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…

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