Prognosis and histologic features of small pulmonary adenocarcinoma based on serum carcinoembryonic antigen level and computed tomographic findings.

OBJECTIVES: In 2001, we proposed the criteria for combined evaluation of the serum carcinoembryonic antigen (CEA) level and the tumor shadow disappearance rate (TDR) to predict pathologic N0 (pN0) disease in pulmonary adenocarcinomas. The objective of the present study was to determine the prognosis and histologic features in small-sized pulmonary adenocarcinomas according to serum CEA level and TDR. METHODS: We reviewed clinical records of 189 consecutive patients with peripheral pulmonary adenocarcinoma 3.0 cm or smaller who underwent major lung resection and systematic lymph node dissection: 50 patients with TDR 0.8 or more and normal CEA level (group I) and 139 patients with TDR <0.8 and/or elevated CEA level (group II). Among them, we investigated histologic features of 177 adenocarcinomas according to serum CEA level and TDR. RESULTS: The 5-year survival rates were 95% for group I and 75% for group II (P = 0.002) and for pN0 patients, 97% in group I and 87% in group II (P = 0.04). In univariate analyses, TDR, preoperative serum CEA level, and the maximum tumor dimension on computed tomographic (CT) scan were significantly associated with prognosis. Multivariate analysis showed that only preoperative serum CEA level and TDR were significant independent prognostic factors, and the maximum tumor dimension was not significant. Group I patients developed no local recurrence, including lymph node metastases. In 25 group I adenocarcinomas 2.0 cm or smaller, no lymph node involvement, two lymphatic permeation, two vascular invasion, and one pleural involvement tumors were observed. These signs of local invasiveness were less frequent than the remaining adenocarcinomas. CT findings correlated well with histologic findings in small-sized adenocarcinomas. CONCLUSIONS: Combined evaluation of preoperative serum CEA level and TDR may enable us to identify minimally invasive adenocarcinomas with good prognosis. Candidates for limited lung resection without systematic lymph node dissection could be selected based on these findings.     

The role of computed tomographic scanning in diagnosing mediastinal node involvement in non-small cell lung cancer

OBJECTIVES: The reliability of computed tomographic scanning in evaluating mediastinal node involvement is controversial because of the high false result rate. We attempted to identify significant factors responsible for false-positive and false-negative scans. METHODS: From August 1992 through April 1997, 401 patients with lung cancer who underwent major lung resection and systematic lymph node dissection were enrolled in this study. We retrospectively examined mediastinal node size, tumor location, maximum tumor dimension, the presence or absence of obstructive pneumonia, atelectasis, pulmonary fibrosis, and lymph node calcification on contrast-enhanced computed tomographic scans. We identified clinical and radiologic factors responsible for the false results by using univariate and multivariable analysis. RESULTS: Central tumor location proved to be a significant factor of false-positive scans. Elevated carcinoembryonic antigen level and larger tumor dimension were significant factors of false-negative scans. In patients with a peripheral tumor smaller than 40 mm and normal levels of serum carcinoembryonic antigen, sensitivity, specificity, positive predictive value, and negative predictive value were 6%, 93%, 8%, and 90%, respectively. The reliability of computed tomographic scanning in this low-risk subgroup was high in detecting N0-1 disease but low in diagnosing N2 disease. CONCLUSION: It is not possible to accurately diagnose N2 disease by using lymph node size on computed tomographic scanning alone, especially in patients with a central tumor, an elevated serum carcinoembryonic antigen level, or a tumor of 40 mm or larger. A preoperative invasive staging procedure is indicated in these populations and may not be indicated in the population with normal computed tomographic scan results without any of these risk factors.     

