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Letter to the Editor
Incisional Metastasis From Lung Cancer After Transcervical Extended Mediastinal Lymphadenectomy
Metástasis incisional de carcinoma broncogénico tras linfadenectomía mediastínica transcervical extendida
D. Pérez-Alonso, F. Hernández-Escobar
Corresponding author
caiscohernandez@gmail.com

Corresponding author.
, L. López-Rivero
Servicio de Cirugía Torácica, Hospital Universitario Insular de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">New lung cancer staging techniques&#44; such as transcervical extended mediastinal lymphadenectomy &#40;TEMLA&#41; and video-assisted mediastinal lymphadenectomy &#40;VAMLA&#41;&#44; provide sensitivity and specificity figures of close to 100&#37;&#44; thanks to the extensive nature of the procedure and the large amounts of lymph node collected&#46; On the other hand&#44; these techniques are highly invasive and their benefits have been questioned&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Our surgical team only performs TEMLA in 2 types of patients&#58; operable patients with N0-1 lymph node staging and a high prevalence of N2 disease&#44; to avoid false negatives on mediastinoscopy&#59; or in patients with a high comorbidity burden&#44; to avoid high-risk thoracotomy in patients for whom this intervention would not benefit survival if they turn out to have N2 disease&#46; We report the case of a patient subjected to TEMLA staging who developed incisional metastasis&#46; This is the first report of this kind in the medical literature&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 72-year-old man presented with multiple comorbidities&#44; including left hilar lung cancer&#44; 55<span class="elsevierStyleHsp" style=""></span>mm&#215;56<span class="elsevierStyleHsp" style=""></span>mm with undetermined station 4R and 6 lymph nodes&#46; TEMLA was used to obtain 28 nodes from stations 1&#43;3&#44; 2R&#47;L&#44; 4R&#47;L 5&#44; 6&#44; 7 and 10R&#47;L &#40;Mountain&#8211;Dresler classification&#41;&#46; Disease was confirmed in multiple stations&#44; with malignancy in stations 10L&#44; 5 and 6&#46; Rescue surgery was indicated after induction chemotherapy&#44; but the patient was finally deemed inoperable due to intrapericardial arterial infiltration&#46; Three months later&#44; he developed a tumor in the site of the TEMLA scar&#44; which was resected with local anesthesia &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Histological examination confirmed metastasis of the primary tumor&#46; The patient died due to progressive disease 23 months later&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Recurrence of lung cancer in surgical wounds is very rare&#44; although reports have been published of implants in surgical wounds following open lung resection or thoracoscopy&#44; and in mediastinoscopy incisions&#46; The low prevalence of recurrence makes it difficult to determine if the primary cancer cell type or degree of differentiation is associated with the incidence of this type of relapse&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> With regard to incisional recurrence in surgical scars after staging&#44; the meta-analysis published by Ashbaugh in 1970 estimated that implants in the mediastinal incision occur in 0&#46;12&#37; of procedures<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a>&#59; the incidence of this type of lesion after maximal staging techniques is unknown &#8211; indeed&#44; no case has been reported to date&#46; The greater invasiveness &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; and volume of lymph node obtained in TEMLA &#8211; both factors impacting on the genesis of incisional metastasis &#8211; prevent any assumption that the incidence of incisional metastasis is comparable to mediastinoscopy&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The detection of the first case of metastasis in a TEMLA scar sets the rate of incisional metastasis in our patient series at 0&#46;09&#37;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The etiology and pathogenesis of these lesions are still to be clarified&#44; but related factors include lymph node or hematogenetic dissemination to the hypervascularized wound &#8211; which would occur in disseminated stage disease &#8211; and the local shedding and implantation of malignant cells&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> in which case the staging defined in the primary staging would not be affected&#44; and long-term survival would remain a possibility&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> In our specific case&#44; the patient&#39;s extended survival supports the second of the above-mentioned etiopathological mechanisms&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; P&#233;rez-Alonso D&#44; Hern&#225;ndez-Escobar F&#44; L&#243;pez-Rivero L&#46; Met&#225;stasis incisional de carcinoma broncog&#233;nico tras linfadenectom&#237;a mediast&#237;nica transcervical extendida&#46; Arch Bronconeumol&#46; 2016&#59;52&#58;276&#8211;277&#46;</p>"
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ISSN: 15792129
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