Systematic Mediastinal Lymph Node Research Articles

Determination of standard number, size and weight of mediastinal lymph nodes in postmortem examinations: reflection on lung cancer surgery

BackgroundMediastinal lymph node dissection is an essential component of lung cancer surgery. Literature lacks established information regarding the number and size of the healthy lymph nodes. In this postmortem autopsy study, we aim to define the number, size and weight of the lymph nodes in each mediastinal lymph node station. To implement the data for the clinical practice, we analyzed the possible number of nodes to be dissected in a systematic mediastinal lymph node dissection from the right and left sides during lung cancer surgery.MethodsSixty-two samples obtained from cadavers who did not die from chest malignancies, extrathoracic malignancies, any kind of infections or previous hospitalization before the death were included to the study. The locations of the nodes were recorded according to the American Thoracic Society Mediastinal Lymph Node Map. The number, size and weight of the nodes were determined at each station.ResultsMedian age of the cadavers was 39 years. Primary causes of death were asphyxia in 10 (16.1%) subjects, trauma in 29 (46.8%) subjects, cardiovascular problems in 10 (16.1%) subjects, and undetermined in 13 (21%) subjects. The median number of lymph nodes resected from each patient was 23 (range: 11–54). The right sided paratracheal lymph nodes (Station 2R and 4R) were more frequent, heavier and longer than left sided lymph nodes (Station 2L and 4L) at the paratrecheal region. Right sided inferior mediastinal lymph nodes were heavier and longer than the left ones; however, their availability was more often on the left.ConclusionsThe properties of mediastinal lymph nodes at particular stations are different for number, size and weight. Station 4R and 7 have the highest number of nodes followed by stations 5 and 6. We recommend removing the lymph nodes of these stations completely in lung cancer patients to rule out the possibility of micrometastatic disease. Diameter of normal lymph node may be 1 cm for the stations other than 4R and 7, but the definition of normal diameter of a lymph node at the stations 4R and 7 may be changed as 1,5 cm and 2,0 cm, respectively. Weight of the nodes may be a new subject to study and may be defined as a new modality to define a staging to be more accurate and the issue needs further investigations.

Long-term survival with surgery as part of a multimodality approach for N3 lung cancer

The extension of non-small-cell lung cancer (NSCLC) to supraclavicular (SC) and contralateral (CL) mediastinal lymph nodes is termed N3 and usually forbids surgical resection. However, scarce surgical series have reported encouraging results, and we sought to analyse our experience with this particular subgroup of patients. We retrospectively reviewed the charts of 5857 patients undergoing surgery for NSCLC during the last 30 years in two French centres. Eleven patients presenting with pathological-N3 were found, and more closely analysed concerning lymphatic spread, surgical indication and prognosis. N3 consisted of tumoural extension to the SC (n = 5), CL mediastinal (n = 5) or both (SC + CL, n = 1) stations. Patients underwent induction treatment with chemotherapy alone (n = 4), chemoradiotherapy (n = 3) or first-line surgery (n = 4). All patients underwent a complete surgical resection of the tumour associated with ipsilateral systematic mediastinal lymph node dissection. Additional resection of N3 lymph nodes was performed in 8 cases. Adjuvant treatment included chemoradiotherapy (n = 6), chemotherapy alone (n = 1) or radiation therapy alone (n = 1). All 5 patients with SC-N3 presented with ipsilateral disease; 3 of them survived 5 years. Four patients with CL-N3 presented with left-sided tumour and nodal extension to the 4R station, and none of them survived. Some N3-patients with specific anatomical location may benefit from multimodality treatment including surgery. These results support further prospective studies for selected N3-patients.

Video-assisted thoracic surgery lobectomy for right lung cancer in a patient with right aortic arch: report of a case

A 57-year-old man with an anomalous right aortic arch presented with cancer of the right lung. The right recurrent laryngeal nerve was found to be hooked around the right aortic arch. Right lower lobectomy with systematic mediastinal lymph node dissection was successfully performed using video-assisted thoracic surgery to provide close intraoperative attention to the branching of recurrent laryngeal nerve.

