Thoracoscopic mediastinal lymph node dissection for lung cancer

In lung cancer, mediastinum lymphatic spread occurs. We review our technique and experience of thoracoscopic mediastinal lymphnode dissection (MLND). Between 1997 and 2011, 992 patients with primary lung cancer underwent thoracoscopic major pulmonary resection with MLND. Initially we used a combination of electrocautery and clips to divide blood vessels and lymphatic channels; our current technique relies on a vessel sealing system (VSS) which is expeditious and leads to less lymphorrhea. Furthermore, dissection of station 7 nodes is performed after each main bronchus or right intermediate bronchus is taped with a 0 silk suture, which is then brought out of the thorax through the access incision for antero-lateral retraction of the tracheal carina. We dissect between 3 and 4 N2 lymph node stations and a total of approximately 20 N2 lymph nodes. Postoperative complications related to MLND occurred in 35 of 992 patients (3.5%), 15 (1.5%) for recurrent laryngeal nerve injury, 3 (0.3%) for bilateral vagal injury, 14 (1.4%) for chylothorax and 3 (0.3%) for airway injury. However, none were lethal. Thoracoscopic mediastinal dissection is safe and feasible in treating lung cancer. We believe our technique and VSS are very useful for thoracoscopic MLND.     

Thoracoscopic mediastinal lymph node dissection for lung cancer

Mediastinal lymph node staging is an important component of the assessment and management of patients with operable non-small cell lung cancer and is necessary to achieve complete resection. During minimally invasive surgery, performance of an equivalent oncologic resection, including adequate lymph node dissection similar in extent to open thoracotomy, is absolutely necessary. We describe our techniques for video-assisted thoracic surgery (VATS) and Robot-assisted VATS (R-VATS) mediastinal lymph node dissection when performing thoracoscopic lobectomy for lung cancer. Between 2008 and 2011, 200 consecutive patients who underwent VATS or R-VATS lobectomies for early stage lung cancer were analyzed. In our series, we removed about 25 lymph nodes per case in both complete VATS and R-VATS. A thorough lymph node dissection in lung cancer is possible with either VATS or R-VATS technique without oncological compromise.     

Systemic mediastinal lymph node dissection of right lung cancer: surgical quality control and analysis of mediastinal lymph node metastatic patterns

Standardization of systemic mediastinal lymph node dissection (SMLD) of lung cancer requires further investigation. A consecutive 124 right lung cancer patients were recruited for pulmonary resection plus SMLD. Three mediastinal lymph node compartments, (i) the upper compartment (station 1-4), (ii) the middle compartment (station 7-8) and (iii) the lower compartment (station 9), were en bloc collected to achieve surgical quality control and to analyze mediastinal lymph node metastatic patterns. The number of total harvested lymph nodes, N1 nodes and N2 nodes were 21.9+/-8.7, 9.2+/-4.7 and 12.8+/-6.7, respectively. Tumor location (peripheral or central) (P=0.023) and status of blood vessel invasion (P=0.002) were identified as risk factors for nodal involvement. Right upper lobe (RUL) cancer with N2 disease primarily metastasized to the upper compartment (27.3%) (P=0.001). For right lower lobe (RLL) cancer, lymph node metastasis most commonly detected in the middle compartment (48.8%) (P=0.001). Single mediastinal compartment metastasis occurred in 64.7% (11/17) of adenocarcinomas from RUL and RML, whereas multiple compartments metastasis occurred in all adenocarcinoma cases (12/12) from RLL (P=0.001). SMLD needs to standardize the extent of lymphadenectomy and number of removed lymph nodes for surgical quality control. Simplifying mediastinal lymph node stations to three compartments may benefit surgical excision.     

Impact of mediastinal lymph node dissection on octogenarians with non-small cell lung cancer.

