N2 Nodal Involvement Research Articles

Clinical significance of the metastatic lymph-node ratio in patients with D2 gastrectomies for gastric cancer

The Union Internationale Contre le Cancer/Tumor, Node, Metastasis (UICC/TNM, 5th edition) Classification established the number of the lymph nodes with metastatic deposits as the determinant factor for nodal category (N category) in patients with gastric cancer. This may suggest that N category could be influenced by the degree to which specimens are pathologically examined and the extension of lymph node surgical dissection. To correct this problem, the Lymph node ratio (LNR), which is the number of positive nodes divided by total number harvested, has been proposed. This study aims to investigate whether the LNR is a better prognostic factor as compared with N category (5th edition) proposed by the UICC in patients with gastric cancer. A retrospective review of a prospectively collected database of 63 patients with gastric cancer who underwent curative D2 gastrectomy between 2003 and 2007 was performed to determine the effect of the LNR on disease-free survival (DFS) and overall survival (OS). Prognostic factors were identified by univariate and multivariate analyses. Survival curves were constructed using the Kaplan-Meier method. The LNR was divided into four categories using the hazard ratio (HR). LNR categories (LNR 0= 0%; LNR 1= 1%–9%; LNR 2= 10%–25%; LNR 3= >25%) were determined by the best cut-off approach. After a median follow-up of 25.1 months (range, 4–32 months), analyzing the survival time comparing the lymph node ratio categories against the N categories (5th edition) demonstrated that the ratio stands out as the best prognostic factor. The implementation of proposed LNR nodal categories led to the identification of groups of patients prognostically more homogeneous than those classified by the UICC proposed nodal categories. Overall survival data according to LNR proposed nodal categories showed a statistically significant decrease in overall survival and disease free survival with increasing scores, which was more statistically significant than that observed with UICC proposed nodal categories (N categories, 5th edition), the LNR also discriminates different prognostic categories among patients with N1 and N2 lymph node involvement. In conclusion, LNR is a simple and reproducible prognostic tool that can stratify patients with gastric cancer. LNR gave a more accurate prognostic information from nodal involvement than the current N category of the TNM (5th edition). These data may represent the rational for improving the prognostic power of current UICC TNM staging system and ultimately the selection of patients who may most benefit from adjuvant treatments.

Results of Surgery for Non-Small Cell Cancer With N2 Involvement Unsuspected Before Thoracotomy

To analyze survival in a group of patients with N2 involvement discovered during or after lung resection for non-small cell lung cancer and to evaluate the variables that affect survival. The study included all patients with non-small cell lung cancer who underwent resection between January 1994 and October 2004 and in whom the definitive tumor classification was stage spIIIA due to N2 extension (n=74). Patients with stage spIIIB undergoing induction chemotherapy and patients for whom surgery was considered incomplete were excluded. Mean survival times were significantly different (P=.002) between resection types: pneumonectomy, 18.1 months (95% confidence interval [CI], 6.9-29.2 months), and lobectomy, 42.4 months (95% CI, 28.7-56.1 months). The number of lymph-node stations affected did not have a significant effect on survival. However, when only 1 station was involved, mean survival was different for lobectomy and pneumonectomy (48.0 months [95% CI, 31-65 months] vs 14.8 months [95% CI, 4.8-24.7 months], respectively; P=.002) but no differences were found when N2 spread involved more than a single station. Adjuvant therapy was used in 50% of cases (n=35): chemotherapy in 6 cases; radiotherapy in 17 cases; and both in 12 cases. The mean survival rate for lobectomy patients with no adjuvant therapy was 31.6 months (95% CI, 15.6-47.5 months) and 46.2 months (95% CI, 32.2-60.1 months) (P=.01) with adjuvant therapy, whereas there were no differences in the group of pneumonectomy patients. Patients who undergo lobectomy clearly survive longer than those who undergo pneumonectomy when N2 lymph node involvement is found in only 1 station during surgery. Furthermore, adjuvant therapy may increase mean survival times for lobectomy patients.