Roentgenological occult large-cell neuroendocrine carcinoma: Report of a long-term survivor

A 64-year-old male patient complained of a one-month history of bloody sputum. A polypoid tumor was almost obstructing the orifice of the subsegmental bronchus (B8b) of the anterior basal segment of the right lower lobe on bronchoscopy. Biopsy specimens of the tumor surface yielded a diagnosis of undifferentiated carcinoma. Clinical staging was T1aN0M0, stage IA. Surgical resection that comprised a right upper lobectomy with systematic mediastinal and hilar lymph node dissection was performed. Histopathologically, the tumor specimen was compatible with large-cell neuroendocrine carcinoma (LCNEC) of the subsegmental bronchus. Pathological staging was T1aN0M0, stage IA. To our knowledge, few cases of central-type LCNEC have been reported in the English literature, and ours is the first report of roentgenological occult LCNEC.

American College of Chest Physicians and Society of Thoracic Surgeons Consensus Statement for Evaluation and Management for High-Risk Patients With Stage I Non-small Cell Lung Cancer

The standard treatment of stage I non-small cell lung cancer (NSCLC) is lobectomy with systematic mediastinal lymph node evaluation. Unfortunately, up to 25% of patients with stage I NSCLC are not candidates for lobectomy because of severe medical comorbidity. A panel of experts was convened through the Thoracic Oncology Network of the American College of Chest Physicians and the Workforce on Evidence-Based Surgery of the Society of Thoracic Surgeons. Following a literature review, the panel developed 13 suggestions for evaluation and treatment through iterative discussion and debate until unanimous agreement was achieved. Pretreatment evaluation should focus primarily on measures of cardiopulmonary physiology, as respiratory failure represents the greatest interventional risk. Alternative treatment options to lobectomy for high-risk patients include sublobar resection with or without brachytherapy, stereotactic body radiation therapy, and radiofrequency ablation. Each is associated with decreased procedural morbidity and mortality but increased risk for involved lobe and regional recurrence compared with lobectomy, but direct comparisons between modalities are lacking. Therapeutic options for the treatment of high-risk patients are evolving quickly. Improved radiographic staging and the diagnosis of smaller and more indolent tumors push the risk-benefit decision toward parenchymal-sparing or nonoperative therapies in high-risk patients. Unbiased assessment of treatment options requires uniform reporting of treatment populations and outcomes in clinical series, which has been lacking to date.

Mediastinal lymph node position variability in non-small cell lung cancer patients treated with radical irradiation

Background and purposeDetailed knowledge on mediastinal lymph nodes position variability is lacking. In this study we quantified the variability over the irradiation course in non-small cell lung cancer (NSCLC) patients. MethodsA 0.35×5mm gold fiducial marker was inserted in mediastinal lymph nodes of 14 stage III NSCLC patients. A respiration correlated 4D-planning-CT (pCT) and daily 4D-Cone Beam (CB)CT-scans were acquired. To calculate the systematic and random baseline variations, and respiratory motion variability of the lymph nodes, all CBCT scans were registered to both the bony anatomy and marker in the pCT. Patient population statistics of the peak-to-peak amplitude and time averaged mean position relative to the bony anatomy were calculated. ResultsThe average peak-to-peak amplitude was 0.21cm, 0.52cm and 0.20cm in the Left–Right, Cranial–Caudal and Anterior–Posterior direction respectively, while the amplitude variability was ⩽0.1cm in each direction. Inter-fraction lymph node baseline variation was 0.21/0.2cm, 0.34/0.23cm, and 0.17/0.15cm systematic/random. PTV margins for these variations were 0.92cm, 1.24cm, 0.82cm for an online bone match and could be reduced to 0.77cm, 0.82cm and 0.86cm for an online carina match. ConclusionsSubstantial and anisotropic, systematic and random mediastinal lymph node baseline variations were found in NSCLC patients indicating that non-uniform margins could be beneficial.

Mediastinal lymph nodes: Ignore? Sample? Dissect? The role of mediastinal node dissection in the surgical management of primary lung cancer

The role of mediastinal lymph node dissection (MLND) during the resection of non-small-cell lung cancer is still unclear although most surgeons agree that a minimum of hilar and mediastinal nodes must be examined for appropriate pathological staging. Current surgical practices vary from visual inspection of the mediastinum with biopsy of only abnormal looking nodes to systematic mediastinal node sampling which is to the biopsy of lymph nodes from multiple levels whether they appear abnormal or not to MLND which involves the systematic removal of all lymph node bearing tissue from multiple sites unilaterally or bilaterally within the mediastinum. This review article looks at the evidence and arguments in favour of lymphadenectomy, including improved pathological staging, better locoregional control, and ultimately longer disease-free survival and those against which are longer operating time, increased operative morbidity, and lack of evidence for survival benefit.

