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J Thorac Cardiovasc Surg 2001;121:399-340
© 2001 The American Association for Thoracic Surgery

Letters to the Editor

Reply

Deparatment of Thoracic Surgery
Hyogo Medical Center for Adults
Akashi City Hyogo 673, Japan

Reply to the Editor:

I appreciate the comments made by Van Schil concerning our article on sleeve lobectomy and lymph node involvement compared with pneumonectomy.

We actually performed 84 pneumonectomies, 6% of 1370 patients undergoing lung cancer surgery during a 14-year period. ¹ That is an extremely low incidence. The 60 patients with pneumonectomy came from those 84 patients. The reasons for exclusion of the other 24 patients with incomplete resection are as follows: 10 for positive cytology with pleural lavage, ² 6 for positive margins or anatomically unresectable disease, 5 for intrapulmonary metastatic nodules, and 3 for unclear distant metastases. The highest positive node in the mediastinum was not a condition for exclusion. On the other hand, sleeve lobectomy was performed in 161 patients (11.7%), and 151 were defined as having undergone curative resection. We have saved the lungs by all efforts and have avoided pneumonectomy by using extended bronchoplasty. ³ The low mortality rate in our series resulted mainly from the fewer number of pneumonectomies.

Van Schil was surprised at the high percentage of N2 disease in both the sleeve lobectomy and pneumonectomy groups. Let us explain. The 30 patients with N2 disease in the sleeve lobectomy group (n = 60 in Table II) were sampled from among the 151 (N0, 56; N1, 56; N2, 39) patients subjected to sleeve lobectomy to compare them with the pneumonectomy group (n = 60), which included 31 patients with N2 disease (52%), to obtain the nearest available match (propensity score). Thus, the actual N2 ratio in the sleeve lobectomy group was 39 of 151 (25.8%), while the general N2 ratio in resected lung cancer in our earlier series was 18.6%. ⁴ This level was reached without routine use of mediastinoscopy.

Clinical N2 disease was defined on the basis of computed tomographic (CT) findings, when a node was larger than 10 mm. When the nodes were bulky (larger than 15 mm in 2 stations or more), we used induction therapy. ⁵

Generally, a patient with N2 disease is not a good candidate for surgery, as Van Schil has stated. However, surgery in N2 disease is more common in Japan than in the United States or Europe. Actually, last year, in the leading hospitals in Japan, about 10% to 20% of the patients operated on for lung cancer had stage 3A disease.

I think surgery is still an option in selected patients with N2 disease. Upper lobe tumors easily metastasize to the nodes in the upper mediastinum ("skip metastases") and lower lobe tumors to the carinal nodes. A surgeon may pick up just the metastatic node with mediastinoscopic forceps. Those patients with skip metastases to the mediastinum have a relatively higher chance to survive after the operation. ⁶ Generally, resected N2 disease in our study provided a 5-year survival of 26%. Survival was 57% in the group with skip metastasis around the aorta in the left lung and 36% with metastases to the upper mediastinum in the right lung. ⁶

I would like to know whether an indication for mediastinoscopy, such as size of the node on the CT film, is needed and whether the post-sampled mediastinum in a patient with no abnormalities on mediastinoscopy is dissected or not. Our current method of preoperative staging is transbronchial needle biopsy with a CT-guided bronchofiberscope in a patient with mediastinal nodes larger than 10 mm on the CT film.

12/8/111200

doi:10.1067/mtc.2001.111200

References

1. Okada M, Yamagishi H, Satake S, Matsuoka H, Miyamoto Y, Tsubota N, et al. Survival related to lymph node involvement in lung cancer after sleeve lobectomy compared with pneumonectomy. J Thorac Cardiovasc Surg 2000;119:814-9.[Abstract/Free Full Text]
   
2. Okada M, Tsubota N, Yoshimura M, Miyamoto Y, Maniwa Y. Role of pleural lavage cytology before resection for primary lung carcinomas. Ann Surg 1999;229:579-84.[Medline]
   
3. Okada M, Tsubota N, Yoshimura M, Miyamoto Y, Matsuoka H, Satake S, et al. Extended sleeve lobectomy for lung cancer: the avoidance of pneumonectomy. J Thorac Cardiovasc Surg 1999;118:710-4.[Abstract/Free Full Text]
   
4. Okada M, Tsubota N, Yoshimura M, Miyamoto Y. Proposal for reasonable mediastinal lymphadenectomy in bronchogenic carcinomas: role of subcarinal nodes in selective dissection. J Thorac Cardiovasc Surg 1998;116:949-53.[Abstract/Free Full Text]
   
5. Okada M, Tsubota N, Yoshimura M, Miyamoto Y, Matsuoka H. Induction therapy for non–small cell lung cancer with involved mediastinal nodes in multiple stations. Ches 2000;118:123-8.
   
6. Okada M, Tsubota N, Yoshimura M, Miyamoto Y, Matsuoka H. Prognosis of completely resected pN2 non–small cell lung carcinomas: What is the significant node that affects survival? J Thorac Cardiovasc Surg 1999:118:270-5.
   

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