Clinical predictors of N2 disease in the setting of a negative computed tomographic scan in patients with lung cancer

OBJECTIVES: Although preoperative cervical mediastinoscopy is absolutely indicated for patients with lung cancer in whom computed tomography demonstrates mediastinal nodal enlargement, the indications when the computed tomographic scan is negative are controversial. To determine the indications in patients with negative computed tomographic scans, we retrospectively studied patients with surgically resected lung cancer. METHODS: Between 1992 and 1997, 379 patients with lung cancer who had clinical N0-1 disease underwent surgical resection of lung cancer. Mediastinal lymph nodes were pathologically examined for metastasis in all the patients. A clinical diagnosis of nodal involvement was determined on the basis of preoperative computed tomographic findings: that is, mediastinal or hilar lymph nodes 1.0 cm or larger in the shortest axis were diagnosed as metastatic. Univariate and multivariate analyses were performed to determine the relationships between 9 clinical factors and pathologically proven N2 disease. RESULTS: Among the patients with clinical N0-1 disease, 68 (17.9%) had pathologic N2 disease. Adenocarcinoma histology, large tumor dimension, and high serum carcinoembryonic antigen levels were significant predictors of pathologic N2 disease on the basis of multivariate analyses (P <.05). When these factors were combined, 43% of adenocarcinomas larger than 2.0 cm with high serum carcinoembryonic antigen levels (P <.001), 34.7% of adenocarcinomas with high serum carcinoembryonic antigen levels (P <.001), 25.6% of adenocarcinomas larger than 2.0 cm (P =.009), and 31.1% of patients with high serum carcinoembryonic antigen levels and large tumor dimension (P <.001) had pathologic N2 disease. CONCLUSION: Preoperative cervical mediastinoscopy should be considered in patients in whom computed tomography is negative for lung cancer and who have some pathologic N2 predictive factors.     

Discrepancy of computed tomographic image between lung and mediastinal windows as a prognostic implication in small lung adenocarcinoma

BACKGROUND: There have been no proven preoperative indicators for postoperative survival of patients with an adenocarcinoma, the incidence of which has been increasing lately. METHODS: Of 952 consecutive patients operated on for primary lung cancer between 1995 and 2002, 167 patients with a proven adenocarcinoma 3 cm or less in diameter underwent complete removal of the primary tumor. We examined their computed tomographic scans to estimate tumor shadow disappearance rate (TDR), which was defined as the ratio of the tumor area of the mediastinal window to that of the lung window, reviewed the clinical records, and evaluated their relation to prognosis. RESULTS: On univariate analyses, size of the tumor (p = 0.0380), TDR (p = 0.0018), carcinoembryonic antigen (p = 0.0001) pathologic stage (p < 0.0001), nodal involvement (p < 0.0001), lymphatic invasion (p = 0.0001), and vascular invasion (p = 0.0017) were significantly associated with prognosis. Also, the outcomes of multivariate analyses for preoperative factors indicated that TDR (p = 0.0340) and carcinoembryonic antigen (p = 0.0047) are significant independent prognostic determinants. The 5-year survival was 48% in cases with a TDR of 0% to 25%, 87% in those with a TDR of 26% to 50%, 97% in those with a TDR of 51% to 75%, and 100% in those with a TDR of 76% to 100%. The incidence of lymphatic, vascular invasion, and nodal metastases was lower in patients with a higher TDR. CONCLUSIONS: Small-sized adenocarcinomas with a higher TDR showed less lymphatic, vascular vessel invasion, or nodal involvement, and demonstrated longer survival, suggesting that TDR was associated with clinical-pathologic characteristics and tumor aggressiveness. Preoperative assessment of TDR may be useful to identify an appropriate candidate for a lesser pulmonary resection.     

Lung adenocarcinoma can be subtyped according to tumor dimension by computed tomography mediastinal-window setting. Additional size criteria for clinical T1 adenocarcinoma

Objective: We sought to verify that the size of the solid component, which can be evaluated using the computed tomography mediastinal-window setting, provides new criteria for CT classification of lung adenocarcinoma. Methods: Between 1994 and September 2002, we examined 60 patients who were clinically classified with stage T1 adenocarcinoma of the lung and normal serum CEA, who underwent standard surgical procedures. Tumor maximum dimension was evaluated using two different CT-imaging settings: the lung window (lDmax), and the mediastinal window (mDmax). We analyzed the relationships between prognosis or lymph node involvement and tumor dimensions. Results: The mDmax was a significant (OR 1.11, P=0.02) predictive factor for lymph node metastasis. However, lDmax was not significant (P=0.83). Age, gender, lDmax, mDmax, and lymph node involvement were analyzed as predictive factors for prognosis. In univariate analysis, mDmax and lymph node involvement were significant predictive factors for prognosis (OR 1.07, P=0.01; OR 2.56, P=0.04; respectively). In multivariate analysis, mDmax was a significant predictive factor for prognosis (OR 1.06, P=0.04). We then classified the C-T1 adenocarcinoma patients into three groups according to mDmax: T1a (≤10 mm), T1b (from 11 to 20 mm), and T1c (from 21 to 30 mm). There was a significant difference between the three groups: the disease-free 5-year survivals were 93.3, 58.1, and 32.7%, respectively (P=0.01). Conclusions: The mDmax can give additional, useful prognostic data. This finding may provide new criteria for CT classification of lung adenocarcinoma.     

