastrectomy. The trial is powered to show superiority for esophagectomy with regards to the primary efficacy endpoint overall survival. Key secondary endpoints are complete resection (R0), number and localization of tumor infiltrated lymph nodes at dissection, post-operative complications, disease-free survival, quality of life and cost-effectiveness. Postoperative survival and quality of life will be followed-up for 24 months after discharge. Further survival follow-up will be conducted as quarterly phone calls up to 60 months.DiscussionTo date, as level 1 evidence is lacking, there is no consensus on which surgery is superior and both surgeries are used to treat GEJ type II carcinoma worldwide. The CARDIA trial is the first randomized trial to compare transthoracic esophagectomy versus transhiatal extended gastrectomy in patients with GEJ type II tumors. Several quality control measures were implemented in the protocol to ensure data reliability and increase the trial’s significance. It is hypothesized that esophagectomy allows for a higher rate of radical resections and a more complete mediastinal lymph node dissection, resulting in a longer overall survival, while still providing an acceptable quality of life and cost-effectiveness.Trial registrationThe trial was registered on August 2nd 2019 at the German Clinical Trials Register under the trial-ID DRKS00016923.

Thoracoscopic esophagectomy with three-field lymphadenectomy for thoracic esophageal cancer in a patient with a double aortic arch: a report of a case

BackgroundWe encountered an esophageal cancer patient with a double aortic arch (DAA) who underwent radical thoracoscopic esophagectomy with three-field lymph node dissection. A DAA generally makes it difficult to perform upper mediastinal lymph node dissection via both sides of the thoracic cavity. Furthermore, most patients with a DAA have a superior right aortic arch and right-sided descending aorta, which hampers radical esophagectomy with a typical right thoracic approach. We herein report our operative strategy of thoracoscopic esophagectomy via the left side of the thoracic cavity with a preceding cervical procedure.Case presentationA 64-year-old man was diagnosed with esophageal squamous cell carcinoma in the upper esophagus at clinical Stage IIB (cT1bN1M0) according to the UICC-TNM classification 7th edition. First, we planned the preceding cervical procedure to complete upper mediastinal lymph node dissection, as the DAA prevented a bilateral thoracic approach to the upper mediastinum. We then planned the left thoracoscopic procedure to perform lymph node dissection below the left aortic arch, as the patient in our case had a right side-dominant DAA and right-sided descending aorta, as is common in such patients. We identified the bilateral recurrent laryngeal nerves during upper mediastinal lymph node dissection in the preceding cervical procedure and ultimately successfully resected the patient’s esophageal cancer.ConclusionThe cervical procedure preceding the left-thoracoscopic approach is reasonable for achieving radical esophagectomy for thoracic esophageal cancer in patients with a DAA.

Clinicopathologic predictors of metastasis of different regional lymph nodes in patients intraoperatively diagnosed with stage-I non-small cell lung cancer

BackgroundSelection of the best lymph node for dissection is a controversial topic in clinical stage-I non-small cell lung cancer (NSCLC). Here, we sought to identify the clinicopathologic predictors of regional lymph node metastasis in patients intraoperatively diagnosed with stage-I NSCLC.MethodsA retrospective review of 595 patients intraoperatively diagnosed as stage I non-small-cell lung cancer who underwent lobectomy with complete lymph node dissection was performed. Univariate and multivariable logistic regression analysis was performed to determine the independent predictors of regional lymph node metastasis.ResultsUnivariate logistic regression and multivariable analysis revealed three independent predictors of the presence of metastatic hilar lymph nodes, five independent predictors for lobe specific mediastinal lymph nodes, two independent predictors for lobe nonspecific mediastinal lymph nodes and two independent predictors for skipping mediastinal lymph nodes.ConclusionsA complete mediastinal lymph node dissection may be considered for patients suspected of nerve invasion and albumin (> 43.1 g/L) or nerve and vascular invasions. Lobe-specific lymph node dissection should probably be performed for patients suspected of pulmonary membrane invasion, vascular invasion, CEA (> 2.21 ng/mL), and tumor (> 1.6 cm) in the right lower lobe or mixed lobes. Hilar lymph node dissection should probably be performed for patients suspected of having bronchial mucosa and cartilage invasion, vascular invasion, and CEA (> 2.21 ng/mL).

