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• W2023173635 abstract "Staging of the intrathoracic mediastinal and pulmonary lymph nodes is one of the most important problems in the treatment of non-small cell lung cancer. The map of the mediastinal and pulmonary lymph nodes proposed by Clifton F. Mountain and Carolyn M. Dresler gained wide acceptance and has become a standard of staging. However, it has some shortcomings of clarity in the description of localization of specific nodal stations. In our opinion, some modifications of this map are necessary. Based on our experience with extended mediastinoscopy and the new procedure, transcervical extended mediastinal lympadenectomy, the main changes we propose are: 1) the left innominate vein as the anatomic separation between nodal stations 1 and 2; 2) the merging of station 2 and 4 in a single right and left paratracheal station; 3) the shift of the midline to the left paratracheal margin; 4) the tracheobronchial angles as the landmark between stations 4 and 10 bilaterally; 5) the separation of three nodal groups in the subcarinal area: subcarinal (number 7), peribronchial (number 10R and 10L), and periesophageal (number 8); 6) the merging of station 5 and station 6 nodes in a single station with the following landmarks: medial border: the midline, lateral border, the descending aorta and upper border: the left innominate vein and lower border: the lower margin of the left pulmonary artery; and 7) the definition of station 3A nodes as those in front of the superior vena cava. Staging of the intrathoracic mediastinal and pulmonary lymph nodes is one of the most important problems in the treatment of non-small cell lung cancer. The map of the mediastinal and pulmonary lymph nodes proposed by Clifton F. Mountain and Carolyn M. Dresler gained wide acceptance and has become a standard of staging. However, it has some shortcomings of clarity in the description of localization of specific nodal stations. In our opinion, some modifications of this map are necessary. Based on our experience with extended mediastinoscopy and the new procedure, transcervical extended mediastinal lympadenectomy, the main changes we propose are: 1) the left innominate vein as the anatomic separation between nodal stations 1 and 2; 2) the merging of station 2 and 4 in a single right and left paratracheal station; 3) the shift of the midline to the left paratracheal margin; 4) the tracheobronchial angles as the landmark between stations 4 and 10 bilaterally; 5) the separation of three nodal groups in the subcarinal area: subcarinal (number 7), peribronchial (number 10R and 10L), and periesophageal (number 8); 6) the merging of station 5 and station 6 nodes in a single station with the following landmarks: medial border: the midline, lateral border, the descending aorta and upper border: the left innominate vein and lower border: the lower margin of the left pulmonary artery; and 7) the definition of station 3A nodes as those in front of the superior vena cava. The map of the mediastinal and pulmonary lymph nodes described by Mountain and Dresler gained a wide acceptance among pulmonologists, radiologists, oncologists, thoracic surgeons, and pathologists involved in the management of lung cancer patients.1Mountain CF Dresler CM Regional lymph node classification for lung cancer staging.Chest. 1997; 111: 1718-1723Crossref PubMed Scopus (1212) Google Scholar The Mountain and Dresler (M-D) map has provided uniform criteria to describe the position of every lymph node and has become a standard for publications on staging of lung cancer. However, it has some shortcomings of clarity in the description of localization of specific nodal stations. These limitations prompted us to submit some new proposals regarding the definitions of some mediastinal lymph node stations. Our special aim was to facilitate the localization of the nodes during mediastinoscopy and thoracotomy. The proposals originate mainly from the experience gained during performance of the extended mediastinoscopy and the transcervical extended mediastinal lymphadenectomy (TEMLA) and are based on 100 consecutive patients with lung cancer who underwent surgery from January 3,2004 to September 2, 2005 and 4221 (mean, 42.2 per patient; range, 23–85) removed lymph nodes. The technique and preliminary results were described in 20052Kuzdzal J Zielinski M Papla B et al.Transcervical extended mediastinal lymphadenectomy: the new operative technique and early results in lung cancer staging.Eur J Cardiothorac Surg. 2005; 27: 384-390Crossref PubMed Scopus (100) Google Scholar and thereafter underwent some technical refinements. According to M-D classification, this station includes the nodes located above the highest point of the left innominate vein as it crosses the trachea at its midline and below the level of the thoracic outlet. The nodes lying above the level of the thoracic outlet (cranial to the upper margin of the manubrium) are the cervical nodes, described as M1, according to the tumor, node, metastasis (TNM) classification. However, the left innominate vein runs obliquely, and its position is highest near the left margin of the sternum; it then descends toward the right side to join the right innominate vein, and both form the superior vena cava. The position of the confluence of both innominate veins lies much below the horizontal line, which is a border of station 1 nodes according to the M-D map (Figure 1). In our opinion, however, all nodes positioned above the left innominate vein to the right or to the left of the midline should be named station 1 nodes because the upper border of the left innominate vein is a real and consistent margin, compared with an imaginary line, and can