Elsevier

The Annals of Thoracic Surgery

Volume 86, Issue 5, November 2008, Pages 1626-1630
The Annals of Thoracic Surgery

Original article
General thoracic
The Significance of One-Station N2 Disease in the Prognosis of Patients With Nonsmall-Cell Lung Cancer

https://doi.org/10.1016/j.athoracsur.2008.07.076Get rights and content

Background

A retrospective study was conducted to define the characteristics and the prognosis of N2 disease subgroups according to their patterns of spread.

Methods

From January 1993 to December 2004, 1,329 patients underwent lung resection for bronchogenic carcinoma The records of all patients with positive mediastinal lymph nodes at the surgical specimen (pIIIA/N2) after radical resection were analyzed, and the pattern of mediastinal lymphatic spread was classified according to regional spread, to skip metastasis, and to one or two or more lymph node stations, in relation to primary tumor location. Age, sex, type of resection, right or left lesion, T status, primary tumor location, tumor size, tumor central or peripheral location, histology, and survival were recorded and analyzed. Survival was analyzed according to regional spread or not, number of mediastinal lymph node stations involved, and skip metastasis status.

Results

Among 302 cases (22.7%) with positive mediastinal lymph nodes pIIIA/N2, 66 (22%) were skip metastases, 72 (24%) had a nonregional mode of spread, and 199 (66%) included two or more stations of mediastinal lymph node invasion. Cox regression analysis of all cases disclosed malignant invasion in only one mediastinal lymph node station as the only favorable factor of survival (p < 0.001, odds ratio 0.57, 95% confidence interval: 0.42 to 0.78).

Conclusions

The presence of one-station mediastinal lymph node metastasis in patients with nonsmall-cell lung cancer who underwent major lung resection with complete mediastinal lymph node dissection proved to be a good prognostic factor that should be taken into account in the future.

Section snippets

Material and Methods

From January 1993 to December 2004, 1,329 patients underwent lung resection for bronchogenic carcinoma pathologically staged as pI–IIIA. The Scientific and Ethics Committee of Sismanogleio General Hospital has approved the conduction of the study. Individual consent for the study was waived.

This group included 1,077 men (81%) and 252 women (19%), aged 44 tp 78 years (median, 62). The types of resection included 372 pneumonectomies (27.9%), 219 right (59%) and 153 left (41%), and 957 lobectomies

Results

Patients at stage pIIIA/N2 were the target group to be studied. This group consisted of 302 patients (22.7%). The demographic and clinicopathologic characteristics of this group are fully described in Table 1.

The incidence of mediastinal lymph node involvement according to primary tumor location was studied (Table 2). In 59% of the cases, the upper mediastinal lymph nodes were invaded, 22.5% of the lower ones and 18.5% of both the upper and lower lymph node stations. Positive lymph nodes

Comment

One should not take for granted that cancer lymphatic spread follows a linear model from intraparenchymal nodes to hilar, mediastinal, and extrathoracic ones. The lymphatic network draining the lung is extensive and variability is probably the rule. Riquet and colleagues [11] have reported direct lymph passages from each lobe to the mediastinum. More commonly, these communications were observed in the upper lobes. This provides multiple pathways for dissemination, creating a complicated model

References (33)

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    To reach as clear a result as possible, our meta-analysis aimed to include a homogeneous population: less than 3% received any preoperative chemotherapy, a proportion thought unlikely to significantly affect outcomes. Patients with bulky or multistation disease have poorer survival than those with single-station disease,41 and multistation N2 disease is more powerfully associated with poor prognosis than concomitant involvement of N1 nodes,42 findings confirmed in the 3 studies here, which detailed the extent of N2 involvement. This meta-analysis has not determined whether the benefit of PORT extends across all patients with N2 disease or is limited to a smaller group, potentially those patients at greater risk with multistation disease, as relatively few studies provided this information.

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