Robotic Anatomic Segmentectomy of the Lung: Technical Aspects and Initial Results

Robotic lobectomy with radical lymph node dissection is a new frontier of minimally invasive thoracic surgery. Series of sublobar anatomic resection for primary initial lung cancers or for metastasis using video-assisted thoracic surgery have been reported but no cases have been so far reported using the robot-assisted approach. We present the technique and surgical outcome of our initial experience. Clinical data of patients undergoing robotic lung anatomic segmentectomy were retrospectively reviewed. All cases were done using the DaVinci System. A 3- or 4-incision strategy with a 3-cm utility incision in the anterior fourth or fifth intercostal space was performed. Individual ligation and division of the hilar structures was performed using Hem-o-Lok (Teleflex Medical, Research Triangle Park, NC) or endoscopic staplers. The parenchyma was transected with endovascular staplers introduced by the bedside assistant mainly through the utility incision. Systematic mediastinal lymph node dissection or sampling was performed. From 2008 to 2010, 17 patients underwent a robot-assisted lung anatomic segmentectomy in two centers. There were 10 women and 7 men with a mean age of 68.2 years (range, 32 to 82). Mean duration of surgery was 189 minutes. There were no major intraoperative complications. Conversion to open procedure was never required. Postoperative morbidity rate was 17.6% with pneumonia in 1 case and prolonged air leaks in 2 patients. Median postoperative stay was 5 days (range, 2 to 14), and postoperative mortality was 0%. Final pathology was non-small cell lung cancer in 8 patient, typical carcinoids in 2, and lung metastases in 7. Robotic anatomic lung segmentectomy is feasible and safe procedure. Robotic system, by improving ergonomic, surgeon view and precise movements, may make minimally invasive segmentectomy easier to adopt and perform.

Lymph nodal staging for non-small-cell lung cancer

We read with interest Matsuguma et al.’s recent paper in the journal [1] on the optimum method of lymph node (LN) staging for non-small-cell lung cancer (NSCLC). We congratulate the authors on their elegant analysis of the data to conclude that the LN ratio had the best discriminatory power, followed by the LN number, both of which were superior to the current nodal staging system. Several other authors [2–5] have come up with similar results and have espoused the use of either the LN ratio or positive LN number for the pathological staging of NSCLC. In an ideal world, with uniform standards of surgery, pathology grossing and reporting, there is no doubt that these methods would be superior to the conventional lymph nodal staging system. We, however, believe that there are several points to be considered before recommending that these be used to modify the existing tumour node metastases (TNM) staging system. First, it is often difficult to get an accurate count of the number of LNs harvested in the mediastinum. Frequently, this depends not only on the expertise of the operating surgeon, but also the diligence of the pathologist grossing the specimen. Moreover, anthracotic LNs in the mediastinum often fragment, thereby giving an erroneous count. Secondly, the ratio of metastatic LNs would be widely variant between surgeons, thoracic units and institutions depending on their surgical philosophy, expertise and again, the pathologist. Surgeons performing mediastinal LN sampling would have very different LN ratios from those who perform a radical systematic mediastinal LN dissection. Paradoxical results could appear due to an inordinately high pick-up of normal LNs, reducing the LN ratio. Thirdly, preoperative LN staging, already inaccurate, would become even more inaccurate as it would be virtually impossible to get a metastatic LN ratio or even an LN number based on radiological investigations or even a mediastinoscopy. Finally, these methods would increase the complexity of staging, making them less likely to be complied with by routine pathology reporting. While we agree wholeheartedly with the authors that the LN ratio or number would be superior to the existing TNM staging system, we would be reluctant to advocate the adoption of these methods in the TNM staging system.

