Negative Mediastinoscopy Research Articles

Performance insights of endobronchial ultrasonography (EBUS) and mediastinoscopy for mediastinal lymph node staging in lung cancer

IntroductionEndobronchial Ultrasonography (EBUS) and mediastinoscopy are used for mediastinal lymph node staging in patients with suspected non-small cell lung carcinoma (NSCLC). In our hospital, confirmatory mediastinoscopy has been largely abandoned, which may reduce the number of surgical interventions and health care costs. This study provides insight into EBUS and mediastinoscopy performance in patients with proven NSCLC from January 2007 until January 2019. MethodsThis is a single-centre, retrospective study, evaluating unforeseen N2 rates, negative predictive value and survival, providing insight into the diagnostic yield of EBUS and mediastinoscopy. Surgical lung resection with lymph node dissection was used as reference. ResultsA total of 418 patients with proven NSCLC after lung resection (mean age: 66 years; 61 % male) and 118 patients who underwent mediastinoscopy, have been included in the study. The overall prevalence of N2 metastases after lung resection was 10.5 %. The percentage of unforeseen N2 cases after negative EBUS was 14.5 %, and 14.3 % after negative mediastinoscopy. Over the past nine years, none of the confirmatory mediastinoscopies were tumor positive after negative EBUS results. The median survival in patients with surgically confirmed N2 metastases was 33 months, compared to 23 months in patients with EBUS/mediastinoscopy-proven N2 metastases. ConclusionDespite optimisation of mediastinal staging procedures, it remains difficult to identify all patients with N2 metastases in the workup of NSCLC. In our institute, confirmatory mediastinoscopy has no added value after tumor-negative EBUS procedures, and has been abandoned as standard procedure.

Oligometastatic NSCLC: the changing role of surgery.

There is a very limited role for pulmonary resection in the management of NSCLC that has already metastasized systemically. Well selected individuals who present with limited metastatic disease (oligometastases) to a single organ may be considered for resection or an alternative local therapy to both the lung and the extrapulmonary site in rare instances where a thorough metastatic evaluation fails to reveal other foci of disease. This evaluation must include a negative mediastinoscopy.

Histological evaluation of preoperative mediastinoscopy lymph node biopsies in non-small cell lung cancer

IntroductionDespite the advent of PET scanning and endoscopic minimally invasive methods of sampling mediastinal lymph nodes, surgical assessment, particularly by mediastinoscopy, remains an important tool for staging non-small cell lung...

Comparison of Integrated Positron Emission Tomography/Computed Tomography and Mediastinoscopy in Mediastinal Staging of Non-Small Cell Lung Cancer: Analysis of 212 Patients

Background : Mediastinal staging is crucial to determine the prognosis and treatment options for patients with non-small cell lung cancer (NSCLC). In this study, we compared the results of integrated positron emission tomography-computerised tomography (PET/CT) with those of mediastinoscopy in mediastinal staging of NSCLC patients. Methods : PET/CT and mediastinoscopy was performed on 250 consecutive patients diagnosed with NSCLC between September 2005 and March 2008. Thirty-eight patients were excluded from the study. Standard cervical mediastinoscopy was performed in all patients, and simultaneous extended cervical mediastinoscopy was performed in 52 patients with left sided lesions. Patients with negative mediastinoscopy underwent resection. The pathological results were correlated with PET/CT findings.Results : A total of 212 patients (199 male, 13 female; mean age: 58.3 years) were evaluated. In PET/CT analysis 60 true-positive, 45 false-positive, 103 true-negative and 4 false-negative patients were found. The rate of PET/CT positivity of mediastinal lymph nodes was 49.5%. The sensitivity, specificity, positive and negative predictive values and accuracy for PET/CT were 93.8%, 69.6%, 57.1%, 96.3% and 76.9% respectively. The incidence of N2 disease in NSCLC patients with negative mediastinal lymph node uptake on PET/CT was 3.7% (4 of 107). In univariate analysis, right upper lobe tumours were significantly (p < 0.05) more associated with occult N2 disease.Conclusions : In patients with positive mediastinal lymph node uptake on PET/CT invasive mediastinal staging appears necessary for exact staging. Mediastinoscopy can be omitted in NSCLC patients with negative mediastinal uptake on PET/CT in regions where the rate of PET/CT positivity of mediastinal lymph nodes is high.