Skip Mediastinal Nodal Metastases in the IIIa/N2 Non-Small Cell Lung Cancer

To study the incidence and characteristics of mediastinal nodal metastases without N1 nodal metastases (skip N2 metastases) in patients with resected pIII/A/N2 non-small cell lung cancer. A total of 323 non-small cell lung cancer patients who underwent radical surgical resection with a systematic mediastinal nodal dissection in 4-year period (2000-2003) were retrospectively reviewed. The 85 patients (26%) at stage IIIA/N2 (pN2+) were grouped according to their skip metastases status. Patient data were statistically analyzed. Skip N2 metastases were found in 21 patients (25%) without N1 nodal involvement. The postoperative survival for skip N2 disease was almost the same as that for pN2 disease with N1 nodal involvement. The incidence of N2 metastases seemed to be more frequent in adenocarcinoma patients (p < 0.005), but skip N2 metastases were significantly higher (p < 0.001) in squamous cell carcinoma patients. Although skip metastases involved more often upper mediastinal lymph nodes and one station level, the difference was not found statistically significant (p < 0.227). Complication rate showed no difference between analyzed groups of patients. Sample mediastinal lymphadenectomy may not be appropriate in surgery for non-small cell lung cancer because skip metastases were found in 25% of patients without N1 nodal involvement.

Pattern and predictors of occult mediastinal lymph node involvement in non-small cell lung cancer patients with negative mediastinal uptake on positron emission tomography

We sought to assess the incidence, pattern and predictors of occult mediastinal lymph node involvement (N2) in non-small cell lung cancer patients with negative mediastinal uptake of 2-deoxy-2-[(18)F]-fluoro-d-glucose ((18)FDG) on integrated positron emission tomography-computerised tomography (PET-CT). All patients who underwent surgical resection in our unit over a 30-month period were reviewed (n=215). All patients had preoperative PET-CT prior to lung resection as an adjunct to a dedicated chest CT. Diabetic patients, patients who received neoadjuvant chemotherapy and those with positive mediastinal nodes on PET-CT (N2/N3) were excluded from this study. The population of interest was 153 non-small cell cancer patients (NSCLC), all of which had no FDG uptake in the mediastinum. No preoperative mediastinoscopy was carried out in this group and all underwent curative intent surgical resection. The pathological results were retrospectively reviewed and correlated with CT and integrated PET-CT findings. The incidence of occult N2 disease in NSCLC patients with negative mediastinal uptake of (18)FDG on PET-CT was 16% (25 of 153). The highest incidence of occult N2 involvement was in American thoracic society (ATS) 7 (16 of 25 patients, 64%) followed by ATS 4 (seven patients of 25, 28%). In univariate analysis, the following were significant predictors of occult N2 disease: centrally located tumours (P=0.049), right upper lobe tumours (P=0.04), enlarged lymph nodes (>1cm) on CT (P=0.048) and PET positive uptake in N1 nodes (P=0.006). In multivariate analysis, the following were independent predictors of occult N2 disease: centrally located tumours, right upper lobe tumours and PET positive uptake in N1 nodes (P<0.05). In NSCLC patients who are clinically staged as N2/N3 negative in the mediastinum by integrated PET-CT, 16% will have occult N2 disease following resection. Patients with the following: centrally located tumours, right upper lobe tumours and positive N1 nodes on PET should have preoperative cervical mediastinoscopy to rule out N2 nodal involvement, especially in ATS stations 7 and 4 as the incidence of occult nodal metastasis in these nodes is high. This study has potential implications in decision-making and planning best treatment approach.

Special Treatment Issues in Lung Cancer: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)

