Reevaluation of diagnostic procedures for transmediastinal gunshot wounds

BACKGROUND: Little controversy surrounds the treatment of hemodynamically unstable patients with transmediastinal gunshot wounds (TMGSWs). These patients generally have cardiac or major vascular injuries and require immediate operation. In hemodynamically stable patients, debate surrounds the extent and order of the diagnostic evaluation. These patients can be uninjured, or can have occult vascular, esophageal, or tracheobronchial injuries. Evaluation has traditionally often included angiography, bronchoscopy, esophagoscopy, esophagography, and pericardial evaluation (i.e., pericardial window) for all hemodynamically stable patients with TMGSWs. Expansion of the use of computed tomographic (CT) scanning in penetrating injury led to a modification of our protocol. Currently, our TMGSW evaluation algorithm for stable patients consists of chest radiograph, focused abdominal sonography for trauma, and contrast-enhanced helical CT scan of the chest with directed further evaluation. The purpose of this study is to evaluate the efficiency of contrast-enhanced helical CT scan for evaluating potential mediastinal injuries and to determine whether patients can be simply observed or require further investigational studies. METHODS: Medical records of hemodynamically stable patients admitted with TMGSWs over a 2-year period were reviewed for demographics, mechanism of injury, method of evaluation, operative interventions, injuries, length of stay, and complications. CT scans were considered positive if they contained a mediastinal hematoma or pneumomediastinum, or demonstrated proximity of the missile track to major mediastinal structures. RESULTS: Twenty-two stable patients were studied. CT scans were positive in seven patients. Directed further diagnostic evaluation in those seven patients revealed two patients who required operative intervention. Sixty-eight percent of patients had negative CT scans and were observed in a monitored setting without further evaluation. There were no missed injuries. The hospital charges generated with the CT scan-based protocol are significantly less than with the standard evaluation. CONCLUSION: Contrast-enhanced helical CT scanning is a safe, efficient, and cost-effective diagnostic tool for evaluating hemodynamically stable patients with mediastinal gunshot wounds. Positive CT scan results direct the further evaluation of potentially injured structures. Patients with negative results can safely be observed in a monitored setting without further evaluation.     

Screening helical computed tomographic scanning in haemodynamic stable patients with transmediastinal gunshot wounds

AIM: The purpose of this study was to review and evaluate the efficacy of contrast-enhanced helical computed tomographic (CT) scanning in evaluating potential mediastinal injuries in stable patients with transmediastinal gunshot wounds (TMGSWs). METHODS: During the review period, 01 January 2002-31 May 2005, the medical records of all haemodynamically stable patients with TMGSWs were retrieved and reviewed for demographics, diagnostic workup, treatment and complications. Screening CT was considered inconclusive in the presence of a mediastinal haematoma, pneumomediastinum or a missile track in proximity of major mediastinal structures. Inconclusive CT scans were further evaluated with angiography, and/or oesophography, and/or cardiac ultrasound. RESULTS: Fifty consecutive haemodynamically stable patients with TMGSWs were identified. Thirty-five CT scans were performed, of which 29 (82.9%) were conclusive. Further diagnostic evaluation in the remaining six patients showed no injury. All patients were observed in a high-care unit and there were no missed injuries. The hospital charges generated with the CT scan based protocol were significantly less than with standard evaluation. CONCLUSION: Contrast enhanced helical CT scanning is a safe, efficient and cost effective screening tool for evaluating haemodynamically stable patients with TMGSWs.     

Transmediastinal gunshot injuries

BACKGROUND: Transmediastinal gunshot injuries are a rarely reported injury. Until recently, assessment of the thoracic aorta by angiography preceded the investigation of the esophagus. This order has been recently debated. METHODS: There were 118 patients with potential transmediastinal injuries included in this retrospective study. Unstable patients who were unresponsive to resuscitation were taken to the operating room without previous investigation. Stable patients were routinely investigated initially for injury of the aorta and then for injury of the esophagus. RESULTS: There were 51 patients who underwent urgent thoracotomy/sternotomy. In 27, the hemorrhage was of mediastinal origin; 17 of these patients died of intraoperative bleeding. Eight of the patients had aortic injury, and only one of this group survived. There were 57 stable patients who were investigated initially for injury of the aorta by angiography. It was positive in only one patient who underwent an operation with good results. An investigation of the esophagus followed and revealed esophageal injury in 17 patients. All of them were treated operatively, 15 of them with satisfactory outcome. CONCLUSIONS: Angiography should at present precede esophageal investigations. There is a need for shortening the time between admission and operation. Other modalities that could expedite the investigation of the thoracic aorta and the esophagus should be prospectively evaluated in multi-center studies.     