OBJECTIVE: Impacts of mediastinal lymph node dissection on a patient's course after pulmonary resection is unclear in octogenarians with non-small cell lung cancer. METHODS: Retrospectively identified subjects included 39 octogenarians and 1 nonagenarian, with grades according to the Charlson Comorbidity Index ranging from only 0 to 2. We performed mediastinal lymph node dissection in 19 patients (D group), and just lymph node sampling biopsy in the other 21 (S group). We compared clinicopathologic features and outcome after surgery between both groups. RESULTS: Deterioration of performance status at the time of discharge, evident in 17 patients overall, was significantly more frequent in the D group. Postoperative complications occurred in 27 patients overall and there was no significant difference between the two groups. Survival rates in younger patients at 1, 3, and 5 years were 86, 59, and 49%, respectively; in octogenarians these were 83, 58, and 42% (no significant difference). Nor did survival differ significantly by surgical management of mediastinal lymph nodes; 1-, 3-, and 5-year survival rates were 94, 63, and 40%, respectively in the D group and 78, 66, and 43%, respectively in the S group. CONCLUSION: Octogenarians with non-small cell lung cancer should be treated by urgent pulmonary resection whenever possible. Since mediastinal lymph node dissection has little effect on long-term survival or the carried risk of worsening performance status at discharge, pulmonary resection without complete mediastinal lymph node dissection should be considered.     

Late-onset chylothorax after pulmonary resection and systematic mediastinal lymph node dissection for lung cancer.

Late-onset chylothorax occurred 49 days after right lower lobectomy for lung cancer in a 76-year-old man. Chylothorax was successfully managed by conservative treatment with chest tube drainage and an enteral low-fat diet. Chylothorax may occur in the late period after pulmonary resection and systematic mediastinal lymph node dissection for lung cancer, for which conservative management is the treatment of choice.     

Impact of mediastinal lymph node dissection on octogenarians with non-small cell lung cancer

Objective: Impacts of mediastinal lymph node dissection on a patient’s course after pulmonary resection is unclear in octogenarians with non-small cell lung cancer. Methods: Retrospectively identified subjects included 39 octogenarians and 1 nonagenarian, with grades according to the Charlson Comorbidity Index ranging from only 0 to 2. We performed mediastinal lymph node dissection in 19 patients (D group), and just lymph node sampling biopsy in the other 21 (S group). We compared clinicopathologic features and outcome after surgery between both groups. Results: Deterioration of performance status at the time of discharge, evident in 17 patients overall, was significantly more frequent in the D group. Postoperative complications occurred in 27 patients overall and there was no significant difference between the two groups. Survival rates in younger patients at 1, 3, and 5 years were 86, 59, and 49%, respectively; in octogenarians these were 83, 58, and 42% (no significant difference). Nor did survival differ significantly by surgical management of mediastinal lymph nodes; 1-, 3-, and 5-year survival rates were 94, 63, and 40%, respectively in the D group and 78, 66, and 43%, respectively in the S group. Conclusion: Octogenarians with non-small cell lung cancer should be treated by urgent pulmonary resection whenever possible. Since mediastinal lymph node dissection has little effect on long-term survival or the carried risk of worsening performance status at discharge, pulmonary resection without complete mediastinal lymph node dissection should be considered.     

Late-onset chylothorax after pulmonary resection and systematic mediastinal lymph node dissection for lung cancer

Late-onset chylothorax occurred 49 days after right lower lobectomy for lung cancer in a 76-year-old man. Chylothorax was successfully managed by conservative treatment with chest tube drainage and an enteral low-fat diet. Chylothorax may occur in the late period after pulmonary resection and systematic mediastinal lymph node dissection for lung cancer, for which conservative management is the treatment of choice.     

