Recent literature suggests that not enough lymph nodes are being tested during lung resection surgery. Originally staged 1A, CT, PET suggested 2 cm tumor URL. PET could not exclude small nodal station, subtle intake, retrocaval pretracheal space. Surgery for URL lobectomy. Tumor was 3.5 cm. 10 nodes on same side biopsied. Right level 3 &4, 1/4 metastatic; right level 10, 1/2 metastatic; right level 8, 0/1 node negative. Restated IIIA. T2N2M0. Adjuvant chemoradiation therapy recommended and in treatment.
Based upon recent literature, case in point, should more nodes be biopsied for distant nodal involvement? Should nodes on left side (or opposite) be biopsied? Why or why not? Does not identifying positive nodes affect outcomes with recommended treatment? Radiation is targeted on area of positive nodes, would there be benefit to possible positive nodes that were not identified and are outside the target area?
Thank you
Reply # - February 3, 2014, 08:38 AM
Reply To: Lung Cancer Stage IIIA -Lymph Node Sampling – Slippery
There's been a lot written here on the subject. The following quote from Dr. West is from a fairly recent blog post (I didn't search long), "The lung surgeons I work with are competitive, and the patients they treat are better for it. They monitor how many lymph nodes they are able collect from the mediastinoscopies and lung cancer surgeries they do, competing against their own targets and each other. Why? Because there’s evidence that nodal yield is related to better outcomes, perhaps because the better surgeons often happen to collect more nodes, perhaps because their patients are more accurately staged, and probably in part because there’s a value in removing cancer-involved lymph nodes, rather than relying on post-surgical treatments to cure them." from http://cancergrace.org/lung/2012/08/15/n1-nodal-yield/
This blog post is older, 2008 but suggests similar, http://cancergrace.org/lung/2008/06/17/peoria-experience-with-surgery/
http://cancergrace.org/lung/2013/12/06/n-stage-flight-risk/
Search the site and you'll find more on the subject; don't miss the additional links at the end of these posts. Here's a search result for mediastinoscopy under the topic of "lung cancer", http://cancergrace.org/search-results?q=mediastinoscopies%20lymph%20nod…
Please let me know if this helps or if I missed something,
Janine
Reply # - February 3, 2014, 08:18 PM
Reply To: Lung Cancer Stage IIIA -Lymph Node Sampling – Slippery
Janine covered the highlights.
We prefer to have a mediastinoscopy performed prior to surgery, since the outcome determines what the optimal treatment is. Ideally, you want to have a mediastinoscopy sample lymph nodes from stations 4R, 4L (so, from both sides of the mediastinum), and station 7 (subcarinal). Having lymph nodes involved on the same side as the primary cancer is called N2 nodal disease. If we see that, we generally favor chemotherapy or chemo/radiation before surgery, or else chemo/radiation to a potentially curative dose and no surgery. Seeing larger lymph nodes or multiple nodes leads us to favor a non-surgical approach, since larger and more nodes are associated with a higher chance of cancer being outside of the area that can be removed with surgery, and more extensive radiation with chemo tends to cast a wider net.
Finding lymph node involved on the side of the mediastinum opposite the original cancer is called N3 nodal disease. In this setting, the main treatment is chemo/radiation and not surgery, which has a very low chance of curing the cancer.
The other point is that the best outcomes tend to be in patients who have had more lymph nodes resected. That may be because the staging is more accurate when more lymph nodes are removed, or that the surgery removes more of the cancer, that the surgeons who remove more nodes are the most meticulous and do the best surgeries, or some combination of these factors.
Good luck.
-Dr. West
Reply # - February 3, 2014, 08:18 PM
Reply To: Lung Cancer Stage IIIA -Lymph Node Sampling – Slippery
Janine covered the highlights.
We prefer to have a mediastinoscopy performed prior to surgery, since the outcome determines what the optimal treatment is. Ideally, you want to have a mediastinoscopy sample lymph nodes from stations 4R, 4L (so, from both sides of the mediastinum), and station 7 (subcarinal). Having lymph nodes involved on the same side as the primary cancer is called N2 nodal disease. If we see that, we generally favor chemotherapy or chemo/radiation before surgery, or else chemo/radiation to a potentially curative dose and no surgery. Seeing larger lymph nodes or multiple nodes leads us to favor a non-surgical approach, since larger and more nodes are associated with a higher chance of cancer being outside of the area that can be removed with surgery, and more extensive radiation with chemo tends to cast a wider net.
Finding lymph node involved on the side of the mediastinum opposite the original cancer is called N3 nodal disease. In this setting, the main treatment is chemo/radiation and not surgery, which has a very low chance of curing the cancer.
The other point is that the best outcomes tend to be in patients who have had more lymph nodes resected. That may be because the staging is more accurate when more lymph nodes are removed, or that the surgery removes more of the cancer, that the surgeons who remove more nodes are the most meticulous and do the best surgeries, or some combination of these factors.
Good luck.
-Dr. West
Reply # - February 4, 2014, 10:42 AM
Reply To: Lung Cancer Stage IIIA -Lymph Node Sampling – Slippery
Thank you for your response. I did get a second opinion and because the CT and PET did not show positive response for mets, it was recommended to proceed with surgery to remove the single tumor. So....now the treatment is chemo and radiation to mop up any cancer cells that were possibly missed. I understand this is protocol at this point followed up with appropriate scans. My next question, should cancer reappear, would you move forward with a second line of treatment? Or are there other options at this point. I failed to mention this is poorly diff squamous.
Reply # - February 7, 2014, 03:28 PM
Reply To: Lung Cancer Stage IIIA -Lymph Node Sampling – Slippery
The only treatment difference being squamous and or poorly diff is that the drugs Avastin and Alimta are not used with squamous cell.
Most cases would move forward with another line treatment if the cancer is thought to have recurred, this would be considered recurrent nsclc which isn't usually considered curable. However there are always exceptions and rarely any real rules. Such as if more than a year passes then it's very possible a new cancer and treated as curable. Too, there's thought that some recurrent cancers may still be curable if there's just one nodule over a period of several months in the brain or adrenal gland, known as precocious metastasis.
Sorry to have missed your question. Please don't hesitate to reply yourself so the thread will be "bump"ed up to the top of the list.
Janine
Reply # - February 7, 2014, 10:33 PM
Reply To: Lung Cancer Stage IIIA -Lymph Node Sampling – Slippery
Yes, most of the time when a cancer recurs after surgery or other initial treatment, it is with distant disease in another part of the body, such as the liver, bone(s), adrenal glands, brain, or another part of the lung. Unfortunately, in the vast majority of such cases, cure isn't possible, but it is still treatable, and many patients live longer due to the effects of chemotherapy. In more unusual circumstances, radiation or surgery would be an option to consider, though that is mostly when the cancer recurs in the same area as where it had initially developed.
Good luck.
-Dr. Wesst