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     

Effect of radioisotope sentinel node mapping in patients with cT1 N0 M0 lung cancer

BACKGROUND: Application of the sentinel node concept to lung cancer is still controversial. Patients with peripheral small lung cancers would gain the most benefit from this concept, if it were valid. We sought to determine whether it is possible to choose between limited lymph node sampling and systematic lymphadenectomy from the distribution of sentinel lymph nodes in patients with node-negative disease on the basis of imaging. METHODS: Sixty-five consecutive patients with cT1 N0 M0 non-small cell lung cancer were enrolled. A radioisotope tracer (4 mCi of technetium-99m tin colloid, 2.0 mL) was injected in the vicinity of the tumor before surgical intervention with computed tomographic guidance. The radioactivity of each resected lymph node was measured separately with a hand-held gamma probe after complete tumor resection. Sentinel nodes were identified, and the accuracy of sentinel node mapping was examined. Whether the location of the sentinel node depended on the site of the primary tumor was also examined. RESULTS: Of the 65 patients, 3 were excluded because of the final pathologic results. Successful radionuclide migration occurred in 39 (62.9%) of the 62 patients. There was 1 (2.6%) false-negative result among 39 patients with a sentinel node, and therefore the sensitivity was 90%, and the specificity was 100%. The most common sentinel lymph nodes were at level 12 (46.7%), followed by level 11 (18.3%), the mediastinum (16.7%), and level 10 (11.7%). CONCLUSION: The sentinel node concept is valid in patients with cT1 N0 M0 lung cancer. The lobar lymph nodes were identified as sentinel nodes more frequently than other lymph nodes. We need to make further efforts to increase the sentinel node identification rate. However, we believe that if sentinel nodes are identified, sentinel node mapping can allow the accurate intraoperative diagnosis of pathologic N0 status in patients with cT1 N0 M0 lung cancer.     

直径≤3cm的周围型非小细胞肺癌纵隔淋巴结转移规律的初步研究

目的探讨直径≤3cm的周围型非小细胞肺癌(non-small cell lung cancer,NSCLC)纵隔淋巴结转移的情况,分析早期周围型NSCLC纵隔淋巴结转移的规律。方法 2000年1月1日～2008年12月31日治疗直径≤3cm的周围型NSCLC161例,男89例,女72例,年龄(63.4±10.7)岁,行肺叶切除或肺局限性切除加系统性纵隔淋巴结清扫术,分析其临床特征、病理特点及纵隔淋巴结转移规律。结果全组手术顺利,无死亡及严重并发症发生。肺叶切除153例,肺楔形切除7例,肺段切除1例。全组共清扫淋巴结2456枚,平均每例4.5±1.6组、13.1±7.3枚。术后病理:腺癌99例,鳞癌30例,肺泡细胞癌19例,其他类型肺癌13例。术后TNM分期:ⅠA期50例,ⅠB期62例,ⅡA期6例,ⅡB期10例,ⅢA期33例。N1组淋巴结转移率为23.6%(38/161),N2组转移率为20.5%(33/161),其中隆突下淋巴结转移率为8.1%(13/161),跳跃式纵隔转移率为6.8%(11/161),全组未发现下纵隔淋巴结转移。肺泡细胞癌及直径≤2cm的鳞癌、直径≤1cm的腺癌均无pN2转移。上肺癌发生pN2转移时上纵隔100%(19/19)受累,其中21.1%(4/19)同时伴有隆突下淋巴结转移;下肺癌则除主要转移至隆突下外(64.3%,9/14),还常直接单独转移至上纵隔(35.7%,5/14)。转移的纵隔淋巴结左肺癌主要分布在第5、6、7组,右肺癌主要分布在第3、4、7组。结论对于直径≤3cm的周围型NSCLC,肿瘤直径越大,其纵隔淋巴结转移率越高,肺泡细胞癌、直径≤2cm的鳞癌和≤1cm的腺癌其纵隔淋巴结转移率相对较低;上肺癌主要转移在上纵隔,下肺癌则隆突下及上纵隔均可转移;第5、6、7组淋巴结是左肺癌主要转移的位置,第3、4、7组是右肺癌主要转移的位置,术中应重点清扫。     