This chapter of the guidelines addresses patients who have particular forms of non-small cell lung cancer that require special considerations. This includes patients with Pancoast tumors, T4N0,1M0 tumors, satellite nodules in the same lobe, synchronous and metachronous multiple primary lung cancers (MPLCs), solitary brain and adrenal metastases, and chest wall involvement.The nature of these special clinical cases is such that in most cases, metaanalyses or large prospective studies of patients are not available. For ensuring that these guidelines were supported by the most current data available, publications that were appropriate to the topics covered in this chapter were obtained by performance of a literature search of the MEDLINE computerized database. When possible, we also referenced other consensus opinion statements. Recommendations were developed by the writing committee, graded by a standardized method (see "Methodology for Lung Cancer Evidence Review and Guideline Development" chapter), and reviewed by all members of the lung cancer panel before approval by the Thoracic Oncology NetWork, Health and Science Policy Committee, and the Board of Regents of the American College of Chest Physicians.In patients with a Pancoast tumor, a multimodality approach seems to be optimal, involving chemoradiotherapy and surgical resection, provided appropriate staging has been conducted. Patients with central T4 tumors that do not have mediastinal node involvement are uncommon. Such patients, however, seem to benefit from resection as part of the treatment as opposed to chemoradiotherapy alone when carefully staged and selected. Patients with a satellite lesion in the same lobe as the primary tumor have a good prognosis and require no modification of the approach to evaluation and treatment than what would be dictated by the primary tumor alone. However, it is difficult to know how best to treat patients with a focus of the same type of cancer in a different lobe. Although MPLCs do occur, the survival results after resection for either a synchronous presentation or a metachronous presentation with an interval of < 4 years between tumors are variable and generally poor, suggesting that many of these patients may have had a pulmonary metastasis rather than a second primary lung cancer. A thorough and careful evaluation of these patients is warranted to try to differentiate between patients with a metastasis and a second primary lung cancer, although criteria to distinguish them have not been defined. Selected patients with a solitary focus of metastatic disease in the brain or adrenal gland seem to benefit substantially from resection. This is particularly true in patients with a long disease-free interval. Finally, in patients with chest wall involvement, as long as tumors can be completely resected and there is absence of N2 nodal involvement, primary surgical treatment should be considered.Carefully selected patients may benefit from an aggressive surgical approach.

Lymph Node Involvement in Gastric Cancer for Different Tumor Sites and T Stage

BackgroundThe aim of lymphadenectomy is to clear all the metastatic nodes achieving a complete removal of the tumor; nevertheless, its role in gastric cancer has been very much debated. Materials and methodsThe frequency of node metastasis in each lymphatic station according to the International Gastric Cancer Association, was studied in 545 patients who underwent D2 or D3 lymphadenectomy from June 1988 to December 2002. ResultsUpper third early cancers have shown an involvement of N2 celiac nodes in 25%. In advanced cancers, there was a high frequency of metastasis in the right gastroepiploic (from 10% in T2 to 50% in T4) and in the paraaortic nodes (26% in T2, 32% in T3, 38 % in T4). N3 left paracardial nodes involvement was observed in an important share of middle third tumors (17% in T3, 36% in T4). Splenic hilum nodes metastasis were common in T3 and T4 cancers located in the upper (39%) and middle (17%) stomach. N2 nodal involvement was frequent in lower third advanced cancers. Metastasis in M left paracardial and short gastric nodes were observed in a small percentage of cases. ConclusionGiven the nodal diffusion in our gastric cancer patients, extended lymphadenectomy is still a rationale to obtain radical resection.

Recursive Partitioning Analysis of Mediastinal N2 Lymph Node Involvement with Selected Biological Markers in Operable Non-small Cell Lung Cancer: A Correlative Study

Background Expressions of various biomarkers in non-small cell lung cancer (NSCLC) have been linked with the prognosis and involvement of mediastinal lymph nodes. Methods In this study, we utilized recursive partitioning analysis (RPA) by using P53, c-erb-B2, and P-glycoprotein (PGP) expressions evaluated by immunohistochemistry to estimate retrospectively the likelihood of the occult N2 mediastinal lymph node involvement in patients with operable NSCLC. Results In univariate tests, immunohistochemical staining of the primary tumor for these 3 markers in 61 patients undergoing surgery revealed no direct relationship with the N2 involvement. However, RPA demonstrated in patients aged &lt;75 and with ≥4 mediastinal lymph nodes removed that, high PGP expression frequency (≥20%) predicted an increased likelihood of the N2 involvement (46.7%, R2 = 0.25). Univariate nominal logistic regression analysis revealed that RPA group affiliation, and the number of mediastinal lymph nodes resected (logarithmic transformation) were associated with the metastasis to N2 lymph nodes (χ2 = 17.59, p = 0.0005, and χ2 = 2.40, p = 0.0654, respectively). Multivariate analysis confirmed that only RPA group affiliation predicted the N2 involvement (χ2 = 14.63, p = 0.0022). Conclusion This study shows for the first time that PGP expression of the primary tumor may help to predict the occult N2 mediastinal lymph node involvement in NSCLC. Thus, further research is required to understand whether PGP expression may aid in the decision process for preoperative mediastinoscopy.

