Ann Thorac Surg 2009;88:928-929. doi:10.1016/j.athoracsur.2009.06.068
© 2009 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited Commentary
Stephen C. Yang, MD
Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, 600 N. Wolfe St, Blalock 240, Baltimore, MD 21287
(Email: syang{at}jhmi.edu).
The optimal management of patients with N2 disease remains one of the most contentious areas of care for patients with nonsmall cell lung cancer (NSCLC). This is likely due to the wide pathologic variations in this stage. Defranchi and colleagues [1] present a series of 59 patients from a cohort of 968 who had clinical stage I disease and were found to have incidental N2 disease after surgical resection. Although a little more than half of the patients had formal invasive mediastinal staging preoperatively, the authors attempted to define the role of mediastinal staging in this group of patients. The 5-year survival for this specific group of patients was 46% in comparison with other published reports, and thus this group had a better survival than other groups with N2 disease, such as multi-station, skip metastases.
These findings underscore the critical importance and continued need for surgeons who operate on lung cancer patients who must stage the mediastinal lymph nodes intraoperatively. Recent data still show an unimpressive, yet improving, compliance rate (33% to 60%) of surgeons who adequately sample or dissect the mediastinum out. The implications are obvious for discovering nodal involvement, and thus, even finding a single positive N2 node would obviously alter care, whereby patients would do much better than the rest of patients at that stage would suggest. It still remains unknown whether mediastinal lymph node dissection is better than sampling for this stage of the disease.
As molecular and genomic techniques evolve and become more practical, the detection of micrometastatic disease in draining lymph nodes will be the ultimate incidental finding. This knowledge will be important in improving prognostic stratification, and elucidation of marker expressions might even improve selection of patients with N2 disease for specific treatment regimens. In this era of personalized cancer care, it becomes imperative that accurate nodal staging be performed so as to develop individualized therapies. Because the trials using induction or adjuvant therapy have focused primarily on bulky N2 disease, newer studies should be developed now for the incidental N2 patient so that definitive treatment plans will be ready once detection of occult disease becomes commonplace. Unfortunately, the upcoming IASLC revisions to the UICC lung cancer staging will not recognize these subtleties in N2 disease, and it will be necessary for the surgeon to understand the heterogeneity of treatment within this group. All patients with N2 disease are not equal and should not be treated as such.
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References
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- Defranchi SA, Cassivi SD, Nichols FC, et al. N2 disease in T1 non-small cell lung cancer Ann Thorac Surg 2009;88:924-929.[Abstract/Free Full Text]
Related Article
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N2 Disease in T1 Non-Small Cell Lung Cancer
- Sebastian A. Defranchi, Stephen D. Cassivi, Francis C. Nichols, Mark S. Allen, K. Robert Shen, Claude Deschamps, and Dennis A. Wigle
Ann. Thorac. Surg. 2009 88: 924-928.
[Abstract]
[Full Text]
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