Skip to main content

Mediastinal lymph nodes: Ignore? Sample? Dissect? The role of mediastinal node dissection in the surgical management of primary lung cancer

Abstract

The role of mediastinal lymph node dissection (MLND) during the resection of non-small-cell lung cancer is still unclear although most surgeons agree that a minimum of hilar and mediastinal nodes must be examined for appropriate pathological staging. Current surgical practices vary from visual inspection of the mediastinum with biopsy of only abnormal looking nodes to systematic mediastinal node sampling which is to the biopsy of lymph nodes from multiple levels whether they appear abnormal or not to MLND which involves the systematic removal of all lymph node bearing tissue from multiple sites unilaterally or bilaterally within the mediastinum. This review article looks at the evidence and arguments in favour of lymphadenectomy, including improved pathological staging, better locoregional control, and ultimately longer disease-free survival and those against which are longer operating time, increased operative morbidity, and lack of evidence for survival benefit.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

References

  1. Halsted WS. The results of operations for the cure of cancer of the breast performed at the Johns Hopkins Hospital from June, 1889, to January 1894. Arch Surg. 1894;20:497–555.

    CAS  Google Scholar 

  2. Martini N. Mediastinal lymph node dissection for lung cancer. The memorial experience. Chest Surg Clin North Am. 1995;5:189–203.

    CAS  Google Scholar 

  3. Graham EA, Singer JJ. Successful removal of an entire lung. J Am Med Assoc. 1933;101:1371–4.

    Article  Google Scholar 

  4. Archibald E. The technique of total unilateral pneumonectomy. Ann Surg. 1934;100:796–811.

    PubMed  Article  CAS  Google Scholar 

  5. Oschner A, Debakey M Symposium on cancer. Primary pulmonary malignancy. Treatment by total pneumonectomy. Analysis of 79 collected cases and presentation of 7 personal cases. Surg Gynecol Obstet. 1939;68:435–41.

    Google Scholar 

  6. Churchill ED, Sweet RH, Soutter L, Scannell JG. The surgical management of carcinoma of the lung. A study of the cases treated at the Massachusetts General Hospital from 1930 to 1950. J Thorac Surg. 1950;20:349–63.

    Google Scholar 

  7. Cahan WG, Watson WL, Pool JL. Radical pneumonectomy. J Thorac Surg. 1951;22:449–73.

    PubMed  CAS  Google Scholar 

  8. Martini N, Flehinger BJ, Zaman MB, Beattie EJ Jr. Results of resection in non-oat cell carcinoma of the lung with mediastinal lymph node metastases. Ann Surg. 1983;198:386–96.

    PubMed  Article  CAS  Google Scholar 

  9. Naruke T, Goya T, Tsuchiya R, Suemasu K. The importance of surgery to non-small cell carcinoma of lung with mediastinal lymph node metastasis. Ann Thorac Surg. 1988;46:603–10.

    PubMed  Article  CAS  Google Scholar 

  10. Tsang GMK, Watson DCT. The practice of cardiothoracic surgeons in the perioperative staging of non-small cell lung cancer. Thorax. 1992;47:3–5.

    PubMed  Article  CAS  Google Scholar 

  11. Goldstraw P. The practice of cardiothoracic surgeons in the perioperative staging of non-small cell lung cancer. Editorial. Thorax. 1992;47:1–2.

    PubMed  Article  CAS  Google Scholar 

  12. Little AG, Rusch VW, Bonner JA, Gaspar LE, Green MR, Webb WR, et al. Patterns of surgical care of lung cancer patients. Ann Thorac Surg. 2005;80:2051–6.

    PubMed  Article  Google Scholar 

  13. Keller SM. Complete mediastinal lymph node dissection—does it make a difference? Commentary. Lung Cancer. 2002;36:7–8.

    PubMed  Article  Google Scholar 

  14. Kondo T, Sagawa M, Tanita T, Sato M, Ono S, Matsumura Y, et al. Is complete systematic nodal dissection by thoracoscopic surgery possible? A prospective trial of video-assisted lobectomy for cancer of the right lung. J Thorac Cardiovasc Surg. 1998;116:651–2.

