Preoperative Mediastinoscopy Research Articles

Videothoracoscopic lobectomy: first year of experience in a single center

Methods From April 2012 to date, we performed 42 completely thoracoscopic lobectomies (non rib-spreading) with anterior approach to the pulmonary hilum. Clinical stages I were included and T3 or T4 tumors, central tumors, cN1-N2, previous ipsilateral thoracotomy were excluded. Whenever possible, we have obtained a preoperative diagnosis with CT-guided needle biopsy (n = 35, 83%); otherwise lobectomy was preceded by atypical resection and extemporaneous examination. A preoperative mediastinoscopy was performed following the guidelines of the National Comprehensive Cancer Network, 2013 (n = 18, 43%), in the same operative time with extemporaneous examination of the lymph nodes. Lung resection was always associated with a lymphadenectomy of at least 4 ilo-mediastinal stations.

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...

Abstract 4671: Radioguided detection of lymph node metastasis in non-small cell lung cancer.

Abstract Background: Lymph node staging provides the most important prognostic information in patients with loco-regional non-small cell lung cancer. We hypothesized that gamma radiation detection using an intra-operative hand-held gamma probe following intravenous 18F-fluorodeoxyglucose (FDG) injection would identify lymph nodes containing metastases in a much more sensitive manner than standard pathological practices. We compared the accuracy of detecting thoracic lymph node metastases using positron emission tomography- computed tomography (PET-CT) versus the gamma probe. Methods: One hundred patients with resectable lung cancers had pre-operative positron emission tomography-computed tomography (PET-CT) and mediastinoscopy. 10mCi of FDG was injected on the day of surgery. A handheld gamma probe detected increased FDG uptake within thoracic lymph nodes during pulmonary resection procedures. The lymph nodes that demonstrated increased FDG uptake, but were non-malignant by conventional H&E staining underwent further serial sectioning, immunohistochemistry (IHC) and RT-PCR (reverse transcriptase - polymerase chain reaction). Sensitivity and specificity for lymph node metastasis detection by PET-CT and the gamma probe were calculated. Results: Three patients had metastatic lymphadenopathy detected at mediastinoscopy, so their procedures were aborted, while the others proceeded to lung resection and complete lymphadenectomy. Fifteen additional patients had lymph node involvement on routine pathologic analysis. IHC and RT-PCR detected micrometastatic lymph node disease in 4 and 29 patients, respectively. Using RT-PCR as the gold standard, the sensitivity and specificity of PET-CT for detection of lymph node metastasis were 11% and 98% respectively, in contrast to 38% and 50% respectively for the gamma probe. Conclusion: The intra-operative hand held gamma probe is more sensitive but less specific than PET-CT in detecting lymph node metastasis from lung cancer. Its overall accuracy was low, resulting in limited up-staging of patients. RT-PCR analysis of FDG-avid lymph nodes for epithelial markers increased the clinical utility of this probe in detecting micrometastasis. Such up-staged patients could derive a survival benefit from adjuvant chemotherapy. More specific radioisotopes are being developed to improve the clinical utility of this technique. Citation Format: Chukwumere Nwogu, Todd Demmy, Sai Yendamuri, Wei Tan, Paul Bogner, Elisabeth Dexter, Anthony Picone, Mark Hennon, Alan Hutson, Mary Reid, Richard Cheney, Alex Adjei. Radioguided detection of lymph node metastasis in non-small cell lung cancer. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 4671. doi:10.1158/1538-7445.AM2013-4671

The clinical value of routine preoperative surgical staging to mediastinal lymph nodes on lung cancer

背景与目的探讨肺癌术前常规纵隔淋巴结外科分期的临床价值。方法76例肺癌患者开胸术前常规行纵隔淋巴结活检，以术后病理为金标准，比对术前胸部CT和纵隔镜对肺癌纵隔淋巴结转移的诊断效能。结果术前胸部CT对纵隔淋巴结转移的诊断敏感性、特异性、准确性、阳性预测值和阴性预测值分别为68.5%、66.7%、68.4%、84.6%和16.7%。纵隔镜检查术则分别为87.5%、100%、84.2%、100%和60%。结论肺癌术前常规纵隔镜检查术对纵隔淋巴结分期的优势明显，具有极高的临床实用价值。

