Surgery for non-small cell lung cancer: systematic review and meta-analysis of randomised controlled trials

BACKGROUND: Surgery is considered the treatment of choice for patients with resectable stage I and II (and some patients with stage IIIA) non-small cell lung cancer (NSCLC), but there have been no previously published systematic reviews. METHODS: A systematic review and meta-analysis of randomised controlled trials was conducted to determine whether surgical resection improves disease specific mortality in patients with stages I-IIIA NSCLC compared with non-surgical treatment, and to compare the efficacy of different surgical approaches. RESULTS: Eleven trials were included. No studies had untreated control groups. In a pooled analysis of three trials, 4 year survival was superior in patients undergoing resection with stage I-IIIA NSCLC who had complete mediastinal lymph node dissection compared with lymph node sampling (hazard ratio estimated at 0.78 (95% CI 0.65 to 0.93)). Another trial reported an increased rate of local recurrence in patients with stage I NSCLC treated with limited resection compared with lobectomy. One small study reported a survival advantage among patients with stage IIIA NSCLC treated with chemotherapy followed by surgery compared with chemotherapy followed by radiotherapy. No other trials reported significant improvements in survival after surgery compared with non-surgical treatment. CONCLUSION: It is difficult to draw conclusions about the efficacy of surgery for locoregional NSCLC because of the small number of participants studied and methodological weaknesses of the trials. However, current evidence suggests that complete mediastinal lymph node dissection is associated with improved survival compared with node sampling in patients with stage I-IIIA NSCLC undergoing resection.     

Primary mediastinal lymph node malignancy with features suggestive of dendritic cell sarcoma

A 56-year-old man underwent preoperative chest computed tomography to further evaluate a well denned mass in the middle lobe with subcarinal lymph node swelling. There was no pathological diagnosis established by either bronchoscopic biopsy specimens or computed tomography-guided percutaneous needle biopsy. The middle lobe and mediastinal lymph nodes were excised, then postoperative radiotherapy (60 Gy) was administered to the mediastinum. Results of histological and immunohistochemical study showed that the lung mass consisted of completely necrotic tissue and that the subcarinal lymph node was involved by malignant cells suggestive of dendritic cell sarcoma. Primary dendritic cell sarcoma of the mediastinal lymph node is extremely rare. Dendritic cell sarcoma is a neoplasm of reticular dendritic origin and includes both follicular dendritic cell sarcoma and interdigitating reticulum (or dendritic) cell sarcoma. These rare neoplasms may pose difficulty in pathologic diagnosis and treatment. Although our patient died of hepatic rupture due to dendritic cell sarcoma or gastric cancer metastases one year after surgery, complete surgical resection with or without postoperative radiotherapy may be an acceptable therapeutic option for localized dendritic cell sarcoma.     

Superior sulcus lung tumors: impact of local control on survival.

OBJECTIVES: Our goal was to assess patient survival and response to treatment for superior sulcus tumors treated with combined radiation therapy and surgery when possible, or with radiation alone when surgery was not possible. METHODS: Seventy-three patients were treated for primary non-small cell carcinoma of the superior pulmonary sulcus. Thirty-four patients received combined resection and irradiation. Thirty-nine patients who had extensive primary disease, distant metastases, or who were medically unfit for surgery were treated with radiation alone. Thirty-one patients (91%) assigned to the resection/irradiation group completed treatment. Combined therapy patients routinely received 40 Gy before the operation, with additional postoperative irradiation based on the surgical findings. RESULTS: Overall survival at 5 years was 19% and disease-specific survival was 20% for all patients. Overall survival and disease-specific survival at 5 years for the resection/irradiation group were 33% and 38%, respectively. Significant indicators of poor prognosis included unresected primary disease, low performance score, T4 stage, or positive node status. Eighty-two percent of the patients who received irradiation alone were treated with palliative intent. Freedom from local-regional progression, achieved initially in 66% of these patients, was associated with a median survival of 8 months. Median survival for 7 patients considered for definitive irradiation was 25 months. During the first 18 months, distant failures occurred in approximately 35% of patients in each treatment group. CONCLUSIONS: Selection of medically fit patients with resectable disease for combined surgery and aggressive radiation therapy resulted in a high likelihood of local control. Overall survival for the resection/irradiation group was significantly poorer for patients with T4 stage, nodal disease, or Horner's syndrome. Distant metastases eventually developed in 56% of patients undergoing resection. Median survival in the resection/irradiation group was significantly prolonged for those patients who could tolerate high-dose radiation treatment.     