    PubMed  Article  CAS  Google Scholar 

  15. Sagawa M, Sato M, Sakurada A, Matsumura Y, Endo C, Handa M, et al. A prospective trial of systematic nodal dissection for lung cancer by video-assisted thoracic surgery: can it be perfect? Ann Thorac Surg. 2002;73:900–4.

    PubMed  Article  Google Scholar 

  16. Watanabe A, Koyanagi T, Obama T, Ohsawa H, Mawatari T, Takahashi N, et al. Assessment of node dissection for clinical stage 1 primary lung cancer by VATS. Eur J Cardiovasc Thorac Surg. 2005;27:745–52.

    Article  Google Scholar 

  17. D’Amico TA, Niland J, Mamet R, Zornosa C, Dexter EU, Onaitis MW. Efficacy of mediastinal node dissection during lobectomy for lung cancer by thoracoscopy and thoracotomy. Ann Thorac Surg. 2011;92:226–32.

    PubMed  Article  Google Scholar 

  18. Oda M, Watanabe Y, Shimizu J, Murakami S, Ohta Y, Sekido et al. Extent of mediastinal node metastasis in clinical stage 1 non-small-cell lung cancer: the role of systematic nodal dissection. Lung Cancer. 1998;22:23–30.

  19. 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.

    PubMed  Article  CAS  Google Scholar 

  20. Asamura H, Nakayama H, Kondo H, Tsuchiya R, Naruke T, et al. Lobe-specific extent of systematic lymph node dissection for non-small cell lung carcinomas according to a retrospective study of metastases and prognosis. J Thorac Cardiovasc Surg. 1999;117:1102–11.

    PubMed  Article  CAS  Google Scholar 

  21. Okada M, Sakamoto T, Yuki T, Mimura T, Miyoshi K, Tsubota N. Selective mediastinal lymphadenectomy for clinico-surgical stage I non-small cell lung cancer. Ann Thorac Surg. 2006;81:1028–33.

    PubMed  Article  Google Scholar 

  22. Ishiguro F, Matsuo K, Fukui T, Mori S, Hatooka S, Mitsudomi T. Effect of selective lymph node dissection based on patterns of lobe-specific lymph node metastases on patient outcome in patients with resectable non-small cell lung cancer: a large-scale retrospective cohort study applying a propensity score. J Thorac Cardiovasc Surg. 2010;139:1001–6.

    PubMed  Article  Google Scholar 

  23. Hata E, Hayakawa K, Miyamoto H, Hayashida R. Rationale for extended lymphadenectomy for lung cancer. Theor Surg. 1990;5:19–25.

    Google Scholar 

  24. Watanabe Y, Ichihashi T, Iwa T. Median sternotomy as an approach for pulmonary surgery. Thorac Cardiovasc Surg. 1988;36:227–31.

    PubMed  Article  CAS  Google Scholar 

  25. Watanabe Y, Shimizu J, Oda M, Hayashi Y, Tatsuzawa Y, Watanabe S, et al. Improved survival in left non-small-cell N2 lung cancer after more extensive operative procedure. Thorac Cardiovasc Surg. 1991;39:89–94.

    PubMed  Article  CAS  Google Scholar 

  26. Nakahara K, Fujii Y, Matsumura A, Minami M, Okumura M, Matsuda H. Role of systematic mediastinal dissection in N2 non-small cell lung cancer patients. Ann Thorac Surg. 1993;56:331–6.

    PubMed  Article  CAS  Google Scholar 

  27. Gaer JAR, Goldstraw P. Intraoperative assessment of nodal staging at thoracotomy for carcinoma of the bronchus. Eur J Cardiothorac Surg. 1990;4:207–10.

    PubMed  Article  CAS  Google Scholar 

  28. Sioris T, Järvenpää R, Kuukasjärvi P, Helin H, Saarelainen S, Tarkka M. Comparison of computed tomography and systematic lymph node dissection in determining TNM and stage in non-small cell lung cancer. Eur J Cardiothorac Surg. 2003;23:403–8.