Risk factor analysis of mediastinal lymph node metastasis in non-small cell lung cancer patients and the strategy of mediastinoscopy prior to surgery

To discuss the strategy of mediastinoscopy for the evaluation of mediastinal lymph node status (metastasis or not) of non-small cell lung cancer (NSCLC) prior to surgery. From October 2000 to June 2007, 152 consecutive NSCLC cases pathologically proven and clinically staged I-III were enrolled in the study. Of the 152 cases, there were 118 males and 34 females. Age ranged 24-79 years old and the median age was 58. All cases underwent CT and mediastinoscopy for the evaluation of mediastinal lymph node status prior to surgery. Compared with the results of final pathology, the positive rate of mediastinoscopy and the prevalence of mediastinal lymph node metastasis were calculated in the NSCLC patients with negative mediastinal or hilar lymph nodes on CT scan (the shortest axis of mediastinal or hilar lymph nodes <1 cm). Clinical characteristics used as predictive factor including sex, age, cancer location, type of pathology, T status, cancer type (central or peripheral), size of mediastinal lymph nodes (the shortest axis <1 cm or >1 cm) on CT scan and serum CEA level were analyzed by univariate and multivariate analysis with Binary logistic regression model to identify risk factors of mediastinal metastasis. The positive rate of mediastinoscopy was 11.6% (8/69) and the prevalence of mediastinal metastasis was 20.1% (14/69) in NSCLC with negative mediastinal or hilar lymph nodes on CT scan respectively. In clinical stage I (cT1-2N0M0) NSCLC the positive rate of mediastinoscopy was 11.3% (7/62), N2 accounting for 6.5% (4/62) and N3 4.8% (3/62), respectively; and the prevalence of mediastinal lymph node metastasis was 19.4% (12/62), N2 ccounting for 14.6% (9/62) and N3 4.8% (3/62), respectively. In the whole group both univariate and multivariate analysis showed that adenocarcinoma or mediastinal lymph nodes > or =1 cm in the shortest axis on CT scan was an independent risk factor to predict mediastinal lymph node metastasis. In NSCLC with negative mediastinal or hilar lymph nodes on CT scan both univariate and multivariate analysis showed that adenocarcinoma was a predictor of mediastinal lymph node metastasis. Conclusion We recommend the policy of routine mediastinoscopy in NSCLC prior to surgery if the mediastinal staging was only based on CT scan. Mediastinal lymph nodes > or =1 cm in the shortest axis on CT scan mandates preoperative mediastinoscopy. Adenocarcinoma also indicates mandatory mediastinoscopy even with negative mediastinal or hilar lymph nodes on CT scan.

Prevalence and Pattern of Lymph Node Metastasis in Malignant Pleural Mesothelioma

The incidence and pattern of nodal metastases in mesothelioma are not well understood. This study was conducted to evaluate the prevalence and pattern of nodal metastasis in mesothelioma patients. The study included 53 patients with mesothelioma. The first 37 patients (group I) underwent combined modality treatment without preoperative mediastinoscopy. The second group included 16 patients (group II) with pretreatment mediastinoscopy. A total of 18 patients had positive lymph nodes, 12 in group I and 6 in group II; of the latter, 4 had positive mediastinoscopy and 2 had positive nodes on final pathology. Postoperatively, a mean of 14 nodes were dissected (range, 5 to 34). In the post-pleuropneumonectomy group, 6 of 14 patients had positive hilar node metastases in addition to positive mediastinal lymph nodes. One patient had positive hilar nodes only. Of the 49 patients operated on, only 7 had no lung invasion by pathologic evaluation, and none had positive hilar nodes. The mechanism of spread of the disease to hilar nodes may be through lung invasion and not due to direct spread from the pleura. This observation raises the possibility that mediastinal nodes should be considered the primary station in patients with mesothelioma, whereas hilar node metastasis necessitated lung invasion first. The pattern of nodal metastases may be different from that of lung cancer, and multicenter studies are needed to evaluate this observation.

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.