False-positivity of mediastinal lymph nodes has negative effect on survival in potentially resectable non-small cell lung cancer

It has been shown that increased metabolic activity of primary tumour has a negative effect on survival in non-small cell lung cancer (NSCLC) staged with positron emission tomography integrated computed tomography (PET/CT). We hypothesized that an increased metabolic activity of mediastinal lymph nodes would have worse survival even if it is false. Three hundred and twenty-eight consecutive patients with NSCLC histology were imaged with PET/CT within 90 days of surgery between September 2005 and March 2009. Patients who had neoadjuvant chemotherapy (n = 22), patients with prior history of NSCLC (n = 9) or other malignancies within 5 years (n = 11) were excluded from the study. Patients with negative mediastinoscopy underwent resection. Pathological results were revised according to the seventh tumor-node-metastasis staging system. Kaplan-Meier test was used for survival. Log-rank and Cox analyses were used for comparisons. A total of 286 patients (262 male; mean age: 58.5 years) were evaluated. There were 22 (6.7%) operative deaths and none of the patients were lost to follow-up. The median follow-up in the remaining 264 patients was 26 months (range, 2-61 months). Tumour size, nodal spread and stage were all strongly associated with survival from NSCLC (P < 0.001). There were 63 true-positive, 65 false-positive (FP), 152 true-negative (TN) and six false-negative findings on mediastinal staging after PET/CT. The maximum standardized uptake value of primary tumour was significantly higher in FP patients than in TN patients (P = 0.012). After excluding pN2-positive patients, TN patients had better survival than FP patients (P = 0.006). Multivariate analysis showed that false-positivity of mediastinal lymph nodes was independently associated with worse survival (hazard ratio = 0.63; P = 0.02). There were 146 patients with pT1-4, pN0 treated with R0 surgical resection. Disease-free survival and overall survival were also significantly better for TN patients in completely resected group (P = 0.009 versus 0.016). We have shown that false-positivity of mediastinal lymph nodes had yielded worse survival in surgically staged or resected NSCLC patients staged with PET/CT. This result may help to allocate patients with potentially poor prognosis for considered additional therapy.

Safety and Utility of Mediastinoscopy in Non-Small Cell Lung Cancer in a Complex Mediastinum

Adequate mediastinal staging is crucial in patients with locally advanced non-small cell lung cancer. Mediastinoscopy is often omitted after induction therapy or prior mediastinoscopy because of concerns for potential morbidity, safety and unknown utility. We sought to determine the safety and utility of restaging mediastinoscopy before surgical resection. A retrospective review was made of non-small cell lung cancer patients who underwent mediastinoscopy with a complex mediastinum, defined as any or all of the following: previous mediastinoscopy or induction chemotherapy or mediastinal radiation. Seventy-five patients underwent mediastinoscopy including 15 redo mediastinoscopies. In the non-redo group, 9 patients received induction chemotherapy, 16 received induction chemoradiotherapy (<46 Gy), 29 received definitive chemoradiotherapy (>50 Gy), and 6 received radiation alone. Two were aborted owing to fibrosis. Stations 4L, 4R, and 7 were accessed in 84% of patients, with confirmed nodal tissue in 88%. There was 1 azygos vein injury that required urgent thoracotomy and 2 recurrent nerve injuries. Resection ensued in 63 patients: 53 with negative mediastinoscopy, 8 with microscopic nodal metastases, and the 2 aborted cases. In patients with negative mediastinoscopy, 5 had N2 disease at thoracotomy: 3 in stations 4 and 7 and 2 in nodal stations inaccessible by mediastinoscopy. The sensitivity was 71%, specificity was 100%, and negative predictive value was 91%. In experienced hands, mediastinoscopy in a complex mediastinum is safe. Preclusive mediastinal fibrosis is rare. Expected lymph node stations can be accessed, and the results strongly correlate with postresection pathology. Mediastinoscopy is valuable to evaluate the nodal response to therapy in the setting of combined modality therapy.