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.     

Surgical treatment of primary lung cancer with synchronous brain metastases

OBJECTIVES: The role of surgical resection for brain metastases from non-small cell lung cancer is evolving. Although resection of primary lung cancer and metachronous brain metastases is superior to other treatment modalities in prolonging survival and disease-free interval, resection of the primary non-small cell lung cancer and synchronous brain metastases is controversial. METHODS: From January 1975 to December 1997, 220 patients underwent surgical treatment for brain metastases from non-small cell lung cancer at our institution. Twenty-eight (12.7%) of these patients underwent surgical resection of synchronous brain metastases and the primary non-small cell lung cancer. RESULTS: The group comprised 18 men and 10 women. Median age was 57 years (range 35-71 years). Twenty-two (78.6%) patients had neurologic symptoms. Craniotomy was performed first in all 28 patients. Median time between craniotomy and thoracotomy was 14 days (range 4-840 days). Pneumonectomy was performed in 4 patients, bilobectomy in 4, lobectomy in 18, and wedge excision in 2. Postoperative complications developed in 6 (21.4%) patients. Cell type was adenocarcinoma in 11 patients, squamous cell carcinoma in 9, and large cell carcinoma in 8. After pulmonary resection, 17 patients had no evidence of lymph node metastases (N0), 5 had hilar metastases (N1), and 6 had mediastinal metastases (N2). Twenty-four (85.7%) patients received postoperative adjuvant therapy. Follow-up was complete in all patients for a median of 24 months (range 2-104 months). Median survival was 24 months (range 2-104). Survival at 1, 2, and 5 years was 64.3%, 54.0%, and 21.4%, respectively. The presence of thoracic lymph node metastases (N1 or N2) significantly affected 5-year survival (P =.001). CONCLUSION: Although the overall survival for patients who have brain metastases from non-small cell lung cancer is poor, surgical resection may prove beneficial in a select group of patients with synchronous brain metastases and lung cancer without lymph node metastases.     

The role of radio-oncology in the treatment of bronchial cancer

The treatment results obtained in patients with both small and non small cell lung cancer have remained stagnant for years. Therefore, in order to select patients who will have a profit from radiotherapy the indication has to take into account prognostic factors such as tumor stage, extent of resection, patient's age, lymph node status, weight loss and the patient's performance status. Non small cell lung cancer: Postoperative radiotherapy seems to benefit only in patients with hilar or mediastinal lymph node involvement, where a five-year survival rate of up to 30% of cases can be achieved. Postoperative irradiation should not be applied following curative resection and negative lymph node status (R0 N0). In inoperable cases conventional fractionated radiotherapy may definitively have a favourable effect on the patient's survival time, even when the treatment was originally intended to be merely palliative. Only those patients will live five years, who received more than 50 Gy to the hilar and mediastinal nodes and at least 60 Gy to the primary lesion. The volume to be irradiated must include the primary tumor, the ipsilateral and contralateral hilum, the mediastinum, and both supraclavicular regions. If a Pancoast tumor is present, radiotherapy alone obtains a similar result as preoperative irradiation followed by resection. Small cell lung cancer: Radiation treatment of the primary tumor region and the lymph drainage area increases the remission rate by roughly 20% compared with chemotherapy alone, considerably reduces the incidence of local recurrences and exerts a beneficial effect on the survival of the patients. Recently, this has been confirmed by prospectively randomised protocols. Prophylactic brain irradiation has been found to decrease the risk of cerebral metastases to 4-6% in patients affected by limited disease and complete tumor remission under chemotherapy, and to improve the quality of life without, however, showing the benefit on survival time. Future efforts in radiotherapy should be aimed not only at increasing dose intensities but also at developing less toxic treatment modalities to the benefit of the quality of life.     

