Cancer pulmonar y upstaging ganglionar post lobectomía

Uncategorized
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…
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¿Qué tan bien seguimos los stándares?

Calidad en salud, Cancer Pulmonar, En Español, Estadificacion Mediastinal
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…
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Are we following the guidelines?

Calidad en salud, Estadificacion Mediastinal
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…
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Should #5 and #6 lymph node station be biopsied in every patient with NSCLC?

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

Calidad en salud, Estadificacion Mediastinal
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…
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Lymph node dissection during lobectomy for lung cancer: stations to be at least sampled in right-sided resections

Calidad en salud, Estadificacion Mediastinal
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…
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