18F‐fluorodeoxyglucose positron emission tomography/computed tomography in the evaluation of clinically node‐negative non‐small cell lung cancer

One in four non‐small cell lung cancer (NSCLC) patients are diagnosed at an early‐stage. Following the results of the National Lung Screening Trial that demonstrated a survival benefit for low‐dose computed tomography screening in high‐risk patients, the incidence of early‐stage NSCLC is expected to increase. Use of 18F‐fluorodeoxyglucose positron emission tomography/computed tomography during initial diagnosis of these early‐stage lesions has been increasing. Traditionally, positron emission tomography/computed tomography scans have been utilized for mediastinal nodal staging and to rule out distant metastases in suspected early‐stage NSCLC. In clinically node‐negative NSCLC, the use of sublobar resection and selective lymph node dissection has been increasing as a therapeutic option. The higher rate of locoregional recurrences after limited resection and the significant incidence of occult lymph node metastases underscores the need to further stratify clinically node‐negative NSCLC in order to select patients for limited resection versus lobectomy with complete mediastinal lymph node dissection. In this report, we review the published data, and discuss the significance and potential role of 18F‐fluorodeoxyglucose positron emission tomography/computed tomography evaluation for clinically node‐negative NSCLC. Consequently, the literature review demonstrates that maximum standardized uptake value is a predictive factor for occult nodal metastasis with an accuracy of 55–77%. In addition, maximum standardized uptake value is a predictor for worse overall, as well as disease‐free, survival.

Non-grasping en bloc mediastinal lymph node dissection through uniportal video-assisted thoracic surgery for lung cancer surgery.

Uniportal video-assisted thoracic surgery (VATS) has been demonstrated to be feasible, safe, and effective for lung cancer surgery compared with traditional multi-portal VATS. However, complete mediastinal lymph node dissection (MLND) through uniportal VATS is still a difficult work due to more limited access, and most thoracic surgeons use strategies of grasping, accompanied with which are complicated instrumentation and mutual interference among them. To simplify the instrumentation and make MLND more comfortable, we developed the method of "non-grasping en bloc MLND" and applied it during uniportal VATS lung cancer surgery. Two main instruments (suction and energy devices) were developed with diversified use. And only the two instruments were used during MLND following the strategy of "non-grasping". This technique incorporates with several advantages, such as: simplified instrumentation, decreased risk of damages to lymph nodes, and en bloc dissection. Considering the limited access, this technique fits well with the uniportal procedure and truly interprets the concept of "less is more" during uniportal VATS MLND.

Clinicopathological characteristics and lymph node metastasis pathway of non-small-cell lung cancer located in the left lingular division.

The purpose of this study is to assess the clinicopathological characteristics of non-small-cell lung cancer (NSCLC) occurring in the left lingular division (LLD) in association with a proposal of the LLD-specific regional lymph node stations. Medical records of patients, who underwent complete tumour resection with mediastinal lymph node dissection (MLND) for LLD-NSCLC from 2000 to 2009 in multiple institutions, were retrospectively examined. We analysed patient clinicopathological characteristics and obtained the LLD-specific regional lymph node stations, and then the validity of intraoperative navigation in lymphadenectomy for LLD-NSCLC was investigated. One hundred and eighty-four LLD-NSCLC patients (97 males and 87 females, and 128 adenocarcinomas and 56 non-adenocarcinomas) were studied. The 5-year overall survival (OS) and disease-free survival (DFS) rates for all LLD-NSCLC patients were 72.9 and 58.3%, respectively. We examined the lymph node metastasis patterns in 42 node-positive tumours. The frequent metastatic lymph node stations were #12u lobar node (n = 22), #5 subaortic node (n = 15) and #11 interlobar node (n = 13) in order. These three node stations were also single metastatic sites in some patients. Metastases to sub-carinal (#7) or inferior mediastinal nodes (#8) were rare. Thus, we assigned the three stations (#5, #11, #12u) as the regional lymph node stations for LLD-NSCLC. If these regional lymph node stations had been examined pathologically during surgery for a total of 160 LLD-NSCLC patients with c-T2N1M0 or lower stage disease, 125 p-N0 and 5 p-N1 patients diagnosed with no metastasis would have been subjected to selective MLND, while 14 p-N1 and all 16 p-N2 patients diagnosed with metastasis would have had complete MLND carried out. As a result, these regional lymph node stations could accurately predict the existence of p-N2 metastasis, and appropriately lead to a selective or complete MLND. An intraoperative pathological examination using our proposed LLD-specific regional lymph node stations may accurately diagnose the status of node metastasis, and appropriately lead to selective or complete MLND in LLD-NSCLC patients with c-T2N1M0 or lower stage disease.

