Anatomic basis of lymphatic spread of lung carcinoma to the mediastinum: anatomo-clinical correlations

Abstract

Correlation of the anatomic and surgical features in 360 cadavers and in 260 patients operated for bronchial carcinoma reveals that the lymphatics of the lung reach the ipsilateral mediastinum, sometimes directly and sometimes by sites which do not correspond to the anatomic site of the injection or of the pulmonary lesion. This implies the need for systematic eradication of all the lymph nodes of the ipsilateral mediastinum during surgery for bronchial carcinoma. In cases of tumoral lesions (N2), the prognosis is better when only one site is involved, whether the nodal disease is microscopic, uni- or multiglandular, with or without rupture of the capsule and whatever treatment is carried out, even when resection seems macroscopically complete to the surgeon. This is explicable in the light of the anatomic study, which shows that the lymph node chain is a functional entity which channels the lymph into the systemic circulation, either at the venous confluence of the neck or into the thoracic duct in the mediastinum. When only a single chain is affected, there is a greater than 70% chance that systemic metastases are already present, 90% when N2 affects 2 chains, while in N3 cases (lymph passage to contralateral chains) the incidence reaches virtually 100%. However, macroscopically satisfactory excision allows management of the local problem, and involvement of the mediastinal nodes, even with capsular rupture, cannot be considered as a contraindication in the absence of clinically detectable systemic metastases.

Anatomical basis of the risk of injury to the right laryngeal recurrent nerve during thoracic surgery

“…These data suggest the interest of systematic eradication of all lymph nodes of the ipsilateral mediastinum [16]. Based on the data, the international guidelines for the management of locally advanced non-small cell lung cancer recommend that surgical resection should be performed with systematic mediastinal lymphadenectomy [9,17].…”

Long-term Survival after Complete Mediastinal Lymph Node Resection and Lobectomy in Patients with Bulky N2 Non-small Cell Lung Cancer

“…13,14) When disease is located in only one lymph node chain, tumor cells with potentially metastatic properties may be absent or controlled within the lymph nodes. If this is the case, lymph node size by itself should not impact the prognosis.…”

From anatomy to lung cancer: questioning lobe-specific mediastinal lymphadenectomy reliability

“…Direct LVs were less frequent from the right and left lower lobes (RLL n=22 and LLL n=19) and mainly went into LN-station 7. However, nine from the RLL (41%) went into the right paratracheal LN [LN-station 2R, 3, 4R (7,8) Another anatomical study including all the lymphatic drainages into the mediastinum and not only the direct ones (9), demonstrated that the RULs (n=99) had 20 LVs (20%) draining into the LN-station 7 and that the RLLs (n=178) had 87 LVs (48.9%) draining into the LN-station 2R, 3, and 4R. The LULs (n=178) had 25 LVs (14%) draining into the LN-station 7 and two (1.1%) into the LNs of the pulmonary ligament [LN-station 9 (7,8)].…”

“…Both kinds of study confirmed the predominance of the drainage into the "lobe-specific" mediastinum, but not exclusively. The highest frequency observed from the lower lobes into the upper mediastinum was explained by the normal ascending drainage of the LVs through LN at that level before they join the cervical venous system (10), whereas descending LVs were particularly infrequent, those from the upper lobes joining the LN-station 7 and those of the lower lobes intra-abdominal LNs (9). Whereas intra-abdominal lymphadenectomy would not be reasonable in the latter, it is reasonably advisable to perform LN-clearance of both mediastina whatever the NSCLC location.…”