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J Thorac Cardiovasc Surg 2005;129:235
© 2005 The American Association for Thoracic Surgery

Letters to the Editor

Isolated mediastinal skip metastasis in lung cancer: Is it real N2 disease?

Francesco Puma, MD, Chief of General Thoracic Surgery

Azienda Ospedaliera S. Maria, University of Perugia Medical School, Terni, Italy

To the Editor:

I read with great interest the study by Keller and colleagues1 for the Eastern Cooperative Oncology Group titled "Prolonged Survival in Patients With Resected Non–Small Lung Cancer and Single-Level N2 Disease," published in the July 2004 issue of the Journal. The better prognosis for single-level N2 disease than for multiple N2 station involvement is a relatively old concept. Keller and colleagues1 correctly reported that several previous studies showed a better clinical outcome of patients with mediastinal skip metastasis than for patients with metastases also in the hilar nodes. The results of the Eastern Cooperative Oncology Group's trial indicated that this advantage is limited to upper lobe tumors, especially to the left upper lobe. The authors stated that "the reason for improved survival remains unclear, although patients with skip metastases may have true regional disease."1

I would suggest that the scientific explanation of such results may be found in the recent studies on the sentinel node in non–small cell lung cancer. The sentinel node should be the first site of metastatic involvement, because it is the first lymph node that receives afferent lymphatic drainage from a primary tumor. The sentinel lymph node is located in the mediastinum in as many as 35% of patients; mediastinal sentinel nodes are generally found from upper lobe tumors, with the highest incidence in the left upper lobe.2-6 Furthermore, such data are not new. An excellent anatomic French study published in the Journal in 1989 demonstrated that the direct lymphatic drainage of lung segments to the mediastinal nodes is quite common for the upper lobes.7 All such reports indicate that isolated involvement of mediastinal sentinel nodes could be considered in the group of N1 disease. It is not surprising that a large, cooperative, randomized, prospective trial led to such conclusions.

In conclusion, I think that the current knowledge on the anatomic pathway of the pulmonary lymphatic drainage indicates that the TNM classification regarding N status is quite rough. The Eastern Cooperative Oncology Group's trial is another important confirmation that stage IIIa non–small cell lung cancer represents an extremely heterogeneous disease stage, open to future staging revision.

References

  1. Keller SM, Vangel MG, Wagner H, Schiller JH, Herskovic A, Komaki R, et al. Prolonged survival in patients with resected non–small lung cancer and single-level N2 disease. J Thorac Cardiovasc Surg. 2004;128:130-137.[Abstract/Free Full Text]
  2. Little AG, DeHoyos A, Kirgan DM, Arcomano TR, Murray KD. Intraoperative lymphatic mapping for non–small cell lung cancer: the sentinel node technique. J Thorac Cardiovasc Surg. 1999;117:220-224.[Abstract/Free Full Text]
  3. Liptay MJ, Grondin SC, Fry WA, Pozdol C, Carson D, Knop C, et al. Intraoperative sentinel lymph node mapping in non-small-cell lung cancer improves detection of micrometastases. J Clin Oncol. 2002;20;:1984-1988.[Medline]
  4. Nomori H, Horio H, Naruke T, Orikasa H, Yamazaki K, Suemasu K. Use of technetium-99m tin colloid for sentinel node identification in non–small cell lung cancer. J Thorac Cardiovasc Surg. 2002;124:486-492.[Abstract/Free Full Text]
  5. Schmidt FE, Woltering EA, Webb WR, Garcia OM, Cohen JE, Rozans MH. Sentinel nodal assessment in patients with carcinoma of the lung. Ann Thorac Surg. 2002;74:870-875.[Abstract/Free Full Text]
  6. Sugi K, Kaneda Y, Sudoh M, Sakano H, Hamano K. Effect of radioisotope sentinel node mapping in patients with cT1 N0 M0 lung cancer. J Thorac Cardiovasc Surg. 2003;126:568-573.[Abstract/Free Full Text]
  7. Riquet M, Hidden G, Debesse B. Direct lymphatic drainage of lung segments to the mediastinal nodes: an anatomic study on 260 adults. J Thorac Cardiovasc Surg. 1989;97:623-632.[Abstract]




This Article
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