be easily identified on computed tomography (CT) at mediastinoscopy and at thoracotomy. According to M-D map, station 2R and 2L nodes lie above the upper margin of the aortic arch and below the lower border of station 1. This definition is not practical for two reasons: 1) the left innominate vein sometimes runs below the upper margin of the aortic arch (Figure 2); 2) both these borders (namely, the lower border of station 1 and the upper border of station 2) are difficult to localize during thoracotomy and are virtually impossible to localize during mediastinoscopy. According to the M-D map, the border between right and left paratracheal nodes is the midline. In our experience, the left and right paratracheal nodes lie asymmetrically, with the right nodes occupying the right paratracheal and pretracheal space (station 3 according to Naruke map) and extending across the midline toward the aortic arch. The left paratracheal nodes are localized around the left laryngeal recurrent nerve and lie mainly behind the nerve. The relation between right and left paratracheal nodes is shown in Figure 3. In our opinion, the midline should not be regarded as a border between right and left paratracheal nodes. This border should be moved to the left tracheal margin, as suggested in 1996 by the Task Force on Intrathoracic Nodal Stating of the International Workshop on Intrathoracic Staging.3Goldstraw P Report on the international workshop on intrathoracic staging, London, October 1996.Lung Cancer. 1997; 18: 107-111Abstract Full Text Full Text PDF Google Scholar There lay the left laryngeal recurrent nerve and the left paratracheal nodes (Figure 3). Because there is no practical separation between nodal stations 2 and 4, in our opinion, they should be merged and simply called right and left paratracheal nodes. They really form only one station on each side that can be removed en bloc. The station 4L nodes pose special problems. According to the M-D map, this station extends from the upper margin of the aortic arch down to the bifurcation of the left main bronchus; therefore, it extends a distance of 10 cm or even more. It is usually impossible to reach all station 4L nodes through left thoracotomy (without the extensive mobilization of the aortic arch) or even during mediastinoscopy, unless the whole length of the left main bronchus is dissected, which is possible only occasionally. Generally, the left main bronchus is dissected down to the level of the left pulmonary artery, but exceptionally it is possible to go below it and then find the origin of the left upper lobe bronchus. For these reasons, the lower border of the station 4L should be located at the lower margin of the aortic arch that lies on the left tracheobronchial angle (Figure 4). The tracheobronchial angle is an anatomic landmark that can be clearly identified on simple postero-lateral chest radiographs, on CT scans, at mediastinoscopy, and at thoracotomy. Likewise, the lower border of station 4R should be the lower margin of the azygos vein as it crosses over the right main bronchus at the right tracheobronchial angle. All nodes beyond the left tracheobronchial angle should be called station 10L nodes, and all nodes beyond the right tracheobronchial angle should be named station 10R nodes. The rationale for separating these more distal areas of the M-D 4R and 4L stations and calling them 10R and 10L, as in the original Naruke map, is based on the fact that the prognosis of their involvement seems to be between that of N1 disease and that of N2 disease,4Asamura H Suzuki K Kondo H Tsuchiya R Where is the boundary between N1 and N2 stations in lung cancer?.Ann Thorac Surg. 2000; 70: 1839-1846Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar representing a progressive degradation of prognosis as the disease spreads centrally along the lymphatic vessels. The relation between stations 5 and 6 and station10L nodes is not described clearly enough in the M-D map. Our proposal regarding these nodal stations is to merge them into a single station. This derives from the fact that the ligamentum arteriosum, which is the main element separating both stations, cannot be identified radiographically, at mediastinoscopy, or at extended cervical mediastinoscopy. The borders of this combined station would be: medial border: the midline; lateral border: the descending aorta; upper border: the left innominate vein; and lower border: the lower margin of the left pulmonary artery. The nodes located beneath the pulmonary artery (between the descending aorta, the left main bronchus, the esophagus, and the left pulmonary artery) (Figure 5) should be regarded as station 10L nodes instead of station 4L nodes, according to the M-D map. The most distal nodes in this station are not accessible during mediastinoscopy, anterior mediastinotomy, video-assisted mediastinoscopic lymphadenectomy (VAMLA), or TEMLA. It is only possible to reach these nodes during thoracotomy or videothoracoscopy (which is very difficult and risky). Station 3A nodes comprise those located in front of the superior vena cava on the right side Station 3P is almost always nonexistent—it is very rare to find any node located behind the trachea in the area of the tracheal bifurcation The distinction among station 7 (subcarinal nodes), station 8 (periesophageal nodes), and station 10 (peribronchial nodes) is not clear enough in the M-D map. The area below the carina and the main bronchi almost invariably contains a cluster of nodes. The most cranial nodes are in contact with the tracheal bifurcation and the main bronchi. At mediastinoscopy, if the mediastinoscope is inserted below the carina, another group of nodes is usually found. In this area, three nodal groups can be defined