    PubMed  Article  Google Scholar 

  29. Lardinois D, Weder W, Hany TF, Kamel EM, Korom S, Seifert B, et al. Staging of non-small-cell lung cancer with integrated positron-emission tomography and computed tomography. N Engl J Med. 2003;348:2500–7.

    PubMed  Article  Google Scholar 

  30. Lardinois D, Suter H, Hakki H, Rousson V, Betticher D, Ris HB. Morbidity, survival, and site of recurrence after mediastinal lymph-node dissection versus systematic sampling after complete resection for non-small cell lung cancer. Ann Thorac Surg. 2005;80:268–75.

    PubMed  Article  Google Scholar 

  31. Darling GE, Maziak DE, Inculet RI, Gulenchyn KY, Driedger AA, Ung YC. Positron emission tomography-computed tomography compared with invasive mediastinal stating in non-small cell lung cancer: results of mediastinal staging in the early lung position emission tomography trial. J Thorac Oncol. 2011;6:1367–72.

    PubMed  Article  Google Scholar 

  32. Lv YL, Yuan DM, Wang K, Miao XH, Qian Q, Wei SZ. Diagnostic performance of integrated position emission tomography/computed tomography for mediastinal lymph node staging in non-small cell lung cancer. A bivariate systematic review and meta-analysis. J Thorac Oncol. 2011;6:1350–8.

    PubMed  Article  Google Scholar 

  33. D’Cunha J, Herndon JE 2nd, Herzan DL, Patterson GA, Kohman LJ, Harpole DH, et al. Poor correspondence between clinical and pathologic staging in stage I non-small cell lung cancer: results from CALGB 9761, a prospective trial. Lung Cancer. 2005;48:241–6.

    PubMed  Article  Google Scholar 

  34. Coughlin M, Deslauriers J, Beaulieu M, Fournier B, Piraux M, Rouleau J, et al. Role of mediastinoscopy in pretreatment staging of patients with primary lung cancer. Ann Thorac Surg. 1985;40:556–60.

    PubMed  Article  CAS  Google Scholar 

  35. Funatsu T, Matsubara Y, Ikeda S, Hatakenaka R, Hanawa T, Ishida H, et al. Preoperative mediastinoscopic assessment of N factor and the need for mediastinal lymph node dissection in T1 lung cancer. J Thorac Cardiovasc Surg. 1994;108:321–8.

    PubMed  CAS  Google Scholar 

  36. Whitson BA, Groth SS, Maddaus MA. Surgical assessment and intraoperative management of mediastinal lymph nodes in non-small cell lung cancer. Ann Thorac Surg. 2007;84:1059–65.

    PubMed  Article  Google Scholar 

  37. Asamura H, Nakayama H, Kondo H, Tsuchiya R, Shimosato Y, Naruke T. Lymph node involvement, recurrence, and prognosis in resected small, peripheral, non-small-cell lung carcinomas: are these carcinomas candidates for video-assisted lobectomy? J Thorac Cardiovasc Surg. 1996;111:1125–34.

    PubMed  Article  CAS  Google Scholar 

  38. Takizawa T, Terashima M, Koike T, Akamatsu H, Kurita Y, Yokoyama A. Mediastinal lymph node metastasis in patients with clinical stage 1 peripheral non-small-cell lung cancer. J Thorac Cardiovasc Surg. 1997;113:248–52.

    PubMed  Article  CAS  Google Scholar 

  39. Ishida T, Yano T, Maeda K, Kaneko S, Tateishi M, Sugimachi K. Strategy for lymphadenectomy in lung cancer three centimeters or less in diameter. Ann Thorac Surg. 1990;50:708–13.

    PubMed  Article  CAS  Google Scholar 

  40. Naruke T, Tsuchiya R, Kondo H, Nakayama H, Asamura H. Lymph node sampling in lung cancer: how should it be done? Eur J Cardiothorac Surg. 1999;16(Suppl 1):S17–24.

    PubMed  Article  Google Scholar 

  41. Tateishi M, Fukuyama Y, Hamatake M, Kohdono S, Ishida T, Sugimachi K. Skip mediastinal lymph node metastasis in non-small cell lung cancer. J Surg Oncol. 1994;57:139–42.