Prognostic variability among nonsmall cell lung cancer patients with pathologic N1 lymph node involvement

Patients who have nonsmall cell lung cancer with N1 lymph node status are an intermediate group of patients who have a variable prognosis. Differences in lymph node level (hilar or pulmonary lymph nodes) may influence patient survival. The authors retrospectively analyzed the factors that influenced prognosis, including the level of N1 lymph node involvement. The authors used the Tuscan Cancer Registry archives to retrieve records on 2523 patients who had lung tumors diagnosed during the period from 1996 and 1998 in the provinces of Florence and Prato, central Italy. To analyze the survival of patients according to the level of lymph node involvement, the prognoses of patients with nonsmall cell lung cancer who had N1 lymph node status were compared in a population-based case series. Among 112 patients with pathologic N1 status, the following variables were analyzed for their influence on postoperative survival: gender, age, cell type, pathologic tumor status, the number of metastatic lymph nodes, the level of metastatic lymph nodes (hilar or pulmonary), and the type of surgical resection. The 5-year survival rates for patients who had involvement of pulmonary and hilar lymph nodes were 41.2% and 21.8%, respectively (P =.005). A Cox proportional hazards model analysis indicated that the presence of hilar lymph node involvement was an independent prognostic factor. N1 pathologic lymph node status was identified in a combination of subgroups with different prognoses, and the presence of hilar lymph node disease had prognostic significance. This difference in survival may lead to the use of different therapies for these subgroups of patients with pathologic N1 non-small cell lung cancer.

Gastric cancer: an audit of 122 consecutive cases and the results of R1 gastrectomy.

In a consecutive series of 122 patients with gastric carcinoma, 9 per cent had no operation, 27 per cent had incurable disease at laparotomy, and 64 per cent underwent gastric resection. R1 gastrectomy was performed in 73 of the 78 resections. The operative mortality after gastric resection was 4 per cent, but there were no deaths after potentially curative resections. The actuarial 5-year survival was 20 per cent overall, 60 per cent in patients undergoing a 'curative' resection with N0 disease, and 18 per cent in patients with N1 disease. Local or regional recurrence without evidence of distant metastases was identified in 11 per cent of cases after 'curative' resections. The probability of survival was adversely affected by N1 nodal involvement (P less than 0.005) and by the presence of poorly differentiated or anaplastic tumours (P less than 0.001). Only 6 per cent of patients had early gastric cancer, and absolute curative resections by Japanese criteria were possible in only 5 per cent of cases. The results suggest that the unfavourable presenting pathology is the principal determinant of the poor prognosis of gastric cancer. A more radical or extended lymphadenectomy (R2/3 gastrectomy) might have cured more patients with N1 metastases, but only 12 per cent of potentially curable patients had N1 disease in this study, and it appears that more radical surgery may have little effect on the overall survival rates for gastric cancer.

Survival of biphasic pulmonary blastoma

Pulmonary blastoma is a rare malignant lung tumor with a poor prognosis. It is composed of immature mesenchymal and epithelial components that resemble fetal lung tissue. We aimed to share our treatment results in biphasic pulmonary blastoma. In Ataturk Chest Disease and Thoracic Surgery Center, five patients with biphasic pulmonary blastoma (four men, one woman, aged between 27 and 61-mean 39.4) were treated between 1987 and 2000 (0.3% of operated NSCC). Hemoptysis, cough, chest pain and dyspnea were the symptoms. Anemia and high erythrocyte sedimentation rate were determined in two patients. Radiological examinations revealed a mass in four patients and massive pleural effusion in one. None of the patients were diagnosed preoperatively and hence all patients underwent exploratory thoracotomy. Three lobectomy, one pneumonectomy and one wedge resection were performed. Histopathological examinations revealed biphasic pulmonary blastoma in all the patients. Pathological stagings were as follows: 1 patient in T1N0M0 and 1 patient in T2N0M0 (198 and 112 months survival, respectively), three patients in T2N1M0 (9,10,17 months survival). In follow up period, prostate carcinoma and rectum carcinoma were detected as second primary tumors in the patient in stage T2N0M0. In patients who have small size tumors without nodal involvement, long-term survival can be obtained with radical surgery; even in biphasic pulmonary blastomas. According to our limited experiences, N1 nodal involvement shows very poor prognosis.