according to their relation to the tracheobronchial tree and the esophagus. Station 7 nodes (subcarinal) are the nodes located precisely at the tracheal bifurcation; that is, right at the angle formed by both main bronchi. Station 8 nodes (periesophageal) are those in contact with the esophagus but completely detached from the tracheal carina and not in contact with the main bronchi. It must be stressed that there are no anatomical landmarks separating stations 7, 8, and 10. Station 10R and 10L nodes are in contact with the lower border of the right and left main bronchi, respectively, and lateral to the station 7 nodes. It makes sense to call the nodes lying along the inferior border of the main bronchi 10R and 10L nodes because they are peribronchial, as the 10R and 10L lying along the superior border and anterior aspect of both main bronchi. For studies with the objective to determine the specific prognosis of each nodal station, the location of the station 10R and 10L nodes could be further specified according to their relative positions: upper 10R and 10L nodes are those along the upper margin and anterior aspect of the main bronchi; lower 10R and 10L are those along the lower margin of the main bronchi. There are very few data regarding the prognostic value of the specific metastatic involvement of the individual mediastinal nodal stations: the deleterious significance of involved subcarinal nodes is generally agreed upon; involvement of station 5 nodes in left upper lobe tumors may have a better prognosis than other involved mediastinal lymph node stations; and involvement of superior mediastinal nodes in tumors of both lower lobes is an indicator of poor prognosis.5Okada M Tsubota N Yoshimura M Miyamoto Y Matsuoka H Prognosis of completely resected pN2 non-small cell lung carcinomas: what is the significant node that affects survival?.J Thorac Cardiovasc Surg. 1999; 118: 270-275Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar, 6Asamura H Nakayama H Kondo H Tsuchiya R Naruke T Lobe-specific extent of systematic lymph node dissection for non-small cell lung carcinomas according to a retrospective study of metastasis and prognosis.J Thorac Cardiovasc Surg. 1999; 117: 1102-1111Abstract Full Text Full Text PDF PubMed Scopus (200) Google Scholar Further studies are needed regarding this issue. We are convinced that establishing a more precise thoracic lymph node map than that currently available is a prerequisite for such studies. The changes proposed in this article derive from surgical practice and are intended to clarify in a practical way the limits of the nodal stations. An anatomical border, such as the left innominate vein, is much easier to identify than the imaginary line separating nodal stations 1 and 2. When there is no clear anatomical separation between nodal stations, as it happens with nodal stations 2 and 4, it is better to merge them. In this particular case, the boundaries of the M-D map are not practical at mediastinoscopy or at thoracotomy. Moreover, the fat pad containing the peritracheal lymph nodes can be dissected en bloc because there is no distinction or anatomical separation between the nodal stations. The same occurs with stations 5 and 6, whose separating structure, the ligamentum arteriosum, cannot be identified on chest radiograph, on CT scans, at mediastinoscopy, or at extended cervical mediastinoscopy. The subcarinal space deserves special attention. It is a complex area in which the right and left lymphatic flows converge. Those practicing mediastinosocpy and TEMLA know that there are many nodes in this pyramidal space, which vertex is the tracheal bifurcation. There is, almost invariably, a node at the tracheal bifurcation. Lateral to this node, there are other nodes along the lower margins of the right and left main bronchi. For the purpose of record keeping, these nodes are sometimes called right and left subcarinal nodes.7Rami-Porta R Mateu-Navarro M Videomediastinoscopy.J Bronchol. 2002; 9: 138-144Crossref Scopus (9) Google Scholar Moreover, caudal to this first row of nodes, there are more nodes, deep subcarinal nodes.7Rami-Porta R Mateu-Navarro M Videomediastinoscopy.J Bronchol. 2002; 9: 138-144Crossref Scopus (9) Google Scholar The three lymph node groups that we propose are easy to identify at mediastinoscopy or TEMLA, at thoracotomy, and with imaging techniques. By differentiating the truly subcarinal node (the node located exactly at the tracheal bifurcation) from the nodes along the lower border of the main bronchi and calling them 10R and 10L, all peribronchial nodes are grouped into one station on each side, regardless of whether they are along the upper or the lower margins of the main bronchi. This has practical importance because the involvement of these nodes has worse prognosis than N1 disease but better prognosis than N2.4Asamura H Suzuki K Kondo H Tsuchiya R Where is the boundary between N1 and N2 stations in lung cancer?.Ann Thorac Surg. 2000; 70: 1839-1846Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar They represent one further step in the progressive degradation of survival as the disease spreads away from the lung. These nodes, part of the lung pedicle, together with the pulmonary arteries and veins, are mediastinal in location and become hilar at the mediastinal aspect of the lung, where the anatomic hilus is. We hope that these proposals will stimulate discussion that will result in a new consensus regarding the mediastinal lymph node classification." @default.
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• W2023173635 title "Proposals for Changes in the Mountain and Dresler Mediastinal and Pulmonary Lymph Node Map" @default.
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