Cervical Mediastinoscopic Lymphadenectomy for Accurate Staging in Lung Cancer

Accurate preoperative staging of the mediastinum is important in the treatment of non-small-cell lung cancer. Enlarged mediastinal lymph nodes on chest computed tomography are positive for malignancy on mediastinoscopy in only half of these patients. After negative mediastinoscopy, some positive nodes are found at thoracotomy. The aim of this study was to attempt to remove all lymph nodes accessible by cervical mediastinoscopic lymphadenectomy and reevaluate the same mediastinal stations at thoracotomy for missed lymph nodes. Between 1999 and 2003, 30 patients with operable non-small-cell lung cancer and enlarged mediastinal lymph nodes (>1 cm in diameter on computed tomography) that were negative on cervical mediastinoscopy underwent pulmonary resection with complete lymph node dissection. The total number of lymph nodes dissected in these 30 patients was 329 (143 at mediastinoscopy and 186 at thoracotomy); the mean numbers of nodes dissected were 4.8 at mediastinoscopy and 6.2 at thoracotomy. Ten (6.5%) residual lymph nodes were detected at thoracotomy in mediastinal stations R4, L4, and 7. The low number of missed lymph nodes demonstrates the accuracy of the technique of cervical mediastinoscopic lymphadenectomy.

Is Lobe-Specific Lymph Node Dissection Appropriate in Lung Cancer Patients Undergoing Routine Mediastinoscopy?

The extent and the necessity of lymph node dissection has yet to be defined after resectional surgery for lung cancer. We aimed to analyze the lobe-specific extent of lymph node positivity in patients who underwent preoperative mediastinoscopy as a routine strategy. A total of 280 patients with non-small cell lung cancer with negative mediastinoscopy were operated on in our center between January 1997 and June 2003. Hilar and mediastinal lymphadenectomy was performed in every patient. The most commonly involved lymph nodes were found to be paratracheal station lymph nodes (n = 83; 96.5 %) for right upper lobe tumors, subcarinal station lymph nodes (n = 52; 88.1 %) for right lower lobe carcinomas, aorticopulmonary lymph nodes (n = 62; 92.5 %) for left upper lobe and subcarinal station lymph nodes (n = 49; 96.0 %) for left lower lobe tumors. In the patients with right upper lobe, right lower lobe and left lower lobe tumors, the presence of a tumor at these stations was found to be an indicator for poor prognosis ( P = 0.033, P = 0.0038 and P = 0.0016, respectively). Patients with multiple station N2 disease did not survive beyond 3 years. In patients who underwent routine mediastinoscopy, lobe-specific lymph node dissection could be recommended. Patients with multilevel N2 involvement did not seem to benefit from resectional surgery.

Selection of Patients for Surgery After Induction Chemotherapy for N2 Non–Small-Cell Lung Cancer

Selection of Patients for Surgery After Induction Chemotherapy for N2 Non–Small-Cell Lung Cancer

Endoscopic Ultrasound-Guided Fine-Needle Aspiration in Patients With Non-Small Cell Lung Cancer and Prior Negative Mediastinoscopy

Endoscopic Ultrasound-Guided Fine-Needle Aspiration in Patients With Non-Small Cell Lung Cancer and Prior Negative Mediastinoscopy

Endoscopic Ultrasound-Guided Fine-Needle Aspiration in Patients With Non-Small Cell Lung Cancer and Prior Negative Mediastinoscopy

Mediastinoscopy and endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) are complementary for staging non-small cell lung cancer (NSCLC) patients. We assessed (1) the yield of EUS-FNA of malignant lymph nodes in NSCLC patients with combined anterior and posterior lymph nodes that had already undergone mediastinoscopy and (2) the cost implications associated with alternative initial strategies. All patients underwent chest computed tomography (CT) and/or positron emission tomography (PET), and mediastinoscopy. Then, the posterior mediastinal stations (7, 8, and 9) or station 5 were targeted with EUS-FNA. The reference standard included thoracotomy with complete thoracic lymphadenectomy, repeat clinical imaging, or long-term clinical follow-up. A Monte Carlo cost-analysis model evaluated the expected costs and outcomes associated with staging of NSCLC. Thirty-five NSCLC patients met inclusion criteria (median age 65 years; 80% men). Endoscopic ultrasound-guided FNA was performed in 53 lymph nodes in various stations, the subcarinal station (7) being the most common (47.3%). Of the 35 patients who had a prior negative mediastinoscopy, 13 patients (37.1%) had malignant N2 or N3 lymph nodes. Accuracy of EUS-FNA (98.1%) was significantly higher than that of CT (41.5%; p < 0.001) and PET (40%; p < 0.001). Initial EUS-FNA resulted in average costs per patient of 1,867 dollars (SD +/- 4,308 dollars) while initial mediastinoscopy cost 12,900 dollars (SD +/- 4,164.40 dollars). If initial EUS-FNA is utilized rather than initial mediastinoscopy, an average cost saving of 11,033 dollars per patient would result. In patients with NSCLC and combined anterior and posterior lymph nodes, starting with EUS-FNA would preclude mediastinoscopy in more than one third of the patients. Endoscopic ultrasound-guided FNA is a safe outpatient procedure that is less invasive and less costly than mediastinoscopy.

