Ann Thorac Surg 2006;81:1033
© 2006 The Society of Thoracic Surgeons
Original article: General thoracic
Invited commentary
Tatsuo Fukuse, MD
Department of Thoracic Surgery, Faculty of Medicine, Kyoto University, Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507 Japan
(Email: thoracic{at}kuhp.kyoto-u.ac.jp).
This study [1] was prospectively designed to evaluate the possibility of lesser mediastinal dissection for early-stage nonsmall cell lung cancer (NSCLC). The authors concluded that selective mediastinal dissection for early stage NSCLC achieved comparable efficacy compared with a complete dissection. "Recently, minimally invasive surgery for NSCLC, such as video-assisted thoracic surgery (VATS) has become of interest. For this reason, this study is particularly interesting, although it is not a randomized control study. However, as the authors point out, readers should be aware of that sampling and examination of a sufficient number of key lymph nodes were extremely important before choosing selective mediastinal dissection. In addition, we should be aware of other studies, which report fewer dissected and pathologically examined lymph nodes and show higher rates of recurrence and death possibly because of the Will Rogers phenomenon or stage migration. In breast cancer surgery, sentinel lymph nodes have been well studied and lesser lymph node resection has been tried successfully. On the other hand, detection of sentinel lymph nodes is not well warranted in lung cancer surgery. Interestingly, this study and a previous study by the same authors show that either of three stations (ie, 10, 11, or 12) of N1 lymph nodes or one station of N2 nodes (ie, 4 for right upper-lobe tumors, 5 for left upper-lobe tumors, and 7 for lower-lobe tumors) are sentinel lymph nodes of lung cancer. In other words, in case of upper-lobe tumors, lower mediastinal lymphadectomy is not necessary, if the hilar and upper mediastinal lymph nodes are tumor free. For lower-lobe tumors, upper mediastinal lymph node dissection is not necessary, if the hilar and subcarinal nodes are tumor free. However, we should be aware that this is not the case when hilar lymph nodes or even one station of N2 nodes are found to be tumor positive. In this instance, we should perform complete lymphadectomy. In addition, this study does not confirm the validity of selective lymphadectomy when the tumor is located in the middle lobe, lingula, or S6 segment. Consequently, when the readers apply the selective lymphadectomy to the patients with early-stage NSCLC, they should follow the selection criteria of this study strictly.
I believe that this article will become one of the milestones for minimally invasive surgery in the field of lung cancer.
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References
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- Okada M, Sakamoto T, Yuki T, Mimura T, Miyoshi K, Tsubota N. Selective mediastinal lymphadenectomy for clinico-surgical stage I non-small cell lung cancer Ann Thorac Surg 2006;81:1028-1033.[Abstract/Free Full Text]
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