Influence of nodal status on the surgical outcome for bronchogenic carcinoma involving the carina: a systematic review and meta-analysis.

INTRODUCTION: Bronchogenic carcinomas involving the carina or the tracheo-bronchial angle represents a challenging surgical procedure because of difficult surgical techniques and complex ventilation procedures. Even though surgical outcomes for this type of procedure has improved over time, the need for surgical management of patients with metastatic mediastinal nodes, that is those that are graded N2 or higher according to the TNM classification, is still controversial.

EVIDENCE ACQUISITION: We searched PubMed, Embase, and CNKI for literature in English or Chinese reporting on this subject, with information on survival rates or survival curves for groups with different grades of nodal status. We then performed a meta-analysis by grouping N0 and N1 patients and compared the surgical outcomes to those graded as N2 or higher. Hazard Ratios for each study were derived from the Kaplan-Meier survival curve.

EVIDENCE SYNTHESIS: Seven studies were included in this meta-analysis. The calculated hazard ratios ranged from 0.146 to 0.455. The weighted average hazard ratio for the N0/N1 group as compared to the N2/N3 group was 0.261 (CI: 0.154-0.441). The Galbraith plot confirmed the homogeneity of the studies included.

CONCLUSIONS: Carinal resection and reconstruction remains a challenging surgical procedure and the rather poor surgical outcomes for patients graded as N2 or higher, according to nodal involvement points to the fact that better pre-operative management is required in terms of tumor grading, induction chemotherapy and radiotherapy to decrease the risks associated with metastatic mediastinal nodal status.