Mediastinal Lymph Node Resection Research Articles

P2.16-022 Initiative for Early Lung Cancer Research on Treatment: Pilot Implementation

We have initiated a new multi-center, international collaborative cohort study, the Initiative for Early Lung Cancer Research for Treatment (IELCART), which focuses on identifying optimal treatment for early stage lung cancer An issue under discussion is the extent of surgery (i.e., sublobar resection and no mediastinal lymph node resection) in order to decrease the length and morbidity of the surgical procedure, preserves pulmonary function, and increases the likelihood of resection of future new occurrences of lung cancers.

P3.13-001 Clinical Significance of Chest Tomography Characteristics in Non-Small Cell Lung Cancer Patients Who Received Anatomic Resection

Characteristics of CT image, including tumor size and component were correlated to survival. However, most studies discuss the survival impact of image characteristics in early clinical stage populations. No articles were discussed the issue from the view of pathology stage, i.e. actual disease presentations of non-small cell lung cancer patients who presented as resectable disease. The aim of study was to analyze radiologic and pathologic findings of non-small lung cancer patients who received curative resection in order to clarify he clinical correlation between image characteristics and survival impaction. From 2010 January to 2014 May, 440 patients who underwent curative resection, i.e. anatomic resection and mediastinal lymph node resection, were included and medical record were reviewed retrospectively. Chest CT characteristics, including tumor size and consolidation-tumor ratio, were re-evaluated and re-measured by radiologists. The correlation between image and pathology characteristics and its survival impaction were analyzed. We identified tumor size presented in CT and pathologic measurements were highly coincidence (p-value<0.001). The presentation of pure GGO and GGO predominant lesion were adenocarcinoma (p<0.001). Majority of these lesions (61/76, 80.2%) were well differentiated (p<0.0001). In addition, pure GGO lesion has less risk for visceral pleura (p <0.0001), angiolymphatic invasion (p <0.002), and lower risk with N1 lymph node metastasis (p = 0.004) In addition, we found excellent disease free and disease free survival for patients who was identified GGO predominant lesion with size ≤2cm. (Fig 3) The difference of disease free (p= 0.0032, log rank test; Fig 3A) and overall survival (p= 0.0066, log rank test; Fig 3B) of these four subgroups was statistically significance. Non-small cell lung cancer patients who presented with ground glass opacity were corrected with well differentiated adenocarcinoma. In addition, less visceral pleura invasion, less angiolymphatic invasion, and less intrapulmonary lymph node metastases risk were also identified. Our results showed lung cancer patients who presented as GGO predominant lesions and size less than 2 cm may had excellent disease free and overall survival.

Four percent matters

Studies like the International Early Lung Cancer Action Program (I-ELCAP) (1) have revolutionized our understanding of early-stage lung cancer and its management. In their recent article (2), Flores and colleagues challenge us with the notion that sublobar resection without mediastinal lymph node sampling may be an adequate treatment for clinical stage IA non-small cell lung cancer (NSCLC). Drawing on the database of the I-ELCAP project (1), they were able to stratify patients into two propensity matched cohorts who received mediastinal lymph node resection (MLNR) and those who did not. A solid statistical and survival analysis methodology failed to demonstrate any significant difference in overall survival between patients who received MLNR during their operation, and those who did not. The authors conclude that subsolid nodules less than 30 mm in diameter, and peripheral solid nodules less than 20 mm in diameter should be treated with sublobar resection without MLNR.

ED14.04 Is There a Role for Surgery in SCLC?

ED14.04 Is There a Role for Surgery in SCLC?