Scandinavian phase III trial of neoadjuvant chemotherapy in NSCLC stages IB-IIIA/T3

7146 Background: Neoadjuvant chemotherapy before surgery for NSCLC has previously shown somewhat promising results, but all prior randomised studies included also patients (pts) with N2-disease or stage IIIB. The aim was thus to evaluate the impact of neoadjuvant chemotherapy for early stage disease (stages IB - IIIA/T3). Methods: Pts had histologically verified NSCLC stages IB, IIA, IIB, and IIIA/T3 based on CT-scan and negative mediastinoscopy, and were randomised to 3 courses of Paclitaxel 225 mg/m2 and Carboplatin AUC 6 day 1 q 3 weeks followed by surgery (regimen A) or immidiate surgery (regimen B). Chest radiotherapy 60 Gy were administered in case of incomplete resection. Survival was primary end-point. It was required to randomise totally 280 pts to detect an 15% increment in 5-year survival rate with a two-sided type I error of 5% and 80% power. The study was stopped prematurely due to slow patient recruitment. Results: 44 pts with a median age of 66 years were randomised to regimen A and 46 with median age 62 years to regimen B from November 1998 to October 2004. There were no differences with respect to performance status, gender, histology, LDH, or stage groups between the treatment regimens. In regimen A, 46% achieved a partial response to the neoadjuvant chemotherapy. Microscopically complete resection was achieved in 79% and 70% in regimen A and B, respectively. Median survival and 5-year survival rates were 34.4 months and 36% compared to 22.5 months and 24% in regimen A and B, respectively (not significant). Conclusions: No statistically significant differences were noted in this prematurely closed trial, but median survival was increased by one year and 5-year survival rate increased by 12% for pts receiving neoadjuvant chemotherapy, suggesting that a beneficial effect can not be ruled out. Follow-up and survival update continues. No significant financial relationships to disclose.

Endoscopic Ultrasound-Guided Fine Needle Aspiration in Patients with Lung Cancer and Prior Negative Mediastinoscopy

Background: Abnormal mediastinal lymph nodes (LNs) sampling is required prior to surgical resection in non-small cell lung cancer (NSCLC) patients. In patients with both anterior and posterior mediastinal LNs, the initial strategy to diagnose metastasis to ipsilateral (N2) or contralateral (N3) LNs remains unknown. Objectives: Our objectives were 1) To evaluate the yield of EUS-FNA in NSCLC patients with both anterior and posterior LNs that had prior negative mediastinoscopy. 2) To assess cost implications associated with alternative initial strategies: initial mediastinoscopy versus initial EUS-FNA. Methods: NSCLC patients first underwent thoracic CT, PET scan, and mediastinoscopy and then underwent EUS-FNA of the posterior mediastinal LNs. Reference standards included: thoracotomy with complete thoracic lymphadenectomy, repeat clinical imaging and/or long term clinical follow-up. A Monte Carlo cost-analysis model evaluated the expected costs and outcomes associated with staging of a hypothetical cohort of NSCLC patients presenting with enlarged anterior and posterior mediastinal LNs. Results: There were thirty-five lung cancer patients (median age of 65 years, 80% male). Of the 35 NSCLC patients who had a prior negative mediastinoscopy, 13 patients (37.1%) (95% CI: 21.5–55.1) had malignant LNs. Lower lobe masses were more likely to have malignant LNs as compared to upper lobe masses (OR = 6.8; 95% CI: 1.2–42.7, P = 0.03). All patients with N2/N3 disease received initial chemotherapy and/or radiation. EUS-FNA yielded one false negative result and no false positives. Final diagnoses were confirmed by surgery in 16 patients (45.7%). Accuracy of EUS-FNA (98.1%; 95% CI: 89.9–100.0) was significantly higher than CT (41.5%; p < 0.001) and PET (40%; p < 0.001). Initial EUS-FNA resulted in an average costs per patient of $1,867 (SD ± 4308) while initial mediastinoscopy cost $12,900 (SD ± 4164). If initial EUS-FNA is utilized rather than initial mediastinoscopy, there would be an average cost saving of $11,033 per patient evaluated. Conclusions: In NSCLC patients with both anterior and posterior LNs, starting with EUS-FNA would obviate the need for mediastinoscopy in over one-third of patients. EUS-FNA is an outpatient procedure that is less invasive, safer and less costly than mediastinoscopy. These finding have major implications on resource utilization in NSCLC patients undergoing invasive tissue sampling for preoperative staging.