Esophageal Gunshot Injuries

During a 15-year period from August 1964 to August 1979, 48 patients with gunshot wound of the esophagus (24 of the cervical, 17 of the thoracic, and seven of the abdominal) were treated at Grady Memorial Hospital. In the majority of the patients, the initial history, physical findings, and chest roentgenograms were nondiagnostic for esophageal injury. Esophageal perforation was mainly suspected because the bullet tract was in close proximity to the esophagus or the bullet had traversed the mediastinum. The diagnosis of esophageal perforation was made by esophagography (29 patients), at the time of emergency surgical exploration for suspected other organ injuries (17 patients), or by esophagoscopy (one patient). All but one patient were treated surgically. The surgical procedure most commonly used was primary repair of the esophageal wound with wide drainage of the mediastinum. Thirty-eight (79.2%) of the 48 patients survived, 21 (87.5%) of the 24 patients with cervical, 11 (64.7%) of the 17 patients with thoracic, and six (85.7%) of the seven patients with abdominal esophageal wounds. Ten patients died, three with cervical wound, six with thoracic wound, and one with abdominal esophageal wound. Three patients died intraoperatively from major bleeding and the remaining seven died from the esophageal and/or other associated injuries, four to eight days after surgery. None of the seven patients who underwent primary repair with wide drainage and plication of the suture line with pleural flap or other tissue, died or developed leak at the suture line. This study suggests that the physical and roentgenographic findings in patients with esophageal injury are often nondiagnostic and frequently are masked by coincidental injury to other organs. Hence, a high index of suspicion is required for the diagnosis of esophageal injury from gunshot wounds and esophagography should be performed as soon as the patient's condition is stable in all patients who present with a missile wound in close proximity to the esophagus or traversing the mediastinum. All patients with perforation of the esophagus from bullet wounds should be operated upon as soon as possible after the diagnosis is made. Wide drainage of the mediastinum and primary repair of the esophageal wound and plication of the suture line with parietal pleura or gastric fundus provide the best possible results.     

The value of CT scan in gunshot injuries of the brain

Summary Fourteen cases of gunshot wounds of the brain, evaluated by CT scanning are presented. The results indicate that CT scanning is superior to other diagnostic tests in missile wounds of the brain. In individual patients it revealed gross injury to the skull, the location of the bullet or its fragments and indriven bone fragments, the track of the bullet, the gross injury suffered by the brain, the extent of oedema, the presence of any intracranial haematoma and late cerebral atrophy.Visualization of the missile track is of particular importance; this cannot be achieved by any other diagnostic method. It is essential for the planning of the surgical approach in these lesions.     

Bullet embolus to the heart after gunshot wound to the neck: a case report

A 43-year-old woman presented with gunshot wounds to the neck, chest, and left thigh. Computed tomography of the neck and chest with intravenous contrast revealed a left common carotid pseudoaneurysm and a foreign body in the right atrium. Preoperative chest x-ray and CT scan confirmed a metallic foreign body in the right heart. At median sternotomy, the intracardiac foreign body could not be located using fluoroscopy. The foreign body (bullet) was subsequently removed in the cardiac catheterization laboratory using a percutaneous transvenous basket extraction through a right femoral vein cutdown.     

Computed tomography in the evaluation of penetrating neck trauma: a preliminary study.

HYPOTHESIS: Penetrating neck trauma has traditionally been evaluated by surgical exploration and/or invasive diagnostic studies. We hypothesized that computed tomography (CT), used as an early diagnostic tool to accurately determine trajectory, would direct or eliminate further studies or procedures in stable patients with penetrating neck trauma. DESIGN: Retrospective case series. SETTING: Academic, urban, level I trauma center. PATIENTS: Hemodynamically stable patients without hard signs of vascular injury or aerodigestive violation who had sustained penetrating trauma to the neck. INTERVENTIONS: Patients underwent a spiral CT as an initial diagnostic study after initial evaluation in the trauma bay. Further invasive studies were directed by CT findings. MAIN OUTCOME MEASURES: Number of invasive studies performed. RESULTS: Twenty-three patients were identified during the 30-month period. Nineteen patients sustained gunshot wounds; 3, shotgun wounds; and 1, a stab wound. One patient died of a cranial gunshot wound. Three isolated zone I, 1 isolated zone II, 9 isolated zone III, and 10 multiple neck zone trajectories were evaluated. Thirteen patients were identified by CT to have trajectories remote from vital structures and required no further evaluation. Ten patients underwent angiography. Only 2 underwent bronchoscopy and esophagoscopy. Four patients were discharged from the emergency department; 7 other patients were discharged within 24 hours. No adverse patient events occurred before, during, or after CT scan. CONCLUSIONS: Computed tomography in stable selected patients with penetrating neck trauma appears safe. Invasive studies can often be eliminated from the diagnostic algorithm when CT demonstrates trajectories remote from vital structures. As a result, efficient evaluation and early discharge from the trauma bay or emergency department can be realized. Further prospective study of CT scan after penetrating neck trauma is needed.     