Thoracoscopic Mediastinal Lymph Node Dissection for Lung Cancer

One of the main criticisms against lobectomy for lung cancer via video-assisted thoracoscopic surgery (VATS) is that mediastinal nodes are not properly assessed; however, VATS lobectomy permits complete nodal dissection that does not differ from that performed by thoracotomy. 1 Watanabe A. Koyanagi T. Ohsawa H. et al. Systematic node dissection by VATS is not inferior to that through an open thoracotomy: A comparative clinicopathologic retrospective study. Surgery. 2005; 138: 510-517 Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar Because recent publications have shown a significant statistical gain in 5-year survival if patients with stage ≥IIa non-small cell lung cancer (NSCLC) are treated with adjuvant chemotherapy, 2 Arriagada R. Bergman B. Dunant A. et al. Cisplatin-based adjuvant chemotherapy in patients with completely resected non–small-cell lung cancer. N Engl J Med. 2004; 350: 351-360 Crossref PubMed Scopus (2100) Google Scholar , 3 Douillard J.Y. Rosell R. De Lena M. et al. Adjuvant vinorelbine plus cisplatin versus observation in patients with completely resected stage IB-IIIA non-small-cell lung cancer (Adjuvant Navelbine International Trialist Association [ANITA]): A randomised controlled trial. Lancet Oncol. 2006; 7: 719-727 Abstract Full Text Full Text PDF PubMed Scopus (1351) Google Scholar a thorough systematic mediastinal lymph node dissection (MLND) is absolutely mandatory to properly stage patients with NSCLC. Stage migration from inadequate mediastinal lymph node assessment has the potential to be detrimental to patients with NSCLC by dictating the wrong postoperative management. In addition, stage migration might lead to completely erroneous survival statistics. It should be kept in mind that randomized controlled trials rely on final histologic staging, which is possible only with an accurate systematic MLND.

Supplement 2, Proceedings of the 14th World Conference on Lung Cancer, Book 2

Supplement 2, Proceedings of the 14th World Conference on Lung Cancer, Book 2

Comparison of Systematic Mediastinal Lymph Node Dissection Versus Systematic Sampling for Lung Cancer Staging and Completeness of Surgery

This self-controlled prospective study was designed to investigate the efficacy of systematic sampling (SS), compared with systematic mediastinal lymph node dissection (SMLD), for pathologic staging and completeness of surgery. Over a period of 11 mo, 110 patients with lung cancer were enlisted and treated by pulmonary resection. Surgeons systematically sampled mediastinal lymph nodes prior to pulmonary resection, and after pulmonary resection SMLD was performed to each patient using Mountain's procedure [1]. After SMLD, pN status was classified as N0 in 57 cases, N1 in 27, and N2 in 26. SS detected 38.3% of pooled nodes and 37.6% of pooled positive nodes collected from SMLD. Pathologic diagnosis after SS was understaged in nine cases (8.2%) compared with staging after SMLD. However, surgery was incomplete in 24 cases (21.8%) if SMLD was not performed after sampling. Negative predictive value for SS was 86.8% on the right side, and 95.0% on the left. Three categories were generated according to pN status: negative nodes in SS and additional negative nodes from SMLD [S(-)D(-)], negative nodes in SS but additional positive nodes from SMLD [S(-)D(+)], and positive nodes in SS [S(+)D(+)]. cN2 (P=0.000) and CEA level (P=0.001) were correlated with pN status. There was significant overall survival difference between non-N2 group and N2 group (P=0.002). SMLD may harvest about three times of mediastinal lymph nodes compared with SS. SS is more likely to affect the completeness of surgery instead of underrating pathologic stage.

Bedeutung der systematischen Lymphknotendissektion im Rahmen der Resektion pulmonaler Metastasen solider extrapulmonaler Tumoren

The systematic mediastinal and hilar lymph node dissection for the treatment of pulmonary metastases has, until now, not attracted much attention. A possible advantage of systematic lymph node dissection is an improved staging and a better locoregional tumour control due to resection of tumour micrometastases and the disintegration of lymphatic vessels. Aim of the study was to investigate the impact of mediastinal and hilar lymphnode metastases on the prognosis of the patient. Between 1978 and 2006, 249 patients underwent resection of pulmonary metastases from renal cell (91), colorectal (89), breast (45) and head and neck cancer (24), in combination with a systematic mediastinal and hilar lymphnode dissection. Survival was analysed by the Kaplan-Meier method. Multivariate analysis was performed using Cox regression analysis. Lymph node metastases were histologically demonstrated in 25.3 % of all patients. They did not correlate with the tumour grading and lymph node status of the primary tumour or the number of pulmonary metastases. Patients with lymph node metastases had a significantly shorter median survival than patients without (18 vs. 53 months, p < 0.001). Patients who underwent a systematic mediastinal and hilar lymph node dissection showed a trend to a prolonged survival (39.1 vs. 31.9 months, p = 0.089). Mediastinal and hilar lymph node metastases are significantly correlated with decreased survival. Systematic mediastinal and hilar lymphadenectomy provides valuable information for the staging and prognosis of patients with pulmonary metastases of kidney, head and neck, breast and colorectal cancers and may help to distinguish those patients who might profit from a more aggressive surgical therapy or an adjuvant therapy.

