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

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

Introduction

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. 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.

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Complete lymph node dissection versus lymph node staging in stage I

Despite a meta analysis demonstrating a survival benefit from mediastinal node dissection for all-comers having NSCLC resection[1], the completion of a large randomised controlled trial by the American College of Surgeons Oncology Group[2], confirmed that this benefit did not extend to patients who were staged intra-operatively with frozen section proven node negative disease. Another small trial of peripheral clinical stage I NSCLC less than 2cm in diameter also failed to demonstrate a benefit of complete mediastinal lymph node dissection[3]. A systematic review and meta analysis confirmed the lack of survival benefit of complete mediastinal lymph node dissection over systematic mediastinal lymph node sampling.[4]

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Evidence summary and recommendations

Evidence summary Level References
Complete mediastinal lymph node dissection does not improve survival for patients having surgical resection for pathologically proven stage I NSCLC.

Last reviewed November 2015

I, II [2], [3], [4]
Evidence-based recommendationQuestion mark transparent.png Grade
Systematic lymph node sampling is recommended to rule out occult nodal disease in clinical stage I patients. There is no apparent additional survival benefit of complete mediastinal node dissection in this group of patients.

Last reviewed November 2015

C


Practice pointQuestion mark transparent.png

For accurate staging according to AJCC TNM Pathological Staging, it is advisable to sample at least three lymph nodes from different stations. This is also required for prognostic purposes and for appropriate referral for adjuvant chemotherapy.

Last reviewed November 2015

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References

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Appendices

Further resources

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