Penetrating injuries of the mediastinum

This study reviews 47 patients who were operated on for acute penetrating mediastinal wounds. These included 40 cases of cardiac tamponade, 2 mediastinal hematomas, 1 contused myocardium, 3 esophageal wounds, and 1 VSD. Stab wounds were most common (73%) followed by gunshot wounds (23%), and shotgun wounds (4%). When measured, central venous pressure was 15 cm or greater in 28 out of 32 patients (87.5%) with proven tamponade. By contrast, Beck's criteria (distended neck veins, distant heart sounds, hypotension) were noted in only 19 (48%) of 40 cases of tamponade. Emergency room pericardiocentesis resulted in improvement in 20 of 22 cases (91%), affording time for definitive operative therapy. The majority of entrance wounds (85%) occurred in the anterior mediastinal region. Peritoneal lavage in 15 cases yielded 5 true positive, 9 true negative, and 1 false positive tests. Most commonly injured areas were right ventricle (20 patients), left ventricle (11 patients), pericardium (5 patients), and right atrium (4 patients). Isolated esophageal injuries occurred in 3 of 11 gunshot wounds (27%). Complications were numerous (70%) and mortality ranges as follows: GSW 27% SW 15% SGW 0%. Central venous pressure determination and early pericardiocentesis are useful in suspected cases of tamponade. In GSW, an esophagogram is indicated to rule out isolated injury. Median sternotomy is the operative exposure of choice for mediastinal injuries causing cardiac tamponade.     

Penetrating zone II neck injury: does dynamic computed tomographic scan contribute to the diagnostic sensitivity of physical examination for surgically significant injury? A prospective blinded study

OBJECTIVE: The purpose of this study was to prospectively evaluate the utility of dynamic computed tomographic (CT) scanning as a diagnostic tool and adjunct to physical examination in the identification of surgically significant penetrating zone II neck injuries. METHODS: All patients older than 14 years of age who suffered penetrating zone II neck injuries were eligible for entry into the study protocol at an urban Level I trauma center. All patients that presented with signs of surgically significant injury on physical examination underwent immediate neck exploration. Patients that did not show signs of surgically significant injury were entered into the study protocol and underwent soft tissue dynamic CT scan (1/2-cm cuts, 250-mL oral contrast) of the neck after initial resuscitation. After CT scan, all patients entered into the study protocol underwent esophagography. After completion of radiologic assessment, all study protocol patients underwent surgical exploration of the neck. The patient's surgical team was blinded to results of the CT scan and esophagography before and during surgical exploration of the neck. RESULTS: During a 42-month period from May 1997 to March 2001, 42 patients were entered into the study protocol. Thirty-six (86%) of the injuries were secondary to stab wounds and the rest were caused by gunshot wounds. Surgical exploration revealed four esophageal injuries, of which two (50%) were missed by CT scan. Esophagography missed the identical esophageal injuries, as did CT scan. Both of the missed esophageal injuries were secondary to stab wounds. Seven internal jugular vein injuries were diagnosed intraoperatively, of which four (57%) were diagnosed by CT scan. During the study period, all patients with carotid artery and tracheal injuries were diagnosed by physical examination and thus underwent immediate surgical exploration without study entry. CONCLUSION: Dynamic CT scan contributes minimally to the sensitivity of physical examination in the diagnosis of surgically significant penetrating zone II neck injury. Diagnosis of esophageal injuries with dynamic CT scan appears no better than esophagography. CT scan has greater sensitivity than physical examination for the diagnosis of jugular venous injuries; however, the majority of these injuries do not require identification or surgical intervention.     

Computerized tomographic scan and gunshot wounds of the head: indications and radiographic findings.