Lymphatic mapping and sentinel lymphadenectomy for primary and metastatic pulmonary malignant neoplasms

BACKGROUND: Mediastinal lymph node sampling understages a significant number of lung cancers, even when nodes are evaluated by immunohistochemical techniques. Intraoperative lymphatic mapping and sentinel lymphadenectomy allows focused pathologic evaluation of a few lymph nodes that accurately stage the entire basin. HYPOTHESIS: Lymphatic mapping and sentinel lymphadenectomy is a practical and accurate method of staging lymph nodes that drain primary and metastatic neoplasms of the lung. DESIGN AND SETTING: Retrospective review at a tertiary referral center. PATIENTS: Sixty-seven patients undergoing resection of lung tumors. MAIN OUTCOME MEASURES: Sentinel lymph node (SN) identification rate, number of SNs, nodal pathologic features, and survival. RESULTS: Twenty-eight patients had primary lung cancer and 39 had pulmonary metastases from melanoma (33 cases), squamous cell carcinoma (2 cases), colon cancer (2 cases), or other cancers (2 cases). Lymphatic mapping and sentinel lymphadenectomy was successful in all patients. The median number of lymph nodes identified by dye alone was 2 (range, 1-7); the median number identified by dye plus radiocolloid was 4 (range, 1-9). Most SNs (69%) were N1; 31% were N2. Lower lobe lesions drained to upper mediastinal nodes in 3 (13%) of 24 cases. Lymph node metastases were found in 11 patients with lung cancer (39%) and 8 patients with pulmonary metastases (21%). Ten (91%) of the 11 patients with lung cancer had SN involvement. In the 33 patients with metastatic melanoma, SN involvement significantly reduced the rate of 2-year survival (0% vs 48%). CONCLUSIONS: Lymphatic mapping and sentinel lymphadenectomy of intrapulmonary malignancies is technically challenging but feasible. Blue dye is most useful for in vivo identification of SNs; ex vivo radioactivity can confirm that excised nodes are SNs. Lymphatic mapping and sentinel lymphadenectomy can provide important prognostic information for patients with melanoma and lung metastases, and it may improve the staging of primary lung cancer.     

Micrometastasis to lymph nodes in stage I left lung cancer patients

BACKGROUND: To evaluate the frequency and clinicopathological characteristics of lymph node micrometastasis in left lung cancer patients diagnosed to be stage IA and IB based on routine histopathologic examinations, we examined the lymph nodes in patients who had undergone an extended mediastinal lymphadenectomy, using immunohistochemical methods. METHODS: Paraffin-embedded tissue sections from the lymph nodes in 49 patients with stage I left lung cancers were studied. We used AE1/AE3 as the anticytokeratin and Ber-EP4 as the antiepithelial cell antibodies when performing immunohistochemical staining. RESULTS: We identified micrometastasis of the lymph nodes in 13 (26.5%) of 49 patients with stage I left lung cancer. NO disease was reclassified as N1 disease in 5 cases, N2 disease in 6 cases, and N3 disease in 2 cases. The location of the micrometastatic lymph nodes proved to be wide regions including the contralateral and highest mediastinal nodes, and 6 (46.2%) out of the 13 patients with micrometastasis were thus presumed not to be completely eliminated by a standard lymphadenectomy through an ipsilateral thoracotomy. The five year survival rate of patients with reclassified N1 to N3 disease was 74%, and the presence of micrometastasis was found to have no significant effect on the outcomes. CONCLUSIONS: The micrometastatic involvement of the lymph nodes was both more frequent and extensive than expected even in stage I left lung cancer. These results suggest that an extended mediastinal lymphadenectomy may therefore be required for the locoregional control of stage I left lung cancer patients.     