Poor correspondence between clinical and pathologic staging in stage 1 non-small cell lung cancer: results from CALGB 9761, a prospective trial

A major problem with the staging system for non-small cell lung cancer (NSCLC) is clinical underestimation of the extent of disease. Many patients with clinical stage 1 disease do not retain that designation following surgical resection. Herein, we present data from Cancer and Leukemia Group B (CALGB) protocol 9761 evaluating the correspondence between clinical and pathologic analysis in early stage NSCLC. Five hundred and two patients with suspected or biopsy-proven NSCLC classified as clinical stage 1 (T1-2, N0) by computed tomography (CT) scan or cervical mediastinoscopy were prospectively enrolled in CALGB 9761. The purpose of CALGB 9761 was to prospectively evaluate molecular markers of micrometastatic disease in stage 1 NSCLC. Enrollment occurred at 11 selected institutions within the CALGB. Patients with clinically suspected resectable early stage lung cancer were eligible for enrollment if they had no evidence of mediastinal or hilar adenopathy on CT scan or if they had CT evidence of potential N2 or N3 disease (lymph node > or =1.0 cm) but with negative mediastinoscopy. No prior chemotherapy or radiotherapy was permitted. Of the 502 patients felt to have clinical stage 1 NSCLC enrolled in CALGB 9761, 489 underwent resection with complete surgical staging and routine histopathologic analysis. From these 489 patients, only 422 (86.3%) turned out to have pathologically documented NSCLC. Of these 422 patients, 302 (71.6%) had pathologic stage 1 disease (173 stage 1A and 129 stage 1B). Despite clinical assessment of stage 1 disease, 59 (14%) patients had pathologic stage 2 disease, 57 (13.5%) had stage 3 disease, and four (0.9%) patients had stage 4 disease. Of the patients undergoing resection for clinical stage 1 NSCLC, 65 patients did not have NSCLC (44 had benign disease and 21 had malignancies other than NSCLC) and two additional patients had dual synchronous primary NSCLC tumors and were not eligible for the study. Overall, only 61.7% (302 of 489) of patients with suspected stage 1 NSCLC disease retained that stage and diagnosis after complete surgical staging, while 38.3% had an inaccurate pre-operative clinical stage or diagnosis. The results from this prospective trial demonstrate the poor predictive value of current clinical staging techniques in early stage NSCLC. These findings will serve as a benchmark for comparison of future clinical imaging modalities and other tests evaluating early stage NSCLC.

