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Eur J Cardiothorac Surg 2002;21:595
© 2002 Elsevier Science NL
Letter to the Editor |
Yedikule Pulmonary Diseases and Chest Surgery Center, Sümer Mah. 27/4 No. 4 Ba
apt. D. 9, Zeytinburno, Istanbul, Turkey
Received 28 March 2001; received in revised form 29 November 2001; accepted 29 November 2001.
* Corresponding author. Tel.: +90-212-415-6841; fax: +90-212-547-22-33
e-mail: okansolak{at}hotmail.com
Key Words: Lung cancer • Skip metastasis • N2
Lung cancer can metastasize to mediastinal lymph nodes without affecting bronchopulmonary lymph nodes. This phenomenon is named skip metastasis (N1 without N2) [1–4]. We aimed to determine the properties of skip metastatic cases and whether skip metastasis (sN2) has an impact on prognosis by evaluating the non-small cell lung cancer (NSCLC) patients operated in our clinic.
Between 1994 and 1998, 165 patients operated for NSCLC were prospectively examined. Thirty-four patients (22.4%) were excluded from the study, because lymphatic curettage was not done; due to the pathologic changes in vital parameters, there is a need for shortening anesthesia period and attendance of different operators to the operation. The mediastinal lymphatic metastasis was detected in 34 of (26.5%) the 128 patients left and these patients have formed our study group. The sN2 was observed in 11 of the 34 patients (32.3%). These two groups were compared according to age, sex, cell type, T stage, the stage and the number of affected lymph nodes and the completely resected cases were compared according to their survivals. In survival analysis, five of the patients in non-skip metastases (nsN2) group were excluded from the study, because they were found to have residual tumor at any surgical resection margin. N2 positivity was detected after thoracotomy in all patients. The dissection technique we prefer instead of en bloc curettage was the large excision of lymph nodes – with their fat tissue nearby – located at ipsilateral paratracheal, subcarinal and inferior mediastinal locations in all patients, aortic window and anterior mediastinal lymph nodes in left upper lobe tumor patients. There were no macroscopic lymph nodes left after dissection.
The total number of N2 positive patients was 34 (26.5%) and 11 (32.3%) of them had sN2 positivity, whereas 23 (67.6%) of them had N2 without skip. Mean age was 54.6. In the sN2 group, right lung tumor incidence was 63.6% (n=7), whereas in nsN2 group it was 56.5% (n=13). In the both groups, N2 positivity was observed more in right lung tumors and the most frequently affected lobe was the right upper lobe. There was no statistically significant difference between the two groups, when T1, T2 and T3 stages were compared (P>0.05). The most frequent histologic cell type was the epidermoid cancer (58.8%), but there was no statistically significant difference observed between the cell types (P>0.05). The lymphadenopathy was detected in four stations (min 3–max 5) in right lung tumors and in five stations (min 4–max 6) in left lung tumors after lymphatic curettage. The mean number of lymphadenopathies detected in N2 group was 30 (min 8–max 45). The most frequently affected mediastinal level was the superior mediastinum (34%). It was affected in 45.4% (n=5) of sN2, 47.8% (n=11) of nsN2 patients but was not statistically significant. There was no statistically significant difference between the aortic level and inferior mediastinal level. In our series, 79.4% of the patients have N2 positivity in one station. Lobectomy was performed in 47% and pneumonectomy in 52.9% of patients. The frequency of lobectomy was high (54.5%) in sN2 group but it was not statistically significant too.
There was no operative mortality. The median follow up period was 14 months (3–48 months); 17 months in sN2 and 13 in nsN2 group. The median survival was 18.2 months in sN2, 16.5 months in nsN2 group. This difference was not statistically significant (P>0.05). We observed that all of our patients in sN2 group were alive, whereas in nsN2 group only 45% were alive. And this difference was statistically significant (P<0.001). For this reason we believe that sN2 is a good prognostic sign for N2 positive patients.
References
shida T. Strategy for lymphadenectomy in lung cancer three centimeters or less in diameter. Ann Thorac Surg 1990;50:708.[Abstract]
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