The case for cervical mediastinoscopy prior to radical surgery for malignant pleural mesothelioma

Eur J Cardiothorac Surg 2004;25:497–501. Pilling JE, Stewart DJ, Martin-Ucar AE, Muller S, O’Byrne KJ, Waller DA. Study Summary: This study was performed to assess whether cervical mediastinoscopy is necessary before radical surgery for malignant pleural mesothelioma (MPM). The authors also study whether lymph nodes size predicts metastatic involvement in patients with MPM. The study included 55 patients who underwent radical excision of MPM. Preoperative assessment included computed tomography (CT) scan of the thorax and upper abdomen in all patients. Only 1 patient had evidence of mediastinal lymph node enlargement on chest CT. Extrapleural pneumonectomy was performed in 51 patients and radical pleurectomy was performed in 4 patients. Most patients had an epithelioid variety of MPM. Mediastinal lymph node dissection showed lymph node metastasis in 17 patients. The mean long axis diameter of malignant lymph nodes was 15.2 mm, whereas that of disease-free lymph nodes was 16.9 mm. According to the authors, malignant lymph nodes in 15 of 17 (88%) patients were accessible by cervical mediastinoscopy. The median survival of 17 patients with extrapleural lymph nodes (4.4 months) was considerably shorter than those without (16.3 months, P = 0.012). The authors concluded that extrapleural metastasis is related to poor survival, and pathologic involvement cannot be predicted from lymph node size. Based on these results, the authors recommend routine mediastinoscopy before radical surgery for MPM. Comments: Malignant pleural mesothelioma has a poor prognosis. Median survival is 8 to 14 months in different studies (Thorax 2001;56:250–256). No form of treatment is conclusively proven to be better than palliative care (Chest 2004;125:1103–1117). Radical surgery as a part of multimodality treatment is an important therapeutic option (BMJ 2004;328:237–238). In a surgical series, overall survival rates were 45% at 2 years and 22% at 5 years. The lymph node-negative patients with epithelial variety of MPM had a 2- and 5-year survival rate of 74% and 39%, respectively (Ann Surg 1996;224:288–294). Mediastinal lymph node involvement is an important predictor of adverse outcome after the surgery (J Thorac Cardiovasc Surg 1996;111:815–825, J Thorac Cardiovasc Surg 1999;117:54–65). Several studies have shown a 28% to 52% incidence of N2 nodal involvement in the resected surgical specimen (Eur J Cardiothorac Surg 2001;19:346–350, J Thorac Cardiovasc Surg 1996;111:815–825). Lymph nodes were found in 31% of patients in the current study, and these patients did not appear to benefit from the radical surgery. Accurate preoperative staging is, therefore, important before surgery. In a prior study, the sensitivity, specificity, and accuracy of CT were 60% 71%, and 67%, respectively, for mediastinal lymph nodes in MPM patients. In contrast, the sensitivity, specificity, and accuracy of cervical mediastinoscopy were 80%, 100%, and 93%, respectively (Ann Thorac Surg 2003;75:1715–1718). The results from current study confirm that chest CT is not sufficient for staging. Chest magnetic resonance imaging (Eur J Cardiothorac Surg 2003;24:1019–1024) and PET scan (J Thorac Cardiovasc Surg 2003;126:11–16) are not reliable and are unlikely to contribute to nodal staging. Cervical mediastinoscopy, therefore, appears to be the only practical way to identify lymph node involvement in MPM. Extrapleural pneumonectomy, the most frequently performed radical surgery, carries a more than 5% operative mortality and more than 25% morbidity (Thorax 2003;58:809–813). Patient selection is of paramount importance. The results of the current study make a strong case for routine preoperative cervical mediastinoscopy before radical surgery for MPM.

Skip mediastinal nodal metastases in non-small cell lung cancer.