An algorithm for managing bilateral lung masses

7371 Background: Ten percent of patients with NSCLC present with bilateral masses. Often these lesions are considered to be metastatic, but may be benign, or a separate primary. Resection is best for benign lesions or separate primaries, but poor therapy for metastases. We report 36 patients with bilateral lung masses on whom we first performed mediastinoscopy. If mediastinal nodes were benign, we then resected both lesions. The resulting data allow the generation of an algorithm to manage patients with bilateral lung masses. Methods: Seventy patients were gleaned from 115 fifteen patients with bilateral lung masses. The CT reports of these patients were read as highly suspicious for malignancy. After negative mediastinoscopy, 36 patients remained, all of whom underwent bilateral resections. Survival was determined for those with “Same Path” in both lesions, “Different Path”, and “One Benign.” Student's t test was used to compare means, and chi-square to compare proportions. Results: There were no differences in the average age of the patients in the three groups. There were striking differences in the survival between those with one benign lesion and those with the same pathology in both lesions (p=0.004). Those patients with different pathologies in each mass had intermediate survival. Conclusions: Our experience demonstrates that patients with similar pathology in bilateral lung masses have very low survival at 24 months, and should not be treated with resection. Patients with bilateral masses should first undergo staging workup and mediastinoscopy. If those are negative, thoracoscopic wedge resection of the smaller lesion combined with needle aspiration of the larger lesion will identify those patients with identical pathology. The larger mass can then be treated with chemoradiotherapy. Patients who are found to have a benign lesion or different pathology should undergo resection. No significant financial relationships to disclose.

Towards a minimally invasive staging strategy in NSCLC: analysis of PET positive mediastinal lesions by EUS-FNA

Study objective: To asses the value of endoscopic ultrasound guided fine needle aspiration (EUS-FNA) in the nodal staging of patients with (suspected) non-small cell lung cancer (NSCLC) and a 18 FDG positron emission tomography (PET) scan suspect for N2/N3 mediastinal lymph node (MLN) metastases. Background: Due to the imperfect specificity of positron emission tomography, PET positive MLN should be biopsied in order to confirm or rule out metastasis. Currently, invasive surgical diagnostic techniques such as mediastinoscopy/-tomy are standard procedures to obtain MLN tissue. The minimally invasive technique of EUS-FNA has a high diagnostic accuracy (90–94%) for the analysis of MLN in patients with enlarged MLN on computed tomography of the chest (CT). Design and patients: Thirty-six patients with proven ( n=26) or suspected ( n=10) non-small cell lung cancer and a PET scan suspect for N2/N3 lymph node metastases underwent EUS-FNA. When EUS-FNA did not confirm metastasis and the PET lesion was within reach of mediastinoscopy, a mediastinoscopy was performed. EUS-FNA negative patients with PET lesions beyond the reach of mediastinoscopy or those with a negative mediastinoscopy were referred for surgical resection of the tumour and MLN sampling or dissection. Results: EUS-FNA confirmed N2/N3 disease in 25 of the 36 patients (69%) and was highly suspicious in one. In the remaining 10 patients, one PET positive and one PET negative N2 metastasis was detected at thoracotomy. The PPV, NPV, sensitivity, specificity and accuracy of EUS-FNA in analysing PET positive MLN were 100%, 80%, 93%, 100% and 94%, respectively. No complications of EUS-FNA were recorded. Conclusions and significance: EUS-FNA yields minimally invasive confirmation of MLN metastases in 69% of the patients with potential mediastinal involvement at FDG PET. The combination of PET and EUS-FNA might qualify as a minimally invasive staging strategy for NSCLC.

Total thoracoscopic pneumonectomy: indications and technical considerations

Although descriptions of series of thoracoscopic wedge resections and lobectomies have been published, with increasing frequency and encouraging results, only a handful of individual reports of minimally invasive pneumonectomy are available. The authors of these publications unanimously have used a limited 6to 16-cm thoracotomy to allow the introduction of traditional surgical instruments and to provide some direct visualization of the surgical field, especially the hilar structures. This has been traditionally accepted as the method of choice in video-assisted thoracic surgery (VATS). However, it is arguable, that the requirement for a minithoracotomy, particularly if rib spreading or rib resection is used, reduces the benefits of minimal trauma associated with the smaller incisions. VATS wedge resections and anatomic lobectomies are frequently performed. The indications, preoperative patient workup, postoperative care, and basic oncologic principles are essentially the same as with open thoracic surgery. We use preoperative mediastinoscopy before any lung cancer resection. We discuss here our initial experience with entirely videothoracoscopic pneumonectomy, such as has not been reported to date.

