Use of a Surgical Specimen-Collection Kit to Improve Mediastinal Lymph-Node Examination of Resectable Lung Cancer

Abstract

Pathologic examination of mediastinal lymph nodes (MLNs) after resection of non-small-cell lung cancer is critical in the determination of prognosis and postoperative management. Although systematic nodal dissection is recommended, the quality of pathologic lymph-node staging often falls short of recommendations in practice. We tested the feasibility of improving pathologic lymphnode staging of resectable non-small-cell lung cancer by using a prelabeled specimen-collection kit. Methods: Case-control study with comparison of 51 resections, using a special lymph-node collection kit, with 51 controls matched for surgeon, extent of resection, pathologist, and T category. Appropriate statistical methods were used for all comparisons. Results: The median number of MLNs examined increased from one in the control group, to six in the case group (p < 0.001). The percentage of resections attaining the National Comprehensive Cancer Network-recommended quality of MLN examination, and the proportion that would have been eligible for recent landmark postresection adjuvant therapy trials increased significantly (p < 0.001). The duration of surgery and postoperative complication rates were similar between cases and controls. Eighteen percent of kit cases had positive MLN, compared with 8% of controls. Conclusions: The use of a specialized specimen-collection kit for MLN examination was feasible, markedly improved MLN staging, and showed a trend toward increased detection of patients with MLN metastasis, with only a modest increase in duration of surgery, and no increase in perioperative morbidity, mortality, or hospital length of stay.

The impact of a novel lung gross dissection protocol on intrapulmonary lymph node retrieval from lung cancer resection specimens

“…23 The strong association between survival and the number of lymph nodes examined 7-10,24 or found to harbor metastasis, 11-16 coupled with recognition that most lung resection cases in large US databases cluster around the lowest end of the lymph node number spectrum, 6-8,10 has raised interest in strategies designed to improve lymph node yield. Some strategies target the intraoperative lymph node harvest, 18 others may be designed to encourage more thorough retrieval of lymph nodes within the resected lung specimen. 17 …”

“…This kit has been described in detail elsewhere. 18 It contains 12 specimen collection cups, each pre-labeled with the International Association for the Study of Lung Cancer lymph node station name and number, thus: right and left upper paratracheal (2R, 2L), prevascular (3a), retrotracheal (3p), right and left lower paratracheal (4R, 4L), sub-aortic (5), para-aortic or phrenic (6), subcarinal (7), paraesophageal (8), pulmonary ligament (9), and hilar (10). One set of kits is labeled for right side resections, a different set for left side resections.…”

Audit of Lymphadenectomy in Lung Cancer Resections Using a Specimen Collection Kit and Checklist

“…Surgeons, operating room nursing staff, and pathology staff received training on the value of rigorous mediastinal lymph node examination and proper use of the specimen collection kit before provision of the kit for use at each institution. The kit, which has been described in detail elsewhere [12], included a standardized checklist on which a member of the operating room team identified the lymph node stations harvested during the operation. Surgeon claims of extent of mediastinal lymphadenectomy were extrapolated from the stations noted on the checklist as having been harvested.…”

“…A lymph node specimen collection kit, which includes a checklist to remind the operating room team of the optimal lymph node dissection procedure required, has consistently improved the quality of pathologic staging, significantly narrowing the nodal staging quality gap [12,13]. In the current study, we evaluated the impact of the kit and checklist on the communication gap between surgeons and pathologists in reporting the extent of mediastinal lymphadenectomy.…”

“…It is possible that unrelated events, such as heightened awareness of the importance of pathologic nodal staging, and increased oversight of the quality of nodal staging, account for the improvements we have described. However, we have previously reported how resections performed without the kit in the era after it had been introduced regressed in quality of pathologic nodal staging back to the era before it was introduced [12]. …”