Extended pneumonectomy for non–small cell lung cancer: Morbidity, mortality, and long-term results

Pneumonectomy is not always sufficient for the radical resection of cancer. In the present study, pneumonectomy may be associated with an extended resection of mediastinal or parietal structures. The postoperative risk and the oncologic benefits of such an extended procedure have not been sufficiently demonstrated. We have defined "extended" pneumonectomy (EP) as the removal of the entire lung, associated with one or more of the following structures: superior vena cava, tracheal carina, left atrium, aorta, chest wall, or diaphragm. Our clinical database was retrospectively reviewed to identify patients who underwent EP to assess their postoperative morbidity, mortality, and long-term survival. Between 1998 and 2005, 47 EPs were performed. The "extended" procedure included left atrium resection in 15 patients, combined SVC and carinal resection in 9 patients, aortic resection in 8 patients (in 3 patients with prosthetic replacement), chest wall or diaphragmatic resection in 6 patients, SVC resection in 4 patients, and carinal resection in 4 patients. A partial esophageal muscular resection was performed in 1 patient. Overall 60-day mortality was 8.5%. Major postoperative complications occurred in 8 patients (17%). The 2- and 5-year survival rates for the overall population were 42% and 22.8%, respectively. Interestingly, long-term survivors were recorded only in the group of patients who received induction treatment. Extended pneumonectomy is a feasible procedure with an acceptable risk factor. To improve the selection of patients, all candidates should undergo preoperative mediastinoscopy and induction chemotherapy. In patients with positive response to chemotherapy or stable disease, extended pneumonectomy may afford a radical resection in more than 80% of cases and may result in a permanent cure in some instances.

A Prospective Phase II Study of a New Treatment Protocol for NSCLC Combined with Preoperative Mediastinoscopy and Chemotherapy

We have developed a new multimodal treatment protocol combined with video-assisted mediastinoscopy (VAM) and chemotherapy. Forty-four pN2 non-small cell lung cancer (NSCLC) cases were selected from the surgically treated groups and the prognoses were compared between October 1998 and December 2004. Patients negative for nodes on examination by VAM (VAM-negative: group 2) underwent thoracotomy, and those positive for nodes (VAM-positive) received induction chemotherapy. After chemotherapy, only patients who met the surgical criteria underwent thoracotomy (group 3), and the remaining cases were allocated to radiotherapy (group 4) or best supportive care. When none of the VAM criteria were met (group 1), thoracotomy was performed without VAM. The overall 3- and 5-year survival rates were 42.1 % and 28.0 %. The survival rates in groups 2 and 3 were almost the same ( P = 0.5392), even though there were significantly more patients with multiple N2 stations in group 3 ( P = 0.0088). Preoperative detection of lymph node metastasis by VAM makes use of the benefits of surgical intervention, and adjuvant therapies improve the survival of NSCLC patients with N2 disease.

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.

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.

Impact of lymph node metastasis on outcome after extrapleural pneumonectomy for malignant pleural mesothelioma

Extrapleural pneumonectomy is a therapeutic option for selected patients with malignant pleural mesothelioma. The impact of lymph node metastasis on the site of recurrence and the role of mediastinoscopy in the selection of patients for extrapleural pneumonectomy, however, remain unclear. We reviewed 50 consecutive patients undergoing extrapleural pneumonectomy for malignant pleural mesothelioma in our institution between January 1993 and March 2005. The median survival was 11 months, with a 3-year survival of 24%. Survival was significantly worse for patients with N2 disease than for those with no lymph node metastasis (median survival 10 months vs 29 months, respectively, P = .005). Patient sex, histologic cell type, stage, and N2 disease, but not mediastinoscopy, had significant impacts on survival according to univariate analysis. In a multivariate analysis, however, only the presence of N2 disease remained a significant predictor of poor outcome. The proportion of patients with N2 disease and the long-term survival was similar regardless of whether preoperative mediastinoscopy yielded a negative result. The initial site of recurrence was determined in 28 patients (locoregional in 10 and distant in 18). The presence of N2 disease had no impact on the site of recurrence. Adjuvant hemithoracic radiation therapy, however, significantly decreased the risk of locoregional recurrence. The presence of N2 disease negatively affects the prognosis of patients with malignant pleural mesothelioma. Mediastinoscopy, however, seems to have a limited role in patient selection for extrapleural pneumonectomy. Adjuvant hemithoracic radiation therapy but not N2 disease affects the risk of locoregional recurrence.