Primary pulmonary collision cancer consisting of large cell carcinoma and adenocarcinoma

A case of pulmonary collision tumor is herein reported. An abnormal shadow was discovered in the right lung of a 53-year-old man. A right upper lobectomy with a mediastinal lymph node dissection was performed. Based on the findings of a postoperative pathologic examination, this tumor was considered to be a collision tumor of large cell carcinoma and adenocarcinoma, as the distribution of each tumor was clearly separated. This case is the first report of a primary pulmonary collision tumor consisting of large cell carcinoma and adenocarcinoma.     

The prognosis of surgically resected N2 non-small cell lung cancer: the importance of clinical N status.

BACKGROUND: Clinical trials dealing with multimodal strategy for N2 non-small cell lung cancer are now being watched with keen interest, and the feasibility of this strategy is to be confirmed. N2 lung cancer, however, is composed of several subgroups with different prognoses. The prognostic factors still remain controversial. METHODS: Between January 1986 and July 1997, 222 patients with lung cancer underwent surgical intervention at our institute; these patients were eventually given a diagnosis of metastasis to ipsilateral mediastinal lymph nodes. All patients underwent mediastinal lymph node dissection or sampling. Sixteen clinicopathologic factors were investigated by univariable and multivariable analyses to identify significant prognostic factors among resected N2 disease. Clinical N status was evaluated by computed tomographic scan. RESULTS: The overall 5-year survival was 27%. Multivariable analyses among overall patients revealed 4 significant prognostic factors (P <.05): clinical N2 status, incomplete resection, larger tumor size, and multiple diseased N2 nodes. Based on the result, 32 patients with both clinical N2 status and pathologic multiple N2 nodes showed a 5-year survival of 5%, whereas 76 patients with neither of the factors showed a 5-year survival of 57% (P <.001). CONCLUSION: The prognosis of surgically resected N2 disease varies tremendously according to the 4 significant prognostic factors. These factors should be clearly described in reporting clinical trials on N2 lung cancer. Clinical N status evaluated by computed tomographic scan should be 1 criterion to perform a clinical trial for N2 disease among a homogeneous population with respect to prognosis.     

Verteilungsmuster und Befall regionärer Lymphknoten bei nicht-kleinzelligem Bronchialcarcinom

Despite the important role of lymph node infiltration for the classification and prognosis of non-small-cell lung cancer (NSCLC), no standards exist to evaluate the quality of mediastinal lymphadenectomy. Researches at several centers are not convinced that complete ipsilateral lymphadenectomy is necessary. We investigated 270 consecutive patients undergoing a potential curative operation for NSCLC including complete ipsilateral lymph node dissection in order to ascertain whether or not there is a correlation between tumor localization and lymph node infiltration. Patients were classified into the UICC (1987) stages I (n = 115), II (n = 42), and IIIa (n = 113). In patients with N1-positive lymph nodes (n = 61) we found higher 5-year survival for patients with only intrapulmonary lymph node infiltration (39%) than for patients with hilar infiltration (21%). Patients with N2 disease showed skip metastases in up to 81% of cases. We found that no tumor location predicted the lymph node infiltration. Due to the variability of lymph node infiltration and the frequently occurring skip metastases, complete ipsilateral lymphadenectomy should be the standard for curative operations for NSCLC.     

Proportion of ground-glass opacity on high-resolution computed tomography in clinical T1 N0 M0 adenocarcinoma of the lung: A predictor of lymph node metastasis