A clinicopathological study of resected non-small cell lung cancers 2 cm or less in diameter: a prognostic assessment

The detection and diagnosis of small-sized (2 cm or less) non-small cell lung cancer (NSCLC) has increased with the development of computed tomography (CT). Over 80% of 5-year survival rate has been reported in surgically treated peripheral lung cancer. There are systematic mediastinal and hilar lymph node involvement pleural invasion and intrapulmonary metastasis even with tumor diameter less than 2 cm. The appropriate surgical procedure for such kinds of lung cancer is lobectomy with mediastinal lymph node dissection. To evaluate the prognostic factors and establish the optimal surgical strategy, we analyzed the clinicopathologic features and survival benefit in different tumor size of peripheral small-sized NSCLC. Among the resected lung cancer cases between January 1999 and July 2001, 185 patients were retrospectively analyzed in surgical methods, lymph node involvement, CT scan findings and survival rates. Survival was analyzed by Kaplan-Meier method and log-rank test. Lymph node involvement was recognized in 26(14.05%) patients. There was no statistically significant difference in the incidence of lymph node involvement between tumors 1.6-2.0 cm (17.82%) in diameter than in those 1.0-1.5 cm (11.94%). There was no lymph node metastasis in tumors less than 1.0 cm in diameter. The 5-year survival rates with or without lymph node involvement were 89.98 and 46.15%, respectively, showing significant difference (P=0.000). The overall 5-year survival rate was 83.78%. The 5-year survival rate in tumors 1.6-2.0 cm, 1.0-1.5 cm and less than 1.0 cm in diameter was 80.20, 85.07 and 100%, respectively, and showing significant difference (P=0.035). The 5-year survival rate of 19 patients showing ground-glass opacity (GGO) on CT scan was 94.74% without any metastasis and recurrence after operation. There are systematic mediastinal and hilar lymph node involvement even with tumor diameter less than 2 cm. The results of the present study suggested that systematic lymph node dissection is necessary even for cases with tumor diameter less than 2 cm. However, if the tumor is within 1.0 cm in diameter with obvious GGO showing on chest CT scan, these are good candidates for partial resection without mediastinal lymph node dissection.

Usefulness of transbronchial needle aspiration for initial lung cancer staging

Besides radio logical methods (especially positron emission tomography combined with computed tomography), endoscopic techniques including transbronchial needle aspiration (TBNA) of mediastinal lymph nodes play an important role in lung cancer staging, thus having a significant effect on further patient management. The aim of the study was to investigate the diagnostic value of blind TBNA in staging of lung cancer, using systematic mediastinal lymph node dissection (SLND) at thoracotomy as a confirmatory test. Patients with lung cancer and enlarged mediastinal lymph nodes on computed tomography scans underwent TBNA. Non-small cell lung cancer (NSCLC) patients with negative TBNA or with single-level N2 disease underwent thoracotomy with appropriate pulmonary resection and with SLND. In 84 lung cancer patients, 166 TBNA were performed. Metastatic lymph node involvement was identified in 57 patients (67.9%). There were 10 patients (11.9%) with small cell lung cancer. Of the 74 NSCLC patients, TBNA revealed meta stases in 48 (64.9%). Twenty-four TBNA-negative patients (32.4%) and 4 patients (5.4%) with single-level N2 disease underwent pulmonary resection with SLND. In 8 of 28 operated patients (28.6%), N2 meta static nodes were identified. The per-patient analysis showed the sensitivity of TBNA to be 81.5%, specificity - 100%, accuracy - 86.5%, and negative predictive value (NPV) - 66.7%. Our results suggest that TBNA may be a useful method for initial NSCLC staging in patients suspected of N2-3 disease. Positive TBNA in 1 station only should not be considered as a true single-level N2 disease, because of a relatively low NPV for TBNA.

