Superior Mediastinal Nodes Research Articles

Risk analysis and long-term survival in patients undergoing resection of T4 lung cancer.

The aim of this study is to identify the risk group of patients with T4 lung cancer who could more likely benefit from surgical resection. Between January 1, 1990, and December 31, 1998, 77 patients underwent pulmonary resection for T4 lung cancer: lobectomy (n = 20), bilobectomy (n = 4) and pneumonectomy (n = 53). The T4 sites of mediastinal involvement were: Intrapericardiac portions of the pulmonary artery (n = 30), left atrium (n = 19), aorta (n = 8), superior vena cava (n = 8), carina (n = 7), the esophagus (n = 8) and the vertebral body (n = 6). Ten patients had multiple neoplastic nodules in the same lobe of the lung. Overall survival rates at 1, 2 and 3 years were 46, 31 and 21%, respectively. Factors adversely affecting survival with univariate analysis included the localization of tumours in the lower lobe (P = 0.04) and both the involvement of superior and inferior mediastinal lymph nodes (P = 0.03). Multivariate analysis included two factors adversely affecting survival: the location of the primary tumour and the nodal stations involved. Regression tree analysis classified the patients into low-risk group (primary tumour in upper lobe or in main stem bronchus and pN0 or pN1 or superior or inferior mediastinal nodes involved), intermediate-risk group (primary tumour in upper lobe or in main stem bronchus and both superior and inferior mediastinal nodes involved, primary tumour in inferior lobe and pN0 or pN1 or inferior mediastinal nodes involved) and high-risk group (primary tumour in inferior lobe and both superior and inferior nodes involved). The 3-year survival rates were 36% for the low-risk group, 4% for the intermediate-risk group and 0% for the high-risk group (P = 0.006). In patients with T4 lung cancer, the surgery can justify itself for tumours in the upper lobe or in the main stem bronchus and with pN0 or pN1.

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.

As originally published in 1990: superior vena caval reconstruction using autologous pericardium. Updated in 1998 by

Tumor involvement of the superior vena cava can occur either by direct extension of the primary tumor or by invasion of superior mediastinal lymph nodes. Removal of a portion of the caval wall may be required to allow adequate margins of resection. The technique described involves placement of an intraluminal shunt and resection of the involved caval wall with reconstruction using autologous pericardium.

A Prospective Randomized Trial of Extended Cervical and Superior Mediastinal Lymphadenectomy for Carcinoma of the Thoracic Esophagus

Background: Recurrence of thoracic esophageal carcinoma in the cervical and superior mediastinal lymph nodes occurs frequently and contributes to a poor prognosis. Extensive lymphadenectomy has been advocated. Findings in support of this to date, however, have been based on a comparison with historical controls. We herein report a prospective randomized trial of extended and conventional lymphadenectomy. Methods: Cases of thoracic esophageal carcinoma meeting criteria predictive of complete resection were randomized into conventional and extended cervical and superior mediastinal lymphadenectomy groups. Results: In the extended and conventional lymphadenectomy groups, respectively, mean operative time was 487 ± 47 and 396 ± 43 minutes, blood loss was 850 ± 429 and 576 ± 261 mL, node count was 82 ± 22 and 43 ± 15, hospital deaths occurred in 3% and 7%, 2-year survival was 83.3% and 64.8%, 5-year survival was 66.2% and 48.0%, and recurrence rate was 19.9% and 24.1%. Conclusion: Extended lymphadenectomy may prevent recurrence and prolong survival after resection of thoracic esophageal carcinoma.

The impact of surgical adjuvant thoracic radiation therapy for patients with nonsmall cell lung carcinoma with ipsilateral mediastinal lymph node involvement.