OBJECTIVE: In patients with clinical T1 N0 M0 lung adenocarcinoma, we investigated whether the proportion of ground-glass opacity area measured on high-resolution computed tomography was valuable for predicting the existence of lymph node metastasis, lymphatic invasion, or vascular invasion. METHODS: Between 1994 and 1999, 111 patients with clinical stage IA adenocarcinoma underwent surgical resection of the lung at our hospital. Of these, 96 patients received high-resolution computed tomography of the chest, and they constituted the study population. The tumors were semiquantitatively classified into 5 groups on the basis of the proportion of ground-glass opacity area to whole tumor shadow on high-resolution computed tomography: group I, 0%; group II, 1% to 25%; group III, 26% to 50%; group IV, 51% to 75%; and group V, 76% to 100%. Correlations of computed tomographic findings, pathologic results of lymph node metastasis and lymphatic and vascular invasion, and the histologic subtype according to the new World Health Organization classification were examined. We also investigated the characteristics of the patients with ground-glass opacity areas on high-resolution computed tomography and their value for predicting lymph node metastasis. RESULTS: Among the 96 patients, 15 (15.6%) had mediastinal lymph node metastases, and 3 (3.1%) had hilar node metastases. Regarding the proportion of the ground-glass opacity area of the tumors, 15 (15.6%) tumors were classified as group V, 11 (11.5%) as group IV, 9 (9.3%) as group III, 22 (22.9%) as group II, and 39 (40.6%) as group I, respectively. Of the 18 patients with lymph node metastases, no patients were found in groups IV and V, 2 (22.2%) were found in group III, 4 (18.2%) were found in group II, and 12 (30.8%) were found in group I (trend P =. 003), respectively. Twenty-six patients classified into groups IV and V also showed neither lymphatic invasion nor recurrence. All the smaller tumors (< or =2.0 cm) in group IV or V were histologically proved to be bronchioloalveolar carcinoma. Adjusted for smoking status and other characteristics, patients without ground-glass opacity on high-resolution computed tomography had a significantly increased risk of concurrent lymph node metastasis compared with those with ground-glass opacity. CONCLUSION: In patients with clinical T1 N0 M0 adenocarcinoma, the proportion of ground-glass opacity area on thin-section computed tomography scans was a strong predictor for tumor aggressiveness and thus could be a useful index for planning limited surgical resection for these patients.     

Selection of Pathological N0 (pN0) in Clinical IA (cIA) Lung Adenocarcinoma by Imaging Findings of the Main Tumor

Objectives: We would like to clarify the imaging findings of the main tumor that may omit the requirement for lymph node dissection in clinical IA (cIA) lung adenocarcinoma.Methods: A total of 336 patients with cIA lung adenocarcinomas with normal preoperative carcinoembryonic antigen (CEA) who underwent surgical resection were analyzed. We investigated the association between various computed tomography (CT) imaging findings or the maximum standardized uptake value (SUVmax) of fluorodeoxyglucose-position emission tomography (FDG-PET) and lymph node metastasis. The maximum tumor diameter was calculated from the CT images using both the lung window setting (LD) and mediastinal window setting (MD). The diameter of the solid component (CD) was defined as consolidation diameter in lung window setting. The solid component ratio (C/T) was defined as CD/LD.Results: SUVmax, MD, and C/T were independent factors related to lymph node metastasis, but CD was not (p = 0.38). The conditions required for the positive predictive value (PPV) to reach 100% were 10.6 mm for MD, 12.5 mm for CD, and 0.55 for C/T. SUVmax did not reach 100%.Conclusions: In cIA lung adenocarcinoma with CEA in the normal range, we found that it may be possible for lymph node dissection to be omitted by MD, CD, and C/T.     

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.     

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.     

Use and prognostic value of staging mediastinoscopy in non-small-cell lung cancer

One hundred sixty patients had preoperative mediastinoscopy, resection of the primary tumor, and complete mediastinal lymphadenectomy for non-small-cell carcinoma of the lung. Minimum follow-up was 24 months (mean 40 months). Postoperative staging based on histologic examination of the specimen of the lung and mediastinal lymphadenectomy categorized 59 patients in stage I, 28 in stage II, and 73 in stage III (20 T3N0, 12 T3N1, 29 T1 or T2N2, and 12 T3N2). The sensitivity rate of cervical mediastinoscopy for detection of mediastinal node metastasis was 48.7%. False-negative results of mediastinoscopy occurred in 21 of 41 patients with normal mediastinoscopy: unreachable nodes in eight patients, sampling error of reachable nodes in 11 patients, and error on frozen section in two patients. Eleven of 65 patients with clinical stage I disease and normal mediastinum on chest roentgenogram had mediastinal node involvement; only three were detected by mediastinoscopy, which resulted in a low sensitivity rate (27.3%) and a high rate of unnecessary mediastinoscopy (62/65 patients). The sensitivity of mediastinoscopy increased as the amount of disease present, as measured by the clinical stage of disease or positive gallium 67 scan of mediastinum, increased. Eleven of 29 patients with T1 to T2N2 disease discovered at mediastinoscopy had similar survival rates compared with 18 of 29 patients who had a normal mediastinoscopy examination and mediastinal node involvement discovered at thoracotomy.     

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.