P1.08-054 Uniportal VATS Lobectomy in the Treatment of NSCLC

Uniportal Video-Assisted Thoracic Surgery (uniportal VATS) lobectomy represents the pinnacle of evolution for minimally invasive techniques in surgical management of lung cancer. Growing evidence suggest that Uniportal VATS procedures are technically feasible and safe with immediate outcomes comparable to traditional VATS approach. Uniportal approach has demonstrated equivalent disease-free survival, at intermediate follow-up for patients with early stage NSCLC, compared to conventional VATS. It represents a less invasive approach, and offers the advantage of minimizing the extent of the surgical access trauma thus resulting in postoperative pain reduction, muffled inflammatory response, early recovery and better cosmesis. Some authors described minimal changes in pulmonary function after uniportal surgery in patients with poor cardio-respiratory function. Here we present our experiences with uniportal VATS lobectomies for NSCLC. Between October 2015 and March 2016, twenty-four (24) patients with non-small lung cancer (NSCLC) underwent uniportal VATS lobectomy and mediasitnal lymph node dissection. Surgical access was performed through a 4-5 cm long utilitarian incision at the 5th intercostal space in the anterior axillary line. Anatomical resection of veins, arteries, bronchi and mediastinal lymph nodes followed established oncological principals. Once the operation was completed a single chest tube was inserted in the anterior part of the incision for uniportal VATS. Fifteen male and nine female patients with an average age of 62.6 years (49-76) were enrolled in the study. Average procedural time was 108 minutes (75min-154min). None of the patients required blood transfusion after the procedure or during the rest of their hospital stay. Average duration of chest drainage was 3.6 days (2-8) and mean hospital stay was 6.3 days (3-10). There were 14 patients with adenocarcinoma and 10 with squamous cell carcinoma. Two patients had prolonged air leak and were treated conservatively. There was no perioperative mortality. Our initial experiences with Uniportal VATS lobectomy is encouraging as it demonstrated benefits to patients due minimal surgical stress, faster recovery, reduced postoperative pain and shorter hospital stay. The authors strongly believe uniportal VATS surgery should be considered for primary surgical treatment of NSCLC.

Left thoracotomy for middle or lower thoracic esophageal carcinoma: still Sweet enough?

Esophagectomy via left thoracotomy (the Sweet procedure) has long been the conventional route for resection of esophageal carcinoma, especially in China. However, this procedure is being increasingly critiqued, mainly regarding the lymphadenectomy. The objective of this study was to compare the Sweet procedure with the right upper mediastinal lymph node resection (MS) and Ivor-Lewis (IL) procedure in the treatment of middle or lower thoracic esophageal squamous cell carcinoma (OSCC-MLT) in terms of lymphadenectomy, postoperative complications, and long-term survival. A total of 336 OSCC-MLT patients underwent radical intent surgery (188 with MS and 148 with IL procedure) between January 2007 and September 2013 in our hospital. After propensity score matching, 129 patients from each procedure were included. The efficacy of lymph node dissection at each station was estimated by the index of estimated benefit from lymph node dissection (IEBLD). IEBLD is relatively high in stations 2L, 2R, 8, 16 and 17. The metastasis rates and ratios were similar between the MS and IL procedures at each station. The MS procedure significantly outperformed the IL procedure with a shorter operating time (212 vs. 317 min), shorter in-hospital stay (10.7 vs. 15.3 days), and fewer postoperative complications (30.2% vs. 43.4%). However, the 5-year survival rates were not significantly different between the two procedures (46.9% vs. 44.0%). The MS procedure of esophagectomy is not inferior to the IL procedure in efficiency, moreover the MS procedure is safer.

The necessity of mediastinal lymph node resection for screen-diagnosed non-small cell lung cancer (NSCLC) manifesting as subsolid nodule.

Dr. Flores and colleagues recently published an article titled “Computed tomography screening for lung cancer” in Annals of Surgery , and was presented at the annual meeting of the 16 th World Conference on Lung Cancer. Therein, they reported the results of survival differences for patients with and without mediastinal lymph node resection (MLNR) in stage IA non-small cell lung cancer (NSCLC) manifesting as subsolid and solid nodules. They concluded that it is not mandatory to perform MLNR when screen-diagnosed NSCLC manifests as a subsolid nodule.

Paraneoplastic Cushing's syndrome associated with bronchopulmonary carcinoid tumor in youth: A case report and review of the literature.

