Tag Archives: MLND

Cancer pulmonar y upstaging ganglionar post lobectomía

En el último número del ATS se publicó un artículo que trae nuevamente a considerar el tema de la disección ganglionar en la resección por cancer pulmonar. Les dejo el link: http://www.annalsthoracicsurgery.org/article/S0003-4975(13)00743-1/fulltext

Es un estudio danés, en el que se compara el ratio de upstaging ganglionar en paciente con resecciones por toracotomía vs. por VATS. Nuevamente (al igual que en un estudio retrospectivo de la base de datos del STS), se encontró que el upstaging ganglionar es significativamente mayor en pacientes con toracotomía vs. VATS (24,6 vs 11,9%; p<0,001). Esta significancia se observó tanto como para el upstaging de cN0 a N1 como de cN0 a N2 y se mantuvo tanto en T1 como en T2. Es probable que, como bien dicen los autores, haya un sesgo de selección que haya hecho que los paciente que se pensaba era más probable que tuviesen metástasis ganglionares se operaran por toracotomía que por VATS, pero sin dudas este estudio nos lleva nuevamente a pensar si las técnicas son comparables. Cabe destacar que los autores no encontraron diferencias en sobrevida entre los dos abordajes. Merece además mencionarse el acertado editorial que hay en el mismo número escrita pro Doug Mathisen (http://www.annalsthoracicsurgery.org/article/S0003-4975(13)01042-4/fulltext)

Es mucho lo que se ha avanzado con la realización de lobectomías por VATS y es bueno que así sea. Los tiempos de recuperación son algo más cortos, el dolor es menor y los pacientes parecen volver más rápidamente a su vida habitual. Pero hay algo que no podemos afirmar y es que se trate de la misma cirugía que la toracotomía. La disección sobre la adventicia de las ramas de la arteria pulmonar, la calidad de la linfadenectomía y la minuciosa resección realizada por toracotomía, no son de ninguna manera iguales a la realizada por VATS. La lobectomía por VATS requiere una importante curva de aprendizaje, pero aún así luego de haber realizado muchas, la resección sigue sin ser la misma. Esto no quiere decir que no haya que hacer lobectomías por VATS, incluso es muy poco claro que realmente haya una diferencia en resultados a largo plazo entre estas técnicas, pero se debe reconocer que es la misma resección quirúrgica la lograda con una y otra técnica.

Como bien dice Doug Mathisen y se discute en el paper, se necesita un trial randomizado para comparar ambas técnicas. Sin embargo, está tan arraigada la lobectomía por VATS en nuestras prácticas, que es muy poco probable que un trial como este sea finalmente completado.

Tendremos que usar nuestro mejor criterio clínico y sentido común para definir a qué pacientes le ofrecemos una y otra resección, y es nuestra obligación informar sobre las posibles ventajas y desventajas de cada una de las opciones. Abajo les dejo un video de cómo se ve una disección ganglionar subcarinal por toracotomía.

¿Ustedes qué criterio utilizan para ofrecerle a un paciente una lobectomía por VATS vs. por toracotomía?

 

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¿Qué tan bien seguimos los stándares?

Hace poco tiempo leí un nuevo artículo en el EJCTS en el que una vez más se muestra que tan poco los cirujanos torácicos adherimos a las guías de lo que deberíamos realizar a la hora de tratar un paciente con cáncer pulmonar. Y una vez más, se refiere al muestro y disección ganglionares mediastinales… ¿suena tema conocido, no? Este estudio realizado en Europa, describe cuántas estaciones ganglionares mediastinales fueron al menos muestreadas en 216 pacientes con cáncer pulmonar a los que se les realizó una resección pulmonar, y compara los hallazgos con las guías Europeas.
Por ejemplo, las guías recomiendan disecar todas las estaciones ganglionares mediastinales al momento de realizar una resección pulmonar por cáncer. Esto se hizo en el 4% de los pacientes. Otra recomendación dice que en el paciente con un T1 periférico, estaría también bien explorando sólo 3 estaciones ganglionares y enumera cuáles debería ser según el lóbulo afectado. Ahora, siempre debe muestrearse la estación 7 (subcarinal), dice la recomendación. El estudio encuentra que no llegó al 50% la cantidad de pacientes que tenían muestreada la estación 7 y el porcentaje de aquellos que tienen al menos 3 estaciones muestreadas era aún menor.
Como dijimos, este es sólo uno de los tantos papers que hay que tocan este tema. Por mucho tiempo y más aún en la actualidad, se considera que la correcta estadificación ganglionar es una medida de calidad de atención en el paciente con cáncer pulmonar. Pero los datos demuestran que esto se hace pocas veces. ¿Qué deberíamos hacer? ¿Buscar otras variables que nos indiquen calidad? Si hay tan poca compliance con esta práctica, ¿es realmente una práctica que debería se considerada a la hora de hablar de calidad de atención? Yo personalmente creo que sí es una medida de calidad, y además considero que hay consenso con especto a este punto, por esto me asombra que a pesar de esto sea una práctica tan poco realizada. ¿Qué opinan?