Previous nonsmall cell lung carcinoma studies have shown that patients with ipsilateral mediastinal (N2) lymph node involvement who underwent surgical resection have a greater local recurrence rate than those with less lymph node involvement (N0, N1). Therefore, it was hypothesized that complete surgical clearance of subclinical lymph node disease is difficult in N2 patients and that adjuvant postoperative thoracic radiotherapy (TRT) may be beneficial. A retrospective review was performed to determine the local recurrence and survival rates for patients with N2 disease undergoing complete surgical resection with or without adjuvant TRT. Between 1987 and 1993 at the Mayo Clinic, 224 patients underwent complete resection of N2 nonsmall cell lung carcinoma. More than one mediastinal lymph node station was sampled in 98% of patients; 39% then received adjuvant TRT (median dose, 50.4 grays). The median follow-up time was 3.5 years for the patients who were alive at the time of the analysis. The surgery alone versus surgery plus TRT groups were well balanced with respect to gender, age, histology, tumor grade, number of mediastinal lymph node stations dissected or involved, and involved N1 lymph node number. There were slightly more patients with right lower lobe lesions (compared with other lobes), patients with multiple lobe involvement, and patients with only one N2 lymph node involved in the surgery alone group. After treatment with surgery alone, the actuarial 4-year local recurrence rate was 60%, compared with 17% for treatment with adjuvant TRT (P < 0.0001). The actuarial 4-year survival rate was 22% for treatment with surgery alone, compared with 43% for treatment with adjuvant TRT (P = 0.005). On multivariate analysis, the addition of TRT (P = 0.0001), absence of superior mediastinal lymph node involvement (P = 0.005), and fewer N1 lymph nodes involved (P = 0.02) were independently associated with improved survival rate. This study, which to the authors' knowledge is the largest evaluating adjuvant TRT in N2 nonsmall cell lung carcinoma, suggests that adjuvant TRT may improve local control and survival.

Mediastinal staging of lung cancer: The changing role of mediastinoscopy: Weissberg D. Department of Surgery, Wolfson Medical Center, 58100 Holon. Isr J Med Sci 1995;31:122–124

In order to evaluate the role of mediastinoscopy in determination of resectability in lung cancer, we reviewed retrospectively our experience with this procedure. Of 936 mediastinoscopies performed during the past 22 years, 830 were performed for preoperative evaluation of patients with presumably resectable bronchogenic carcinoma. Metastases in superior mediastinal lymph nodes were found in 295 of 798 patients with histologically proven lung cancer (37%). These patients were spared an unnecessary thoracotomy. There was one death and no other major complications. Computerized tomography of the chest should be performed in all patients with bronchial cancer. If enlarged mediastinal nodes are demonstrated, mediastinoscopy is indicated for histologic evaluation of those nodes and for staging. Mediastinoscopy is a safe and highly reliable procedure with 100% specificity and over 90% accuracy, and is extremely important in staging and predicting resectability in lung cancer. It helps to avoid a futile thoracotomy in patients with incurable disease.

Lymph node metastasis and the recurrence of esophageal carcinoma with emphasis on lymphadenectomy in the neck and superior mediastinum.

A series of 335 patients with squamous cell carcinoma of the thoracic esophagus undergoing resection and reconstruction via a right thoracotomy and laparotomy with cervical anastomosis between 1973 and 1990, were reviewed. Prior to 1982, the removal of lymph nodes was limited to the nodes in the mediastinum below the tracheal bifurcation and upper abdomen (142 patients). Nodal metastases were found in 89 of these patients at operation. The upper abdominal nodes were the most frequent sites of metastasis (47.2%). None of the 38 patients with positive nodes sampled from the neck and superior mediastinum survived for more than 45 months. In the 50 patients with recurrences, 30 were in the neck and/or superior mediastinum. During or after 1983, the superior mediastinal nodes, particularly the bilateral recurrent nerve nodal chains, were routinely removed (193 patients). Nodal metastasis was proven in 131 of the 193 patients, in whom 87 (45.1%) had metastasis in the neck and superior mediastinum. Eleven of these 87 patients survived for 45 months or more. In the 61 patients with recurrences, 20 were in the neck and/or superior mediastinum. These data suggest that recurrent nerve nodal chains should be removed to improve survival in patients with esophageal carcinoma.