Treatment of superior sulcus tumor (Pancoast tumor)

It appears that combined preoperative radiation and surgery continue to offer the best survival results in patients with superior sulcus tumors. Patients with involvement of the brachial plexus, Horner's syndrome, rib invasion, and ipsilateral neck node metastases are still candidates for combined modality therapy, with expectations of survival of about 30 to 40 per cent. However, those presenting with invasion of vertebrae, involvement of subclavian vessels, and mediastinal lymph node metastases do poorly. In this latter group, treatment by high-dose external radiation alone may prove to be as effective as combined modality treatment.     

支气管内超声引导针吸活检术在非小细胞肺癌术前分期中的临床应用

目的探讨支气管内超声引导针吸活检术(EBUS-TBNA)在非小细胞肺癌纵隔淋巴结分期中的应用价值。 方法2010年9月至2012年9月,北京大学人民医院利用EBUS-TBNA对术前确诊或CT扫描高度怀疑非小细胞肺癌且伴有纵隔淋巴结肿大(N₂站淋巴结短径≥1.0cm,或N₁站淋巴结短径≥1.0cm且N₂多站短径≥0.5cm者),有手术切除可能,术前无放、化疗史的126例患者进行纵隔淋巴结分期。最终入组82例非小细胞肺癌患者。 结果该组82例患者,经EBUS-TBNA检查证实纵隔淋巴结转移(阳性)者54例,未见纵隔淋巴结转移(阴性)者28例。EBUS-TBNA在该组肺癌术前纵隔淋巴结分期中的敏感度、特异度和准确性分别为94.7%(54/57)、100.0%(25/25)和96.3%(79/82),阳性预测值及阴性预测值分别为100.0%(54/54)和89.3%(25/28)。而CT对于本组患者纵隔淋巴结分期中的敏感度、特异度和准确性分别为98.2%(55/56)、38.5%(10/26)和79.3%(65/82),阳性预测值及阴性预测值分别为77.5%(55/71)和90.9%(10/11)。CT在术前纵隔淋巴结分期中的假阳性率为22.5%(16/71)。全组中,16例(19.5%)肺癌患者因EBUS-TBNA病理结果改变了治疗策略。 结论EBUS-TBNA用于非小细胞肺癌纵隔淋巴结分期的敏感性、特异性和准确性较高。EBUS-TBNA可以作为非小细胞肺癌术前分期、指导治疗策略的检查手段。     

Surgical treatment of 125 patients with non-small cell lung cancer and chest wall involvement.

BACKGROUND: The optimum operative procedure for lung cancer with chest wall invasion (T3) remains controversial. In this study results of en bloc resection and extrapleural dissection are reviewed to determine survival characteristics. METHODS: Between 1977 and 1993 125 patients underwent surgery for primary non-small cell lung cancer with chest wall invasion. Patients with superior sulcus tumours, metastatic carcinomas, synchronous tumours, or recurrences were excluded. Extrapleural dissection was performed in 73 patients and en bloc resection (range 1-4 ribs) in 52. Resection was regarded as complete in 86 and incomplete in 39 patients. Actuarial survival time was estimated and risk factors for late death were identified. RESULTS: Hospital mortality was 3.2%. (n = 4). Estimated mean five year survival was 24% for all hospital survivors (n = 121), 11% for patients with incomplete resection, and 29% for patients having a complete resection. In patients who underwent complete resection mediastinal lymph node involvement and intrapleural tumour spill worsened the prognosis. Patients with adenocarcinoma had a better chance of long term survival. No relationship was found between survival and age, type of operative procedure, depth of chest wall invasion, and postoperative radiotherapy. CONCLUSIONS: Both operative procedures show reasonable survival results. Incomplete resection, mediastinal lymph node involvement, and intrapleural tumour spill adversely influence survival.     