The authors document their experience with the computerized tomographic (CT) scanner for evaluating gunshot wounds of the head. Only those patients who were considered to be operative candidates and who were neurologically stable were scanned. In the postoperative period, patients who were not scanned preoperatively and those whose condition did not improve were also scanned. In the preoperative period the CT scanner is useful for identifying and localizing missile tracks, bony and metallic fragments, intra- and extraparenchymal hematomas, intracranial air, and brain swelling. In the postoperative period the CT scanner may demonstrate retained bone fragments, edema, brain abscess, and intracranial air. The limitations of the CT scan in evaluating gunshot wounds include an inability to define vascular lesions suchas traumatic aneurysms and post-traumatic spasm. Metallic scatter from missile fragments may render certain CT cuts uninterpretable. In addition, the CT scan may appear minimally abnormal in spite of immediate and irreversible injury caused by a shock wave transmitted to brain stem structures. The CT scanner has superceded angiography as a diagnostic tool for evaluating gunshot wounds of the head because it is noninvasive and rapid, allows visualization of the entire head, can resolve very small lesions that produce little or no mass effect, can help to determine the nature of intracranial lesions and may quantitate the amount of hemorrhage and edema. Because it enables physicians to visualize intracranial structures in three dimensions, the CT scan may precisely define missile tracks and contiguous lesions in a manner not heretofore possible with other diagnostic modalities. Thus, it is invaluable for the rational planning of surgical therapy.     

Infection about the spine associated with low-velocity-missile injury to the abdomen

We reviewed the cases of twenty patients who had a fracture or disruption of the disc space of a lower thoracic or lumbar vertebra that was associated with a low-velocity-missile wound to the abdomen. All of the patients underwent an exploratory laparotomy at the time of admission and all received broad-spectrum antibiotics for a minimum of two days. None of the patients had an immediate laminectomy or an immediate debridement of the paraspinal area. In eight patients the gastrointestinal tract was not perforated, and none of them had evidence of infection. In four patients the stomach and small bowel were perforated by the bullet before it struck the vertebral column, and none of them had meningitis, paraspinal infection, or osteomyelitis. In contrast, meningitis, paraspinal infection, or osteomyelitis did develop in seven of eight patients in whom the bullet perforated the colon before it hit the vertebra. Perforation of the colon by a low-velocity missile before the missile fractured the thoracic or lumbar vertebra was associated with a high incidence of infection. The appropriate management may require early operative intervention. This is in contrast to the non-operative approach that has been advocated for low-velocity gunshot wounds to the spine. We agree that a non-operative approach is indicated for gunshot wounds of the abdomen that do not involve the colon.     

Transmediastinal gunshot wounds in a mature trauma centre: Changing perspectives

Background

Transmediastinal gunshot wounds are associated with a high mortality and frequently require operative intervention. The purpose of this study was to identify the diagnostic and therapeutic challenges of these injuries in a mature trauma system with decreasing prehospital time intervals.

Methods

Patients admitted to a large urban Level 1 trauma centre between 1/2006 and 12/2010 sustaining a firearm injury to the torso were identified. Transmediastinal gunshot wounds were defined as missile tracts traversing the mediastinum identified on CT images, operative notes or autopsy reports.

Results

Overall, 133 patients met study criteria. A total of 116 patients (87.2%) were haemodynamically unstable or had no vital signs on arrival to the Emergency Department. Ninety-seven (83.6%) of these patients required a resuscitative thoracotomy resulting in 8 survivors (6.0%). There were 17 haemodynamically stable patients (12.8%) identified, 14 of whom underwent CT scan evaluation. Six patients subsequently required operative intervention. Only 11 patients (8.3%) in the study population were successfully managed nonoperatively. The overall mortality was 78.9%, and for those who reached the hospital with vital signs, the mortality was 24.3%.

Conclusions

Transmediastinal gunshot wounds encountered in a mature trauma centre are highly lethal injuries requiring resuscitative thoracotomy in most instances. Changing perspectives in these injuries may reflect the effects of an evolving prehospital care.     