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Are we following the guidelines?

New piece of evidence suggest that guidelines are often times not followed. The EJCTS published last month an article about thoracic and general surgeon’s adherence to mediastinal lymph sampling during lung resection for lung cancer. This article describes how many LN stations were sampled and compares the number to the gold standard –in this case they considered the European guidelines as the gold standard-.
As an example, the guide recommends to dissect all mediastinal LN station when doing lung resection for cancer. In this paper only 4% of 216 patients had this kind of mediastinal exploration.
Also, the guidelines said that when dealing with a peripheral T1 lesion, you might be OK exploring only 3 LN stations. Station 7 should always be dissected, regardless of the affected lobe. The study shows that less than 50% of patients had station 7 dissected and even a lower percentage had at least 3 mediastinal LN stations explored.
This is not the only paper that address this issue, there are many paper from the US as well that underlines the suboptimal staging of the mediastinal in lung cancer patients.
For much time, mediastinal lymph node dissection has been considered a measure of quality in lung cancer treatment; however, data is showing that this measure is seldom times fulfilled. Are we looking into the right set of data? Is MLND a real measure of quality or should we look at something else? This is one more report that shows how far away are the guidelines from everyday practice.
Should MLND be considered a measure of quality in lung cancer treatment? I believe it should, but it be great to hear your ideas.

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Should #5 and #6 lymph node station be biopsied in every patient with NSCLC?

Back in 1988, Patterson and colleges described a better 5 year survival for those patients with isolated metastasis to LN stations #5 and 6 when a complete resection was done (around 42% 5-year survival). This is a much better 5- survival than the described for patients with N2 disease in other mediastinal LN stations. Cerfolio compared three different methods of getting to these stations: EUS, Chamberlain procedure and left VATS are compared, concluding that VATS achieves the best sensibility and specificity for these locations. There are other ways of getting these nodes, but to me a left VATS is the easiest one. However, is it always necessary to get these stations? I certainly do not routinely biopsy this station in every patient with a left upper lobe tumor, I just do it when the patient is not a good candidate for lung resection and I want to prove mediastinal disease. The situation is different when CT scan or PET scan is positive for this location. Two options are possible: the first one is to biopsy these nodes and send the patient for induction therapy if nodes are positive and the second one to do surgery right from the beginning if reasonable in terms of tumor size, absence of disease elsewhere and operative risk for lung resection. I don’t know which one is the right answer. I usually feel more like resecting these patients and doing the best possible lymphadenectomy, followed by adjuvant therapy if indicated by the path report. There is evidence that isolated metastasis to stations #5 and 6 behave more as N1 disease in terms of survival and this is the rationale I use for this decision. What I’m sure about is that tailoring a strategy for each particular patient is the best way to treat them, until we have solid evidence on how to deal with patients in this particular situation.
What do you usually do in these patients?
Sebastian

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Left sided lung cancer resection: lymph node stations that should be looked into

We already went through the importance of the adequate staging of lung cancer. It’s not only about the stage of the disease, but also because the stage dictates treatment. Also, mediastinal staging has been considered a quality measure of lung cancer treatment. In the upcoming (February) issue of JTO there’s a very interesting article about this, I recommend you to check it up.