Advances of mediastinal lymph node metastasis and the extent of lymph node dissection in patients with stage T1 non-small cell lung cancer

肺癌是我国发病率和死亡率最高的恶性肿瘤。非小细胞肺癌（non-small cell lung cancer, NSCLC）约占肺癌80%。临床上，早期NSCLC以手术治疗为主要治疗方式，淋巴结分期及手术中清扫程度直接影响着患者的预后。不同肺叶原发NSCLC的淋巴结转移区域存在一定规律。解剖性肺叶切除加系统性淋巴结清扫一直以来被认为是NSCLC的标准手术方式，但近年来T1期NSCLC手术中纵隔淋巴结清扫的程度存在较大争议，选择性淋巴结清扫已逐渐被大多数学者所重视。

The learning curve of the three-port two-instrument complete thoracoscopic lobectomy for lung cancer—A feasible technique worthy of popularization

Cosmetic factors are important when considering minimally invasive surgery. For cosmetic improvement, a complete thoracoscopic lobectomy is accomplished via the three-port two-instrument (TPTI) technique. The resected specimen is removed without extending the port wounds. Only three wounds at 1.2cm are used to finish the procedure. From June 2012 to December 2013, 60 patients with lung cancer were to undergo lobectomy and complete mediastinal lymph node dissection via the TPTI technique without an accessory wound. The initial 28 cases (learning curve group) and the latest 28 cases were compared to assess the learning curve. Excluding four cases of conversion, there were 28 cases in each group. There were no differences between these two groups with respect to age, sex, tumor size, location of the lobectomy, mean blood loss, mean postoperative drainage time, and mean hospitalization time (p>0.05). The mean surgery time significantly decreased, the mean number of lymph nodes removed significantly increased, and the postoperative stage was significantly more advanced in the latest 28 cases (p<0.05). The conversion rate was similar in both groups. Three-port complete thoracoscopic lobectomy with the two-instrument technique is feasible for lung cancer treatment. The length of the learning curve consisted of 28 cases. This TPTI technique should be popularized.

Single incision thoracoscopic right upper lobectomy with systematic lymph node dissection

Video-assisted thoracic surgery (VATS) provides less postoperative pain, preservation of the immune response and shorter recovery period, compared with thoracotomy. However, many patients complain of postoperative pain and paresthesia because VATS requires 3 or 4 incisions including a utility incision of 3–5 cm. To overcome this problem, single incision thoracoscopic surgery has emerged; this technique has been adopted for lung cancer surgery since 2010. Complete mediastinal lymph node dissection is the major role of lung cancer surgery. We describe a case of a right upper lobectomy with complete mediastinal lymph node dissection via single incision thoracosopic surgery.

Extent of Removal for Mediastinal Nodal Stations for Patients with Clinical Stage I Non-Small Cell Lung Cancer: Effect on Outcome

Lobectomy and mediastinal lymph node dissection comprise the standard surgical treatment for non-small cell lung cancer (NSCLC). Although complete mediastinal lymph node dissection has been recommended as part of the procedure for achieving complete resection, the benefits for early lung cancer are unclear. The purpose of this study was to determine the effects of different degrees of mediastinal lymph node dissection on the clinical outcomes of patients with clinical stage I NSCLC. The records of patients with clinical stage I NSCLC treated between January 2000 and September 2010 were reviewed retrospectively. This study consisted of 211 patients who underwent lobectomy plus mediastinal lymph node dissection and sampling. Patients were divided into a group who underwent lymphadenectomy (LA) including complete mediastinal node dissection or lobe-specific lymph node dissection and a group who underwent selective lymph node sampling (LS). Clinical outcomes, including survival, and prognostic factors were determined. The mean (±) number of extracted lymph nodes for the LS and LA patients was 7.50 ± 5.44 and 14.09 ± 7.57, respectively (p < 0.001). Male and diabetes mellitus patients were more associated with LS. Survival of the LA patients was significantly longer (p = 0.029). By multivariate analysis, extent of mediastinal nodal sampling (p = 0.029) and positive for mediastinal nodal (N2-positive) disease (p = 0.046) were significant predictors for survival. The extent of dissection of mediastinal lymph nodes affected the clinical outcomes of our study patients with clinical stage I NSCLC. At least evaluation of lobe-specific lymph node dissection is required.

