肺癌跳跃式纵隔淋巴结转移的临床病理探讨

目的　探索肺癌跳跃式纵隔淋巴结转移的病理特点 ,为合理施行淋巴结清除术提供可靠的理论依据。方法　 1992年 10月至 1998年 6月 ,为 398例肺癌病人施行了根治性肺切除、规范淋巴结清除术 ,对其中 4 7例 ( 2 9 4 % )跳跃式纵隔转移淋巴结病例进行病理学研究。结果　各型或各叶肺癌中 ,跳跃式转移淋巴结分布最密集的部位依次是第 7、4、3、5组淋巴结 ,分别占 2 9 8%、2 4 5 %、14 9%与10 6 % ;就鳞癌与腺癌而言 ,肿瘤长径在 1cm以内者均无跳跃式淋巴结转移 ,跳跃式淋巴结转移率随长径增加而增加 ;低分化腺癌淋巴结转移率明显高于高分化者 (P <0 0 1) ;发生跳跃式淋巴结转移的肿瘤平均长径鳞癌与腺癌分别为 15 3mm与 9 1mm。结论　对肺癌淋巴结的廓清 ,切勿仅凭手触摸或靠肉眼观察淋巴结大小而盲目判定其是否转移或清除。除T1 中肿瘤长径 <1cm的鳞癌外 ,淋巴结的规范清除应重视其跳跃性 ,原则上必须包括同侧胸腔的肺门及上、下纵隔各组淋巴结 ,尤其要重视跳跃式淋巴结转移分布较密集区域 ,即右侧的第 3、4、7组与左侧的第 4、5、7组淋巴结     

Rational lymph node dissection for lung cancer according to the occurrence lobe and histological type]

Between January 1989 and December 1998, 134 cases of squamous cell carcinoma and 244 cases of adenocarcinoma underwent surgical resection of the lung with systematic lymph node dissection in our hospital. The cN diagnosis by CT scan and pN diagnosis were compared. In squamous cell carcinoma pN 2-3 cases were only one patient (2%) out of 60 patients with cN 0, 5 patients (18%) out of 28 patients with cN 1, and 21 patients (46%) out of 46 patients with cN 2-3. On the other hand in adenocarcinoma pN 2-3 cases were 27 patients (14%) out of 193 patients with cN 0, 3 patients (25%) out of 12 patients with cN 1, and 24 patients (62%) out of 39 patients with cN 2-3. The pathways of the lymphatic metastases to the mediastinal nodes were analized in 27 patients with squamous cell carcinoma and 54 patients with adenocarcinoma undergoing systematic lymph node dissection. All patients had histologically proven mediastinal metastasis. Histologically there was no difference in pathways of the lymphatic metastases to the mediastinal nodes. 1. The dominant lymphatic drainage from the right upper lobe flowed into the superior mediastinal nodes. The direct metastatic passages to the superior mediastinal nodes were observed (47%). Subcarinal and inferior mediastinal node involvement was rare (3%). 2. The dominant lymphatic drainage from the middle and the lower lobe flowed into the subcarinal nodes (85%). The involvement of the superior mediastinal nodes occurred in 53% of subcarinal node positive patients on the right side. 3. The dominant lymphatic drainage from the left upper lobe flowed into the subaortic or paraaortic nodes (69%). Subcarinal and inferior mediastinal node involvement was rare (6%). We conclude that subcarinal and inferior mediastinal lymph node dissection is not necessary for upper lobe lung cancers, and that superior mediastinal lymph node dissection can be omitted in middle and lower lobe lung cancers without hilar and subcarinal lymph node involvement, especially in the cases of cN 0.     

肺癌淋巴结廓清程度对手术根治性的评价

作者近９年来，对３８６例肺癌患者施行了手术切除。术中按成毛韶夫肺癌淋巴结分布图对肺门和同侧纵隔淋巴结进行了广泛廓清。共清除淋巴结２６０３组，平均每例清除６．７４组。淋巴结转移率为４９．２％（１９０／３８６）。单纯Ｎ１４３例，占１１．１％；Ｎ２（包括Ｎ１＋Ｎ２）１４７例，占３８．１％。Ｎ２转移率在鳞癌、腺癌、小细胞癌及大细胞癌分别为３０．１％、４４．１％、４８．０％及５０．０％。肺癌淋巴结转移具有跳跃性和多发性。作者强调只有广泛清除了肺内和纵隔淋巴结才有可能达到根治，否则应被视为非根治术。     