To reveal the incidence and clinical significance of mediastinal nodal metastases without N1-station nodal metastases ('skip-N2 metastases') in non-small cell lung cancer (NSCLC). A total of 450 NSCLC patients who underwent tumor resection with a systemic mediastinal nodal dissection were retrospectively reviewed. p53 status and proliferative activity represented as proliferative index (PI) were also examined immunohistochemically. Skip-N2 metastases were documented in 49 (13%) patients of all 450 patients; among 334 patients without N1-nodal involvement, 18% patients had skip-N2 metastases. The postoperative survival of skip-N2 patients was almost same as that for patients with metastases to both N1 and N2 nodes. Skip-N2 metastases were significantly more frequent in male patients and squamous cell carcinoma patients. In addition, the mean PI for tumor with skip-N2 metastases was significantly higher than that for any other pathologic nodal (pN)-status diseases. Combined with histologic type and PI, the incidences of skip-N2 metastases for adenocarcinoma showing lower PI were only 5% (7/137) of all patients and 7% (7/94) of patients without N1-nodal involvement. N1 nodal status is not a useful predictor of N2 nodal status in NSCLC, because skip-N2 metastases were documented in 18% patients showing no N1-nodal involvement. However, N1 node-guided dissection might be performed in patients with adenocarcinoma showing lower PI, because the incidence of skip-N2 metastases was extremely low.

Neoadjuvant therapy in non-small cell lung cancer. Prognostic impact of "mediastinal downstaging"

In the course of a prospective multicenter study, 40 (26 squamous cell and 14 adenocarcinomas) patients with stage IIIA and IIIB non-small cell lung cancer (NSCLC) were submitted to surgery after neoadjuvant radiochemotherapy. Pretherapeutic clinical lymph node status was compared to the lymph node involvement established in the resection specimens. Therapy-induced tumor regression was classified according to a three-step tumor regression grading system. In 29 patients (72.5%) a downward shift in lymph node involvement could be established,whereas in 27.5% ( n=11) pretherapeutic lymph node status was maintained. Of 26 patients with post-therapeutic N0 or N1 status, 21 revealed less than 10% vital tumor tissue in the resection specimens (regression grades IIb or III). Patients with post-therapeutic N0 or N1 lymph node status were found to have a survival benefit compared to patients with N2 lymph node involvement, though this difference was not statistically significant (p=0.27). On the other hand, tumor regression showed a significant correlation to the overall survival period (p=0.02). Thus, therapy-induced tumor regression grading seems to be a more precise method to predict the outcome of the disease.

Potential role and chronology of abnormal expression of the Deleted in Colon Cancer (DCC) and the p53 proteins in the development of gastric cancer.

BackgroundLoss of activity of tumor suppressor genes is considered a fundamental step in a genetic model of carcinogenesis. Altered expression of the p53 and the Deleted in Colon Cancer (DCC) proteins has been described in gastric cancer and this event may have a role in the development of the disease. According to this hypothesis, we investigated the p53 and the DCC proteins expression in different stages of gastric carcinomas.MethodsAn immunohistochemical analysis for detection of p53 and DCC proteins expression was performed in tumor tissue samples of patients with UICC stage I and II gastric cancer. For the purpose of the analysis, the staining results were related to the pathologic data and compared between stage categories.ResultsNinety-four cases of gastric cancer were analyzed. Disease stage categories were pT1N0 in 23 cases, pT2N0 in 20 cases, pT3N0 in 20 cases and pT1-3 with nodal involvment in 31 cases. Stage pT1-2N0 tumors maintained a positive DCC expression while it was abolished in pT3N0 tumors (p <.001). A significant higher proportion of patients with N2 nodal involvement showed DCC negative tumors. In muscular-invading tumors (pT2-3N0) the majority of cases showed p53 overexpression, whereas a significantly higher proportion of cases confined into the mucosa (pT1N0) showed p53 negative tumors. Also, a higher frequency of p53 overexpression was detected in cases with N1 and N2 metastatic lymphnodal involvement.ConclusionsAltered expression of both DCC and p53 proteins is detectable in gastric carcinomas. It seems that loss of wild-type p53 gene function and consequent p53 overexpression may be involved in early stages of tumor progression while DCC abnormalities are a late event.