Thoracic Lymphatic Involvement in Patients Having Pulmonary Metastasectomy: Incidence and the Effect on Prognosis

Mediastinal and hilar lymph node involvement are rarely reported in the literature concerning pulmonary metastasectomy. The first problem is to determine with accuracy the incidence and location of thoracic lymph node involvement in patients with lung metastases. Determination of the impact on survival of this type of lymphatic spread may contribute to assessing whether metastatic nodal disease identified preoperatively is an absolute contraindication to metastasectomy. Systematic mediastinal lymph node dissection has revealed a statistically significant difference in survival between patients with lymph node involvement and those without lymph node metastases. Videomediastinoscopy to identify involved mediastinal lymph nodes can be safely performed and may have a role in a more accurate staging of the metastatic disease. The authors conclude that attention should be paid to ensuring that we do not operate on patients in whom we will leave behind diseases that we cannot reach. The discovery of mediastinal lymph node involvement may also influence decisions with respect to postresection adjuvant therapy.

A randomized trial comparing endosonography followed by surgical staging versus surgical mediastinal staging alone in non-small cell lung cancer: The ASTER study.

7000 Background: Invasive mediastinal staging in patients with resectable non-small cell lung cancer (NSCLC) can be performed with endosonography (ES) followed by surgical staging (SS; for negative findings) or SS alone. We conducted a prospective randomized multicenter trial to compare both strategies. Primary endpoint was detection of nodal metastasis (N2/3), secondary endpoints were the rate of futile thoracotomy and complications. Methods: Consecutive patientswith (suspected) resectableNSCLC in whom invasive mediastinal staging was indicated based on computed or positron emission tomography were randomly assigned between ES [combined transoesophageal and endobronchial ultrasound (EUS-FNA and EBUS-TBNA)] followed by SS (in case of negative findings) or SS (mediastinoscopy, mediastinotomy or video-assisted thoracoscopic surgery) alone. Thoracotomy with systematic mediastinal lymph node dissection was performed in the absence of mediastinal metastases after SS in both arms. Results: 241 patients were randomized as planned: 123 to ES+SS and 118 to SS alone. Nodal metastases were found in 62 patients (50%) (56 by EUS/EBUS + 6 by subsequent SS) vs. 41 (35%) by SS alone (p = 0.019). The sensitivity for mediastinal metastases for ES+SS was 94% (95% CI, 85- 98) versus 80 % (95 CI, 68-89) for SS alone (p = 0.042). Thoracotomy was futile in 8 patients (7%) staged by ES+SS vs. 21 (18%) in those staged by SS alone (p = 0.009). The rate of complications during staging was similar in both arms (6 vs. 7 patients, p = 0.8), however 12/13 were due to SS. Conclusions: Starting mediastinal staging with endosonography in resectable NSCLC 1) improves the detection of nodal metastasis 2) reduces futile thoracotomies 3) and has a similar complication rate, as compared to surgical staging alone. No significant financial relationships to disclose.

Effect of selective lymph node dissection based on patterns of lobe-specific lymph node metastases on patient outcome in patients with resectable non–small cell lung cancer: A large-scale retrospective cohort study applying a propensity score

Lobectomy with systematic complete mediastinal lymph node dissection is standard surgical treatment for localized non-small cell lung cancer. However, selective mediastinal lymph node dissection based on lobe-specific metastases (selective dissection) has often been performed. This study was designed to evaluate the validity of the selective lymph node dissection. From 1995 through 2003, 625 patients in our hospital had surgery for complete mediastinal lymph node dissection and 147 for selective dissection. We evaluated whether selective dissection adversely affected overall survival. To minimize possible biases due to confounding by treatment indication, we performed a retrospective cohort analysis by applying a propensity score. The propensity score was calculated by logistic regression based on 15 factors available that were potentially associated with treatment indication. Patients were divided into 4 groups according to quartile, and comparison between selective dissection and complete mediastinal lymph node dissection was made using propensity score quartile-stratified Cox proportional hazard models. Comparison of baseline characteristics between patients having selective dissection and patients having complete mediastinal lymph node dissection according to propensity score quartile supported comparability of the 2 groups. The 5-year overall survival rates were 76.0% for selective dissection versus 71.9% for complete mediastinal lymph node dissection. The 5-year survival probabilities stratified by propensity score quartile consistently showed no marked difference. In multivariate models, there was no significant difference between the 2 groups (hazard ratio = 1.17, P = .500) as also seen in the analysis without propensity score (hazard ratio = 1.06; 95% confidence interval, 0.68-1.64; P = .810). Therefore, selective dissection showed no significant impact on poor survival compared with complete mediastinal lymph node dissection. Selective lymph node dissection did not worsen the survival of patients with non-small cell lung cancer.

