Radical Systematic Mediastinal Lymphadenectomy Research Articles

Editorial Comment: Leave no lymph nodes behind!

pathological noninvasiveness in peripheral clinical IA lung cancer ( Japan Clinical Oncology Group 0201). J Thorac Oncol 2011;6:751–6. [13] Goldstraw P. Report on the international workshop on intrathoracic staging. London, October 1996. Lung Cancer 1997;18:107–11. [14] Suzuki K, Kusumoto M, Watanabe S, Tsuchiya R, Asamura H. Radiologic classification of small adenocarcinoma of the lung: radiologicpathologic correlation and its prognostic impact. Ann Thorac Surg 2006; 81:413–9. [15] Darling GE, Allen MS, Decker PA, Ballman K, Malthaner RA, Inculet RI et al. Randomized trial of mediastinal lymph node sampling versus complete lymphadenectomy during pulmonary resection in the patient with N0 or N1 (less than hilar) non-small cell carcinoma: results of the American College of Surgery Oncology Group Z0030 Trial. J Thorac Cardiovasc Surg 2011;141:662–70. [16] Izbicki JR, Passlick B, Pantel K, Pichlmeier U, Hosch SB, Karg O et al. Effectiveness of radical systematic mediastinal lymphadenectomy in patients with resectable non-small cell lung cancer: results of a prospective randomized trial. Ann Surg 1998;227:138–44. [17] Wu Y, Huang ZF, Wang SY, Yang XN, Ou W. A randomized trial of systematic nodal dissection in resectable non-small cell lung cancer. Lung Cancer 2002;36:1–6. [18] Takizawa T, Terashima M, Koike T, Akamatsu H, Kurita Y, Yokoyama A. Mediastinal lymph node metastasis in patients with clinical stage I peripheral non-small-cell lung cancer. J Thorac Cardiovasc Surg 1997;113: 248–52. [19] Prenzel KL, Monig SP, Sinning JM, Baldus SE, Gutschow CA, Grass G et al. Role of skip metastasis to mediastinal lymph nodes in non-small cell lung cancer. J Surg Oncol 2003;82:256–60. [20] Misthos P, Sepsas E, Athanassiadi K, Kakaris S, Skottis I. Skip metastases: analysis of their clinical significance and prognosis in the IIIA stage of non-small cell lung cancer. Eur J Cardiothorac Surg 2004;25:502–8. [21] Watanabe S, Suzuki K, Asamura H. Superior and basal segment lung cancers in the lower lobe have different lymph node metastatic pathways and prognosis. Ann Thorac Surg 2008;85:1026–31. [22] Winton T, Livingston R, Johnson D, Rigas J, Johnston M, Butts C et al. Vinorelbine plus cisplatin vs. observation in resected non-small-cell lung cancer. N Engl J Med 2005;352:2589–97. [23] Pignon JP, Tribodet H, Scagliotti GV, Douillard JY, Shepherd FA, Stephens RJ et al. Lung adjuvant cisplatin evaluation: a pooled analysis by the LACE Collaborative Group. J Clin Oncol 2008;26:3552–9. [24] Satoh Y, Okumura S, Nakagawa K, Horiike A, Ohyanagi F, Nishio M et al. Postoperative ischemic change in bronchial stumps after primary lung cancer resection. Eur J Cardiothorac Surg 2006;30:172–6.

Prevention of refractory cough with mediastinal fat to fill the residual cavity after radical systematic mediastinal lymphadenectomy in patients with right lung cancer

背景与目的肺癌手术系统性清扫淋巴结能一定程度上提高肺癌患者生存率，但也会造成术后并发症增多，例如乳糜胸、喉返神经损伤致声音嘶哑、顽固性咳嗽等。目前国内外尚无外科手术方法改进以减少顽固性咳嗽的发生。本研究旨在探讨前纵隔脂肪填塞残腔是否可减少顽固性咳嗽的发生。方法2008年1月-2008年12月，依纳入标准收治右肺癌患者60例，按随机数字表随机分为使用前纵隔脂肪填塞上纵隔淋巴结清扫遗留的残腔实验组（30例）和未使用前纵隔脂肪填塞上纵隔淋巴结清扫遗留的残腔对照组（30例）。术中依据分组采取不同的方法处理上纵隔淋巴结清扫遗留残腔，记录两组患者术后第1天引流量、拔管时间、住院时间、拔管前后日间和夜间咳嗽评分等具体外科临床资料。分别随访两组患者出院后术后咳嗽情况，并指导患者填写咳嗽量化评分表和FACT-L评分表。结果① 两组患者手术时间、术中失血量、术后第1天胸引量、拔管时间、住院天数无明显差异；②两组患者在拔管前日间、夜间咳嗽及拔管后夜间咳嗽评分无明显差异，在拔管后日间咳嗽评分有统计学差异；③两组患者术后随访咳嗽评分表评分有明显差异；④两组患者FACT-L评分中生理状况、社会/家庭状况、情感状况、功能状况、附加关注五项评分中，后三项评分两组患者有明显差异。结论前纵隔脂肪填塞残腔能有效减少术后顽固性咳嗽的发生，提高患者生存质量。