Risk factors influencing lymph nodes metastasis in lung cancer with stage I, II or IIIA

The purpose of this study was to assess the risk factors involved in the intrapulmonary, hilar and mediastinal lymph nodes metastases in seventy-eight patients with stage I, II or IIIA lung cancer postoperatively, which were resected from 1978 to 1988. In the histological type, the incidence of the mediastinal lymph nodes metastases in adenocarcinoma was higher than that in other types, such as squamous cell carcinoma and large cel carcinoma. In addition, the incidence of mediastinal lymph nodes metastases in the papillary type was significantly higher than that in the tubular type (p less than 0.05). The incidence of mediastinal lymph nodes metastases increased as invasion into the lymphatic duct and/or vessel was demonstrated (p less than 0.01, p less than 0.05). The proximal type, in which the cancer spread to the secondary segmental bronchus, metastasized to the hilar lymph nodes more frequently than the distal type, in which the cancer was located in the bronchus distal to the third segmental one. Although there was no significant relationship between the site of the cancer and the incidence of the metastatic lymph nodes, the hilar and superior mediastinal lymph nodes (#1-4, 3a, 3p) metastases were demonstrated regardless of the lobe in which the cancer was located. The primary tumor located in the left lower lobe of the lung tended to metastasize to the inferior mediastinal lymph nodes (#8, 9). Twenty-five out of 33 patients with the lymph nodes metastases had hilar metastatic lymph nodes. However, the mediastinal lymph nodes metastases were proved in 5 patients without any intrapulmonary and hilar lymph nodes metastases. No relationship between the histological differentiation, size of tumor, pT factor and the incidence of lymph nodes metastases was found.     

Mediastinal lymph node involvement as the initial manifestation of occult thyroid cancer in the surgical treatment of lung cancer: Report of a case

A 63-year-old man was referred to our institute for the treatment of squamous cell carcinoma of the upper lobe of his right lung. A right upper lobectomy of the lung was performed with a mediastinal lymph node dissection. The postoperative pathological examination of the dissected specimens revealed one of the superior mediastinal lymph nodes to be morbid with micrometastasis of occult thyroid cancer, while no node involvement was seen due to lung cancer. A right lobectomy of the thyroid gland with a modified radical neck dissection was done 4 years later after the confirmation of the absence of any recurrent sign of lung cancer. In the resected specimen, papillary thyroid microcarcinoma was observed with several intraglandular metastases and right regional lymph node involvement. Eight months later, a new primary lung cancer developed in the left lung, and a left upper lobectomy of the lung with a mediastinal lymph node dissection was performed. At that time, the absence of mediastinal lymph node metastasis from lung cancer or thyroid cancer was confirmed. Mediastinal lymph node involvement as the initial manifestation of occult thyroid cancer in surgical treatment for lung cancer is rare, but it is important to be aware of the possibility of incidentally detecting occult thyroid cancer in surgical dissections in this area for lung cancer. The appropriate surgical treatment should be determined while carefully considering the prognosis of the lung cancer as well as that of any coexisting malignancy.     

In what case can we abbreviate mediastinal lymph nodes dissection of peripheral small-sized lung cancer?

We analyzed 723 cases of non small cell lung cancer (459 adenocarcinomas and 264 squamous cell carcinomas) from the view point of lymph nodes metastases, according to histological type, location of cancer and tumor size. METHOD: Histological type was adenocarcinoma or squamous cell carcinoma. Location was divided into 8 areas [right side; 4 areas, upper lobe (RUL)/middle lobe (RML)/S6 (RS6)/basal segment of lower lobe (RBS): left side; 4 areas, upper division of upper lobe (LUD)/lingula (LLS)/S6 (LS6)/Basal segment of lower lobe (LBS)]. Tumor size was divided by centimeters, namely 0.0-1.0 cm, 1.1-2.0 cm, 2.1-3.0 cm, etc.. RESULTS: Safety size of lung cancer in which we can abbreviate mediastinal lymph nodes dissection was as follows. In adenocarcinoma, in RUL/RML/RBS 1.0 cm, in RS6 2.0 cm, in LUD 1.0 cm, in LLS/LS6/LBS 2.0 cm. In squamous cell carcinoma, in RUL 1.0 cm, in RML/RS6/RBS 2.0 cm, in LUD 1.0 cm, in LLS/LS6/LBS 2.0 cm. CONCLUSION: In 1.0 cm or smaller non small cell lung cancer we might abbreviate mediastinal lymph nodes dissection. Moreover, in squamous cell carcinoma of (RML, LLS, right or left lower lobe) of 2.0 cm or smaller size, we might abbreviate mediastinal lymph nodes dissection.     