Multimodal treatment of non small cell lung cancer

The primary treatment of lung cancer depends on tumor stage. Chest CT scan and bronchoscopy are used to define the TNM stage and resectability. In case of lung cancer without mediastinal lymph node enlargement or direct mediastinal involvement (clinical stage I-IIb + T3N1) surgical treatment is recommended. The use of adjuvant chemotherapy has to be defined, but will be indicated in stage II and IIIa. Expected 5-year survival achieves 40 to 80 % depending on tumor stage. Exceeds the shorter diameter of mediastinal lymph nodes in chest CT scan more than 1 cm (or in case of positive PET scan) mediastinoscopy is indicated. In case of N2-disease and after tumor response to preoperative chemotherapy (about 60 %) secondary resection of the tumor leads to higher 5-year survival rates (20-40 %) compared to patients without induction therapy (5-20 %). In these patients and after unexpected detection of solitary lymph node metastasis by primary resection adjuvant mediastinal radiotherapy should be added. If the tumor has infiltrated the mediastinum or the upper sulcus (T3/4) and/or mediastinal lymph nodes are obviously tumor burden (e. g. > 3 cm, N2 bulky, N3) radical primary resection may not be possible. In these patients combined radio- and chemotherapy induces a high percentage of tumor regression and can be used before secondary resection (5-year survival 5-20 %). Locally advanced tumors infiltrating the main bronchus close to the carina or the carina itself and tumors with metastases in the same lobe, both without mediastinal lymph node metastases (T3/4N0-1), can be resected by sleeve pneumonectomy and lobectomy with satisfactory results respectively. In patients with resectable lung cancer and no clinical sign of tumor disease (f. e. anemia, weight loss, pain) limited staging procedure with chest CT scan including upper abdomen and bronchoscopy is reasonable. In the remaining patients complete staging is necessary. We recommend an interdisciplinary approach to patients with lung cancer.     

An indication for surgery of the advanced small size lung carcinoma: results of surgical therapy of pT1N2 non-small cell lung carcinoma]

A clinico-pathological study of the advanced small size lung carcinoma was performed to clarify its surgical indication. In 31 pT1N2 non-small cell lung cancer patients, postoperative survival time was compared with their surgical curativity, histologic type, histologic differentiation, cellular atypia and extent of mediastinal lymph node metastasis. In general, postoperative outcome was poor in pT1N2 non-small cell lung cancer. But postoperative survival is over 40% in moderately differentiated adenocarcinoma of relative curative resection in which mediastinal lymph node metastasis proved in only one station. It is suspected that surgery would be indicated in this group.     

Superior pulmonary sulcus carcinoma

Carcinomas in the superior pulmonary sulcus produce "Pancoast's syndrome," involving pain in the shoulder and the ulnar distribution of the arm and hand, as well as Horner's syndrome. Careful evaluation and appropriate staging select the patients for preoperative irradiation (3000 rads) over a two- or three-week period. After a two- to four-week interlude, surgical resection of the chest wall, lower brachial plexus, and lung en bloc produces a five-year survival rate of over 30 per cent. Contraindications to this therapeutic approach include an excessive extension of the tumor into the neck or vertebrae, substantial mediastinal node metastases, and peripheral tumor dissemination.     

Prognostic factors in surgically resected N2 non-small cell lung cancer: the importance of patterns of mediastinal lymph nodes metastases.

