Does complete mediastinal lymph node dissection improve overall survival compared to mediastinal lymph node staging in stage II NSCLC?

From Cancer Guidelines Wiki



Does complete mediastinal lymph node dissection improve overall survival compared to mediastinal lymph node staging in stage II NSCLC?

Introduction

This evidence relates to patients who have had standard therapy with at least lobectomy and lymph node sampling. Mediastinal lymph node staging, either by pre-operative (mediastinoscopy, endobronchial ultrasound FNA) or intra-operative sampling is an integral part of surgical resection of NSCLC. Besides the prognostic value of proper staging, the current evidence base for adjuvant chemotherapy shows a survival advantage for patients receiving chemotherapy if any nodes are found to be positive.

Back to top

Complete lymph node dissection versus lymph node staging in stage II

Whilst accurate lymph node staging should be standard practice, the evidence to date has been unclear as to when a complete mediastinal lymph node dissection is indicated, if at all. In a Cochrane review by Manser et al[1], it was found that the evidence already existed for a survival benefit from complete mediastinal lymph node dissection. This was specifically reported in 2006[2], but did not generate the level of interest that accompanies new pharmacological interventions. The randomised trials by Wu et al[3] and Passlick et al[4] showed an increasing benefit for higher stage disease, but the Will Rogers phenomenon of stage migration could not be ruled out as a source of bias. It was not until the publication of the American College of Surgeons Oncology Group Z30 trial[5], that it could be inferred that the benefit of complete mediastinal dissection is clearest in stage II and higher NSCLC. A further systematic review and meta analysis by Huang et al[6] included patients with all stages of NSCLC and found no difference in overall survival between complete mediastinal lymph node dissection and systematic lymph node sampling. However this analysis was heavily weighted towards very early pathologic Stage I patients by inclusion of the ACOSOG Z30 trial.[5]

Back to top

Evidence summary and recommendations

Evidence summary Level References
Complete mediastinal lymph node dissection may be associated with improved overall survival compared to lymph node staging alone in patients with unknown stage or stage II-III NSCLC.

Last reviewed November 2015

I, II [1], [4], [2], [3], [6]
Evidence-based recommendationQuestion mark transparent.png Grade
A complete mediastinal lymph node dissection of at least Stations 2R, 4R, 7 and 8 (right side) or Stations 5, 6, 7 and 8 (left side) is recommended for surgically resected pathologically confirmed (node positive) stage II NSCLC.

Last reviewed November 2015

B


Back to top

References

  1. 1.0 1.1 Manser R, Wright G, Hart D, Byrnes G, Campbell DA. Surgery for early stage non-small cell lung cancer. Cochrane Database Syst Rev 2005 Jan 25;(1):CD004699 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15674959.
  2. 2.0 2.1 Wright G, Manser RL, Byrnes G, Hart D, Campbell DA. Surgery for non-small cell lung cancer: systematic review and meta-analysis of randomised controlled trials. Thorax 2006 Jul;61(7):597-603 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16449262.
  3. 3.0 3.1 Wu Y, Huang ZF, Wang SY, Yang XN, Ou W. A randomized trial of systematic nodal dissection in resectable non-small cell lung cancer. Lung Cancer 2002 Apr;36(1):1-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11891025.
  4. 4.0 4.1 Passlick B, Kubuschock B, Sienel W, Thetter O, Pantel K, Izbicki JR. Mediastinal lymphadenectomy in non-small cell lung cancer: effectiveness in patients with or without nodal micrometastases - results of a preliminary study. Eur J Cardiothorac Surg 2002 Mar;21(3):520-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11888774.
  5. 5.0 5.1 Darling GE, Allen MS, Decker PA, Ballman K, Malthaner RA, Inculet RI, et al. Randomized trial of mediastinal lymph node sampling versus complete lymphadenectomy during pulmonary resection in the patient with N0 or N1 (less than hilar) non-small cell carcinoma: Results of the American College of Surgery Oncology Group Z0030 Trial. J Thorac Cardiovasc Surg 2011 Mar;141(3):662-70 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21335122.
  6. 6.0 6.1 Huang X, Wang J, Chen Q, Jiang J. Mediastinal Lymph Node Dissection versus Mediastinal Lymph Node Sampling for Early Stage Non-Small Cell Lung Cancer: A Systematic Review and Meta-Analysis. PLoS One 2014;9(10):e109979 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25296033.

Back to top

Appendices

Further resources

Back to top