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

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 side to get these nodes. One of my teachers (one of those surgeons that taught me most of the things I know), used to do what he called the double sucker manouver to get these nodes: he’d take two suckers (regular size, not cherry tip) and he’d push the aorta and esophagus back with one and the pericardium and left bronchus to the front with the other one. By doing he’d expose for you the subcarinal space and with forceps and bovie you could take some nodes out. Let me tell you that this works great and it’s one of the things I just can’t do when I do VATS lobes.

After taking #7s, I move to the anterior aspect of the mediastinal pleura, expose the superior pulmonary vein and get around the pulmonary hilium to watch the left PA. Above the left PA and below the aortic arch, you’ll find #5s lymph nodes (the nodes of the aorto-pulmonary window). Care should be taken not to injure the left recurrent nerve as it runs below the aortic arch. Then, you open the mediastinal pleura on the aortic arch to get #6. #6s lymph nodes are between the phrenic nerve (anteriorly) and the neumogastric nerve (posteriorly). That’s why you should always open this pleural parallel to these nerves so you don’t cut them. There are always nodes in this area.

Left paratracheal lymph nodes (say #4L and #2L) are not routinely taken from the left side.  The aortic arch doesn’t allow you to reach the paratracheal area; that’s why you should be thinking about doing mediastinoscopy if you are concern about metastasis in this group.

Once the mediastinal dissection is complete you should have #5 and #6, #7, #8L and 9L lymph node stations.

N1 nodes are taken with the specimen and as in the right sided resections, I usually separate the nodes from the lung once the lung is out, so I make sure the pathologists will look into them.

By doing this you know you are doing the best possible mediastinal lymph node sampling/dissection and you are staging your patients the right way.

It’d be great to hear what you do in your lung resections for lung cancer…

Lymph node dissection during lobectomy for lung cancer: stations to be at least sampled in right-sided resections

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 lymph node stations do I look for in right-side lung resection? If the patient has a biopsy proven lung cancer I start doing the lymph node dissection. The first station I get is station #9R when I take down the inferior pulmonary ligament. At the same time I look for para-esophageal lymph nodes, say station #8R. Then, I keep opening the posterior mediastinal pleura and get all the #7s. Doing a #7 lymph node dissection involves to dissect from the inferior border of the right bronchus all the way to the left bronchus, and anteriorly to the posterior aspect of the pericardium. There is always a substantial amount of lymph nodes in this position. Then, I focus in #4R and #2Rs. I open the mediastinal pleura above and below the azigos vein. I don’t ligate this vein, but instead dissect below it and up above it to get all the adipose and lymphatic tissue in the right para-tracheal area. Care should be taken not to damage the left recurrent nerve when dissecting behind the airway. I submit all these tissue labelled as #2R and 4Rs. The superior limit of this dissection is the right subclavian artery, but I never go that far up as a lesion of this vessel it’s a hard one to repair from a thoracotomy.

In this way I cleared up all the mediastinal lymph nodes and proceed to the lung resection. N1 nodes are usually taken out with the lung specimen, but I try to separate #10Rs and #11Rs if possible. If the patient hasn’t a biopsy proven lung cancer, I usually start by getting the diagnosis and if frozen section shows cancer, do the lymph node dissection thereafter.

I consider this to be the best way to rule out lymph node spread from the lung. Getting all these lymph node stations gives you more certainty that you are not missing a patient with lymph node disease and best of all that you are not down-staging any patient.

What lymph node stations do you usually sample or dissect during a right-side lung resection?