OBJECTIVE: Patients with non-small cell lung cancer (NSCLC) with metastases to ipsilateral mediastinal lymph nodes (N2) are an heterogeneous group of patients as regard to prognosis and treatment. Indication and timing of surgery remain controversial. The present study investigates the prognostic factors, in order to identify homogenous subgroups of patients. METHODS: Histologically proven N2-NSCLC patients, who underwent a complete surgical resection were retrospectively reviewed. Clinical and pathological features were reported and analyzed, and survival study was performed. RESULTS: One hundred eighty-three patients were analyzed. Overall 1.3 and 5 years survival rates were, respectively, 70, 35 and 20%, with a median survival time of 24 months. Univariate analysis showed a significant better prognosis for: incidental N2 respect to clinical N2 (5-years 35.4 vs 17.4%); single level lymph node involvement respect to multiple levels (5-years 23.8 vs 14.7%); metastases to superior mediastinal or aortic nodes respect to lower mediastinal nodes (5-years 32 and 24.3 vs 16.3%); right upper lobe tumors with superior mediastinal nodes and left upper lobe tumors with aortic nodes respect to lower lobes tumors with lower mediastinal nodes (5-years 31.8 and 26.9 vs 15.7%). Skip metastases had not a significant survival advantage respect to continuous lymphatic spread. N2 clinical status, the number of levels involved and the two specific patterns of lymphatic spread resulted significant prognostic factors at multivariate analysis. CONCLUSIONS: Clinical N2 status, number of lymph nodes levels involved and specific patterns of lymphatic spread identify homogenous subgroups of patients that can be proposed for different therapeutic strategies.     

Sealing of the mediastinum with a local hemostyptic agent reduces chest tube duration after complete mediastinal lymph node dissection for stage I and II non-small cell lung carcinoma

BACKGROUND: We assessed the impact of coverage of the mediastinum with a local hemostyptic agent as well as the impact of perioperative thromboembolic prophylaxis on cumulative chest drain volume and on the duration of chest tubes after surgical resection with complete mediastinal lymph node dissection for stage I or II non-small cell lung cancer. METHODS: In a prospective, randomized two-by-two factorial design, 80 patients with clinical stage I or II non-small cell lung cancer were allocated to one of two surgical therapy arms (TachoComb or conventional surgical hemostasis) and one of two anticoagulation arms (enoxaparin 4,000 IU or dalteparin 5,000 IU). Primary end point was cumulative chest drain volume; secondary end point was duration of chest tubes. Additionally clinical data were obtained. RESULTS: Comparison of the surgical arms revealed significantly lower cumulative chest drain volumes and thereby an earlier chest tube removal in the TachoComb group (p = 0.045). With regard to thromboembolic prophylaxis, a significantly earlier chest tube removal was found for patients treated with dalteparin (p = 0.039). Analysis of the interaction of surgical and anticoagulation treatment revealed the combined use of TachoComb and dalteparin was superior to other combinations (cumulative chest drain volumes 498 +/- 67 mL versus 1,000 +/- 88 mL, 924 +/- 87 mL, and 895 +/- 118 mL; p = 0.008; mean duration of chest tubes 1.78 +/- 0.15 days versus 2.96 +/- 0.21 days, 2.93 +/- 0.17 days, and 3.06 +/- 0.27 days; p = 0.019). CONCLUSIONS: The combined use of a local hemostyptic agent and dalteparin seems superior as compared with other regimens of hemostasis and thromboembolic prophylaxis in patients undergoing surgical resection and complete mediastinal lymph node dissection for stage I and II non-small cell lung cancer with regard to cumulative chest drain volume as well as duration of chest tubes.     

Carcinoma of the lung: results of treatment over ten years.

Mediastinal lymph node dissection in conjunction with pulmonary resection was performed on 437 patients with bronchogenic carcinoma at the University of Michigan Medical Center from 1959 to 1969. The absolute five- and ten-year survival rates for patients undergoing curative resection were 36.2 and 14.4%, respectively. The five-year survival of those without nodal metastases was 49.3%, and it was 31.1% in patients with hilar metastases only. The five-year survival of patients with mediastinal metastases who received radiation therapy was 23.1%. Of the 193 patients with squamous cell carcinoma, 43% lived five years free from disease. The five-year survival of patients undergoing resection who had no hilar lymph node metastases was 53%, and it was 47.5% in those with hilar metastases only. The five-year survival in patients with mediastinal metastases who received postoperative irradiation was 34.4%.     