Can non-performance of radical systematic mediastinal lymphadenectomy be justified in elderly lung cancer patients? An evaluation using propensity-based survival analysis☆

The increasing age of the population has raised the importance of determining the minimally required surgical treatment for elderly lung cancer patients. Despite a number of previous studies, the therapeutic impact of a radical mediastinal lymphadenectomy (RLA) associated with a pulmonary resection for lung cancer remains controversial. Herein, we investigated the impact of lymph node dissection on the overall survival for elderly lung cancer patients and assessed whether the non-performance of an RLA could be justified in the surgical treatment for these elderly patients. We analysed the data for 160 patients aged 70 years and older (113 males, 47 females) who underwent curative-intent surgery for non-small-cell lung cancer. They were divided into two groups, according to the method used for the intra-operative mediastinal lymph node dissection, the radical systematic lymphadenectomy (RLA, n=76) and the non-radical lymphadenectomy (NLA, n=94) groups. A Cox proportional hazards model and the Kaplan-Meier method were used for the survival analyses. Propensity-based analyses were also used to reduce the effect of non-randomisation and possible bias in indication of treatment between the two groups. RLAs had no protective effect on mortality; the hazard ratio for the RLA group in comparison to the NLA group was 0.97 (95% confidence interval (CI): 0.32-2.89) in the multivariate analysis and 1.43 (95% CI: 0.42-4.91) in the propensity-based stratifying analysis. The 3-year survival probability was 81.3% (95% CI: 67.1-89.8) for the NLA group, which was marginally better than that of the RLA group (77.5% (95% CI: 63.3-86.8)). There was no significant difference in the overall survival between the two groups (p=0.26). The 3-year survival probability of the NLA group at each quartile of the propensity score also tended to be better than that of the RLA group, which did not show any significant difference. There was no survival benefit shown for RLA associated with pulmonary resections in the present cohort, even in the propensity-based analyses. Although some reports recommend a systematic mediastinal lymphadenectomy for proper staging and better survival, a pulmonary resection with non-performance of radical lymphadenectomy could be an acceptable surgical treatment for the increasing number of elderly lung cancer patients.

Radical systematic mediastinal lymphadenectomy versus mediastinal lymph node sampling in patients with clinical stage IA and pathological stage T1 non-small cell lung cancer

To explore the appropriate method of mediastinal lymph node dissection for selected clinical stage IA (cIA) non-small cell lung cancer (NSCLC). From 1998 through 2002, the curative-intent surgery was performed to 105 patients with cIA NSCLC who had been postoperatively identified as pathologic-stage T1. According to the method of intraoperative medistinal lymph node dissection, they were divided into radical systematic mediastinal lymphadenectomy (LA) group (n = 42) and mediastinal lymph-node sampling (LS) group (n = 63). The effects of LS and LA on morbidity, N staging, overall survival (OS) and disease-free survival (DFS) were investigated. Also, associations between clinicopathological parameters and survival were analyzed. The mean numbers of dissected lymph nodes per patient in the LA group was significantly greater than that in the LS group (15.59 +/- 3.08 vs. 6.46 +/- 2.21, P < 0.001), and the postoperative overall morbidity rate was higher in the LA group than that in the LS group (26.2 vs. 11.1%, P = 0.045). There were no significant difference in migration of N staging, OS and DFS between two groups. However, for patients with lesions between 2 and 3 cm, the 5-year OS in LA group was significantly higher than that in LS group (81.6 vs. 55.8%, P = 0.041), and the 5-year DFS was also higher (77.9 vs. 52.5%, P = 0.038). For patients with lesions of 2 cm or less, 5-year OS and DFS were similar in both groups. Multivariate analysis showed that lymph node metastasis was the unique unfavorable prognostic factor (P < 0.001). After being intraoperatively identified as stage T1, patients with lesions between 2 and 3 cm in cIA NSCLC should be performed with LA to get a potentially better survival, and patients with lesions of 2 cm or less should be performed with LS to decrease invasion.

Impact of different mediastinal lymphadenectomy on clinical-stage IA non-small cell lung cancer