纵隔淋巴结清扫对Ⅰ期非小细胞肺癌预后的影响

目的探讨纵隔淋巴结清扫范围对I期非小细胞肺癌预后的影响。方法回顾性分析从1994年1月至2003年12月在我院接受手术切除的330例I期非小细胞肺癌患者的临床、病理和随访资料。根据纵隔淋巴结清扫范围将全组患者分为纵隔淋巴结清扫组（LND）和淋巴结取样组（LNS）。运用Kaplan—Meier生存分析和COX比例风险模型,对影响预后的因素进行单因素和多因素分析。结果本组患者男性233例,女性97例;中位年龄60岁。IA期98例,IB期232例。LND组140例,LNS组190例;平均每例患者淋巴结清扫个数两组分别为（13,3±4,7）个和（5,2±3,0）个（P〈0,01）;平均每例患者纵隔淋巴结清扫组数两组分别为（3．7±0,9）组和（1．3±1．1）组（P〈0．01）。LND组5年和10年生存率分别为72,0％和66,1％,LNS组为65,9％和43．0％（P〈0,05）。其他影响预后的因素包括诊断时是否出现症状、肿瘤分期、是否侵犯脏层胸膜和肿瘤大小。COX比例风险模型分析结果显示,淋巴结清扫范围和术前有无症状是影响预后的因素。结论纵隔淋巴结清扫可以提高I期非小细胞肺癌术后的生存率。     

Limited mediastinal lymph node dissection for non-small cell lung cancer according to intraoperative histologic examinations

BACKGROUND: Although radioisotopic procedures are commonly used to detect sentinel lymph nodes in breast cancer surgery, these procedures are often problematic and not necessarily suitable for lung cancer surgery. METHODS: Our previous study revealed that the mediastinal sentinel lymph node, defined as the regional mediastinal lymph node, consisted of nodes 2, 3, or 4 in right upper lobe cancers; 3, 7, or 8 in right lower lobe cancers; 4, 5, or 7 in left upper lobe cancers; and 4, 7, or 8 in left lower lobe cancers. On the basis of these findings, we pathologically investigated one representative lymph node at each of the 3 levels dissected during surgical intervention in 69 patients with non-small cell lung cancer from September 1993 through December 2002. Fifty-eight patients with lung cancer underwent lobectomies with limited mediastinal lymph node dissection according to this strategy. RESULTS: Mediastinal lymph node recurrence was observed in only one patient during 41 +/- 25 months (maximum, 98 months) of follow-up. The cancer-specific 5-year survivals were 96.6% in patients with pathologic stage IA disease (n = 31) and 67.4% in patients with stage IB disease (n = 16). CONCLUSION: These results suggested that limited mediastinal lymph node dissection is applicable to patients with non-small cell lung cancer whose regional mediastinal lymph nodes are not metastatic.     

The discussion of the need of mediastinal lymph node dissection in the surgical treatment of lung cancer

The need of lymph node dissection in the case of operative lung cancer with negative mediastinoscopy was discussed. As a preliminary study, the N-number obtained from the mediastinoscopy and that of postoperative examination was compared. The rate of agreement of N-number was as high as 96%. Secondary, 183 cases of lung cancer with squamous-or adenocarcinoma pathologically T-1 or 2. N-0 and P-0 or 1 were picked up and examined. In those cases, the result of 3 years survival rate was 80% in the cases of absolute curative operation and 60% in that of relative non-curative cases, and 5 years survival rate was 70% and 52% respectively, and the cases of absolute curative operation was statistically excellent than that of another group. However, the background of the two groups was different to some degree on account of the advancement of the cancer and the age of the patients. Therefore, the randomized study as for the lymph node dissection in the cases of negative mediastinoscopy was finally performed. In the 30 cases of squamous cell carcinoma where dissection was carried out in 13 cases and not done in 17 cases, the result of 3 years survival was 84% (dissecting group) and 89% (non-dissecting group), and 5 years survival was 73% and 63% respectively. In 23 cases of adenocarcinoma (13; dissecting, 10; non-dissecting), the result of 3 years survival was 100%, 63% and that of 5 years survival rate was 100%, 63% respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Radical resection with autonomic nerve preservation and lymph node dissection techniques in lower rectal cancer surgery and its results: the impact of lateral lymph node dissection

