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Rusch, Valerie W. MD; Asamura, Hisao MD; Goldstraw, Peter MD
Memorial Sloan-Kettering Cancer Center; New York, NY (Rusch)
National Cancer Center Hospital; Tokyo, Japan (Asamura)
Royal Brompton Hospital; London, UK; email@example.com (Goldstraw)
Disclosure: The authors declare no conflicts of interest.
We thank Ichimura et al.1 for their careful review of our article proposing a new international lymph node map for the staging of lung cancer (International Association for the Study of Lung Cancer [IASLC] lymph node map). They raise a question about the border between the upper and lower right paratracheal lymph nodes at levels 2R and 4R. We proposed that this border be defined as the intersection of the caudal margin of the innominate vein with the trachea. Ichimura et al. correctly pointed out that the orientation of the innominate vein to some degree is diagonal and proposed that a horizontal line drawn at either of the two points of the intersection of the vein with the trachea be used as the border between levels 2R and 4R lymph nodes. However, in developing the IASLC lymph node map, we explicitly intended to minimize the use of arbitrary nonanatomic and, thus, not easily reproducible boundaries between lymph node levels. Although somewhat diagonal in orientation, the inferior border of the innominate vein is easily visible by computed tomography, especially when intravenous contrast is used, and is an internationally reproducible landmark. Therefore, we feel that this is more accurate way to distinguish between levels 2R and 4R. As illustrated in Figure “B” of their article, some lymph nodes will overlap the borders between lymph node levels no matter how these are defined and will need to be labeled according to where they predominantly reside. The lymph node shown in Figure “B” is predominantly located below the caudal margin of the innominate vein and would, therefore, probably be most appropriately labeled as a 4R node.
The title of our article indicated that the IASLC map was a proposal for a new international lymph node map. We are grateful for the careful study of this proposal by other authors, because it is precisely through thoughtful commentary that this map may be improved in the future. Our principal intent was to develop international nomenclature that can now be used in the prospective IASLC (and other) lung cancer databases. This will permit future analyses that may refine the N-stage descriptors in the next (eighth) edition of the staging manuals.
Valerie W. Rusch, MD
Memorial Sloan-Kettering Cancer Center
New York, NY
Hisao Asamura, MD
National Cancer Center Hospital
Peter Goldstraw, MD
Royal Brompton Hospital
© 2010International Association for the Study of Lung Cancer
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