Aktueller Stand in der chirurgischen Therapie von Lungenmetastasen

Surgical resection has been the first choice for the treatment of isolated pulmonary metastases secondary to extrapulmonary malignancies. Despite recent advances, systemic chemotherapy for metastatic disease without the use of surgery is considered to be merely palliative, as there are rarely long-term survivors. Criteria for resection and prognostic parameters help facilitate patient selection. In addition to the established parameters the most significant factors in selecting patients for operation include the number of pulmonary metastases, disease-free interval, serum tumour marker level, and the question of mediastinal and hilar lymph node metastases. Complete surgical resection is critical to achieving long-term survival and is best accomplished via open thoracotomy accompanied by a systematic mediastinal and hilar lymph node dissection. The recent development of video-assisted thoracoscopic surgery (VATS) and advances in thoracic imaging technique has made the VATS approach more amenable for resection of small pulmonary nodules. However, the oncological radicality of VATS is questionable for pulmonary metastasectomy, thus the VATS approach is mostly limited to diagnostic purposes and in highly selected groups of patients with limited, peripherally located lesions. These operations should be performed preferably within a prospective study setting. All results together demonstrate that resection and re-resection of pulmonary metastases can be beneficial in patients, carefully selected by a multidisciplinary tumour board of thoracic surgeons and medical oncologists.

Analysis of the T Descriptors and Other Prognosis Factors in Pathologic Stage I Non-small Cell Lung Cancer in China

The seventh edition of the tumor, node, metastasis Classification of Malignant Tumors is due to be published in 2009. The recommendations of International Association for the Study of Lung Cancer for changes to the T descriptors have been published. We combined this new parameter with other well-established prognostic factors and performed multivariate survival analyses to validate its value in Chinese stage I non-small cell lung cancer (NSCLC). We try to validate the new staging project in 325 patients who underwent complete surgical resection for stage I NSCLC in Single Institution of Shanghai Chest Hospital from 1998 to 2003. Variables in the analysis included age, gender, performance status, history of smoking, pathologic type, type of resection (pneumonectomy, lobectomy, and bilobectomy), tumor size (greatest dimension of tumor), T-status (T1 or T2), type of lymph node resection (systematic mediastinal lymphadenectomy or mediastinal lymph node sampling), lymphovascular vessel invasion, and adjuvant chemotherapy. The 5-year overall survival (OS) of patients whose tumor measured no larger than 2 cm in largest diameter or larger than 2 cm but no larger than 3 cm were 75.49 and 74.58%, respectively. For those with tumors measured larger than 3 cm but smaller than 5 cm or larger than 5 cm but smaller than 7 cm were 60.87 and 55.63%. The 5-year OS of patients whose tumor measured larger than 7 cm was 46.15% (p = 0.025). The 5-year disease-free survival rates of patients whose tumor measured no larger than 2 cm in largest diameter or larger than 2 cm but no larger than 3 cm were 67.65 and 66.67%, respectively. For those with tumors measured larger than 3 cm but smaller than 5 cm or larger than 5 cm but smaller than 7 cm were 53.14 and 52.63%. The 5-year disease-free survival rate of patients whose tumor measured larger than 7 cm was 30.77% (p = 0.009). Multivariate analyses revealed that age, gender, type of resection (pneumonectomy, lobectomy, and bilobectomy), tumor size (greatest dimension of tumor), type of lymph node resection (systematic mediastinal lymphadenectomy or mediastinal lymph node sampling), and lymphovascular vessel invasion were significant predictive factors for OS. The tumor size is a significant independent prognostic factors in stage I NSCLC.