Proposal for reasonable mediastinal lymphadenectomy in bronchogenic carcinomas: Role of subcarinal nodes in selective dissection

Objective: The aims of this study were to reveal the characteristics of skipping N2 lung cancer and to develop a more reasonable approach for dissecting mediastinal lymph nodes. Methods: Of consecutive 956 patients who were operated on for primary lung cancer from 1986 through 1996, 760 (79.5 %) had a diagnosis of non-small cell carcinoma and were subjected to complete resection of the tumor together with hilar and mediastinal lymphadenectomy. Results: Of 141 patients with N2 disease, 53 (37.6%) had skipping metastases, Among 78 patients with N2 cancer of the upper lobe, 37 (47.4%) had skipping metastases affecting upper or aortic mediastinal nodes whereas none of them had skipping metastases affecting lower mediastinal nodes. Among 47 patients with N2 cancer of the lower lobe, 13 (27.7%) had skipping metastases affecting mediastinal bodes. Of these 13 patients, 11 (84.6%) had skipping metastases affecting the subcarinal node. The remaining 2 patients had a huge primary tumor. Conclusions: Dissection of the upper part of the mediastinum including the aortic regions should be performed regardless of the operative appearance when cancer is located in the upper lobe, but it is not required for lower lobe tumors with negative hilar and subcarinal nodes. Dissection of the subcarinal node in patients with an upper lobe tumor is not routinely needed when the nodes in both the hilum and upper mediastinum are intact. We consider that the subcarinal node is of significance and skipping metastases should be defined as metastases that skip the subcarinal node in addition to N1 nodes.