    PubMed  Article  CAS  Google Scholar 

  42. Izbicki JR, Thetter O, Habekost M, Karg O, Passlick B, Kubuschok B, et al. Radical systematic mediastinal lymphadenectomy in non-small cell lung cancer: a randomized controlled trial. Br J Surg. 1994;81:229–35.

    PubMed  Article  CAS  Google Scholar 

  43. Allen MS, Darling GE, Pechet TTV, Mitchell JD, Herndon JE 2nd, Landreneau RJ. Morbidity and mortality of major pulmonary resections in patients with early-stage lung cancer: initial results of the randomized, prospective ACOSOG Z0030 trial. Ann Thorac Surg. 2006;81:1013–20.

    PubMed  Article  Google Scholar 

  44. Bollen ECM, van Duin CJ, Theunissen PHMH, vt Hof-Grootenboer BE, Blijham GH. Mediastinal lymph node dissection in resected lung cancer: morbidity and accuracy of staging. Ann Thorac Surg. 1993;55:961–6.

    PubMed  Article  CAS  Google Scholar 

  45. Lewis RJ. Is radical lymphadenectomy a valid oncologic procedure? Editorial. Eur J Cardio-Thorac Surg. 1999;16(Suppl 1):S11–2.

    Article  Google Scholar 

  46. Reid SE, Kaufman MW, Murthy S, Scanlon EF. Perioperative stimulation of residual cancer cells promotes local and distant recurrence of breast cancer: collective review. J Am Coll Surg. 1997;185:290–306.

    PubMed  CAS  Google Scholar 

  47. Ginsberg RJ. Lymph node involvement, recurrence, and prognosis in resected small, peripheral, non-small-cell lung carcinomas. Editorial. J Thorac Cardio Vasc Surg. 1996;111:1123–4.

    Article  CAS  Google Scholar 

  48. Ginsberg RJ, Rubinstein LV, for the Lung Cancer Study Group. Randomized trial of lobectomy versus limited resection for T1N0 non-small cell lung cancer. Ann Thorac Surg. 1995;60:615–23.

    Google Scholar 

  49. Thomas P, Rubinstein L. Lung Cancer Study Group. Cancer recurrence after resection: T1N0 non-small cell lung cancer. Ann Thorac Surg. 1990;49:242–7.

    PubMed  Article  CAS  Google Scholar 

  50. Izbicki JR, Passlick B, Karg O, Bloechle C, Pantel K, Knoefel WT, et al. Impact of radical systematic mediastinal lymphadenectomy on tumor staging in lung cancer. Ann Thorac Surg. 1995;59:209–14.

    PubMed  Article  CAS  Google Scholar 

  51. Graham ANJ, Chan KJM, Pastorino U, Goldstraw P. Systematic nodal dissection in the intra thoracic staging of patients with non-small cell lung cancer. J Thorac Cardio Vasc Surg. 1999;117:246–51.

    Article  CAS  Google Scholar 

  52. Keller SM, Adak S, Wagner H, Johnson DH. Mediastinal lymph node dissection improves survival in patients with stages II and IIIa non-small cell lung cancer. Ann Thorac Surg. 2000;70:358–66.

    PubMed  Article  CAS  Google Scholar 

  53. Doddoli C, Aragon A, Barlesi F, Chetaille B, Robitail S, Giudicelli R, et al. Does the extent of lymph node dissection Influence outcome in patients with stage 1 non-small cell lung cancer? Eur J Cardio-Thorac Surg. 2005;27:680–5.

    Article  Google Scholar 

  54. Massard G, Ducrocq Y, Kochetkova EA, Porhanov VA, Riquet M. Sampling or node dissection for intraoperative staging of lung cancer: a multicentric cross-sectional study. Eur J Cardio-Thorac Surg. 2006;30:164–7.

    Article  Google Scholar 

  55. Varlotto JM, Recht A, Nikolov M, Flickinger JC, Decamp MM. Extent of lymphadenectomy and outcome for patients with stage 1 nonsmall cell lung cancer. Cancer. 2009;115:851–8.

