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Journal of Thoracic Oncology:
doi: 10.1097/JTO.0b013e3181bcc474
Letters to the Editor

Comments on the Proposed New International Lymph Node International Association for the Study of Lung Cancer Map

Rusch, Valerie W. MD; Asamura, Hisao MD; Watanabe, Hirokazu MD; Giroux, Dorothy J. MS; Rami-Porta, Ramon MD; Goldstraw, Peter MD

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Author Information

Thoracic Surgery Service; Memorial Sloan-Kettering Cancer Center; New York, New York (Rusch)

Division of Thoracic Surgery; National Cancer Center Hospital; Tokyo, Japan (Asamura)

Division of Diagnostic Radiology; National Cancer Center Hospital; Tokyo, Japan (Watanabe)

Cancer Research and Biostatistics; Seattle, Washington (Giroux)

Thoracic Surgery Service; Hospital Mutua de Terrassa; Terrassa, Spain (Rami-Porta)

Royal Brompton Hospital; London, United Kingdom (Goldstraw)

Disclosure: The authors declare no conflicts of interest.

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In Response:

Irion et al. raise several issues regarding nomenclature in our recently published article describing the proposed new international IASLC lymph node map. Our responses to their points are as follows:

1. We understand that the recommended nomenclature for the main pulmonary artery in the source cited by Irion et al. is “pulmonary trunk.” However, this is not a term commonly used by clinicians or radiologists. We have chosen to use terminology widely accepted in clinical practice.

2. and 3. The figures provided for the lymph node map are intended to serve as an illustrative guide for clinicians and radiologists. Dr. Frazier was especially well positioned to do these illustrations because she is a practicing radiologist as well as a medical illustrator. Her final illustrations were based on a more schematic version of the lymph node map developed by the Department of Medical Graphics at Memorial Sloan-Kettering Cancer Center in collaboration with Drs. Rusch and Asamura and members of the IASLC Staging Committee. Poster size versions of both Dr. Frazier’s illustrations and the earlier Memorial Sloan-Kettering Cancer Center version of the lymph node map along with other educational materials relevant to the new lung cancer staging system are now easily available through the web site of the IASLC (www.iaslc.org). Irion et al. will be able to appreciate on these magnified versions of the map that the boundaries of the subcarinal lymph nodes correspond to those described in the table accompanying the map. However, no illustration can fully portray the complicated three-dimensional anatomy of the lung, pulmonary vessels, and mediastinum. Therefore, we encourage physicians to refer to the table of anatomic definitions for the lymph node stations included in our article.

4. The boundaries between lymph node stations 7 and 10 have long been a source of controversy, especially among thoracic surgeons. Indeed, it was this very issue that led to the major discrepancy in nodal staging between the cases submitted to the IASLC database from Japan as opposed to those from other countries. We would again refer Irion et al. to the table of anatomic definitions in our article to clarify the issue of the boundaries between lymph node stations 7 and 10. Station 10 lymph nodes are not in the mediastinum. Again, the two-dimensional anatomy of medical illustrations or even of computed tomography scans often does not allow a full understanding of the three-dimensional anatomy of the patient. A trip to the operating room to see the actual anatomy of these areas and the boundaries of various lymph node stations as demonstrated by a thoracic surgeon who performs systematic lymph node dissection can be very instructive. Accessing the station 7 lymph nodes requires incising the mediastinal pleura, whereas accessing the station 10 lymph nodes does not.

We appreciate the interest of Irion et al. in our work and their thoughtful review of our article.

Valerie W. Rusch, MD

Thoracic Surgery Service

Memorial Sloan-Kettering Cancer Center

New York, New York

Hisao Asamura, MD

Division of Thoracic Surgery

National Cancer Center Hospital

Tokyo, Japan

Hirokazu Watanabe, MD

Division of Diagnostic Radiology

National Cancer Center Hospital

Tokyo, Japan

Dorothy J. Giroux, MS

Cancer Research and Biostatistics

Seattle, Washington

Ramon Rami-Porta, MD

Thoracic Surgery Service

Hospital Mutua de Terrassa

Terrassa, Spain

Peter Goldstraw, MD

Royal Brompton Hospital

London, United Kingdom

© 2009International Association for the Study of Lung Cancer

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