ESTS guidelines for intraoperative lymph node staging in non-small cell lung cancer☆

Abstract

The European Society of Thoracic Surgeons (ESTS) organized a workshop dealing with lymph node staging in non-small cell lung cancer. The objective of this workshop was to develop guidelines for definitions and the surgical procedures of intraoperative lymph node staging, and the pathologic evaluation of resected lymph nodes in patients with non-small cell lung cancer (NSCLC). Relevant peer-reviewed publications on the subjects, the experience of the participants, and the opinion of the ESTS members contributing on line, were used to reach a consensus. Systematic nodal dissection is recommended in all cases to ensure complete resection. Lobe-specific systematic nodal dissection is acceptable for peripheral squamous T1 tumors, if hilar and interlobar nodes are negative on frozen section studies; it implies removal of, at least, three hilar and interlobar nodes and three mediastinal nodes from three stations in which the subcarinal is always included. Selected lymph node biopsies and sampling are justified to prove nodal involvement when resection is not possible. Pathologic evaluation includes all lymph nodes resected separately and those remaining in the lung specimen. Sections are done at the site of gross abnormalities. If macroscopic inspection does not detect any abnormal site, 2-mm slices of the nodes in the longitudinal plane are recommended. Routine search for micrometastases or isolated tumor cells in hematoxylin-eosin negative nodes would be desirable. Randomized controlled trials to evaluate adjuvant therapies for patients with these conditions are recommended. The adherence to these guidelines will standardize the intraoperative lymph node staging and pathologic evaluation, and improve pathologic staging, which will help decide on the best adjuvant therapy.

Survival After Surgical Resection for Lung Cancer in Patients With Chronic Obstructive Pulmonary Disease

“…An explanation to the relatively high level of early lung cancer deaths may be related to insufficient perioperative lymph node dissection. Despite careful, guidelinerecommended dissection of lymph nodes, some patients in our material may have been staged too low [84]. This may have contributed to early tumor relapse.…”

Postoperative Radiotherapy of Non-Small Cell Lung Cancer

“…Европейское общество торакальных хирургов EuropeanSocietyofThoracicSurgeons (ESTS) пред-ложил руководящие принципы для надлежащегоинтра-операционного и предоперационного лимфатического стадирования [44] и [45]. Международная ассоциация по изучению рака легкого (IASLC) предложил определение полной резекции [46].…”

Video-Assisted Thoracic Surgery (VATS) Systematic Mediastinal Nodal Dissection

“…However, we harvest #3 (precarinal) when indicated on the left chest without dividing the ligamentum arteriosum by retracting the main pulmonary artery up and pushing the carina down 1 . Subcarinal nodes #7 were mandatory for the definition of SND, and if these were not harvested the procedure would have been classified as 'Nodal sampling' and not SND [6]. The procedure extends the operative time by 30 minutes on the right chest and between 45-60 minutes on the left chest.…”

“…3 ports are fashioned, 2X1cm and a utility port 3-4cm long at the mid-axillary line over the 4th or 5th intercostal space. Nodal harvesting can be performed before, during or after the VATS resection (lobectomy, pneumonectomy, segmentectomy etc) according to published European and international standards [6,26,28,31].…”