My father was diagnosed with stage 3a lung cancer recently. A 8 cm tumor was evident on pet/ct scan in his right lung. He went straight to surgery with no mediastinal sampling done prior to surgery. This may be because there was no evidence of lymph node involvement on his pet/ct scan. During surgery, the lymph nodes on the right side were resected and sampled. Path report shows lymph node involvement in station 7, 13 and in one of the hilar nodes within the lobe (3 nodes in all were positive; uncertain how many nodes sampled as some of them were fragmented).
None of the nodes on the left side were resected or sampled. Is this standard procedure? We now know he has N2 disease but we have no idea if any of his n3 nodes are positive. what are the chances that some of them are positive? He will now undergo chemoradiation. Does knowing whether or not n3 nodes were positive change treatment? or simply prognosis?
Thank you.
Reply # - September 6, 2014, 01:39 PM
Hello ameslee,
Hello ameslee,
Welcome to GRACE. I am sorry to hear of your father's diagnosis, and I hope that we will be able to assist you with information and answers to your questions.
The distinction between treatment for Stage IIIa (N2 nodes) and Stage IIIb (N3 nodes) lung cancer is that although some doctors make exceptions in particular circumstances, surgery is not usually favored for Stage IIIb as much as it is for Stage IIIa. But since your father has already had surgery, that question is moot, and for either stage chemoradiation is the appropriate treatment. It is true that prognosis is worse when there are N3 nodes affected, but knowing that would not change management of his cancer.
You may find the following links helpful:
Dr. Weiss' Introduction to Lung Cancer: http://cancergrace.org/lung/2010/04/05/an-introduction-to-lung-cancer/
Dr. West's post on Stage IIIa lung cancer: http://cancergrace.org/lung/2010/04/23/stage-iiia-n2-nsclc-summary-ref-…
Dr. Pinder's discussion of Stage III lung cancer: http://cancergrace.org/lung/2010/08/22/introduction-to-locally-advanced…
Good luck with your father's chemorads. Please let us know as more questions arise.
JimC
Forum moderator
Reply # - September 6, 2014, 02:17 PM
Jim's exactly right. While
Jim's exactly right. While there's a small difference in prognosis, there is no difference in treatment if the plan is now chemo and radiation, as this would be an appropriate recommendation whether N2 or N3 nodal disease was the highest noted.
Surgery without a preceding mediastinoscopy is common, but it's suboptimal, except for patients with a very low risk of mediastinal involvement (such as patients undergoing surgery for a cancer that has been seen to grow from 6 to 7 mm over 6 months or a year, with no other findings visible). Some surgeons, especially the ones who aren't specially trained as lung surgeons (some cardiothoracic or even general surgeons do lung cancer surgery, but that doesn't mean that they do a comparable job to that of the best trained thoracic surgeons) consider a PET scan that is negative in the mediastinum as sufficient evidence that you don't need to do a mediastinoscopy, though we know there's a non-trivial "false negative" rate of about 9%. Combining the skipping of a mediastinoscopy with an incomplete mediastinal dissection is less than ideal, as you've found.
That said, I'd come back to the point that it doesn't necessarily change things now. The point I'd hope to leave is that I would strongly encourage patients and family members to pursue the most thorough pre-operative workup by the most experienced and skilled thoracic surgeon they can get to, rather than relying on the judgment of closest person who has the words "lung surgery" on their business card.
Good luck.
-Dr. West
Reply # - September 6, 2014, 06:57 PM
Thank you Dr. West and JimC
Thank you Dr. West and JimC for your replies!