Predictors of lymph node and intrapulmonary metastasis in clinical stage IA non-small cell lung carcinoma

BACKGROUND: The feasibility of limited surgical resection for clinical stage IA non-small cell lung cancer still remains controversial. METHODS: From July 1987 through April 1998, 389 patients with clinical stage IA disease underwent major lung resection and complete mediastinal lymph node dissection. Univariate and multivariable analyses were performed to determine predictors of local or regional tumor spread: pathologic lymph node involvement, intrapulmonary metastases, and lymphatic invasion. RESULTS: Of the 389 patients, 88 (23%) had lymph node involvement or intrapulmonary metastases pathologically. According to multivariable analyses, grade of differentiation and pleural involvement were significant predictors of local or regional tumor spread (p < 0.01). Based on these results, more than 40% of clinical stage IA non-small cell lung cancer patients showed pathologic lymph node involvement or intrapulmonary metastases, or both, if the patients had both of the predictors of pathologic local or regional involvement: moderate or poor differentiation of the primary tumor and pleural involvement by tumor cells. CONCLUSIONS: Limited surgical resection is not feasible for clinical stage IA non-small cell lung cancer, especially when the tumor shows moderate or poor differentiation, or pleural involvement.     

Lymph node staging in non-small cell lung cancer: evaluation by [18F]FDG positron emission tomography (PET)

BACKGROUND: A study was undertaken to investigate the accuracy of positron emission tomography (PET) with 2-[18F]-fluoro-2-deoxy-D- glucose (FDG) in the thoracic lymph node staging of non-small cell lung cancer (NSCLC). METHODS: Forty six patients with focal pulmonary tumours who underwent preoperative computed tomographic (CT) and FDG- PET scanning were evaluated retrospectively. Thirty two patients had NSCLC and 14 patients had a benign process. The final diagnosis was established by means of histopathological examination at thoracotomy, and the nodal classification in patients with lung cancer was performed by thorough dissection of the mediastinal nodes at surgery. RESULTS: FDG-PET was 80% sensitive, 100% specific, and 87.5% accurate in staging thoracic lymph nodes in patients with NSCLC, whereas CT scanning was 50% sensitive, 75% specific, and 59.4% accurate. The absence of lymph node tumour involvement was identified by FDG-PET in all 12 patients with NO disease compared with nine by CT scanning. Lymph node metastases were correctly detected by FDG-PET in three of five patients with N1 disease compared with two by CT scanning, in nine of 11 with N2 disease compared with six by CT scanning, an in all four with N3 nodes compared with two by CT scanning. CONCLUSIONS: FDG-PET provides a new and effective method for staging thoracic lymph nodes in patients with lung cancer and is superior to CT scanning in the assessment of hilar and mediastinal nodal metastases. With regard to resectability, FDG-PET could differentiate reliably between patients with N1/N2 disease and those with unresectable N3 disease.     

Clinical Characteristics of Resected T3 Non-small Cell Lung Cancer Characterized by Parietal Pleural Invasion or Chest Wall Invasion