Interobserver Variation in the Computed Tomographic Evaluation of Mediastinal Lymph Node Size in Patients With Potentially Resectable Lung Cancer

To measure the reliability of the assessment of mediastinal lymph node size in computed tomographic (CT) scans of the thorax. Observer agreement study in which radiologists, blinded to one anothers' interpretation, were randomized to read 30 scans each. Sixty scans from patients with apparently operable non-small cell carcinoma of the lung were read by radiologists responsible for clinical interpretation (clinical radiologists) and four radiologists with a special interest in thoracic CT (study radiologists). Radiologists measured the size of left and right superior mediastinal nodes, aortic nodes, and the subcarinal nodes and, on the basis of whether any nodes accessible to mediastinoscopy were greater than 1 cm, recommended whether mediastinoscopy be undertaken. Agreement was quantified using kappa, a measure of chance-corrected agreement. Among all radiologists, agreement on whether there were any nodes larger than 1 cm for right superior mediastinal nodes was 0.68; for left superior mediastinal nodes it was 0.28; for aortic pulmonary nodes it was 0.62; for subcarinal nodes it was 0.58; and for any node greater than 1 cm and accessible to mediastinoscopy it was 0.61. The agreement was very similar when the analysis was restricted to the study radiologists. Although the good level of overall agreement suggests that CT provides useful information in the evaluation of mediastinal lymph node size, the disagreement was sufficient that it likely contributes to suboptimal sensitivity and specificity of CT in detecting tumor spread reported in previous studies.

Lymph node dissection.

Cervical lymph nodes are involved in 43% of patients with an upper esophageal lesion, 33% of patients with a middle third tumor, and 29% with a tumor of the lower third. Conventional two-field lymph node dissection removing the abdominal and lower mediastinal lymph node groups leads to inaccurate staging and is inadequate for preventing local recurrence. Three-field lymphadenectomy involves bilateral removal of the lower cervical groups of nodes, the superior, middle, and inferior mediastinal lymph nodes and the abdominal groups. The advantages of this extended dissection are improved survival, diminished incidence of local recurrence, and more accurate staging. The benefits in terms of improved survival may accurate to patients both with and without cervical lymph node involvement. Three-field node dissection improves 5-year survival to around 35% without an increase in the mortality rate. The incidence of recurrent laryngeal nerve paralysis is increased with the operation and could be as high as 14% or more.

頚胸境界部食道癌の合理的リンパ節郭清 生物学的悪性度に応じた合理的切除・郭清

During the period from 1980 to 1991, sixteen cases of carcinoma involving the cervicothoracic esophagus were resected in our institute. Among these, nine cases died of a recurrence in the superior mediastinal lymph nodes or in the lungs. Suggesting that prophylactic strategies against these two patterns of recurrence should be considered. As an approach to carcinoma in the cervicothoracic esophagus, we designed an exclusive right thoracic approach: a right anterolateral incision through the fourth intercostal space with an upper median sternotomy, namely an “door open method.” By opening the incised anterior chest wall laterally, optimal access to the cervicothoracic esophagus and the lymph nodes along the recurrent laryngeal nerve is obtained. We have become able to identify preoperatively esophageal cancer patients with high malignancy by factors such as the tendency to relapse in distant organs after surgery, and by an examination of the amplification of some oncogenes (namely int-2/hst-1) in endoscopically biopsied specimens. For this kind of patient, limited field surgery, namely transhiatal esophagectomy, is desirable in order to conserve the patient's immunity, which then makes possible an effective adjuvant chemotherapy following surgery.