EComment. Laser application on lung parenchyma

We have read the important contribution by Kirschbaum and colleagues about the airtightness of lung parenchyma without a closing suture after atypical resection [1]. Laser resections might extend the indications for pulmonary metastasectomy [2]. Animal models might enhance the knowledge for daily clinical practice. However, we would like to comment on the limitations of the study. The authors state that lung metastases can be resected in case of absent lymph node metastases. In an ESTS survey, 64% of responding surgeons expressed their believe that the presence of clinically positive lymph nodes is a relative contraindication to pulmonary metastasectomy. However, only 55.5% of the surgeons perform mediastinal lymph node sampling and 13% complete mediastinal lymph node dissection at the time of pulmonary metastasectomy, whereas 32.2% of the surgeons perform any lymph node assessment during metastasectomy [3]. Thus, there is a lack of data confirming this hypothesis since lymph node assessment has not been routinely done in most studies. The number of study objects are very low. It remains inappropriate to conclude that there is no need for closing suture after laser resection since there are no two groups comparing the airtightness with and without closing suture. The coagulation necrosis zone and airtightness might be influenced by the duration of laser application at a specific point on lung parenchyma. The authors do not state about their technique of laser application on lung parenchyma. The conclusions are not based on their own results. Laser induced coagulation necrosis might be the reason for immediate airtightness. On the other hand, repair of the coagulation might lead to re-permeability of the lung parenchyma leading to fistulas in the later course. Thus, long-term results would be of great interest. We think that the above-mentioned concerns should be considered cautiously when the results of the study are interpreted. It would be great if the authors could address the above-mentioned issues in further experimental studies. Conflict of interest: none declared.

Risk factors for locoregional recurrence in patients with resected N1 non-small cell lung cancer: a retrospective study to identify patterns of failure and implications for adjuvant radiotherapy

BackgroundMeta-analysis of randomized trials has shown that postoperative radiotherapy (PORT) had a detrimental effect on overall survival (OS) in patients with resected N1 non–small cell lung cancer (NSCLC). Conversely, the locoregional recurrence (LR) rate is reported to be high without adjuvant PORT in these patients. We have evaluated the pattern of failure, actuarial risk and risk factors for LR in order to identify the subset of N1 NSCLC patients with the highest risk of LR. These patients could potentially benefit from PORT.MethodsWe conducted a retrospective study on 199 patients with pathologically confirmed T1–3N1M0 NSCLC who underwent surgery. None of the patients had positive surgical margins or received preoperative therapy or PORT. The median follow-up was 53.8 months. Complete mediastinal lymph node (MLN) dissection and examination was defined as ≥3 dissected and examined MLN stations; incomplete MLN dissection or examination (IMD) was defined as <3 dissected or examined MLN stations. The primary end point of this study was freedom from LR (FFLR). Differences between patient groups were compared and risk factors for LR were identified by univariate and multivariate analyses.ResultsLR was identified in 41 (20.6%) patients, distant metastasis (DM) was identified in 79 (39.7%) patients and concurrent LR and DM was identified in 25 (12.6%) patients. The 3- and 5-year OS rates in patients with resected N1 NSCLC were 78.4% and 65.6%, respectively. The corresponding FFLR rates were 80.8% and 77.3%, respectively. Univariate analyses identified that nonsmokers, ≤23 dissected lymph nodes, visceral pleural invasion and lymph node ratio >10% were significantly associated with lower FFLR rates (P < 0.05). Multivariate analyses further confirmed positive lymph nodes at station 10 and IMD as risk factors for LR (P < 0.05). The 5-year LR rate was highest in patients with both these risk factors (48%).ConclusionsThe incidence of LR in patients with surgically resected T1–3N1M0 NSCLC is high. Patients with IMD and positive lymph nodes at station 10 have the highest risk of LR, and may therefore benefit from adjuvant PORT. Further investigations of PORT in this subset of patients are warranted.