This study investigated the clinicopathological characteristics and the surgical outcome in patients with non-small cell carcinoma (NSCLC) with parietal pleura invasion or chest wall invasion (p3/T3). This study clinicopathologically evaluated 760 patients who had undergone a resection for NSCLC between 1999 and 2008. There were 43 (5.7 %) patients with p3/T3 NSCLC. The patients included 37 males and 6 females. The histological types included 23 squamous cell carcinomas, 13 adenocarcinomas, 3 large cell carcinomas, 3 pleomorphic carcinomas, and 1 spindle cell carcinoma. Pneumonectomy was performed in 2 patients, bilobectomy in 1, lobectomy in 31, segmentectomy in 3, and partial resection of the lung in 6. The combined resection regions were parietal pleural in 23, ribs in 16, pericardium in 2, and diaphragm in 2 patients. Major complications included empyema in 1, chylothorax in 1, and postoperative bleeding in 1 patient. The first recurrence sites in 16 patients with recurrent disease were the lung in 5 patients, brain in 3, bone in 2, adrenal gland in 2, skin in 2, liver in 1, mesenterium in 1, mediastinal lymph node in 1, axillary lymph node in 1, and carcinomatous pleuritis in 1. The overall 5-year survival rate after surgery was 50.6 %. An en bloc resection for p3/T3 NSCLC provides a modestly favorable prognosis. Local recurrence was observed in a minority of case, and recurrence by distant metastasis was observed in most cases, suggesting a greater need for postoperative chemotherapy.     

Effectiveness of radical systematic mediastinal lymphadenectomy in patients with resectable non-small cell lung cancer: results of a prospective randomized trial.

OBJECTIVE: To evaluate the effectiveness of lymphadenectomy in the treatment of non-small cell lung cancer (NSCLC). SUMMARY BACKGROUND DATA: The extent of lymphadenectomy in the treatment of NSCLC is still a matter of controversy. Although some centers perform mediastinal lymph node sampling (LS) with resection of only suspicious lymph nodes, others recommend a radical, systematic mediastinal lymphadenectomy (LA) to improve survival and to achieve a better staging. METHODS: In a controlled, prospective, randomized clinical trial, the effects of LA on recurrence rates and survival were analyzed, comparing LS and LA in 169 patients with operable NSCLC. RESULTS: After a median follow-up of 47 months, LA did not improve survival in the overall group of patients (hazard ratio: 0.78; 95% confidence interval: 0.47-1.24). Although recurrences rates tended to be reduced among patients who underwent LA, these decreases were not statistically significant (hazard ratio: 0.82; 95% confidence interval: 0.54-1.27). However, analysis of subgroups of patients according to histopathologic lymph node staging revealed that LA appears to prolong relapse-free survival (p = 0.037) with a borderline effect on overall survival (p = 0.058) in patients with limited lymph node involvement (pN1 disease or pN2 disease with involvement of only one lymph node level); in patients with pN0 disease, no survival benefit was observed. CONCLUSIONS: Radical systematic mediastinal lymphadenectomy does not influence disease-free or overall survival in patients with NSCLC and without overt lymph node involvement. However, a small subgroup of patients with limited mediastinal lymph node metastases might benefit from a systematic lymphadenectomy.     

腹腔镜联合胸腔镜一期切除结直肠癌肺转移的疗效及预后因素

目的：探讨腹腔镜联合胸腔镜（双镜）一期切除结直肠癌肺转移的疗效及预后相关因素。方法：回顾性分析35例结直肠癌同时肺转移患者的临床资料,其中17例进行了双镜一期手术切除（双镜手术组）,术后接受化疗;其余18例仅接受全身化疗（非手术组）,比较两组疗效并分析双镜手术患者的预后因素。结果：双镜手术组患者原发性病灶及肺转移灶均达到R0切除。双镜手术组与非手术组1、2年生存率分别为82.3%、44.4%（P=0.028）和52.3%、22.2%（P=0.001）。单因素分析显示,肺转移瘤数量（P=0.002）及纵膈淋巴结阳性（P<0.001）与患者术后生存有关,而患者的性别、年龄,原发肿瘤部位、病理类型、T分期,肺转移瘤大小、切除方式,手术前CEA水平,化疗方案均与其术后生存时间无关（均P>0.05）;多因素分析显示,肺转移瘤数量（P=0.005）、纵膈淋巴结转移（P=0.006）是患者术后的预后独立影响因素。结论：结直肠癌肺转移双镜一期手术切除可提高患者的总生存率;肺转移瘤数量及有无纵膈淋巴结转移是影响术后预后的独立因素。