Clinical feasibility and surgical benefits of video-assisted mediastinoscopic lymphadenectomy in the treatment of resectable lung cancer

Objective: This study was performed to assess the clinical feasibility and surgical outcomes of video-assisted mediastinoscopic lymphadenectomy in the treatment of resectable lung cancer. Methods: Between July 2004 and December 2009, we retrospectively analyzed 108 consecutive video-assisted mediastinoscopic lymphadenectomies in lung cancer patients from a prospectively collected database. Ninety-seven (89.8%) patients underwent combined operation during the same anesthesia and six (5.3%) patients underwent a staged operation for the resection of lung cancer and systematic lymphadenectomy. We reviewed the indication and duration of video-assisted mediastinoscopic lymphadenectomy, its complication, combined or staged operation type, the number of dissected lymph nodes and nodal stations, and pathologic staging of the mediastinal node. Results: Mean operative time of video-assisted mediastinoscopic lymphadenectomy was 39.8 ± 12.3 min (range of 14–85 min). Mean number of resected lymph nodes was 16.0 ± 7.7 (range of 3–37). In video-assisted mediastinoscopic lymphadenectomy, the rates of lymph node dissection of stations 4R, 4L, and 7 were 71.3%, 88.0%, and 100%, respectively, whereas the rates of dissection of lymph nodes in station 2R and 2L were only 22.2% and 17.6%, respectively. There was no operative mortality. We identified five complications of recurrent nerve palsy. Conclusions: Video-assisted mediastinoscopic lymphadenectomy is a clinically feasible procedure with acceptable complication rate and provides more accurate staging of mediastinal node in lung cancer patients. It may be also an excellent supplementary technique used for complete mediastinal node dissection at minimal invasive surgery for cancer resection, especially with left-sided video-assisted thoracoscopic lobectomy.     

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.     

A clinical study of small advanced lung cancer with metastasis to mediastinal lymph node

From January 1981 through December 1989, 15 patients with small advanced lung cancer were treated surgically at the Tenri Hospital. In these cases, the diameter of peripheral lung cancer did not exceed 3.0 cm (T1) and mediastinal lymph nodes were proved to be N2 postoperatively by lymph node dissection or sampling. The histological types were as follows: 8 adenocarcinoma, 4 large cell carcinoma, 1 squamous cell carcinoma, 1 small cell carcinoma, and 1 adenosquamous carcinoma. All but one patient were received postoperative chemotherapy and/or radiotherapy. The survival rate was 44.5% at 3 years, and median survival time was 36 months. The mediastinal lymph node metastasis with small peripheral lung cancer (T1N2) was ominous, and it should be said that complete mediastinal lymph node dissection and adjuvant therapy were indispensable to small advanced adenocarcinoma of lung.     

Recurrence in regional pulmonary lymph nodes after surgery for isolated pulmonary metastasis from hepatocellular carcinoma

Hepatocellular carcinoma occasionally metastasizes to extrahepatic organs, rarely to the mediastinal lymph nodes. We present the case of a 64-year-old man who presented with nodules in the upper and right lower lobes of the lung 4 years after undergoing resection of a hepatocellular carcinoma. We performed wedge resection of both lesions. Pathological examination showed that the lesion in the right upper lobe was non-small cell lung cancer and that in the right lower lobe hepatocellular carcinoma. We accordingly performed right upper lobectomy with lymph node dissection. Nine months later, enlarged subcarinal and segmental lymph nodes were detected and mediastinal lymph node metastases from the hepatocellular carcinoma diagnosed by transbronchial needle aspiration.     

Sentinel node sampling limits lymphadenectomy in stage I non-small cell lung cancer.

