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Eur J Cardiothorac Surg 2007;31:142-143. doi:10.1016/j.ejcts.2006.10.011
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

Letters to the Editor

Is radical mediastinal dissection mandatory for curative resection of NSCLC?

Department of Thoracic Surgery, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK

Received 23 August 2006; accepted 12 October 2006.

^_* Corresponding author. Fax: +44 207 351 8560 (Email: p.goldstraw{at}rbht.nhs.uk).

Key Words: Lung cancer • Resection • Lymph node dissection • Systematic nodal dissection • Intrathoracic staging

We read with interest the article by Massard et al. [1] comparing nodal ‘sampling’ and ‘formal nodal dissection’ sequentially at thoracotomy, in which they found that sampling underestimated mediastinal nodal involvement that would have lead to inaccurate staging and more incomplete resections had nodal dissection not been performed. However, to fully understand the significance of their findings it would be helpful to clarify the definitions of each of these terms, to be given more details of the protocol and to be provided with more raw data.

‘Sampling’ may refer to the removal of part of one node, removal of one node from a nodal station or the removal of selected stations. The ACOSOG study provided one such definition [2]. Similarly there is no universally accepted standard for ‘the usual formal lymph node dissection’ used in this study. The IASLC International Workshop on Intrathoracic Staging, held in London in 1996 [3] provided an internationally agreed term, systematic nodal dissection (SND), which avoided imprecise terms such as ‘sampling’, recommended the labelling of excised nodes according to one of the Internationally agreed nodal charts, extended the evaluation of nodal disease into the hilum and other N1 stations and set a standard for adequate mediastinal nodal evaluation of three nodal stations. This was subsequently clarified in a discussion document on the definition of complete resection [4], which recommended an additional three N1 stations should also be removed for complete nodal assessment.

Would Dr Massard and his colleagues tell us the number and site of N2 nodes or stations specified in the protocol for ‘sampling’ and ‘formal dissection’ and the actual number removed in the study patients? Did such evaluations include those N1 nodes/stations not included in the ‘intrapulmonary nodes’, which were dissected by the surgeon during resection and the pathologist subsequently?

From the data provided we can only identify 44 patients who had N2 disease identified on nodal dissection in whom this would have been missed or under-estimated on sampling, and hence cannot understand why ‘resection based on sampling would have been incomplete in 53 (88%)’ of those with pN2 disease. The discussion document by Rami-Porta et al. [4] emphasises that ‘complete resection’ entails much more than a thorough nodal evaluation and one assumes that these other features, such as negative margins, were also considered in this protocol.

We are assured that the ‘stations were adequately labelled’. In view of the multicentre, international nature of this study it is clearly important to know if this was in accordance with an internationally accepted nodal chart. Such a study is prone to inter-observer variability. Discordance between observers in distinguishing between stations #10 and #4 and between stations #10 and #5 occurs in one third of patients with resulting distortion of the reported stage [5]. We would ask the authors to tell us which nodal map or definitions were utilised and whether inter-observer variability was assessed between participating surgeons.

We hope that this additional information will reinforce and clarify the conclusions suggested by the authors.

References

1. Massard G, Ducrocq X, Kotchetkova E, Porhanov CA, Riquet M. Sampling or node dissection for intraoperative staging of lung cancer: a multicentric cross-sectional study. Eur J Cardiothorac Surg 2006;30(1):157-164.
2. Goldstraw P. Report on the international workshop on intrathoracic staging. London, October 1996. Lung Cancer 1997;18:107-111.
3. Rami-Porta R, Wittekind C, Goldstraw P. Complete resection in lung cancer surgery: proposed definition. Lung Cancer 2005;49:25-33.[CrossRef][Medline]
4. Allen MS, Darling GE, Pechet TTV, Mitchell JD, Herndon JE, Landreneau RJ, Inculet RI, Jones DR, Meyers BF, Harpole DH, Putnam JB, Rusch VW, The ACOSOG Z0030 Study Group Morbidity and mortality of major pulmonary resection in patients with early-stage lung cancer: initial results of the randomised prospective ACOSOG Z0030 trial. Ann Thorac Surg 2006;81:1013-1020.[Abstract/Free Full Text]
5. Watanabe MD, Ladas G, Goldstraw P. Inter-observer variability in systematic nodal dissection: comparison of European and Japanese nodal designation. Ann Thorac Surg 2002;73:245-248.[Abstract/Free Full Text]

This article has been cited by other articles:

				W. Zhong, X. Yang, J. Bai, J. Yang, C. Manegold, and Y. Wu Complete mediastinal lymphadenectomy: the core component of the multidisciplinary therapy in resectable non-small cell lung cancer. Eur. J. Cardiothorac. Surg., July 1, 2008; 34(1): 187 - 195. [Abstract] [Full Text] [PDF]

				G. Massard, E. A. Kochetkova, V. A. Porhanov, and M. Riquet Reply to Belcher and Goldstraw Eur. J. Cardiothorac. Surg., January 1, 2007; 31(1): 143 - 144. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Elizabeth Belcher Peter Goldstraw Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Belcher, E. Articles by Goldstraw, P. Search for Related Content PubMed PubMed Citation Articles by Belcher, E. Articles by Goldstraw, P. Related Collections Lung - cancer