Article

Border between N1 and N2 stations in lung carcinoma: Lessons from lymph node metastatic patterns of lower lobe tumors

Department of Thoracic Surgery, Hyogo Medical Center for Adults, Akashi city, Japan.
Journal of Thoracic and Cardiovascular Surgery (Impact Factor: 4.17). 04/2005; 129(4):825-30. DOI: 10.1016/j.jtcvs.2004.06.016
Source: PubMed

ABSTRACT

Distinction of lymph node stations is one of the most crucial topics still not entirely resolved by many lung cancer surgeons. The nodes around the junction of the hilum and mediastinum are key points at issue. We examined the spread pattern of lymph node metastases, investigated the prognosis according to the level of the involved nodes, and conclusively analyzed the border between N1 and N2 stations.
We reviewed the records of 604 consecutive patients who underwent complete resection for non-small cell lung carcinoma of the lower lobe.
There were 390 patients (64.6%) with N0 disease, 127 (21.0%) with N1, and 87 (14.4%) with N2. Whereas 11.3% of patients with right N2 disease had skip metastases limited to the subcarinal nodes, 32.6% of patients with left N2 disease had skip metastases, of which 64.2% had involvement of N2 station nodes, except the subcarinal ones. The overall 5-year survivals of patients with N0, N1, and N2 disease were 71.0%, 50.8%, and 16.7%, respectively (N0 vs N1 P = .0001, N1 vs N2, P < .0001). Although there were no significant differences in survival according to the side of the tumor among patients with N0 or N1 disease, patients with a left N2 tumor had a worse prognosis than those with a right N2 tumor (P = .0387). The overall 5-year survivals of patients with N0, intralobar N1, hilar N1, lower mediastinal N2, and upper mediastinal N2 disease were 71.0%, 60.1%, 38.8%, 24.8%, and 0%, respectively. Significant differences were observed between intralobar N1 and hilar N1 disease ( P = .0489), hilar N1 and lower mediastinal N2 disease (P = .0158), and lower and upper mediastinal N2 disease (P = .0446). Also, the 5-year survivals of patients with involvement up to station 11, up to station 10, and up to station 7 were 41.4%, 37.9% and 37.7%, respectively (difference not significant).
N1 and N2 diseases appeared as a combination of subgroups: intralobar N1 disease, hilar N1 disease, lower mediastinal N2 disease, and upper mediastinal N2 disease. Interestingly, the survivals of patients with involvement up to interlobar nodes (station 11), main bronchus nodes (station 10), and subcarinal nodes (station 7) were identical. These data constitute the basis for a larger investigation to develop a lymph node map in lung cancer.

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    • "En fait, d'après nos travaux, il paraissait logique d'aller encore plus loin et de proposer 3 types de N différents en incluant les N1 intralobaires dans les N0, les N1 extralobaires et hilaires dans les N2 à une seule chaîne et en classant les N2 multichaînes à part [26]. Quelques travaux ultérieurs ont montré que les N1 hilaires avaient cette valeur pronostique [27] [28] et que les N2 ne touchant qu'une seule station avaient un meilleur pronostic que ceux en touchant 2 ou plusieurs [29] [30]. Dans la classification internationale, une seule chaîne ganglionnaire est concernée quand une seule station est métastatique, mais malheureusement, il peut souvent s'agir d'une même chaîne quand 2 stations le sont. "
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    ABSTRACT: Lung cancer is characterized by its lymphophilia. Its metastatic spread mainly occurs by tumor cells lymphatic drainage into the blood circulation. Initially, the lymph node TNM classification was based on clinical and therapeutic considerations, particularly concerning N2 involvement. The goals were to avoid futile exploratory thoracotomies without lung resection, to provide more accurate data from mediastinoscopy, and to take into account the radiation therapy fields. Since 1997, the international lymph node classification was more used to analyse the disparities within N1 and N2 groups. However, this attempt did not succeed in clarifying the lymphatic metastazing process, and was not progressing any more. Anatomy not being considered, it did not permit to grasp the anatomical and physiological significances of N2 and N3 involvement. In effect, this classification is now confined in zones and is lacking the anatomical and physiological descriptions that characterise the lymphatic pathways draining the lungs and their tumoral pathology. The stations proposed in numbers in cartographies should have gained in accuracy and in prognostic value if they had been expressed in their anatomical counterparts.
    Full-text · Article · Feb 2014 · Revue de Pneumologie Clinique
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    • "En fait, d'après nos travaux, il paraissait logique d'aller encore plus loin et de proposer 3 types de N différents en incluant les N1 intralobaires dans les N0, les N1 extralobaires et hilaires dans les N2 à une seule chaîne et en classant les N2 multichaînes à part [26]. Quelques travaux ultérieurs ont montré que les N1 hilaires avaient cette valeur pronostique [27] [28] et que les N2 ne touchant qu'une seule station avaient un meilleur pronostic que ceux en touchant 2 ou plusieurs [29] [30]. Dans la classification internationale, une seule chaîne ganglionnaire est concernée quand une seule station est métastatique, mais malheureusement, il peut souvent s'agir d'une même chaîne quand 2 stations le sont. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Lung cancer is characterized by its lymphophilia. Its metastatic spread mainly occurs by tumor cells lymphatic drainage into the blood circulation. Initially, the lymph node TNM classification was based on clinical and therapeutic considerations, particularly concerning N2 involvement. The goals were to avoid futile exploratory thoracotomies without lung resection, to provide more accurate data from mediastinoscopy, and to take into account the radiation therapy fields. Since 1997, the international lymph node classification was more used to analyse the disparities within N1 and N2 groups. However, this attempt did not succeed in clarifying the lymphatic metastazing process, and was not progressing any more. Anatomy not being considered, it did not permit to grasp the anatomical and physiological significances of N2 and N3 involvement. In effect, this classification is now confined in zones and is lacking the anatomical and physiological descriptions that characterise the lymphatic pathways draining the lungs and their tumoral pathology. The stations proposed in numbers in cartographies should have gained in accuracy and in prognostic value if they had been expressed in their anatomical counterparts.
    Full-text · Article · Jan 2014 · Revue de Pneumologie Clinique
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    • "The presence of clinically evident, bulky nodal disease is accompanied in most cases – regardless of the intensity of treatment – by poor survival. On the other hand, metastasis in a single nodal station with closed anatomical relationship to the lobe of origin of the primary tumour has been correlated with a more favourable outcome, comparable with that of N1-disease [7]. "
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    Full-text · Article · Dec 2011
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