Paraneoplastic Cushing's syndrome (CushingPS) caused by bronchopulmonary carcinoid tumors presents a diagnostic challenge for clinicians. The present study reports the case of an 18-year-old male patient presenting with rapid weight gain, polyuria, polydipsia and progressive muscle weakness. Chemical and imaging findings suggested ectopic secretion of adrenocorticotropin. Whole-body 18fluorine-fluorodeoxyglucose (18FDG-PET/CT) positron-emission tomography revealed an increased uptake of 18FDG-PET/CT in the right middle lung mass and lobar lymph node. Postoperative pathology confirmed the presence of a typical carcinoid, as well as a lobar lymph node metastasis. The patient underwent a right middle lobectomy with mediastinal lymph node resection, which resulted in symptom clearance, followed by rapid weight loss. No CushingPS or tumor recurrence was observed at the 3-month postoperative follow-up.

Uniportal video-assisted thoracic surgery lobectomy in semiprone position: primary experience of 105 cases.

Uniportal video-assisted thoracic surgery (VATS) is becoming popular, and uniportal lobectomy in semiprone position was reported in 2014. This study aimed to investigate the feasibility and safety of uniportal VATS in semiprone position. From May 28, 2014 to October 19, 2015, we attempted uniportal VATS lobectomy in semiprone position in 105 cases. Forty-five patients were male, and 60 patients were female. Average age was 57.1±10.6 years (24-76 years). Perioperative parameters were documented. There were two conversions to three-port lobectomy, one conversion to double-port lobectomy, and three conversions to thoracotomy. Among the patients who received uniportal VATS in semiprone position, mean operation duration was 137.4±47.8 minutes. Mean estimated blood loss was 60.7±102.7 mL. Mean time of drainage was 3.0±2.1 days, and postoperative length of stay averaged 4.9±2.3 days. In the cases of primary lung cancer, the mean number of nodal stations explored was 7.2±1.3, with a mean of 20.8±6.3 lymph nodes resected. As to the mediastinal lymph node specifically, a mean of 4.4±1.0 nodal stations were explored, and the number of resected mediastinal lymph nodes averaged 12.8±5.1. No perioperative death or major complication occurred. Uniportal VATS lobectomy in semiprone position is feasible and safe.

FDG PET/CT for assessing the resectability of NSCLC patients with N2 disease after neoadjuvant therapy.

Neoadjuvant chemoradiotherapy (CMRT) is the most effective treatment of stage III non-small-cell lung cancer (NSCLC). The present study aimed at assessing FDG PET/CT for defining the response of N2 disease to neoadjuvant CMRT, as surgical resection after such therapy significantly improves 5-year survival in responding N2 disease. Forty-five patients with locally advanced NSCLC underwent both pre-neoadjuvant therapy FDG PET/CT and post-neoadjuvant therapy FDG PET/CT followed by anatomical resection of lung and ipsilateral mediastinal lymph nodes (LN). Seventeen of these patients who had PET/CT studies in our institution and were operated after CMRT were retrospectively included in the study group (12 males, ages 43-78 years; stage IIIA: 14 patients, stage IIIB: 3 patients). PET/CT response in N2 was visually scored per-lymph node station and per patient. Quantitative N2 response was evaluated by SUVmax and total lesion glycolysis (TLG) measurements after therapy alone and in comparison with pre-therapy values. PET/CT N2 response was confirmed at surgery. Seventeen NSCLC patients with 29 metastatic N2 lymph nodes (LN) were assessed. Histopathology confirmed 14 responders and 3 non-responders, and was available in 20/29 metastatic LN, showing complete response in 17 and residual disease in 3 LN. LN-based visual analysis of N2 response on PET/CT defined 3 TP, 16 TN and 1 FP, for sensitivity, specificity, accuracy, negative and positive predictive values (NPV and PPV) of 100, 94, 95, 100 and 75%, respectively. Patient-based visual analysis defined 3 TP, 13 TN and 1 FP study, for sensitivity, specificity, accuracy, NPV and PPV of 100, 93, 94, 100 and 75%, respectively. Nodal-based quantitative analysis of FDG uptake in N2 nodes revealed a significant difference between responding and non-responding LN only of SUVmax post-therapy (2.5 ± 1.21 vs. 3.5 ± 2.36, P = 0.04). FDG PET/CT after neoadjuvant therapy accurately defined response in metastatic N2 nodes of NSCLC patients, presenting very high sensitivity and NPV for detecting responding nodes. PET/CT may enable selection of candidates for curative resection of stage III NSCLC. Mediastinoscopy may not be mandatory in patients with a negative PET/CT after neoadjuvant therapy.