    PubMed  Article  Google Scholar 

  56. Ma K, Chang D, He B, Gong M, Tian F, Hu X, et al. Radical systematic mediastinal lymphadenectomy versus mediastinal lymph node sampling in patients with clinical stage 1A and pathological stage T1 non-small cell lung cancer. J Cancer Res Clin Oncol. 2008;134:1289–95.

    PubMed  Article  Google Scholar 

  57. Takizawa H, Kondo K, Matsuoka H, Uyama K, Toba H, Kenzaki K, et al. Effect of mediastinal nodes sampling in patients with clinical stage 1 non-small cell lung cancer. J Med Investig. 2008;55:37–43.

    Article  Google Scholar 

  58. Okasaka T, Usami N, Taniguchi T, Kawaguchi K, Okagawa T, Suzuki H, et al. Can non-performance of radical systematic mediastinal lymphadenectomy be justified in elderly lung cancer patients? An evaluation using propensity-based survival analysis. Eur J Cardio-Thorac Surg. 2010;38:27–33.

    Article  Google Scholar 

  59. Izbicki JR, Passlick B, Pantel K, Pichlmeier U, Hosch SB, Karg O, et al. Effectiveness of radical systematic mediastinal lymphadenectomy in patients with resectable non-small cell lung cancer. Results of a prospective randomized trial. Ann Surg. 1998;227:138–44.

    PubMed  Article  CAS  Google Scholar 

  60. Sugi K, Nawata K, Fujita N, Ueda K, Tanaka T, Matsuoka T, et al. Systematic lymph node dissection for clinically diagnosed peripheral non-small-cell lung cancer less than 2 cm in diameter. World J Surg. 1998;22:290–5.

    PubMed  Article  CAS  Google Scholar 

  61. Wu YL, Huang ZF, Wang SY, Yang XN, Ou W. A randomized trial of systematic nodal dissection in resectable non-small cell lung cancer. Lung Cancer. 2002;36:1–6.

    PubMed  Article  Google Scholar 

  62. Darling GE, Allen MS, Decker PA, Ballman K, Malthaner RA, Inculet RI, et al. Randomized trial of mediastinal lymph node sampling versus complete lymphadenectomy during pulmonary resection in the patient with N0 or N1 (less than hilar) non-small cell carcinoma: results of the American College of Surgery Oncology Group Z0030 trial. J Thorac Cardio Vasc Surg. 2011;141:662–70.

    Article  Google Scholar 

  63. Tagaki H, Matsui M. Alice in Wonderland of mediastinal lymph nodes. Letter to the Editor. J Thorac Cardiovasc Surg. 2011;142:477–9.

    Article  Google Scholar 

  64. Cox CE, Pendas S, Cox JM, Joseph E, Shons AR, Yeatman T, et al. Guidelines for sentinel node biopsy and lymphatic mapping of patients with breast cancer. Ann Surg. 1998;227:645–53.

    PubMed  Article  CAS  Google Scholar 

  65. Krag D, Weaver D, Ashikaga T, Harlow SP, O’Connell M. The sentinel node in breast cancer: a multicenter validation study. N Engl J Med. 1998;339:941–6.

    PubMed  Article  CAS  Google Scholar 

  66. Liptay MJ. Commentary on sentinel lymph node identification with technetium-99 m tin colloid in non-small cell lung cancer. Editorial. J Thorac Cardiovasc Surg. 2002;124:428–30.

    PubMed  Article  Google Scholar 

  67. Schmidt FE, Woltering EA, Webb WR, Garcia OM, Cohen JE, Rozans MH. Sentinel node assessment in patients with carcinoma of the lung. Ann Thorac Surg. 2002;74:870–5.

    PubMed  Article  Google Scholar 

  68. Yoshimasu T, Miyoshi S, Oura S, Hirai I, Kokawa Y, Okamura Y. Limited mediastinal lymph node dissection for non-small cell lung cancer according to intraoperative histologic examinations. J Thorac Cardiovasc Surg. 2005;130:433–7.

    PubMed  Article  Google Scholar 

  69. Liptay MJ, Masters GA, Winchester DJ, Edelman BL, Garrido BJ, Hirschtritt TR, et al. Intraoperative radio isotope sentinel lymph node mapping in non-small cell lung cancer. Ann Thorac Surg. 2000;70:384–90.

