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Kyohei Masai



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    WS05 - Staging Workshop Part 2: The Importance of Invasive Nodal Staging in Thoracic Malignancies (ID 106)

    • Event: WCLC 2019
    • Type: Workshop
    • Track: Staging
    • Presentations: 1
    • Now Available
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      WS05.03 - How to Perform a Proper Systematic Nodal Dissection in Lung Cancer Surgery (Now Available) (ID 3686)

      15:45 - 17:15  |  Presenting Author(s): Kyohei Masai

      • Abstract
      • Presentation
      • Slides

      Abstract

      In 1960, Cahan first reported lobectomy with regional lymph node dissection, which was called “radical lobectomy.”1 Since then, this procedure has been widely accepted, and systematic nodal dissection (SND) is an internationally accepted standard procedure for lymph node dissection in cases of non-small cell lung cancer (NSCLC). The purpose of SND is aimed at removal of all mediastinal lymph node stations regardless of the anatomical location of the primary tumor in the lobe. The significance of SND can be discussed from the clinical aspects of accurate staging and survival benefit. Metastatic lymph nodes obtained via SND can undergo careful and accurate accurate histopathological evaluation, which offers several clinical advantages. However, the therapeutic effect of SND remains unclear.2-5

      Technically, SND involves complete excision of all tissues in a particular anatomical compartment along with a few components of surrounding anatomical structures. An ideal technique involves en bloc removal of all tissue that may contain cancer cells, including lymph nodes and surrounding fatty tissue within pre-defined anatomical landmarks. All of lobectomies for NSCLC are performed via posterolateral incision using minimally invasive open surgery (MIOS) approach in our institution. Common to both sides, the fourth or fifth intercostal space provides better access in SND. During the SND, special care is warranted to prevent interruption of the lymphatic vessels and/or injury to the lymph nodes themselves. Additionally, connective tissue ligation is necessary in a few cases to prevent postoperative chylothorax. Identification of the bilateral recurrent nerves is important because recurrent nerve paralysis can cause serious postoperative complications. Based on AOSOG Z0030 trial, complications of SND include postoperative chylothorax (1.7%), intraoperative bleeding (1.1%), and recurrent laryngeal nerve injury (0.9%).5

      Although SND is a standard procedure of lymph node dissection for NSCLC, previous studies have analyzed in detail the lymphatic pathway and the pattern of lymph node involvement based on the primary location by lobe. Asamura et al. 6 reported that right upper lobe tumors and left upper segment tumors tend to metastasize to the superior mediastinum and that these lesions rarely metastasize to the subcarinal nodes without concomitant metastasis to the hilar or superior mediastinal nodes.6 The lobe-specific patterns of nodal metastases are being recognized owing to increasing analyses of the lymph node metastatic pathway.6-9 Based on these results, lobe-specific lymph node dissection is being increasingly performed under certain conditions, for example, based on tumor location, tumor size, cell type, and the percentage of the area of ground glass opacity visualized in the tumor on computed tomography.

      References

      1. Cahan WG. Radical lobectomy. J Thorac Cardiovasc Surg; 1960;39:555-572.
      2. Izbicki JR, Passlick B, Pantel K, et al. Effectiveness of radical systematic mediastinal lymphadenectomy in patients with resectable non small cell lung cancer. Ann Surg 1998;227:138-144.
      3. Sugi K, Nawata K, Fujita N, et al. Systematic lymph node dissection for clinically diagnosed peripheral non-small-cell lung cancer less than 2 cm in diameter. World J Surg 1998;22:290-294.
      4. Wu Y, Huang ZF, Wang SY, et al. A randomized trial of systematic nodal dissection in resectable non-small cell lung cancer. Lung Cancer 2002;36:1- 6.
      5. Wright G, Manser RL, Byrnes G, et al. Surgery for non-small cell lung cancer: systematic review and meta-analysis of randomised controlled trials. Thorax 2006;61:597-603.
      6. Asamura H, Nakayama H, Kondo H, Tsuchiya R, Naruke T. Lobe-specific extent of systematic lymph node dissection for non-small cell lung carcinomas based on a retrospective study of metastasis and prognosis. J Thorac Cardiovasc Surg 1999; 117:1102-1111
      7. Asamura H, Nakayama H, Kondo H, Tsuchiya R, Naruke T. Lymph node involvement, recurrence, and prognosis in resected small, peripheral non-small cell carcinoma of the lung. Are these carcinomas candidates for video-assisted lobectomy? J Thorac Cardiovasc Surg 1996;111:1125-1134
      8. Okada M, Tsubota N, Yoshimura M, et al. Prognosis of completely resected pN2 non-small cell carcinomas: what is the significant node that affects survival? J Thorac Cardiovasc Surg 1999;118:270-275
      9. Watanabe S, Suzuki K, Asamura H. Superior and basal segment lung cancers in the lower lobe have different lymph node metastatic pathways and prognosis. Ann Thorac Surg 2008;85:1026-1031.

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