Isolated Mediastinal Kocuria rosea Infection Mimicking Malignancies

Isolated mediastinal Kocuria rosea infection is a rare condition and presentation can be variable. We report an unusual case of Kocuria rosea infection which presented as solitary pulmonary nodules and isolated lymph node swelling, entirely confined within the tracheal bifurcation and 18-fluoredeoxyglucose position emission tomography and computed tomography (18FDG PET/CT)-avid, thereby mimicking a neoplastic lesion. Owing to the large differential diagnosis, which includes diseases such as pulmonary neoplasia and lymph node metastases, a biopsy via mediastinoscopy was to be attempted, so hopefully avoiding thoracotomy. Histopathology analysis of the resected mediastinal lymph nodes (MLNs) demonstrated no malignant cells, but rather necrotizing MLNs, which is classically associated with Kocuria rosea infection. The patient was asymptomatic and biopsy allowed a precise diagnosis. Kocuria rosea infection is rare; it should be considered when FDG PET shows intense FDG uptake in non-regionally swollen lymph nodes. J Med Cases. 2015;6(8):339-341 doi: http://dx.doi.org/10.14740/jmc2122w

Isolated Mediastinal Kocuria rosea Infection Mimicking Malignancies

Isolated mediastinal Kocuria rosea infection is a rare condition and presentation can be variable. We report an unusual case of Kocuria rosea infection which presented as solitary pulmonary nodules and isolated lymph node swelling, entirely confined within the tracheal bifurcation and 18-fluoredeoxyglucose position emission tomography and computed tomography (18FDG PET/CT)-avid, thereby mimicking a neoplastic lesion. Owing to the large differential diagnosis, which includes diseases such as pulmonary neoplasia and lymph node metastases, a biopsy via mediastinoscopy was to be attempted, so hopefully avoiding thoracotomy. Histopathology analysis of the resected mediastinal lymph nodes (MLNs) demonstrated no malignant cells, but rather necrotizing MLNs, which is classically associated with Kocuria rosea infection. The patient was asymptomatic and biopsy allowed a precise diagnosis. Kocuria rosea infection is rare; it should be considered when FDG PET shows intense FDG uptake in non-regionally swollen lymph nodes. J Med Cases. 2015;6(8):339-341 doi: http://dx.doi.org/10.14740/jmc2122w

Technical difficulties and extending the indications for VATS lobectomy.

Data on advantages of video-assisted thoracoscopic surgery (VATS) lobectomies has been accumulated during the last 10 years then number of thoracoscopic anatomic pulmonary resections rapidly increased. But still there is no agreement about limitations of the method. The most popular "technical contraindications" for VATS anatomic pulmonary resections are: dense pleural adhesions, incompleteness of interlobar fissure, previous chemo- or/and radiotherapy, perivascular or/and peribronchial fibrosis, tumor larger than 5 cm, chest wall involvement, centrally located tumor, severe comorbidity, advanced age, severe COPD and emphysema. Extending of indications for the VATS anatomic pulmonary resection and its influence on the immediate outcomes was investigated. Ninety two consecutive cases of VATS anatomic pulmonary resection performed by the single surgeon from January 2012 till December 2013 at the Federal University Hospital #122 in Saint Petersburg, Russia were retrospectively analyzed. Forty three males and 49 females at the age from 21 to 87 years old (mean age 59±7.2). The most of the cases were comprised by lung cancer of I-III stage together with bronchiectasis and tuberculomas. Conversion rate was 3.2% mostly due to perivascular calcification and/or fibrosis. There were no cases of 30-days mortality and readmission. All those patients retrospectively divided into two groups: with standard and extended indications for the VATS lobectomy. Inclusion in "extended" group was made if patients had one or more technical challenges among following: size of the lesion 5 cm and more; strong pleural adhesions and/or "bad fissure"; adjacent structures involvement; hilar or mediastinal lymph nodes enlargement or involvement; centrally located tumors; previous chemo- or chemoradiotherapy or previous thoracic surgery. According to these criteria, 45 standard (S) and 47 extended (E) patients were pair-matched with no statistically significant differences between the groups in common patients' characteristics. Postoperative comparison of "standard" and "expanded" groups revealed some differences in average operation time (152 vs. 189 min), in number of resected mediastinal lymph nodes (10.2 vs. 13.1), and in the mean time before removal of the chest tube (3.9 vs. 5.2 days). But the blood loss, morbidity and the length of hospital stay were almost the same in the two groups. Extension of indications to VATS lobectomy does not compromise the short-term results. Incompleteness of interlobar fissures, pleural adhesions, preoperative chemotherapy, big size of lesion, and some cases of centrally located tumors are not supposed to be the contraindications for VATS lobectomy. Peribronchial and perivascular lymph node calcification may complicate and even preclude lobectomy by VATS.