Surgical management of non-small-cell lung cancer with ipsilateral mediastinal node metastasis (N2 disease)

Between 1979 and 1989, 876 patients with non-small-cell lung carcinoma were referred to our unit for surgical treatment. One hundred forty-six patients were judged not suitable for surgical treatment on clinical, radiologic, or bronchoscopic findings. Cervical mediastinoscopy or anterior mediastinotomy (or both) showed that 151 patients had mediastinal involvement by invasion or metastases into the ipsilateral (N2 disease) or contralateral (N3 disease) superior mediastinal lymph nodes and were therefore deemed inoperable. Except for one patient who had involvement of a single nodal station at mediastinoscopy, all other patients ( n = 578) undergoing thoracotomy were thought, on the basis of computed tomographic scan or mediastinal exploration (or both) not to have N2 disease. Despite our efforts to avoid surgery on patients with N2 disease, at thoracotomy routine mediastinal node dissection disclosed that 149 patients had unsuspected N2 disease. Resection was possible in 130 (87.3%) by pneumonectomy ( n = 72), bilobectomy ( n = 7), lobectomy ( n = 49), or lesser resection ( n = 2). In three patients the resection was incomplete (2.3%), but in 127 a complete resection was performed (85%). Histologic examination in these 149 patients showed that 72 tumors were squamous cell carcinoma, 54 adenocarcinoma, 14 large-cell carcinoma, and 9 of mixed type. Eight patients died in the hospital after thoracotomy. Adjuvant therapy was not used after complete resection. Complete follow-up was obtained in 134 patients and the mean follow-up period was 27.25 months (1 to 116 months). The actuarial 5-year survival for those having complete resection was 20.1%. There was a statistically significant difference favoring long-term survival in those patients with squamous cell carcinoma ( p < 0.01) and those in whom only one nodal station was involved ( p < 0.05). Neither the extent of resection nor the involvement of any specific nodal station influenced long-term survival. Despite rigorous preoperative investigations, routine mediastinal node dissection demonstrated mediastinal node metastasis for the first time at thoracotomy in 26% of our patients. We believe resection is justified in these patients, who have already necessarily incurred the morbidity and mortality of thoracotomy, so long as complete resection is possible. (J THORACCARDIOVASCSURG1994;107:19-28)

A SURGICAL CASE OF NON-HODGKIN LYMPHOMA ORIGINATING FROM THE THYMUS

A 65-year-old was admitted to the hospital because of dyspnea on exertion. There were previous histories of pulmonary tuberculosis, emphysema and right pneumothorax. Chest X-ray film showed an superior mediastinal tumor. Chest CT, MRI and Ga-scintigraphy showed the tumor originating from the thymus with metastasis to the superior mediastinal lymph nodes. It was difficult to perform transcutaneous needle biopsy and mediastinoscopy based on his radiologic studies. Therefore, surgical extirpation of the tumor was performed by median sternotomy for differential diagnosis. Although the tumor had invaded the right phrenic nerve, the surgery resulted in incomplete resection due to his reduced pulmonary function. The pathological diagnosis was non-Hodgkin lymphoma, diffuse and mixed type. Postoperatively, he received chemotherapy. For mediastinal malignant lymphoma, chemotherapy with or without radiation therapy is the treatment of choice. Surgical resection is rarely performed in the management of these patients. However, surgery should be performed for differential diagnosis, if biopsy is not feasible and the tumor is localized in the anterior mediastinum.

Endoscopic Ultrasound Examination for Mediastinal Lymph Node Metastases of Lung Cancer

Among patients with primary lung cancer who were admitted to the National Cancer Center Hospital from July 1987 to April 1988 for surgical treatments, 132 underwent preoperative transesophageal endoscopic ultrasound examination (EUS) on mediastinal lymph nodes. Of the 132 patients, 101 were pathologically evaluated and studied in this article. A GF-UM2 radial scanner with 7.5-MHz (Olympus Co Ltd) was used for image examination. The lymph nodes were diagnosed as positive for metastasis when they had thickened images, clear contours, and low echoing images of fusion or lobulation. The results obtained from 509 sites were as follows: sensitivity, 53.6 percent; specificity, 97.5 percent; positive predictive accuracy, 77.1 percent; negative predictive accuracy, 93.1 percent; and overall accuracy, 91.6 percent. The sensitivity rate was 80.6 percent excluding the result of the right superior mediastinal lymph nodes that were difficult to examine for anatomic reasons. Although EUS was considered to be an excellent method in diagnosing lymph node metastases, it had a blind angle in the field. More accurate diagnoses of mediastinal lymph node metastases could be achieved by using EUS and computed tomography (CT) together.