Superior Vena Cava Resection for Lung and Mediastinal Malignancies: A Single-Center Experience With 70 Cases

The oncologic value of superior vena cava (SVC) resection for lung and mediastinal malignancies remains controversial. In this context, we have reviewed our experience in the treatment of locally advanced lung and mediastinal tumor invading the SVC system, analyzing postoperative outcome and long-term oncologic results. The clinical data of patients who underwent SVC resection were retrospectively analyzed to assess postoperative mortality, and overall and procedure-specific morbidity. Overall survival was calculated for mediastinal and lung tumor groups. From 1998 to 2004, 70 consecutive patients (52 with lung cancer and 18 with mediastinal tumors) underwent SVC system resection. There were 25 replacements (36%) of the SVC system by prosthesis, whereas the remaining underwent partial resection. Major postoperative morbidity and mortality rates in lung cancer patients were 23% and 7.7%, respectively (50% and 5.6% in mediastinal tumors). In the lung cancer group, 5-year survival probability was 31%, and it was affected by mediastinal nodal status (5-year survival in N0-N1 patients 52%, 21% in N2 patients, 0 in N3 patients). Median survival for mediastinal tumors was 49 months. In conclusion, SVC resection may achieve permanent cure in patients who would have been defined as inoperable 10 years ago. In the case of mediastinal tumors, the need for SVC resection alone should not be considered a contraindication for surgery when prosthetic replacement is feasible. In the case of lung tumors, infiltration of SVC can achieve satisfactory long-term results after neoadjuvant chemotherapy, only when pathologic N2 disease is excluded by preoperative mediastinoscopy.

Patterns of Surgical Care of Lung Cancer Patients

This survey was performed to determine the patterns of surgical care provided patients with non-small cell lung carcinoma (NSCLC). In 2001, the American College of Surgeons carried out a patient care survey of 729 hospitals to retrieve information of NSCLC patients' history, evaluation, pathology, and surgical treatment. Inclusion criteria were met by 40,090 patients: of whom 11,668 (29.1%) were treated surgically; 74.2% alone and 25.8% as part of multimodality therapy. Of these patients, 59.5% were in stage I, 17.5% in stage II, 17.0% in stage III, and 6.0% in stage IV. Surgery patient demographics were the following: 55% male and 45% female; 46.8% 70 years or older; and 76.3% had significant comorbidities. Tumor characteristics: squamous 28%, adenocarcinoma 37.6%, other 34.4%. Staging: in addition to radiologic examinations, preoperative mediastinoscopy was performed in 27.1% of operated patients with node biopsy in only 46.6% of these procedures. wedge resection 15.6%, lobectomy 70.8%, pneumonectomy 13.6%. Surgical margins were positive in 7.8%, but only 65.2% had frozen section analysis. Perioperative mortality was 5.2%, but was 4.0% in nontransfused patients and 12.7% in transfused patients and was 3.2% in high-volume (more than 90 operations per year) versus 4.8% in low-volume hospitals (p < 0.001). (1) Patients being operated for NSCLC are elderly with significant comorbid conditions. (2) More patients than previously are female and have adenocarcinoma. (3) Mediastinoscopy is infrequently performed and lymph nodes are biopsied in less than 50% of them. (4) Lobectomy is the most common operation, and positive surgical margins are too frequent. (5) Operative mortality is reasonable but transfusion is a marker for increased risk and outcomes are superior in high-volume hospitals. (6) Hospitals with higher volume had fewer perioperative deaths.

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.