    PubMed  Article  CAS  Google Scholar 

  70. Nomori H, Horio H, Naruke T, Orikasa H, Yamazaki K, Suemasu K. Use of technecium-99 m tin colloid for sentinel lymph node identification in non-small cell lung cancer. J Thorac Cardiovasc Surg. 2002;124:486–92.

    PubMed  Article  Google Scholar 

  71. Ueda K, Suga K, Kaneda Y, Li TS, Ueda K, Hamano K. Preoperative imaging of the lung sentinel lymphatic basin with computed tomographic lymphography: a preliminary study. Ann Thorac Surg. 2004;77:1033–8.

    PubMed  Article  Google Scholar 

  72. Compton CC, Fielding LP, Burgart LJ, Conley B, Cooper HS, Hamilton SR, et al. Prognostic factors in colorectal cancer. College of American Pathologists consensus statement 1999. Arch Pathol Lab Med. 2000;124:979–94.

    PubMed  CAS  Google Scholar 

  73. Wu YC, Lin CFJ, Hsu WH, Huang BS, Huang MH, Wang LS. Long-term results of pathological stage 1 non-small cell lung cancer: validation of using the number of totally removed lymph nodes as a staging control. Eur J Cardio-Thorac Surg. 2003;24:994–1001.

    Article  Google Scholar 

  74. Gajra A, Newman N, Gamble GP, Kohman LJ, Graziano SL. Effect of number of lymph nodes sampled on outcome in patients with stage 1 non-small-cell lung cancer. J Clin Oncol. 2003;21:1029–34.

    PubMed  Article  Google Scholar 

  75. Ludwig MS, Goodman M, Miller DL, Johnstone PAS. Postoperative survival and the number of lymph nodes sampled during resection of node-negative non-small cell lung cancer. Chest. 2005;128:1545–50.

    PubMed  Article  Google Scholar 

  76. Saji H, Tsuboi M, Yoshida K, Kato Y, Nomura M, Matsubayashi J, et al. Prognostic impact of number of resected and involved lymph nodes at complete resection on survival in non-small cell lung cancer. J Thorac Oncol. 2011;6:1865–71.

    PubMed  Article  Google Scholar 

  77. Chen ZL, Perez S, Holmes EC, Wang HJ, Coulson WF, Wen DR, et al. Frequency and distribution of occult micrometastases in lymph nodes of patients with non-small cell lung carcinoma. J Natl Cancer Inst. 1993;85:493–8.

    PubMed  Article  CAS  Google Scholar 

  78. Passlik B, Kubuschock B, Sienel W, Thetter O, Pantel K, Izbicki JR. Mediastinal lymphadenectomy in non-small cell lung cancer: effectiveness in patients with or without nodal micrometastasis: results of a preliminary study. Eur J Cardio-Thorac Surg. 2002;21:520–6.

    Article  Google Scholar 

  79. Passlik B, Izbicki JR, Kubuschok B, Thetter O, Pantel K. Detection of disseminated lung cancer cells in lymph nodes: impact on staging and prognosis. Ann Thorac Surg. 1996;61:177–83.

    Article  Google Scholar 

  80. Maruyama R, Sugio K, Mitsudomi T, Saitoh G, Ishida T, Sugimachi K. Relationship between early recurrence and micrometastases in the lymph nodes of patients with stage 1 non-small-cell lung cancer. J Thorac Cardio Vasc Surg. 1997;114:535–43.

    Article  CAS  Google Scholar 

Download references

Conflict of interest

None.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Jean Deslauriers.

Additional information

This review was submitted at the invitation of the editorial committee.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (JPEG 1702 kb)

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Deslauriers, J. Mediastinal lymph nodes: Ignore? Sample? Dissect? The role of mediastinal node dissection in the surgical management of primary lung cancer. Gen Thorac Cardiovasc Surg 60, 724–734 (2012). https://doi.org/10.1007/s11748-012-0086-3

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11748-012-0086-3

Keywords

  • Lung cancer
  • Surgery for lung cancer
  • Mediastinal lymphadenectomy