Surgical management of late bullet embolization from the abdomen to the right ventricle: Case report

IntroductionSecondary embolus from gun projectile is a rare entity, it represents a clinical and therapeutic dilemma because the potential complications involving central and peripheral circulation. Each case reported in the literature represents a challenge because their unique and different clinical scenarios.Presentation of caseWe present the management of a 33-year-old man with past history of a gunshot wound on left flank with no evidence of any exit wounds, treated with exploratory laparotomy without removing the gunshot bullet from the abdomen. The patient presents 6 years later with non-productive cough and retrosternal pain with no other symptoms; the patient underwent a chest x-ray, electrocardiogram, thoracoabdominal CT, echocardiogram and cardiac catheterization and showed a bullet in the right ventricular floor. The projectile was extracted by sternotomy with extracorporeal circulation through the right atrium, without any complications.DiscussionIn 1834, Thomas David reported for the first time a wood-fragment embolization. There have been reported less than 200 cases including embolization of other materials; most of the gunshot bullet embolization cases reported on literature were reported after war. Clinical manifestations are associated with the anatomical site of embolism and mortality rate for a retained bullet is 6% associated with complication in 25% of cases. Mortality rate decreases to 1–2% if the bullet is removed.ConclusionThere are no established guidelines about the management of migrating foreign bodies or bullets, however, conservative, endovascular and surgical management have been proposed. In the cases of bullet embolization to the thoracic cavity, surgery represents a safe, low risk approach with high success rates.     

Management of esophageal gunshot wounds

The records of 20 patients with gunshot wounds of the esophagus seen from 1973 through 1985 were reviewed. Nine perforations were cervical, 10 were thoracic, and 1 was abdominal. Because physical findings and plain roentgenograms lack specificity, a high index of suspicion based on the path of the bullet tract is essential for early diagnosis. Esophageal injury should especially be suspected when the bullet wound is transcervical or transmediastinal. Perforation was diagnosed by esophagoscopy in 9 patients, esophagography in 4, and surgical exploration in 7. Mean time from admission to operation was 3.8 hours. Associated injuries occurred frequently. Eighteen patients were treated by primary closure and wide drainage, and 2 were managed by esophageal exclusion. There were 2 perioperative deaths, both in patients with associated aortic injuries, and 1 late death, for an overall mortality of 15%. There was one postoperative leak following a cervical repair. No leaks occurred in patients having a thoracic repair. The findings indicate that esophageal perforation must be sought by a variety of methods. With prompt diagnosis and early operation, primary repair can be safely accomplished. When sepsis from esophageal leak is avoided, mortality and major morbidity are related to associated injuries.     

Current treatment of gunshot wounds to the spine

The incidence of spinal cord injury from gunshot wounds in penetrating trauma continues to increase with the violent nature of society. This particularly is true in urban areas, as is found with other violent crime. Either the direct path of the bullet or the concussive effects cause injury to the spine and spinal column. Thorough patient evaluation and appropriate radiographic studies will provide the keys to treatment of these patients. Criteria are given for treatment related to neurologic findings and progressive neurologic evaluation. Infection related to missiles penetrating through the alimentary tract and then lodging in the spine is a relatively rare complication and appropriate standards for debridement and fragment removal are discussed. Principles of treatment in all missile injuries to the spine evolve around spine stability, aggressive rehabilitation, and preservation of neurologic function.     

Prognostic factors and treatment of penetrating gunshot wounds to the head

BACKGROUND: In an attempt to evaluate the predictive factors of morbidity and mortality in patients who suffered from civilian gunshot wounds to the head, we reviewed a series of 319 patients admitted to the Hospital Santa Marcelina, S?o Paulo, Brazil, between 1994 and 2000. METHODS: Clinical and cranial computed tomography (CT) results are described. The initial Glasgow Coma Scale (GCS), the presence of an unilateral dilated pupil or medium fixed pupils, and five different findings in the CT scan were considered as variables. The Qui-Square Fisher test was utilized to verify the correlation between the presence of the variables and the occurrence of an increased mortality rate and of an unfavorable outcome (Glasgow Outcome Scale = 2 and 3). RESULTS: In 265 cases the missile penetrated the dura (83%). In our study there was a significant correlation between the low GCS scores on admission and a higher mortality (p < 0.001). This kind of correlation was also noted with patients admitted with unilateral dilated pupil and medium fixed pupil. There were 187 patients (70.5%) evaluated by CT scan. There was a significant correlation between the presence of transventricular or bihemispheric central type trajectory and high mortality. The patients admitted with unilobar supratentorial wounds resulted in better outcome when compared to those with bilobar or multilobar wounds (p < 0.001). A group of 156 patients was submitted to an aggressive surgical protocol. The best results were seen in patients admitted with initial GCS score higher than 8. CONCLUSIONS: We conclude that low GCS scores at admission, unilateral dilated pupil or medium fixed pupil, transventricular or bihemispheric central type trajectory, and bilobar or multilobar wounds noted through CT scan are predictive factors of high morbidity and mortality in patients with gunshot wounds to the head, in our clinical experience. We also conclude that surgical treatment is not recommended for patients with penetrating wounds and GCS score of 3 to 5 in the absence of hematoma causing a mass effect.     