Results of preoperative mediastinoscopy for small cell lung cancer

Background. The significance of mediastinoscopy for small cell lung cancer is unclear owing to the small number of surgical cases. Methods. To determine the N component of the TNM staging system, computed tomographic findings and the results of mediastinoscopy were compared with the pathologic examination of surgical specimens. Results. Four cases among 37 patients (10.8%) were determined as inoperable by mediastinoscopy because of mediastinal lymph node metastasis. A thoracotomy was performed in 33 patients. Six patients (18.2%) who had been judged to have no metastasis by mediastinoscopy were found to have N2 disease after examination of the surgical specimens. In the identification of all mediastinal metastases, mediastinoscopy was 40.0% sensitive, 100% specific, and 83.8% accurate. When the superior mediastinal, paratracheal, pretracheal, tracheobronchial, and subcarinal lymph nodes were defined as approachable nodes, mediastinoscopy was 66.7% sensitive, 100% specific, and 94.6% accurate in the evaluation of these restricted nodes. Four cases among 8 patients with cN1 lesions resulted in a designation as pN2. Conclusions. Mediastinoscopy is useful for the diagnosis of an approachable mediastinal lymph node in small cell lung cancer cases. This exploration is necessary for patients with small cell lung cancer who are diagnosed as cN1 before thoracotomy.

Clinical Predictors of N2 Disease in Non-small Cell Lung Cancer

To identify clinical or radiologic predictors of mediastinal lymph node involvement in patients with non-small cell lung cancer, and to define the indications of preoperative mediastinoscopy. From August 1992 through April 1997, 387 patients with lung cancer (290 adenocarcinoma and 97 squamous cell carcinoma) underwent surgical resection. We retrospectively measured all mediastinal lymph node sizes both in the shortest and longest axes on contrast-enhanced CT scan to determine the optimal size criteria. Using multivariate logistic regression analysis, we identified clinical or radiologic predictors of N2 disease. We could not identify reliable size criteria for nodal involvement. We found two significant predictive factors of N2 disease on the basis of multivariable analysis: maximum tumor dimension and serum carcinoembryonic antigen (CEA) concentrations. The lymph node size did not prove to be a significant factor. Among 50 patients with serum CEA concentrations < 5.0 ng/mL and maximum tumor dimension < 20 mm, pathologic N2 disease was proven only in three patients (6%), regardless of the lymph node size on CT scan. Among 140 patients with serum CEA concentrations > or = 5.0 ng/mL and maximum tumor dimension > or = 20 mm, approximately one third (n = 46) showed N2 disease. Serum CEA concentrations and maximum tumor dimension were more valuable in predicting N2 disease than the lymph node size on CT scan. Mediastinoscopy is indicated in patients with serum CEA concentrations > or = 5.0 ng/mL and maximum tumor dimension > or = 20 mm, and not indicated in patients with serum CEA concentrations < 5.0 ng/mL and maximum tumor dimension < 20 mm.

Resection of lung cancer invading the diaphragm

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-

465 Outcome of surgery for non small cell lung cancer, without preoperative mediastinoscopy

465 Outcome of surgery for non small cell lung cancer, without preoperative mediastinoscopy

Preoperative mediastinoscopic assessment of N factors and the need for mediastinal lymph node dissection in T1 lung cancer

The significance of preoperative N factor assessment in T1 lung cancer and the need for mediastinal node dissection in T1 N0 M0 cases were investigated. The results of mediastinoscopy were evaluated in patients with T1 adenocarcinoma or squamous cell carcinoma who underwent preoperative mediastinoscopy and thoracotomy from 1971 to 1991 ( n = 164). Mediastinoscopy gave true negative results in 90% of patients, false negative in 1%, and true positive in 9%. The 5-year survival was 90% for patients with T1 N0 M0 disease who underwent nonradical dissection ( n = 64) and 70% for those who underwent radical dissection ( n = 61), indicating that the prognosis was significantly better ( p < 0.05) with nonradical dissection. Distant metastasis was a common cause of death, and no death was related to local recurrence, whether nonradical or radical dissection had been performed. The results strongly suggest that preoperative mediastinoscopy and intraoperative node sampling are sufficient for assessment of N factors in T1 lung cancer. The possible relation between immunologic functional changes associated with mediastinal lymph node dissection and the prognosis in patients without evidence of positive lymph nodes should be clarified by a prospective randomized study. (J T HORAC C ARDIOVASC S URG 1994;108:321-8)