Resection of lung cancer invading the diaphragm

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Each year, stage III non-small-cell lung cancer (NSCLC) is diagnosed in approximately 30,000 patients. Locally advanced NSCLC (stage IliA) includes a group of biologically diverse tumors with subgroups of truly locally advanced disease--T3 tumors and advanced locoregional disease with the presence of N2 disease. The prognosis of patients with a diagnosis of stage III lung cancer is mainly dependent on the status of the mediastinal nodes. Good long-term results are achieved in patients with NO disease, whereas patients with N2 disease are poor candidates for resection as a primary treatment. 1-3 Information is not available on results of surgical treatment of patients with stage III disease and tumors involving the diaphragm. Patients and methods. From January 31, 1974, to August 17, 1995, a total of 4668 patients underwent exploration for resection of NSCLC at Memorial Hospital. By analyzing our database we identified eight patients (0.17%) who had exploratory thoracotomy for resection of NSCLC invading the diaphragm. The medical records of these eight patients were retrospectively analyzed. Data are reported as mean -+ standard deviation. Survival data are reported as mean and 95% confidence interval (CI) for the mean. The Kaplan-Meier method was used to calculate actuarial survival. Results. The demographics of these eight patients are shown in Table I. The mean age at diagnosis was 65.8 + 10.2 years, ranging from 52.6 to 82.4 years. The most common symptoms were cough in four patients, hemoptysis in two patients, and chest pain in one patient. One patient had clubbing of the fingers. Three patients were free of symptoms. All patients smoked. The mean time from first symptoms to referral for treatment was 25.1 -+ 16.6 weeks, ranging from 5.3 to 49 weeks. The histologic diagnosis was made by bronchoscopic examination in four patients and by fluoroscopic guided needle biopsy in two. In two patients the diagnosis was made in the operating room. Four tumors were on the right side and four on the left side. Two patients underwent mediastinoscopy, both studies yielding negative results. The other six did not undergo preoperative mediastinoscopy. Among the eight patients, diaphragmatic invasion was not suspected at exploration in six and it was suspected before the opera-