Civilian gunshot wounds to the brain: prognosis and management

The extent of treatment for the victims of gunshot wounds to the brain remains quite controversial, particularly when these patients present with extensive neurological dysfunction. We propose guidelines regarding the degree and aggressiveness of therapy. The factors that seem to have a significant impact on the patient's final outcome are the neurological examination at the time of admission, the radiological findings, and the motivation for the shooting. Thus, the authors propose a nonsurgical line of therapy for comatose patients with unilateral or bilateral cerebral gunshot wounds where bone or metal fragments are visualized away from the bullet path on computed tomography scan, particularly when these individuals are suicide victims.     

Arthroscopic management of intra-articular low-velocity gunshot wounds of the knee

This article reports on the arthroscopic management of intra-articular low-velocity gunshot wounds. Thirteen (12 men and 1 woman) patients comprised the study population treated over a 5-year period. All patients underwent arthroscopy within 24 hours of injury. Four patients had additional limited arthrotomies for internal fixation of associated fractures and removal of an embedded bullet. Allograft reconstruction as a delayed procedure was required in 1 patient with extensive bone deficiency of the medial femoral condyle. Two patients suffered cruciate ligament tears: one avulsion fracture of the femoral attachment of the posterior cruciate ligament and one avulsion tear of the tibial attachment of the anterior cruciate ligament. Meniscal damage was observed in 2 patients, one of which required a primary repair. No infections or operative complications occurred. Arthroscopic evaluation of the affected knees allowed debridement of osteochondral loose bodies, retained foreign materials and bullet fragments, and also aided in surgical decision making.     

Penetrating wounds of the esophagus

The histories of 22 patients with perforation of the esophagus from bullet or stab wounds who were treated at Grady Memorial Hospital between August, 1964, and July, 1971, were reviewed. The presenting symptoms, signs, and plain roentgenographic findings in this group of patients, because of the frequent existence of injuries to other organs, were not diagnostic for esophageal perforation. The routine use of esophagography in all patients who have a penetrating wound close to the esophagus or in whom the bullet or weapon may have traversed the mediastinum has been of great value in diagnosing esophageal injury resulting from such wounds. The treatment of choice for these patients is surgical repair of the esophageal wound with wide drainage of the soiled mediastinum as soon as the diagnosis is made.     

Value of systematic mediastinal lymph node dissection during pulmonary metastasectomy

BACKGROUND: Systematic mediastinal lymph node dissection is the accepted standard when curative resection of bronchial carcinoma is performed. However, mediastinal lymph node dissection is not routinely performed with pulmonary metastasectomy, in which only enlarged or suspicious lymph nodes are removed. The incidence of malignant infiltration of mediastinal lymph nodes in patients with pulmonary metastases is not known. METHODS: Sixty-three patients who underwent 71 resections through a thoracotomy for pulmonary metastases of different primary tumors were studied prospectively. Selected patients showed no evidence of tumor progression or extrathoracic metastases and pulmonary metastasectomy was planned with curative intent. All patients underwent preoperative helical computed tomography (CT) scanning. Only patients with no evidence of suspicious mediastinal lymph nodes on the CT scan (less than 1 cm in the short axis) were included in this study. A mediastinal lymph node dissection was performed routinely with metastasectomy. RESULTS: In 9 patients (14.3%) at least one mediastinal lymph node revealed malignant cells in accordance with the resected metastases. When compared with the preoperative CT scan, additional pulmonary metastases were detected in 16.9% of performed operations. There was a trend toward an improved survival rate in patients without involvement of the mediastinal lymph nodes. The number of pulmonary metastases had no influence on survival. CONCLUSIONS: On a patient-by-patient basis, the frequency of misdiagnosed mediastinal lymph node metastases is about the same as compared with non-small cell bronchial carcinomas. Systematic mediastinal lymph node dissection reveals a significant number of patients, who otherwise are assumed free of residual tumor. The knowledge of metastases to mediastinal lymph nodes after complete resection of pulmonary metastases could influence the decision for adjuvant therapy in selected cases.