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Eur J Cardiothorac Surg 2007;32:949-950. doi:10.1016/j.ejcts.2007.08.018
Copyright © 2007, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
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Letters to the Editor

Reply to Ismail

Masashi Muraoka*

Division of Surgical Oncology, Department of Translational Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan

Received 13 August 2007; accepted 22 August 2007.

* Corresponding author. Address: Department of Chest Surgery, Health Insurance Isahaya General Hospital, 24-1 Eishohigashi-machi, Iasahaya-city, Nagasaki 854-8501, Japan. Tel.: +81 957 22 1380; fax: +81 957 22 1184. (Email: mmuraoka{at}lucky.odn.ne.jp).

Key Words: Lung cancer • Diagnosis and staging • Lung cancer surgery • Lymph nodes • Mediastinal lymph nodes

I thank Dr Ismail sincerely for his interest and the comments regarding our paper [1]. I respect his extensive knowledge about the lymph node metastasis of primary lung cancer.

Is his opinion, as current reports suggest, the positron emission tomography (PET) scan is more accurate than CT in detecting mediastinal LN metastases? However, some authors reported that PET and helical CT perform similarly in the mediastinal staging of non-small cell lung cancer (NSCLC) [2], and the staging by PET still has some limitations which include inflammatory condition, the size of mediastinal lymph nodes, mislocalization of the hot nodes, and others [3,4]. We performed the presurgical staging by CT findings only in the first study [5], because our hypotheses were led from our preliminary study which determined the clinical staging by CT. PET scan has not yet become popular in Japan and unfortunately, our institution did not have the PET system in this study period.

We need to pay serious attention to the existence of skip metastases if we undergo selective lymphadenectomy for the patients with lung cancer. In the six patients with skip metastases in our first study, however, macroscopic pleural invasion was correlated with mediastinal LN metastasis rather than the tumor size. We think that the skip metastasis might be caused by the lymph flow from tumors with pleural invasion through the thoracic cavity to the mediastinum and induces LN involvement through the direct lymphatic pathway. We believe that the skip metastasis cases in the mediastinum can be identified by excluding the patients with tumors invading the pleura or with positive lavage cytology.

References

  1. Ismail MF. Sentinel node sampling in stage I non-small cell lung cancer. Eur J Cardiothorac Surg 2007;32:948-949.[Free Full Text]
  2. Pozo-Rodriguez F, Martin de Nicolas JL, Sanchez-Nistal MA, Maldonado A, de Barajas SG, Calero-Garcia R, Pozo MA, Martin-Escribano P, Martin-Garcia I, Garcia-Lujan R, Lopez-Encuentra A, de Pablo AA. Accuracy of helical computed tomography and fluorodeoxyglucose positron emission tomography for identifying lymph node mediastinal metastases in potentially resectable non-small cell lung cancer. J Clin Oncol 2005;23:8348-8356.[Abstract/Free Full Text]
  3. Takamochi K, Yoshida J, Murakami K, Niho S, Ishii G, Nishimura M, Nishiwaki Y, Suzuki K, Nagai K. Pitfall in lymph node staging with positron emission tomography in non-small cell lung cancer patients. Lung Cancer 2005;47:235-242.[CrossRef][Medline]
  4. de Langen AJ, Raijmakers P, Riphagen I, Paul MA, Hoekstra OS. The size of mediastinal lymph nodes and its relation with metastatic involvement: a meta-analysis. Eur J Cardiothorac Surg 2006;29:26-29.[Abstract/Free Full Text]
  5. Muraoka M, Akamine S, Oka T, Tagawa T, Nakamura A, Tsuchiya T, Hayashi T, Nagayasu T. Sentinel node sampling limits lymphadenectomy in stage I non-small cell lung cancer. Eur J Cardiothorac Surg 2007;32:356-361.[Abstract/Free Full Text]




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