Superior vena caval reconstruction using autologous pericardium

Tumor involvement of the superior vena cava can occur either by direct extension of the primary tumor or by invasion of superior mediastinal lymph nodes. Removal of a portion of the caval wall may be required to allow adequate margins of resection. The technique described involves placement of an intraluminal shunt and resection of the involved caval wall with reconstruction using autologous pericardium.

Hodgkin disease: CT of the thymus.

The computed tomography (CT) scans in two groups of patients with Hodgkin disease were reviewed to determine the frequency of thymic enlargement. In 50 CT scans from 50 patients with evidence of thoracic disease on CT scans who were examined for primary staging, the thymus was enlarged in 15 of 50 (30%). Fifty CT scans were obtained from 44 patients at the time of 50 separate episodes of known or suspected relapse. Relapse occurred in the mediastinum in 12 episodes, lung parenchyma in five, and both sites in one. Thymic enlargement thought to be due to involvement by disease was present in seven of 18 (38%). Mediastinal disease was associated with thymic enlargement in all but one patient in whom a thymic cyst developed after radiation therapy. Differentiation of thymic enlargement from enlarged superior mediastinal lymph nodes was easily made in all but two patients. Thymic enlargement in the absence of lymph node enlargement may indicate a different disease, since isolated Hodgkin disease of the thymus is uncommon. Primary thymic tumor should be considered initially, whereas after treatment, rebound hyperplasia of the thymus may be the cause of enlargement.

Ｃｏｍｐｕｔｅｄ ｔｏｍｏｇｒａｐｈｙ（ＣＴ）による胸部食道癌の術前診断の有用性について

One hundred and twenty eight patients with thoracic esophageal carcinomas encountered clinically were admitted to this study. In the present study, we diagnosed the metastasis of esophageal carcinoma to cervical and superior mediastinal lymph nodes, and its invasion into the neighboring structures such as trachea and bronchus based on CT scan.We mentioned the usefulness and limitation of diagnosis by CT. Diagnostic accuracy of the metastasis to lymph nodes on CT was 93.3%. For lymph nodes more than 1cm in diameter, correct diagnosis by CT was made in 96.0%. About 25% of large lymph nodes in the area of 107 were complicated with anthracosis, so it seemed difficult to diagnose the presence of metastasis by CT. Diagnostic accuracy of the direct invasion was 99.2% in the trachea and 99.2% in the bronchus. Accordingly, CT scan was a useful method to know the degree of the tumor invasion in these regions.

TWO CASES OF OAT CELL CARCINOMA OF THE ESOPHAGUS

Two cases of oat cell carcinoma of the esophagus are reported together with a review of the related literature. Case No. 1, a 54-year-old-man with a 3-month history of dysphagia, was found to have a spiral-shaped lesion 16cm in length along the entire thoracic esophagus (In Im Ei). After preoperative irradiation at a dose of 40 Gy which was fairly effective, radical esophageal resection and reconstruction were performed. The patient was discharged and soon returned to work. Approximately 10 months after surgery, however, a recurrent tumor was found in the superior mediastinum. Irradiation at a dose of 60 Gy and immunochemotherapy with CDDP and OK-432 proved effective, and the patient has survived for approximately 29 months since the first operation, an extremely long period for a case of oat cell carcinoma. Case No. 2, a 59-year-old man with a 3-month history of dysphagia, was found to have not only a spiral-shaped lesion 10cm in length in the middle to lower esophagus (Im Ei), but also an early-stage cancer (IIa) in the anterior wall of the antrum of the stomach. Because of hepatic and pulmonary dysfunction, surgery was divided into 2 stages. In the early postoperative period after subtotal esophagectomy, however, the patient developed extensive metastasis in the superior mediastinal and abdominal lymph nodes and died of pneumonia caused by Pneumocystic carinii. Light microscopy revealed the cellular morphology in the esophageal lesions of both cases. Argyrophilic cytoplasm was not demonstrated by histochemistry, but electron microscopy revealed the presence of the neurosecretory granules in the two lesions. Therefore, the esophageal lesions in both cases were diagnosed as oat cell carcinoma.

