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Division of Thoracic Surgery, Rush University Medical Center, Suite 774, 1725 W Harrison St, Chicago, IL 60612-3824
(Email: michael_liptay{at}rush.edu).
Malignant pleural mesothelioma is an aggressive diffuse spreading tumor that has a generally poor outlook with mean survivals of less than 2 years regardless of treatment approach. These authors [1] examined the pattern of lymph node metastases in their series from the National Cancer Institute of Cairo, Egypt.
Lymph node metastases were originally shown to be a bad prognostic factor in mesothelioma by Sugarbaker and colleagues [2] in 1993. Since then several groups have touted the importance of mediastinoscopy in the preoperative assessment of patients prior to planned resection.
A standard cervical mediastinoscopy allows an incomplete assessment of the N2 nodes and no evaluation of N1 disease. These authors noted a 25% rate of positive nodes outside the reach of the mediastinoscope. In their series, de Perrot and colleagues [3] found mediastinoscopy to only have a negative predictive value of 68% due to similar reasons. Survival in their small series noted significantly poorer survival for those with nodal metastases, but no distinction between patients with N1 or N2 involvement.
Endobronchial ultrasound-directed needle biopsy can aid in accessing hilar and lobar N1 stations, whereas endoesophageal ultrasound may supplement those nodes out of the reach of cervical mediastinoscopy. The use of these investigations to stratify patient management in lung cancer is becoming well established, but more data is needed in mesothelioma cases.
N1 involvement representing a more advanced nodal spread in comparison with mediastinal N2 disease is on the surface counterintuitive. However, if one considers mesothelioma as a pleural tumor superficial to the lung parenchyma itself, then deeper invasion into the lung substance is likely necessary for N1 involvement, signifying a more advanced tumor.
These authors raise an interesting hypothesis of inverted nodal spread. Their recommendations for investigating the hilar nodes in the setting of parenchymal invasion or circumferential diffuse pleural thickening on computed tomographic scan seems reasonable. The assertion that N1 nodal involvement should represent a higher and more advanced stage of disease deserves further study with larger series of patients confirming their findings.
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