Keller S M, Adak S, Wagner H, Johnson D H
Department of Surgery, The Beth Israel Medical Center, New York, New York 10003, USA.
Ann Thorac Surg. 2000 Aug;70(2):358-65; discussion 365-6. doi: 10.1016/s0003-4975(00)01673-8.
Mediastinal lymph node dissection (MLND) is an integral part of surgery for non-small cell lung cancer (NSCLC). To compare the impact of systematic sampling (SS) and complete MLND on the identification of mediastinal lymph node metastases and patient survival, the Eastern Cooperative Oncology Group (ECOG) stratified patients by type of MLND before participation in ECOG 3590 (a randomized prospective trial of adjuvant therapy in patients with completely resected stages II and IIIa NSCLC).
Eligibility requirements for study entry included a thorough investigation of the mediastinal lymph nodes with either SS or complete MLND. The former was defined as removal of at least one lymph node at levels 4, 7, and 10 during a right thoracotomy and at levels 5 and/or 6 and 7 during a left thoracotomy, while the latter required complete removal of all lymph nodes at those levels.
Three hundred seventy-three eligible patients were accrued to the study. Among the 187 patients who underwent SS, N1 disease was identified in 40% and N2 disease in 60%. This was not significantly different than the 41% of N1 disease and 59% of N2 disease found among the 186 patients who underwent complete MLND. Among the 222 patients with N2 metastases, multiple levels of N2 disease were documented in 30% of patients who underwent complete MLND and in 12% of patients who had SS (p = 0.001). Median survival was 57.5 months for those patients who had undergone complete MLND and 29.2 months for those patients who had SS (p = 0.004). However, the survival advantage was limited to patients with right lung tumors (66.4 months vs 24.5 months, p<0.001).
In this nonrandomized comparison, SS was as efficacious as complete MLND in staging patients with NSCLC. However, complete MLND identified significantly more levels of N2 disease. Furthermore, complete MLND was associated with improved survival with right NSCLC when compared with SS.
纵隔淋巴结清扫术（MLND）是非小细胞肺癌（NSCLC）手术的一个重要组成部分。为比较系统采样（SS）和完整MLND对纵隔淋巴结转移的识别及患者生存的影响，东部肿瘤协作组（ECOG）在患者参与ECOG 3590（一项针对完全切除的II期和IIIa期NSCLC患者的辅助治疗随机前瞻性试验）之前，根据MLND的类型对患者进行了分层。
研究入选的资格要求包括用SS或完整MLND对纵隔淋巴结进行全面检查。前者定义为在右胸开胸手术期间切除第4、7和10组至少一个淋巴结，在左胸开胸手术期间切除第5和/或6组及第7组至少一个淋巴结，而后者则要求完整切除这些组的所有淋巴结。
373名符合条件的患者被纳入该研究。在接受SS的187名患者中，40%被诊断为N1期疾病，60%为N2期疾病。这与在接受完整MLND的186名患者中发现的41%的N1期疾病和59%的N2期疾病没有显著差异。在222名有N2转移的患者中，30%接受完整MLND的患者和12%接受SS的患者有多组N2期疾病记录（p = 0.001）。接受完整MLND的患者中位生存期为57.5个月，接受SS的患者为29.2个月（p = 0.004）。然而，生存优势仅限于右肺肿瘤患者（66.4个月对24.5个月，p<0.001）。
在这项非随机比较中，SS在NSCLC患者分期方面与完整MLND一样有效。然而，完整MLND识别出的N2期疾病组明显更多。此外，与SS相比，完整MLND与右肺NSCLC患者生存率提高相关。