Acrometastasis from an epidermal-growth-factor-receptor (EGFR) mutation-positive lung adenocarcinoma

We report the first case of epidermal-growth-factor-receptor (EGFR) mutation-positive lung adenocarcinoma with acrometastasis in a 51-year-old woman who presented with a swelling on her right hand. Magnetic resonance imaging revealed an expansile lesion at the base of the 5th metacarpal bone of her right hand with cortical erosion and patchy enhancement suggestive of a malignant transformation of a giant-cell tumor. A core needle biopsy of this lesion showed a metastatic adenocarcinoma on histopathological examination which was immunoreactive to cytokeratin (CK) 7 and thyroid transcription factor (TTF)-1 but not to CK20 suggesting a lung primary. A chest radiograph and computed tomography (CT) scan revealed a right upper lobe lung mass. Fluoro-deoxyglucose hypermetabolism was noted in the lung mass and the right 5th metacarpal bone lesion but not elsewhere on positron-emission-tomography/CT scan. Needle biopsy of the lung mass showed adenocarcinoma with histopathological and immunohistochemical features similar to that of the right 5th metacarpal bone lesion. Both the primary lung adenocarcinoma and the acrometastatic lesion were tested positive for EGFR mutation in exon 21 (L858R substitution). She underwent R0 resection of her right upper and middle lobes with systematic mediastinal lymph nodes resection and wide excision of the metacarpal metastasis followed by cytotoxic chemotherapy. A curative approach with complete resection of the primary tumor and oligometastastic site in Stage IV non-small cell lung carcinoma (NSCLC) followed by additive cytotoxic chemotherapy has not been reported to date and as such there is still no data on disease-free survival with this approach.

In Surgical Treatment of Non-Small-Cell Lung Cancer a Minimum Number of Resected Mediastinal Lymph Nodes Is Mandatory for Accurate Staging

Objective: Increased numbers of removed lymph nodes (LN) are resulting in more accurate staging of the patient (Will-Rogers-Phenomenon). This study evaluates dependence of lymph node sample size to 1) Will-Rogers-Phenomenom, 2) influence of sample size on overall survival and in terms of 3) morbidity and mortality. Methods: 131 patients after pulmonary resection were retrospectively analysed concerning surgery, number of removed lymph nodes, stage, complications and survival. Patients were stratified according to the median number of lymph nodes in two groups (A <12 lymph nodes and B ≥12 lymph nodes). Results: 5% of the patients had only local lymphadenectomy and in 14% a systematic lymphadenectomy was performed. 17% of the patients showed skip metastasis. Lymph node positivity was correlated to the number of removed lymph nodes (p = 0.003). The approximated median survival for UICC (Union internationale contre le cancer) stage I was 511, stage II 521 and stage III 290 days. Subgroup analysis of survival data showed in group A an approximated median survival at stage I of 495 days, at II 537 days and at III 451.5 days. Group B showed at stage I 675 days, at II 521 days and at III 221 days. There was no difference in complications and mortality. Conclusion: A too low sample size leads to understaging due to skip metastasis. Obligatory mediastinal lymph node sampling would decrease the risk of understaging due to skip metastasis and does not increase morbidity or complications. Lymph node sampling is not inferior concerning morbidity and survival in our patient collective. This study cannot recommend a minimum number of LN to be resected. The evaluated limit of 12 LN proves to be suitable as a guideline.