Validity of using lobe-specific regional lymph node stations to assist navigation during lymph node dissection in early stage non-small cell lung cancer patients

The validity of our proposed lobe-specific regional lymph node stations (LSRLNS) was evaluated as a method for navigation during lymphadenectomy in patients with early stage non-small cell lung cancer (NSCLC). A total of 725 NSCLC patients with c-T2N1M0 or less extensive disease who had undergone a curative operation with complete mediastinal lymph node dissection (MLND) were studied. The LSRLNS were #2, #3, #4 and #10 for the right upper lobe, #11i, #11s, #7 and #8 for the right lower lobe, #4, #5 and #6 for the left superior division, #11, #5 and #7 for the left lingular division and #11, #7 and #8 for the left lower lobe. If the LSRLNS were used for pathological examinations during surgery, 599 p-N0 and 39 p-N1 patients diagnosed with no metastasis would have been subjected to a selective MLND, while 20 p-N1 and 65 p-N2 patients who had a diagnosis of metastasis would have been navigated to a complete MLND. Two p-N2 patients with a diagnosis of no metastasis would have inappropriately undergone a selective MLND, resulting in the false negative rate at 0.3 %. Intra-operative pathological examination using our LSRLNS may accurately reveal the status of metastasis, and appropriately lead to a selective or complete MLND in patients with c-T2N1M0 or less extensive disease.

Comparison of complete and minimal mediastinal lymph node dissection for non-small cell lung cancer: Results of a prospective randomized trial.

To compare surgical results, pathological staging, and survival between complete and minimal mediastinal lymph node dissection for non-small cell lung cancer (NSCLC). A randomized controlled trial was carried out in 202 patients who were assigned to undergo either skeletonized complete mediastinal lymph node dissection (CLD) or minimal mediastinal lymph node dissection (MLD). Clinical and pathological characteristics, surgical results, postoperative staging, and five-year survival were recorded for statistical analysis. Significantly more stations of lymph nodes were harvested through CLD, than MLD (8.9 vs. 6.2, P < 0.001). There was no difference in major complications (CLD 14.7% vs. MLD 14.0%, P = 0.884) or postoperative death (CLD 2.1% vs. MLD 1.9%, P = 0.904). No significant difference was detected in pathological staging between the two groups. The pN2 rates (27.1% vs. 24.2%), skip-mediastinal metastasis (9.3% vs. 7.4%), and multi-stational mediastinal involvement (15.0% vs. 16.8%) were similar between MLD and CLD. However, CLD had significantly better five-year survival than MLD (55.7% vs. 37.7%, P = 0.005), especially in patients with a tumor size >3 cm, pleural invasion, pN1-N2, stage II-III, adenocarcinoma, and low-differentiation carcinoma. Upon multivariate analysis, CLD, along with stage I and high-differentiation, were independent prognostic factors for better overall survival. Complete and minimal mediastinal dissections have similar surgical risks and mediastinal staging effect in patients with NSCLC. Minimal dissection is enough for early stage high-differentiation tumors. For patients with stage II-III or low-differentiation carcinoma, skeletonized complete mediastinal dissection may improve survival compared with minimal dissection.

Towards optimal pathologic staging of resectable non-small cell lung cancer.

Pathologic nodal staging is the most accurate means of determining prognosis of patients with resectable non-small cell lung cancer (NSCLC), but confusion prevails about the optimal pre-operative and surgical lymph node examination procedures for candidates of curative-intent resection. The landmark American College of Surgeons Oncology Group Z0030 trial revealed no difference in the survival of patients with clinical T1 or T2, N0 or N1 (hilar node-negative), M0 NSCLC who either had a fastidious, pre-defined systematic hilar and mediastinal lymph node sampling procedure, or who received a complete mediastinal lymph node dissection. We place the results of this major trial into a contemporary clinical practice context, and discuss problems associated with apparent misunderstanding of the lessons from this trial, especially in light of evidence of prevailing sub-optimal nodal examination practices. We also discuss evolving knowledge about the origin of the quality gap in pathologic nodal staging and the emerging literature on corrective interventions.