Lateral lymph node metastases occur in 9% of rectal cancer patients. For cancers localized in the lower rectum below peritoneal reflection, the frequency increases to 13% of all cases and to 25.5% in those of Dukes' stage C. The most important technique in colorectal surgery for decreasing local failure in the pelvis is lateral lymph node dissection. Today, however, it is also regarded as crucial that with perfect lymph node dissection of the lateral area outside of the pelvic plexus, the postoperative functions of urination and sexual ability are preserved. Since 1988 we have performed autonomic nerve-preserving curative resection (ANP) with lateral dissection in most patients with advanced lower rectal cancer. The mean 5-year survival rate of patients with lateral lymph node metastasis from the lower rectum was 37.5%, improving from 32.1% to 43.4% during this period. In cases of ANP with lateral dissection the local recurrence rate was 4.8% overall and 7.4% in the Dukes' C group. Postoperative urinary function has been good or fair in all ANP patients. Sexual function remained problematic, especially regarding male ejaculation. We describe our method for preserving the autonomic nervous system in the pelvis and for achieving complete dissection in the lateral area. Received: 20 August 1998 / Accepted: 14 October 1998     

The adequate diagnostic criterion of mediastinal lymph node size for detection of metastasis in primary lung cancer

The size of lymph node is one of the most important factor in evaluation of lymph node metastasis in lung cancer. The most appropriate size for detecting lung cancer lymph node metastasis was studied by 2403 dissected lymph nodes in 75 operated cases of lung cancer. From the result of Receiver Operating Characteristic (ROC) curve analysis, long-axis diameter of the lymph node showed higher accuracy of diagnosis of metastasis than short-axis diameter. Metastasis of squamous cell carcinoma was diagnosed more accurately than that of adenocarcinoma. The most adequate threshold for detection of metastasis in squamous cell carcinoma was 10 mm in long-axis diameter with sensitivity of 73.8% and specificity of 78%. On the other hand, that of adenocarcinoma was 7 mm in long-axis diameter with sensitivity of 65.7% and specificity of 55.9%. That threshold value of adenocarcinoma was approximate to the value of normal lymph node size in the mediastinum. It was suggested that the size for detection of lymph node metastasis was depended upon histological type, and detection of lymph node metastasis in adenocarcinoma was extremely difficult.     

非小细胞肺癌淋巴结清扫方式临床研究

目的 比较非小细胞肺癌不同纵隔淋巴结清扫方式间的差异,为规范化开展肺癌淋巴结清扫临床研究提供依据.方法 在202例Ⅰa-Ⅲa期肺癌中进行前瞻性临床对照试验,比较常规清扫(RMLD)和全纵隔骨骼化清扫(SCLD)两种术式,分析手术经过和术后病理分期情况.结果 RMLD 107例,SCLD 95例.两组术前一般情况、临床分期及肺切除方式无明显差异,SCLD组平均扫除淋巴结组数显著高于RMLD组(8.9组对6.2组,P＜0.001),术后总体并发症(14.7%对14.0%,P=0.884)和病死率(2.1%对1.9%,P=0.904)无差异,但SCLD组分别有3例(3.2%)右侧乳糜胸和左侧喉返神经损伤发生.术后病理证实两组组织学类型及分期无明显差异,RNLD和SCLD组pN2分别占27.1%和24.2%(P=0.888),跳跃性纵隔转移率(RMLD 9.3%对SCLD 7.4%,P=0.613)以及纵隔多组转移率(RMLD 15.0%对SCLD 16.8%,P=0.714)亦无明显差异.分析纵隔各组淋巴结转移率发现上叶肺癌下纵隔转移率＜5%,而中、下叶肺癌上、下纵隔转移率均＞10%;cT1病例以及低度恶性肿瘤无一发生纵隔转移.结论 对非小细胞肺癌行常规纵隔清扫可达到与全纵隔骨骼化清扫同样的分期效果,后者手术风险并不高于常规清扫,但应避免右侧乳糜胸和左侧喉返神经损伤的发生;上叶肺癌仅需扫除上纵隔淋巴结而无需常规清扫下纵隔;早早期肺癌以及低度恶性肿瘤没有必要进行常规纵隔清扫.