![]() Although survival benefit after lymph node dissection is unclear, most authors consider that complete mediastinal lymphadenectomy or sampling should be recommended during pulmonary metastasectomy to achieve accurate staging and guide additional chemotherapy. The complete mediastinal lymphadenectomy may prolong operative time, but associated morbidity is very rare ( Allen et al., 2006). ![]() Central localization of pulmonary metastases may also be associated with increased rate of lymph node involvement. In addition, they did not find statistical difference on a 5-year survival between LN sampling and radical removal. Interestingly, unexpected LN involvement was found in 35% with breast cancer, in 9.2% with colorectal cancer, and in 20.8% with renal cell carcinoma. (2015) reported recently 256 procedures of pulmonary metastasectomy with lymph node sampling or complete dissection. The incidence of positive lymph node may be different according to different primary tumors. Median survivals for the no LND group, negative LND group, and positive LND group were 52, 58.5, and 34 months, respectively. One hundred ninety-nine patients had no lymphadenectomy, 279 patients underwent mediastinal LND that was negative, and 40 patients underwent LND that contained one or more positive LNs for metastases. (2012) reported retrospectively 518 patients operated for lung metastasectomy of colorectal cancer. Median survival was 64 months for patients without nodal metastases and 33 and 21 months for patients with hilar and mediastinal metastases, respectively. ![]() Pfannschmidt reported 245 patients who underwent systematic lymph node dissection during pulmonary metastasectomy and founded hilar or mediastinal lymph node involvement in 32% ( Pfannschmidt et al., 2006a). Systematic mediastinal lymph node dissection has been reported to have a significative difference in survival between patients with positive lymph node in comparison with negative lymph node. The incidence of mediastinal LN metastases with pulmonary metastases ranges between 12% and 32% ( Hamaji et al., 2012 Seebacher et al., 2015 Pfannschmidt et al., 2006a Ercan et al., 2004 Veronesi et al., 2007 Szoke et al., 2010). Given this unclear sensitivity, neither CT nor PET seems to be an appropriate screening tool for mediastinal lymph nodes (LNs), and authors have suggested that at the time of pulmonary metastasectomy, thoracic and mediastinal lymph nodes dissection (LND) are the best diagnostic procedures to evaluate mediastinal LN metastasis ( Hamaji et al., 2012 Seebacher et al., 2015). The sensitivity of PET scan for detecting mediastinal lymph node metastases has been reported to be between 35% and 100% ( Pastorino et al., 2003 Hamaji et al., 2012). Lymph node may be involved in two distinct scenarios: (1) lymph node involvement discovered on the preoperative imaging or invasive mediastinal staging, and (2) incidental lymph node involvement discovered during surgery after mediastinal sampling or complete dissection. An (European Society of Thoracic Surgery) ESTS survey reported that 56% of surgeons performed mediastinal sampling during lung metastasectomy, 13% performed complete dissection, and 32% did not perform lymph node biopsy ( Internullo et al., 2008). The probability of survival seems considerably lower if lymph node involvement is present. Mediastinal lymph node dissection or sampling is not routinely performed during lung metastasectomy in comparison with primary lung cancer. Perentes, in Introduction to Cancer Metastasis, 2017 8 Lymph Node Involvement
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