Prognostic significance of surgical-pathologic N1 disease in non-small cell carcinoma of the lung

Background. N1 disease represents a heterogeneous group of non-small cell lung carcinoma with varying 5-year survival rates. Specific types of N1 lymph node involvement need to be further investigated and their prognostic significance clarified. Methods. From 1984 to 1993, 1,174 patients with non-small cell lung cancer had complete mediastinal lymph node dissection: N0, 50.25% (n = 590); N1, 21.8% (n = 256); and N2, 27.95% (n = 328). The N1 subgroup cases were reviewed. Four levels of N1 nodes were identified using the New Regional Lymph Node Classification for Lung Cancer Staging. Their prognostic significances were tested and 5-year survival rates were compared with those of N0 and N2 patients of the whole group. Results. The overall 5-year survival rate of N1 patients was 47.5%. Survival was not related to site of the primary lung cancer, pathologic T factor, histologic type, type of resection, number of N1 station involved, nor type of N1 involvement (direct extension or metastases). Five-year survival was significantly better when N1 involvement was intralobar (levels 12 and 13, n = 102), as compared with extralobar (hilar) involvement (levels 10 and 11, n = 154): 53.6% versus 38.5% ( p = 0.02). Intralobar N1 5-year survival was similar to that of N0 (53.6% vs 56.5%, p = 0.01), and extralobar 5-year survival with that of N2 (38.5 vs 28.3%, p = 0.01) when N2 was present in only one station in the ipsilateral mediastinum. Conclusions. N1 disease is a compound of two subgroups: one located inside the lobes is related to N0, and the other (extralobar or hilar) behaves like an early stage of N2 disease. This offers further information for clinical, therapeutic, and research purposes.

Spread of gallbladder carcinoma: CT evaluation with pathologic correlation.

To assess the accuracy of computed tomographic (CT) imaging in the detection of spread and staging of gallbladder carcinoma. CT findings of spread of gallbladder carcinoma in 59 Japanese patients who underwent radical surgery were correlated retrospectively with pathologic findings. The incidence of histologically proven nodal involvement was 54% (32 patients) and the most common spread of gallbladder carcinoma. The sensitivities in CT detection of N1 and N2 nodal involvement were 36% and 47%, respectively; positive predictive values were 94% and 92%, respectively. Direct extension to the liver, extrahepatic bile duct, and gastrointestinal tract or pancreas were histologically confirmed in 24, 18, and five patients. The sensitivities in the CT detection of direct spread to the liver of less than 2 cm, more than 2 cm, the extrahepatic bile duct, and the gastrointestinal tract or pancreas were 65%, 100%, 50%, and 57%, respectively; positive predictive values were 77%, 100%, 90%, and 100%, respectively. The incidence of liver metastases and involvement of interaortocaval nodes were 7% and 16%, respectively. The sensitivities in CT detection of liver metastases and involvement of interaortocaval nodes were 75% and 21%, respectively; positive predictive values were 100% and 86%, respectively. CT could not detect direct spread to omentum and peritoneal seedings. For detecting the spread of gallbladder carcinoma, CT imaging has low to moderate sensitivity; however, CT imaging can help in determining resectability and in planning the treatment, especially in advanced-stage gallbladder carcinoma, because of a high positive predictive value.

Carcinoma of the oropharynx. Results of megavoltage radiation therapy in 305 patients

Three hundred and five patients with oropharyngeal carcinomas received linear accelerator radiation therapy at the Stanford University Medical Center between 1956 and 1973. All were staged by the TNM system, using the UICC Classification of 1962. Actuarial five year survival for patients with tonsil cancers ranged from 50% to 18% for those with T1 and T3 lesions, respectively. Disease-free survival was higher than actuarial survival for patients with T1 and T2 lesions, reflecting an alteration of the latter curves by deaths from intercurrent diseases and second primary malignancies. Actuarial survival for patients with base of the tongue carcinomas was approximately 35% for those with T1 and T2 primary lesions and 22% for patients with T3 carcinomas. Considering all oropharyngeal sites of involvement together, clinically involved cervical lymph nodes were controlled by radiation therapy alone in 60 of 91 patients with N1 nodal involvement (67%), in twelve of 25 with N2 neck disease (48%) and in 46% of those patients with N3 involvement (34 of 74). Eighty-nine percent of patients whose lymph nodes were not controlled by radiation therapy alone also had uncontrolled primary cancers. Over 90% of the patients whole cervical lymph nodes were initially uninvolved remained free of late nodal metastases if at least the regional (first echelon) lymph nodes were included in the primary treatment fields. The results of a randomized trial which compared surgery and radiation therapy alone and the two modalities in combination for the treatment of a limited number of patients with advanced cancers of the oropharynx, supraglottic larynx and hypopharynx suggest that surgery alone is not the treatment of choice.