To study the role of different lymphadenectomy in the treatment of selected clinical-stage IA non-small cell lung cancer. All 115 postoperative patients admitted from January 1997 to May 2002 with pathologic-stage T1 who had been preoperatively diagnosed as clinical-stage I A non-small cell lung cancer were divided into a radical systematic mediastinal lymphadenectomy (LA) group and a mediastinal lymph node sampling (LS) group. Impacts on morbidity, N staging, overall survival (OS) and disease-free survival (DFS) were evaluated in each group respectively. Associations between clinical-pathological parameters (age, sex, tumor location, tumor size, pathological type and lymph node metastases) and OS, DFS were analyzed. The cumulative OS and DFS was calculated by the Kaplan-Meier method and compared by the Log-rank test. The mean number of dissected lymph nodes was (15.98 +/- 3.05) in LA group and (6.48 +/- 2.16) in LS group with a significant difference (P < 0.01). No statistically significant difference existed in modification of N staging, OS and DFS between LA group and LS group. However, for patients with lesions of a diameter more than 2 cm, 5-year OS in LA group was significantly higher than that in LS groups (LA vs. LS = 78.2% vs. 54.5% ,P < 0.05), also 5-year DFS was significantly higher (LA vs. LS = 75.1% vs. 51.3%, P < 0.05). For patients with lesions of 2 cm or less, 5-year OS and 5-year DFS were similar in both groups. The early surgery-related parameters (duration of surgery, drain secretion and morbidity) indicated a slighter invasion in LS group. In addition, patients with large cell carcinoma and adenosquamous carcinoma were associated with significantly poor 5-year OS (P < 0.05) , and patients with lymph node metastases were associated with poor 5-year OS as well as 5-year DFS (P < 0.01). After being intraoperatively identified as T1 stage, patients with lesions of more than 2 cm in clinical-stage IA non-small cell lung cancer should be performed with LA to get a better survival, and patients with lesions of 2 cm or less should be performed with LS to decrease invasion.

Surgical strategy for clinical stage I non-small cell lung cancer in octogenarians.

The purpose of this study was to determine whether lobectomy without radical systematic mediastinal lymphadenectomy (LA) is a satisfactory alternative surgical treatment for octogenarians with clinical stage I non-small cell lung cancer (NSCLC). From April 1985 through December 2001, 49 patients aged 80 years and older who underwent surgical treatment for clinical stage I NSCLC were reviewed. Lobectomy without radical systematic mediastinal LA was performed for 27 patients (LA0 group) and lobectomy with radical systematic mediastinal LA was performed for 22 patients (LA group). The mortality rate was 0% in the LA0 group and 4.5% in the LA group. Five-year survival rate according to the type of surgery was 44.8% in the LA0 group and 55.5% in the LA group, a difference that was not significant (P=0.88). Although there was no significant statistical difference, postoperative pulmonary complication was more frequent in the LA group than in the LA0 group (32% in the LA group versus 11% in the LA0 group P=0.07). Five-year survival rates according to serum carcinoembryonic antigen (CEA) levels were 0% for patients with elevated CEA levels (n=9) and 56.5% for patients with normal CEA levels (n=40) (P<0.01). Lobectomy without radical systematic mediastinal LA appears to be a satisfactory surgical procedure for octogenarians with clinical stage I NSCLC. However, mediastinoscopy is necessary in such octogenarians if their serum CEA level is elevated so that the precise clinical stage can be determined and an accurate prognosis can be given.

Impact of radical systematic mediastinal lymphadenectomy on tumor staging in lung cancer: Izbicki JR, Passlick B, Karg O, Bloechle C, Pantel K, Knoefel WT et al. Department of Surgery, University of Hamburg, Martinistrasse 52, 20246 Hamburg. Ann Thorac Surg 1995;59:209–214

Impact of radical systematic mediastinal lymphadenectomy on tumor staging in lung cancer: Izbicki JR, Passlick B, Karg O, Bloechle C, Pantel K, Knoefel WT et al. Department of Surgery, University of Hamburg, Martinistrasse 52, 20246 Hamburg. Ann Thorac Surg 1995;59:209–214

Radical systematic mediastinal lymphadenectomy in non-small cell lung cancer-Is it worthwhile?- : Results of a randomized trial

Radical systematic mediastinal lymphadenectomy in non-small cell lung cancer-Is it worthwhile?- : Results of a randomized trial

Impact of radical systematic mediastinal lymphadenectomy on tumor staging in lung cancer

The extent of lymphadenectomy in the treatment of non-small cell lung cancer is still a matter of controversy. While some centers perform mediastinal lymph node sampling with resection of only suspicious lymph nodes, others recommend a radical, systematic mediastinal lymphadenectomy (LA) to improve survival and achieve a better staging. Herein we report on the impact of LA on tumor staging in a controlled, prospective, randomized clinical trial comparing lymph node sampling and LA in a total of 182 patients with operable non-small cell lung cancer. Regardless of the type of lymphadenectomy performed, the percentage of patients with pathologic N1 or N2 (sampling: n = 23, 23.0%; LA: n = 22, 26.8%) 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 lymph node sampling group only 4 of 23 patients (17.4%) with N2 disease were found to have more than one lymph node level involved, whereas LA results in the detection of excessive N2 disease in 12 of 21 patients (57.2%; p = 0.007), which was associated with a shorter distant metastases-free (p = 0.021) and overall survival. In conclusion, LA is not essential to determine the N stage of a patient, but results in a more detailed staging of the N2 region, which is of prognostic significance. Therefore, it might be useful to identify patients with a higher risk for tumor relapse.