OBJECTIVE: It is controversial whether a systematic mediastinal lymph node dissection (MLND) needs to be performed in all patients with stage I lung cancer. The present study was done to examine the new sentinel lymph nodes hypothesis based on the lobe of the primary tumor. METHODS: In our first study, the lymph node (LN) metastases were assessed in 291 stage I non-small cell lung cancer (NSCLC) patients who had a major lung resection with a systematic mediastinal lymph node dissection. We evaluated the validity of using our new sentinel lymph nodes method based on the lobe of the primary tumor as follows: the pretracheal (#3), tracheobronchial (#4), and hilar nodes (#10) for right upper lobe tumors; #4, subcarinal (#7), and #10 for middle lobe tumors; the subaortic (#5), paraaortic (#6), and #10 for left upper lobe tumors; and the #7, #10, and interlobar nodes (#11) for tumors in either lower lobes. In the second study, we performed a lobectomy with new sentinel node sampling in 64 patients with preoperative complications. If all of the sampling nodes showed no metastases on frozen section diagnosis, systematic node dissections were not performed. RESULTS: Six of 291 patients in the first study had skip metastases that did not involve the new sentinel nodes; 5 of the 6 patients had macroscopic pleural invasion. Thus, we defined pleural invasion as an exclusion criterion for the second study. In the second study, the median follow-up time was 39 months. Metastatic lymph nodes were detected in 11 of 64 patients. Fifty-three patients (83%) had no metastasis in the sampled nodes, and, therefore, a mediastinal lymph node dissection was not done. The morbidity rate in the sampling group was 36%, and there was no mortality. In the sampling group, local recurrences were observed in two patients, distant metastases in eight, and carcinomatous pleuritis in one; the overall 5-year survival rate was 82%. CONCLUSIONS: We found that it is possible to perform a less invasive lymphadenectomy for patients with stage I lung cancer using intra-operative sampling of new sentinel lymph nodes.     

The spread of metastatic lymph nodes to the mediastinum from left upper lobe cancer: results of superior mediastinal nodal dissection through a median sternotomy.

BACKGROUND: This study endeavored to clarify the location, frequency, and prognostic value of metastatic lymph nodes in the mediastinum among patients with left upper lung cancer who underwent complete dissection of the superior mediastinal lymph node through a median sternotomy. METHODS: Forty-four patients with left upper lobe cancer underwent extended radical mediastinal nodal dissection (ERD), all of whom were analyzed in this retrospective study. The group comprised 12 females and 32 males, with ages ranging from 28 to 70 years (median age, 60 years). Mediastinal nodal status was assessed according to the systems of Mountain/Dresler 7 and Naruke 8. The clinicopathological records of each patient were examined for prognostic factors, including age, sex, histology, tumor size, c-N number, preoperative serum CEA level, metastatic stations and distribution of metastatic nodes according to Naruke's system 8. The superior mediastinal lymph nodes which cannot be dissected through a left thoracotomy (bilateral #1 and #2, #3, right #3a, and right #4 according to Naruke's map 8 were defined as extra-superior mediastinal nodes for left lung cancer (ESMD). RESULTS: Fourteen patients had one or more metastases to mediastinal lymph nodes, among whom the most common metastatic station was the aortic nodes: 71.4% had metastasis to #5 or #6 (57.1% to #5 and 50% to #6). The next most common metastatic station was the left tracheobronchial nodes (42.8%). Metastasis to the ESMD occurred in 7 of the 44 study subjects (16%), representing a 50% rate of occurrence (7/14) among those with mediastinal nodal involvement. Univariate analysis found that CN factor and aortic nodal involvement (#5, #6) were significant predictive factors for ESMD metastasis. Multivariate analysis determined that only aortic nodal involvement was significant (p = 0.008). Furthermore, ESMD metastasis was rare (5.8%) in the absence of aortic node metastasis. The overall survival rate at 5 years was 50% among the patients without ESMD metastasis. However, the survival rate was 32% at 3 years and 0% at 5 years among the seven patients with ESMD metastasis. CONCLUSIONS: The aortic lymph node is the most common site of metastasis from left upper lobe cancer. Multivariate analysis demonstrated that aortic nodal involvement was a significant predictive factor for ESMD metastasis. Based upon the rates of metastasis and the post-operative prognosis in our study patients, dissection of aortic nodes and left tracheobronchial nodes may be important for patients with left upper lobe cancer. Whether ESMD dissection has a beneficial effect on prognosis remains controversial.     

A clinical study for improving the survival rate of pN2 lung cancer through our case of 53 patients]

BACKGROUND: In management of non-small cell lung cancer, the evaluation and treatment of N2 disease has a lot of controversy. MATERIALS AND METHODS: Between 1983 and 1998, 53 patients of pN2 non-small cell lung cancer were operated by standard lymph node dissection method (R2) using CUSA system. We studied the sensitivity of the diagnosis of preoperative N factor, survival rate, and analysed the relationship between the postoperative mediastinal lymph node metastasis and the site of recurrence. RESULTS: Three-year and five-year survival rates for 53 cases were 46.8% and 33.4% respectivery. Preoperative sensitivity of CT scan for N factors were only 45% in squamous cell carcinoma and 24.2% in adenocarcinoma. Even with intraoperative findings, the sensitivity was not better. In a follow up survey, ipsilateral mediastinal lymph node recurrence was not detected, contralateral mediastinal lymph node recurrences were rare and the distant metastases were common cause of death. CONCLUSION: It is more important to accomplish the standard lymph node dissection completely in all cN cases than to evaluate the preoperative node stage aggressively using invasive methods.     

