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Hopital Europeen Georges Pompidou, Service de Chirurgie Thoracique, 20-40 rue Leblanc, Paris Cedex 15 75908, France
(Email: marc.riquet{at}hop.egp.ap-hop-paris.fr).
When we first reviewed factors determining overall survival of resected N2 nonsmall lung cancers (NSCLC) [1], we observed that the presence of a small metastasis in a mediastinal lymph node had the same clinical significance as that of a whole chain of tumor-bearing lymph nodes with extracapsular invasion.
In recent years, minimal N2 disease is emerging as a criterion of better prognosis for NSCLC patients with mediastinal lymph node involvement, and this understanding adds validity to the statement that primary surgical resection of more extensive N2 disease ("bulky N2") is futile.
These observations were different from previous experiences, and they stimulated an update of our total series of patients versus 260 [2]. The greatest surprise was the observation that lymph node micrometastases, which form a specific subset of minimal N2, indicated poor prognosis as bulky N2 disease. This questions the whole concept that minimal N2 is a good prognostic factor, supporting a decision to deny initial surgery for resectable clinical N2 NSCLC patients.
The incidence of pneumonectomy was higher in our series in N2 cases (60.6%), and the incidence increased from micrometastatic to bulky N2 (45.3% to 65.9%). However, pneumonectomy was independent of N2 involvement, despite higher rates for multiple N2 nodes (70.5% vs 55.4%) or increasing N2 size. The size of the lung tumor seems to play an important role and as Dr Grannis [3] suggested, we wonder whether preoperative chemotherapy or concomitant chemoradiation may shrink tumors sufficiently to permit the dissection necessary to perform lobectomy. In effect, we observed that tumor size within the lung was the main reason limiting a lesser resection, such as sleeve lobectomy [4].
Another reason for pneumonectomy was intrapulmonary lymph node involvement of stations 11 and 12, which prevents intra-fissural pulmonary vessel dissection because of nodal size or capsular rupture. In such cases, the "planes of surgical dissection" may be obliterated after induction treatment, just as observed by Grannis [3] after mediastinoscopy, which induces artificial capsular rupture and renders dissection no longer possible when followed by neoadjuvant therapy.
The presence of intrapulmonary involved lymph nodes can be predicted by tomodensitometry and positron emission tomographic scan. Involved intrapulmonary nodes in association with the size of the primary tumor and the size and number of N2 metastases are the main predictive criteria for pneumonectomy; thus, these are an indication for neoadjuvant therapy to reduce the possibility of a pneumonectomy. However, the prediction of an unavoidable pneumonectomy should not contraindicate pneumonectomy for resectable N2, particularly a left pneumonectomy, which carries a mortality risk similar to lobectomy.
We thank Dr Grannis [3] for supporting our article and for advocating surgery for selected clinical N2 lung cancers, which may provide a better chance of cure for these patients.
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