On the left side I also start with station #9L when I take the inferior pulmonary ligament. At the same time, you can reach some #8L nodes, the nodes that are around the esophagus. Going up the posterior mediastinal pleura and right above the posterior aspect of the inferior pulmonary vein you’ll get #7s. It’s a little bit trickier from the left side than from the right side to get these nodes. One of my teachers (one of those surgeons that taught me most of the things I know), used to do what he called the double sucker manouver to get these nodes: he’d take two suckers (regular size, not cherry tip) and he’d push the aorta and esophagus back with one and the pericardium and left bronchus to the front with the other one. By doing he’d expose for you the subcarinal space and with forceps and bovie you could take some nodes out. Let me tell you that this works great and it’s one of the things I just can’t do when I do VATS lobes.

After taking #7s, I move to the anterior aspect of the mediastinal pleura, expose the superior pulmonary vein and get around the pulmonary hilium to watch the left PA. Above the left PA and below the aortic arch, you’ll find #5s lymph nodes (the nodes of the aorto-pulmonary window). Care should be taken not to injure the left recurrent nerve as it runs below the aortic arch. Then, you open the mediastinal pleura on the aortic arch to get #6. #6s lymph nodes are between the phrenic nerve (anteriorly) and the neumogastric nerve (posteriorly). That’s why you should always open this pleural parallel to these nerves so you don’t cut them. There are always nodes in this area.

Left paratracheal lymph nodes (say #4L and #2L) are not routinely taken from the left side.  The aortic arch doesn’t allow you to reach the paratracheal area; that’s why you should be thinking about doing mediastinoscopy if you are concern about metastasis in this group.

Once the mediastinal dissection is complete you should have #5 and #6, #7, #8L and 9L lymph node stations.

N1 nodes are taken with the specimen and as in the right sided resections, I usually separate the nodes from the lung once the lung is out, so I make sure the pathologists will look into them.

By doing this you know you are doing the best possible mediastinal lymph node sampling/dissection and you are staging your patients the right way.

It’d be great to hear what you do in your lung resections for lung cancer…

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Lymph node dissection during lobectomy for lung cancer: stations to be at least sampled in right-sided resections

No one doubts about the need of doing mediastinal lymph node sampling during lobectomy for lung cancer. In the presence of a patient deemed cN0, it is well known that sampling, or better yet, dissecting mediastinal lymph nodes will result in a significant number (up to 20%) of patients that will be upstaged to N1 or N2 after the lung resection.

N1 and N2 patients are better off treated with postoperative chemotherapy to improve survival. If you don’t look hard enough for the lymph node stations, you will downstage patients with nodal disease, and this means a patient getting suboptimal lung cancer treatment.

That’s why we put so much emphasis on at least sampling every lymph node station at the time of the lung resection.

So the question is: what lymph node stations do I look for in right-side lung resection? If the patient has a biopsy proven lung cancer I start doing the lymph node dissection. The first station I get is station #9R when I take down the inferior pulmonary ligament. At the same time I look for para-esophageal lymph nodes, say station #8R. Then, I keep opening the posterior mediastinal pleura and get all the #7s. Doing a #7 lymph node dissection involves to dissect from the inferior border of the right bronchus all the way to the left bronchus, and anteriorly to the posterior aspect of the pericardium. There is always a substantial amount of lymph nodes in this position. Then, I focus in #4R and #2Rs. I open the mediastinal pleura above and below the azigos vein. I don’t ligate this vein, but instead dissect below it and up above it to get all the adipose and lymphatic tissue in the right para-tracheal area. Care should be taken not to damage the left recurrent nerve when dissecting behind the airway. I submit all these tissue labelled as #2R and 4Rs. The superior limit of this dissection is the right subclavian artery, but I never go that far up as a lesion of this vessel it’s a hard one to repair from a thoracotomy.

In this way I cleared up all the mediastinal lymph nodes and proceed to the lung resection. N1 nodes are usually taken out with the lung specimen, but I try to separate #10Rs and #11Rs if possible. If the patient hasn’t a biopsy proven lung cancer, I usually start by getting the diagnosis and if frozen section shows cancer, do the lymph node dissection thereafter.

I consider this to be the best way to rule out lymph node spread from the lung. Getting all these lymph node stations gives you more certainty that you are not missing a patient with lymph node disease and best of all that you are not down-staging any patient.

What lymph node stations do you usually sample or dissect during a right-side lung resection?

Sebastian

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