Immunostaining for Detecting Lymph Node Metastases in Non-small Cell Lung Cancer

Objective- To detect lymph node metastases by immunohistochemistry, where previously undetected by routine histopathology. Design- Immunostaining was carried out for high- and low molecular weight cytokeratins, and Ber-EP4 in 19 consecutive lung cancer patients who had undergone systematic mediastinal lymph node dissection. Results- Eleven (58%) epidermoid carcinomas, 6 (32%) adenocarcinomas, and 2 (10%) bronchiolo-alveolar carcinomas were detected. These included 4 (21%) stage IA carcinomas, 6 (32%) stage IB, 6 (32%) stage IIB, 1 (5%) stage IIIB and 2 (10%) stage IV. Immunostaining did not reveal any undetected metastases. Two patients (squamous cell carcinoma T1N0; adenocarcinoma T1N0) had metastases (skeletal; ipsilateral lung) at time of surgery, and one patient (squamous cell carcinoma T₂N0) had a regional and systemic relapse 10 months later. Serial sectioning with immunostaining of the lymph nodes from these three patients was also negative. Conclusion- We conclude that, even with the use of immunostaining, negative lymph nodes will not assure a good prognosis, and different determinants probably exist for lymphatic and hematogenic metastases in non-small cell lung cancer.     

T1、T2肺鳞癌及腺癌淋巴结转移特点及其临床意义

目的 研究Ｔ１、Ｔ２肺鳞及腺癌淋巴结转移频度、分布范围及特点,为广泛清扫提供依据。方法 按Ｎａｒｕｋｅ肺癌淋巴结分布图对２５４例Ｔ１、Ｔ２肺鳞癌及腺癌施行了手术切除及广泛肺内、叶间及纵阴淋巴结清扫术并对其进行统计分析。结果 清除淋巴结１６８５组。Ｎ１淋巴结转移率２０．０％,Ｎ２淋巴结转移率为１０．２％。Ｔ１、Ｔ２间淋巴结转移率差异有非常显著性意义（Ｐ〈０．０１）。Ｔ１鳞癌无Ｎ２转移,Ｎ２转移在鳞癌     

Adrenal metastasis of lung adenocarcinoma with unusual sites of lymph node metastasis and concomitant renal cell carcinoma: a case report

A 58-year-old male presented to a clinic with general weakness. Right adrenal tumor was found by computed tomography and he was referred to our hospital. Imaging studies revealed right adrenal tumor (8 cm) with marked swelling of surrounding lymph nodes and synchronous left renal tumor (2 cm) that was weakly enhanced by contrast media. Needle biopsy of the left kidney proved to be clear cell type renal cell carcinoma (RCC) and the preoperative diagnosis was left RCC and right primary adrenal cancer with lymph node metastasis. We performed right adrenalectomy, lymph node dissection and left radical nephrectomy. Pathological findings of right adrenal tumor and lymph nodes were both metastatic adenocarcinoma, which was not consistent with RCC or adrenal-derived carcinoma. Then, we extensively reviewed preoperative radiological examinations and found a small lesion in the left upper lung. This lesion was attached to the mediastinal shadow and there was no obvious lymph node swelling around this lesion. According to pathological findings and an elevation of carcinoembryogenic antigen, the adrenal lesion was diagnosed as adrenal metastasis of lung adenocarcinoma.     

Induction chemoradiotherapy in small adenocarcinoma of the lung with bulky mediatinal lymph node metastasis

A 56-year-old man, who visited our hospital due to chest pain, was pointed out a large tumor, 60 mm in diameter, on the left superior mediastinum on the chest computed tomography (CT) scan. He was diagnosed as having mediastinal lymph nodes metastasis of adenocarcinoma through video-assisted thoracoscopic surgery (VATS) biopsy. He received induction chemoradiotherapy: cisplatin and paclitaxel were administered once per week for 2 weeks, and radiotherapy was simultaneously performed. No serious adverse reactions were noted. The ipsilateral mediastinal lymph nodes dissection was performed. Intraoperative frozen section analysis showed a small nodule in the left upper lobe, 5 mm in diameter, was adenocarcinoma. He was finally diagnosed as having mediastinal lymph nodes metastasis from the small adenocarcinoma of the lung, and left upper lobectomy was performed. Histopathological examination of the mediastinal lymph nodes showed no evidence of viable maligmant cell. Induction chemoradiotherapy with cisplatin and paclitaxel might be effective treatment for locally advanced non-small cell lung cancer.     