Prognostic Factors for Lymph Node Negative Stage I and IIA Non-small Cell Lung Cancer: Multicenter Experiences

Surgery is the only curative treatment for operable non-small lung cancer (NSCLC) and the importance of adjuvant chemotherapy for stage IB patients is unclear. Herein, we evaluated prognostic factors for survival and factors related with adjuvant treatment decisions for stage I and IIA NSCLC patients without lymph node metastasis. We retrospectively analyzed 302 patients who had undergone curative surgery for prognostic factors regarding survival and clinicopathological factors related to adjuvant chemotherapy. Nearly 90% of the patients underwent lobectomy or pneumonectomy with mediastinal lymph node resection. For the others, wedge resection were performed. The patients were diagnosed as stage IA in 35%, IB in 49% and IIA in 17%. Histopathological type (p=0.02), tumor diameter (p=0.01) and stage (p<0.001) were found to be related to adjuvant chemotherapy decisions, while operation type, lypmhovascular invasion (LVI), grade and the presence of recurrence were important factors in predicting overall survival (OS), and operation type, tumor size greater than 4 cm, T stage, LVI, and visceral pleural invasion were related with disease free survival (DFS). Multivariate analysis showed operation type (p<0.001, hazard ratio (HR):1.91) and the presence of recurrence (p<0.001, HR:0.007) were independent prognostic factors for OS, as well visceral pleural invasion (p=0.01, HR:0.57) and LVI (p=0.004, HR:0.57) for DFS. Although adjuvant chemotherapy is standard for early stage lymph node positive NSCLC, it has less clear importance in stage I and IIA patients without lymph node metastasis.

Prevalence of lymph node metastases in superficial esophageal squamous cell carcinoma

Endoscopic treatment of superficial esophageal carcinoma has been increasingly conducted around the world. Because no lymph nodes are removed in such a procedure, the risk of lymph node metastases (LNMs) should be clearly understood. The aim of the present study was to accurately clarify the pattern of lymphatic spread in patients with superficial esophageal squamous cell carcinoma and analyze the factors potentially related to LNMs. The pattern of lymphatic spread was studied in 189 patients who had undergone radical lymphadenectomy from 2006 to 2011. The risk factors associated with LNMs were determined by multivariate logistic regression analysis. According to the depth of tumor invasion, mucosal tumors were classified as M1, M2, and M3 and submucosal tumors as SM1, SM2, and SM3. A total of 4252 lymph nodes were resected (average, 23 ± 9; range, 12-68). LNMs occurred in 49 patients (25.9%). The frequency of LNMs was 4.3% in those with mucosal and 33.1% in those with submucosal cancer. LNMs were found in 0%, 0%, 11.8%, 24.0%, 20.5%, and 43.8% of the M1, M2, M3, SM1, SM2, and SM3 cancer, respectively. For submucosal cancer, SM3 cancer (P=.006) and lymphovascular invasion (P=.001) were significant independent risk factors for LNMs. Paratracheal nodes were the most frequently involved. "Skip" metastases occurred in 20 of 49 patients (40.8%). Endoscopic treatment can be attempted when the tumor is limited to the lamina propria mucosa. However, 2-field radical lymphadenectomy with careful upper mediastinal lymph node resection should be conducted for submucosal squamous cell carcinoma.

F-096DOES VIDEO-ASSISTED MEDIASTINOSCOPIC LYMPHADENECTOMY FULFIL CRITERIA TO BECOME A STANDARD PROCEDURE FOR EARLY STAGE LUNG CARCINOMA?

