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Ann Thorac Surg 2002;73:1562
© 2002 The Society of Thoracic Surgeons
a Division of Thoracic Surgery, Toronto General Hospital, 200 Elizabeth Street, EN-10-226, Toronto, Ontario M56 2C4, Canada
e-mail: robert.ginsberg{at}uhn.on.ca
This article from the Mitsui Memorial Hospital once again identifies the fact that micrometastasis to hilar and mediastinal lymph nodes can be identified by immunohistochemical staining when routine pathologic examination fails to identify metastatic disease. In their methodology, they do not indicate how many routine sections from each lymph node block were examined by hematoxylin and eosin staining and whether further sections would have altered the original No result. Despite this, their findings confirm the findings of many other groups.
Much more intriguing is the conclusion reached that an extended mediastinal lymph node dissection to include the superior mediastinal and thoracic inlet region in left-sided tumors may improve survival by removing all sites of occult micrometastatic involvement.
Dr Hata’s group has performed extended mediastinal lymphadenectomy for left-sided tumors for almost 20 years and their results have convinced other Japanese surgeons to modify their approach to left-sided tumors. Unfortunately, their experience has never been reported in the English literature and, indeed, has only been reported in abstract form. In their abstract presentations, they have claimed that extended mediastinal lymphadenectomy improves survival in left-sided tumors. Recently, Keller and colleagues [1] analyzed the result of a North American trial, comparing patients undergoing mediastinal lymph node dissection with those receiving nodal sampling only. In left-sided tumors, where the superior mediastinal lymph nodes are not routinely dissected, there was no difference in results between sampling and lymphadenectomy. However, in right-sided tumors, where the superior mediastinal lymph nodes are routinely dissected during lymphadenectomy, the 5-year survival was improved by this latter procedure. Kellar and colleagues suggested that the equivalent survival between sampling and lymphadenectomy on the left side perhaps was the failure of left-sided lymphadenectomy to remove the superior mediastinal lymph node tissue.
Two current ACOSOG trials (ACOSOG Z0030 and Z0040) may shed further light on all of these questions as, in those trials, superior mediastinal lymphadenectomy is not carried out in left-sided tumors and an attempt is being made to identify occult mediastinal nodal disease using immunohistochemistry.
Whether or not routine mediastinal lymphadenectomy improves survival in lung cancer is still a moot point and is worthy of further study. I would urge the Mitsui Memorial Hospital group to publish their total experience with extended lymphadenectomy for left-sided tumors in a widely read journal so that the results of this approach can be analyzed by all interested parties.
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