Role of Mediastinoscopy in Pretreatment Staging of Patients with Primary Lung Cancer

Since the introduction of mediastinoscopy, there has been a great deal of discussion regarding indications for this technique and the significance of positive findings. We undertook this study to determine the role of clinical staging and the value of routine mediastinoscopy in the treatment selection of patients with primary lung cancer. From 1975 to 1983, 1,259 consecutive patients with proven and operable lung cancer underwent preresection mediastinoscopy. Nodes were sampled at three levels, and findings were recorded by location, invasiveness, and histology. There were no operative deaths, but 3 patients had a major complication. Mediastinoscopy was positive in 339 (27%) patients and negative in 920 (73%). In the group with positive findings, 303 patients had no operation because a curative resection was not possible (extranodal metastases, 180; location, 76; histology, 47). No patient survived 5 years, and only 4% survived 2 years. Of the 36 patients considered to have operable disease, 28 underwent resection with a projected 5-year survival of 18%. In the group with negative findings, 89% had a curative resection with a hospital mortality of 3.2% and 5-year survival of 53%. When results of mediastinoscopy were correlated with findings at thoracotomy, the sensitivity of the test was 93% on nodes in the superior mediastinum and the specificity, 100%. This study shows that mediastinoscopy is safe and is an accurate indicator of the presence or absence of tumor in superior mediastinal nodes. If positive nodes are found, a curative resection is generally not possible, thoracotomy is avoided, and the overall survival is low.

Significance of positive superior mediastinal nodes identified at mediastinoscopy in patients with resectable cancer of the lung

The prognosis for resectable lung cancer with metastases in mediastinal nodes is not clear. There are 12 papers reporting results in such cases, and the 5 year survival figures range from 0% to 30%. During the past 17 years at Toronto General Hospital, 141 patients had a thoracotomy for presumably operable, non-oat cell lung cancer with metastases in mediastinal nodes. Group 1, those with “mediastinoscopy positive” nodes, comprised 79 cases. This is a highly selected subset of patients with presumably operable lung cancer who had ipsilateral superior mediastinal metastases identified by mediastinoscopy, and in whom a curative resection was deemed possible. This subset represents only one fifth of our patients with presumably operable lung cancer in whom N2 status is defined at mediastinoscopy. The actuarial 5 year survival rate for all 79 patients was 9%. The 5 year survival rate in 51 curative resections was 15%, and no patient having a palliative resection survived 5 years. Group 2, those with “mediastinoscopy negative” nodes (N2 status determined at thoracotomy) comprised 62 cases. All 62 patients had negative mediastinoscopy, and the N2 status was established only at subsequent thoracotomy. The actuarial 5 year survival rate was 24% for all 62 patients, 41% for the 25 curative resections and 14% for the 22 palliative resections. The survival rate is significantly worse in those patients whose N2 status is established at mediastinoscopy than in those patients with a “negative mediastinoscopy” in whom the N2 status is established at subsequent thoracotomy. The application of mediastinoscopy in the selection of operable N2 lesions is emphasized.

The role of mediastinoscopy in the selection of treatment for bronchial carcinoma with involvement of superior mediastinal lymph nodes

The role of mediastinoscopy in the selection of treatment for bronchial carcinoma with involvement of superior mediastinal lymph nodes