肺癌淋巴结转移规律的临床研究

目的 探讨原发性肺癌淋巴结转移频率,分布范围及特点,为广泛廓清提供依据。方法 按Ｎａｒｕｋｅ肺癌淋巴结分布图对３８６例肺癌病人施行了手术切除及广泛肺门、叶间及纵隔淋巴结廓清术。结果 清除淋巴结２６０３组,Ｎ１淋巴结转移率２０．１％,Ｎ２淋巴结转移率１６．２％。Ｔ１,Ｔ２,Ｔ３间淋巴结经差异非常显著。     

Does endoesophageal ultrasound-guided fine-needle aspiration replace mediastinoscopy in mediastinal staging of thoracic malignancies?

OBJECTIVE: To determine the impact of endoesophageal ultrasound-guided fine-needle aspiration (EUS-FNA) on management of thoracic malignancies. METHODS: One hundred and twenty patients referred for invasive diagnostic and resection of thoracic malignancies were studied prospectively. Negative and inconclusive EUS-FNA findings were assessed by video-assisted mediastinoscopic lymphadenectomy (VAMLA) or open lymphadenectomy. RESULTS: One hundred and twenty patients, aged 64.1 years (range 38-85) underwent 120 EUS-FNA, 53 video-assisted mediastinoscopic and 48 open lymphadenectomies for diagnosis and treatment of 99 lung carcinoma, six lung metastases, five mesothelioma, three lymphoma, and eight other conditions. EUS-FNA showed T4 in 15/120 and adrenal or hepatic metastases in 9/120 cases. Prevalence of mediastinal lymph node metastases was 51.7%. EUS-FNA false-negative rate was 25.3%. EUS-FNA sensitivity was 91.7%, 78.1% and 43.8% for bulky disease, enlarged mediastinal nodes or normal nodes on CT scan, 50% and 96.6% for right- and left-sided tumours, and 80.6%, 78.9%, 23.8% and 25.0% for the lymph node stations 7, 5/6, 4R, and 4L. A 38.3% respectively 100% cut-down of mediastinoscopies leads in 7.5% respectively 20.8% to incorrect treatment decisions. CONCLUSIONS: EUS-FNA sensitivity depends on the localisation of the primary tumour, and extent and location of mediastinal disease. For left-sided tumours, EUS-FNA improves mediastinal staging by assessing stations 5 and 6 inaccessible to conventional mediastinoscopy. For extended mediastinal disease, mediastinoscopy can be avoided or spared for restaging after neoadjuvant therapy. Exclusion of mediastinal involvement requires mediastinoscopy or open lymphadenectomy. Beyond mediastinal nodal staging, EUS-FNA may detect T4 and M1 situations. Thus, EUS-FNA is a useful supplement to and not the replacement of mediastinoscopy.     

T1、T2肺鳞癌及腺癌淋巴结转移特点及其临床意义

目的研究T1、T2肺鳞及腺癌淋巴结转移频度、分布范围及特点,为广泛清扫提供依据。方法按Naruke肺癌淋巴结分布图对254例T1、T2肺鳞癌及腺癌施行了手术切除及广泛肺内、叶间及纵隔淋巴结清扫术并对其进行统计分析。结果清除淋巴结1685组。N1淋巴结转移率20．0％,N2淋巴结转移率为10．2％。T1、T2间淋巴结转移率差异有非常显著性意义(P<0．01)。T1鳞癌无N2转移,N2转移在鳞癌、腺癌分别为22．0％和40．9％,差异有非常显著性意义(P<0．01)。64．3％的鳞癌为某1组N2转移,腺癌≥3组转移占46．2％,跳跃式转移占N2转移的57．5％。N2阳性上叶肺癌下纵隔转移占13．6％,N2阳性的下叶肺癌上纵隔转移占51．6％。结论随着瘤体增大,淋巴结转移频度增加,腺癌比鳞癌淋巴结转移更加活跃,任何部位的肺癌都可跨区域纵隔转移。除T1鳞癌外,只有广泛清扫同侧肺内及纵隔淋巴结才能达到根治。