Resultados del tratamiento quirúrgico del carcinoma broncogénico N2 patológico con mediastinoscopia negativa

To analyze the survival of patients undergoing lung resection for N2 bronchogenic carcinoma with negative findings at mediastinoscopy. Twenty-nine patients with N2 bronchogenic carcinoma were analyzed. The patients were taken from a series of 170 patients who underwent surgery between 1993 and 1997 and whose data were recorded by the Bronchogenic Carcinoma Cooperative Group of the Spanish Society of Pneumology and Thoracic Surgery (GCCB-S). In 26 patients, nodes were found in the upper mediastinum; in three patients nodes were paraesophageal or in the area of the pulmonary ligament. In 11 cases, extracapsular nodal disease was found. Three patients who died in the postoperative period were excluded from survival analysis. The five-year survival rate for the series of 170 patients was 39%. For the 26 patients with N2 carcinoma, five-year survival was 14% (median 12 months). Five-year survival for the remaining patients (excluding those with N2 carcinoma) was 46%. Although the median survival of patients with intracapsular nodal disease was more than twice (25 months) that of patients with extracapsular nodal disease (12 months), the difference was not significant. Lung resection in patients with N2 bronchogenic carcinoma with negative mediastinoscopy has little impact on survival. Surgical exploration of the mediastinum classifies such patients with greatest certainty, although the sensitivity of staging techniques warrants improvement to assure that thoracotomy is not used unnecessarily.

Prospective comparison of radiologic, thoracoscopic, and pathologic staging in patients with early non-small cell lung cancer

Background. More accurate staging at the time of initial presentation could improve design of clinical trials and avoid inappropriate surgical decisions in individual patients. Preresection staging of patients with non-small cell lung cancer (NSCLC) is not straightforward, especially in patients with negative mediastinal nodes. The purpose of this study was to compare the results of radiologic, thoracoscopic, and pathologic staging in patients with NSCLC and negative mediastinoscopy. Methods. All patients with NSCLC underwent computed tomographic (CT) scanning before surgical staging with mediastinoscopy. Patients with negative mediastinoscopy then underwent thoracoscopic staging with examination of pleural surfaces, and identification of T (visceral and parietal pleural invasion, sampling of pleural fluid, and pleural lavage) and N (intraparenchymal and inferior mediastinal nodal sampling, if possible) stage descriptors before resection. Results. Thoracoscopy was more accurate than CT scanning in the staging of 50 patients with early lung cancer (stages IA, IB, IIA, and IIB), especially as regards T stage. Further, thoracoscopic examination ruled out malignant pleural effusions in 7 (14%) patients with radiologically obvious effusions, and identified radiologically silent malignant pleural effusions in 3 (6%) patients. Chest wall invasion was accurately identified at thoracoscopy in most patients. Finally, 3 patients with T1 lower lobe lesions and negative mediastinoscopy were found to have involvement of inferior mediastinal nodes (level 8 or 9) at thoracoscopy. However, thoracoscopy did not allow sampling of aortopulmonary window nodes in some patients with bulky left upper lobe lesions. Conclusions. Errors in thoracoscopic staging resulted in no inappropriate operations. However, errors in CT staging would have resulted in operations unlikely to help the patients, or would have inappropriately excluded patients from surgery. Thoracoscopic staging was more accurate than CT staging in this cohort of patients with NSCLC and negative mediastinoscopy.

Prognosis of unsuspected but completely resectable N2 non-small cell lung cancer

Of 111 patients with non-small cell lung cancer without clinically evident N2 disease 95 underwent mediastinoscopy between 1975 and 1985. In 63 cases mediastinoscopy was positive and in 32 negative. The patients with a positive mediastinoscopy were considered to have inoperable disease. Their 3- and 5-year survival rates were 5% and 0%, respectively. The patients with a negative mediastinoscopy and 16 patients in whom no mediastinoscopy was performed because of a peripheral tumor underwent operation. They underwent complete tumor resection and mediastinal lymph node dissection. Unsuspected N2 disease was found. Their 3- and 5-year survival rates were 19% and 10%, respectively. The better survival rate in the operated group was statistically significant and mainly due to a better survival of the lobectomy group. Multiple regression analysis showed no favorable prognostic factors in the nonoperated group, but in the operated group lobectomy and central location of the tumor significantly improved the prognosis. We conclude that patients with unsuspected stage IIIa non-small cell lung cancer discovered at thoracotomy benefit from complete tumor resection and mediastinal lymph node dissection, especially if the resection can be confined to lobectomy and if the tumor is located centrally.