Video-assisted mediastinoscopic lymphadenectomy (VAMLA) is a procedure for complete bilateral resection of mediastinal lymph nodes in stations 4, 10 and 7. Here, we present recent data on the use of VAMLA for mediastinal lymph node staging in early stage lung carcinoma. We evaluated the end-points disease free survival (DFS), overall survival (OS) and additionally stratified according to risk factors. Between 2005 and 2011, a total of 76 patients with NSCLC in UICC stage IA-IIB underwent VAMLA followed by thoracoscopic or open lobectomy. Data were compared retrospectively with 54 patients with NSCLC (same stages) who received thoracoscopic lobectomy followed by unilateral lymphadenectomy (control group, no prior mediastinoscopy). There was no significant difference between groups concerning age, gender, histology or involvement of the mediastinal lymph nodes (pN0/1). DFS was significantly lower in the VAMLA group (P = 0.004) than in the contol group, and also significantly lower in VAMLA subgroups with tumours up to 5 cm diameter (P = 0.02), with squamous cell carcinoma (P = 0.007), or with patients over 75 years of age (P = 0.021). OS was not different between the VAMLA and control groups (P = 0.06). In total, involvement of mediastinal lymph nodes was confirmed in 8 patients (pN1). VAMLA detected nodal involvment (pN1) in 3 patients, which had been radiologically classified as cN0, and confirmed lymph node metastases in 2 patients with cN1 classification. Similarily, in the control group, 3 patients were found pN1 that were originally classified cN0. Relapse of mediastinal lymph node metastases was observed in VAMLA group in 2.6% (n = 2) and 5.6% (n = 3) in control group (P = 0.46). The present data indicate that VAMLA patients have lower DFS than patients with unilateral VATS-lymphadenectomy. However, the statistical power of the present study is limited due to small patient numbers. Based on these observations it seems questionable that VAMLA fulfils criteria for a standard procedure. All authors have declared no conflicts of interest.

Sampling versus systematic full lymphatic dissection in surgical treatment of non-small cell lung cancer

The extent of mediastinal lymph node assessment during surgery for non-small cell cancer remains controversial. Different techniques are used, ranging from simple visual inspection of the unopened mediastinum to an extended bilateral lymph node dissection. Furthermore, different terms are used to define these techniques. Sampling is the removal of one or more lymph nodes under the guidance of pre-operative findings. Systematic (full) nodal dissection is the removal of all mediastinal tissue containing the lymph nodes systematically within anatomical landmarks. A Medline search was conducted to identify articles in the English language that addressed the role of mediastinal lymph node resection in the treatment of non-small cell lung cancer. Opinions as to the reasons for favoring full lymphatic dissection include complete resection, improved nodal staging and better local control due to resection of undetected micrometastasis. Arguments against routine full lymphatic dissection are increased morbidity, increase in operative time, and lack of evidence of improved survival. For complete resection of non-small cell lung cancer, many authors recommend a systematic nodal dissection as the standard approach during surgery, and suggest that this provides both adequate nodal staging and guarantees complete resection. Whether extending the lymph node dissection influences survival or recurrence rate is still not known. There are valid arguments in favor in terms not only of an improved local control but also of an improved long-term survival. However, the impact of lymph node dissection on long-term survival should be further assessed by large-scale multicenter randomized trials.

Sampling versus systematic full lymphatic dissection in surgical treatment of non-small cell lung cancer.

The extent of mediastinal lymph node assessment during surgery for non-small cell cancer remains controversial. Different techniques are used, ranging from simple visual inspection of the unopened mediastinum to an extended bilateral lymph node dissection. Furthermore, different terms are used to define these techniques. Sampling is the removal of one or more lymph nodes under the guidance of pre-operative findings. Systematic (full) nodal dissection is the removal of all mediastinal tissue containing the lymph nodes systematically within anatomical landmarks. A Medline search was conducted to identify articles in the English language that addressed the role of mediastinal lymph node resection in the treatment of non-small cell lung cancer. Opinions as to the reasons for favoring full lymphatic dissection include complete resection, improved nodal staging and better local control due to resection of undetected micrometastasis. Arguments against routine full lymphatic dissection are increased morbidity, increase in operative time, and lack of evidence of improved survival. For complete resection of non-small cell lung cancer, many authors recommend a systematic nodal dissection as the standard approach during surgery, and suggest that this provides both adequate nodal staging and guarantees complete resection. Whether extending the lymph node dissection influences survival or recurrence rate is still not known. There are valid arguments in favor in terms not only of an improved local control but also of an improved long-term survival. However, the impact of lymph node dissection on long-term survival should be further assessed by large-scale multicenter randomized trials.