Ann Thorac Surg 2006;81:297
© 2006 The Society of Thoracic Surgeons
Original article: General thoracic
Invited Commentary
Frederic Grannis, Jr, MD
Department of General and Oncologic Surgery, City of Hope National Medical Center, 1500 E Duarte Rd, Duarte, CA 91010
(Email: fgrannis{at}coh.org).
Each year 40,000 Americans present with locally advanced nonsmall cell lung cancer (NSCLC). Only a small percentage of stage IIIA and very few IIIB patients achieve long-term survival. Most research in this country concentrates on preoperative chemotherapy in stage III, whereas the contributions of pulmonary resection, mediastinal node dissection, and postoperative radiation therapy receive less attention. After the introduction of mediastinoscopy in Scandanavia in the 1950s, it became generally accepted by most American thoracic surgeons that N2 metastasis was a contraindication to primary pulmonary resection, and many publications refer to such resections as futile. However, primary pulmonary resection and mediastinal node dissection has been widely applied in many Japanese and European surgical centers continuously since the 1970s.
Data from these groups indicates that patients with limited N2 benefit from pulmonary resection and mediastinal node dissection, and since there are long-term survivors even after resection of multiple, large N2 nodes, it is difficult to set exact limits on the size and number of N2 nodes that should contraindicate the primary resection. Patients with cN2 disease must be carefully selected before considering pulmonary resection and mediastinal node dissection as first line therapy. Preoperative computed tomography and positron emission tomographic scans, mediastinoscopy, and endoscopic ultrasound techniques facilitate recognition of T3-4, large or extranodal N2, multi-station N2 and N3 disease that identify questionable candidates for primary resection.
Sakao and his colleagues [1] from the Juntendo University School of Medicine examine the question of whether surgical treatment plays a potentially curative role in patients with involvement of the highest mediastinal nodes (ie, those lying above a horizontal line at the upper rim of the left brachiocephalic (left innominate) vein where it ascends to the left crossing in front of the trachea at its midline. It is generally considered that metastatic involvement of these nodes indicates incomplete (R1) resection and carries a poor prognosis. The Juntendo group has adopted a technique originally described by Hata, in extending their mediastinal dissections to the apex of the right pleura and through a median sternotomy to the upper left mediastinum and lower neck in the case of left-sided lung cancers. They report on survival in a group of 53 patients (T1-3 N2) who were not treated with preoperative chemotherapy. They confirm the adverse prognostic significance of involvement of the highest nodes. There were no long-term survivors in this group, even with extended nodal dissection. However, they do make the important additional observation that absence of metastasis in these nodes is an important prognosticator. They observed substantial 5-year survival in patients with N2 disease, even when clinically enlarged, multiple nodes, in multiple nodal stations were involved, as long as the highest nodes remained uninvolved.
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- Sakao Y, Miyamoto H, Yamazaki A, et al. The prognostic significance of metastasis to the highest mediastinal lymph node in non-small cell lung cancer Ann Thorac Surg 2006;81:292-297.[Abstract/Free Full Text]
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