Positive mediastinoscopy. An ominous finding

Surgical treatment of patients with nonsmall-cell lung cancer and mediastinal lymph node involvement

Between 1974 and 1988, 115 patients admitted to our surgical unit underwent resection of nonsmall-cell lung cancer in the presence of mediastinal lymph node involvement (N2 disease). The overall 5 year survival rate was 18%, and the rates in patients with curative and noncurative operation were 26% and 9%, respectively (P less than 0.05). Based on the morphological evidence of N2 disease, the patients were placed in three groups: those with microscopic metastasis, moderate metastasis, and gross metastasis, the incidences being 29%, 28%, and 43%, respectively. The survival rates were 41%, 6%, and 16%, respectively. The difference among microscopic vs. moderate and microscopic vs. gross metastasis was statistically significant (P less than 0.01). Survival rates in patients with intranodal and extranodal invasion, as seen in the histologic examinations, were 34% and 11%, respectively (P less than 0.01). The incidence of gross metastasis and/or extranodal invasion was higher in those who underwent noncurative operation. Postoperatively adjuvant irradiation was not effective in prolonging the survival in patients with curative operation, but the local residual disease was controlled. Therefore, our working criteria are, if N2 lung cancer is present, a complete resection of the primary tumor and the mediastinal lymph nodes should be done. Patients with microscopic metastasis and intranodal invasion can expect a fairly long survival.

Current staging of lung cancer: an overview of current and newer approaches

The purpose of this chapter is to update some of the current approaches to the pretreatment assessment of patients with lung cancer. We will place emphasis on both standard staging and newer techniques. Because of their clinical relevancy, small-cell (SCLC) and non-small-cell (NSCLC) lung cancers have been divided to emphasize the special needs and approaches to each.

Computed tomography of the aortopulmonary window: normal anatomy and pathology

There can be many diagnostic pitfalls in the evaluation of the aortopulmonary window by chest radiography alone. Large masses that are easily identified on computed tomography may be essentially undetectable; also the appearances of aortopulmonary window lesions on conventional radiographs are frequently nonspecific, or may even be misleading. Careful evaluation of this region of the mediastinum is important because the aortopulmonary window is commonly the site of adenopathy secondary to neoplastic and inflammatory diseases, as well as vascular pathology. After review of the normal anatomy of the aortopulmonary window, seven selected cases are presented that demonstrate the importance of computed tomography in arriving at the correct diagnosis when conventional chest radiographs are nonspecific or equivocal.

Mediastinal assessment for staging and treatment of carcinoma of the lung

Invasive diagnostic procedures for mediastinal assessment, such as mediastinoscopy, are necessitated by the importance of staging lung cancers, both to plan the treatment and to estimate the prognosis. Other noninvasive techniques may complement or be substituted for mediastinoscopy under certain specific clinical settings. Thus with the introduction of newer diagnostic technologies, such as computed axial tomography, the strategy for mediastinal assessment should be continually reevaluated. In this review, the diagnostic sensitivity, specificity, and overall accuracy of various techniques reported in the literature are examined to elucidate their current roles in assessing the mediastinal involvement in patients with lung cancer.

Pre-operative mediastinal evaluation in primary bronchial carcinoma--a review of staging investigations

A review of staging investigations in the preoperative evaluation of mediastinal involvement in primary bronchial carcinoma is presented. The following conclusions are offered as guidelines for the use of mediastinal staging procedures in clinical practice: Surgical staging methods have the over-riding advantage of superior specificity over indirect imaging techniques. Where 67Ga-imaging or CT scanning are not available, routine pre-operative mediastinoscopy or, when appropriate, mediastinotomy will identify most patients with non-resectable disease but this approach entails a high proportion of true negative examinations. Radioisotope ventilation and perfusion lung imaging has no place in the pre-operative staging of lung cancer. Where the techniques are available, 67Ga-imaging and CT scanning have a use in selecting patients for mediastinal exploration. A negative mediastinal 67Ga scan or a negative CT examination suggest that mediastinal exploration will be unrewarding in the vast majority of cases and may be omitted prior to thoracotomy. A positive mediastinal 67Ga scan or the demonstration of abnormal mediastinal nodes by CT is an indication for mediastinal exploration which, if negative should be followed by thoracotomy.

The role of limited resection in carcinoma of the lung

Thirty years ago lobectomy was considered inadequate excision for carcinoma of the lung. In 1982 we are at the same point in comparing lobectomy with lesser resections. Limited pulmonary reserve and second carcinomas, as well as evidence of control by wedge and segmental resection, indicate that the need for lobectomy should be reappraised in carcinomas limited to smaller portions of the lungs.

Selection by mediastinoscopy and long-term survival in bronchial carcinoma

In order to reduce the high rate of inoperability in patients with bronchial carcinoma, mediastinoscopy was carried out as a routine preoperative selection in 874 patients during 13 years. Two hundred thirty-six patients (27%) were found to have involved lymph nodes at mediastinoscopy and were not treated surgically. Follow-up data were available on 210 of them: 165 (79%) died within a year, 16 survived for 2 years, and 4 for 5 years. Pulmonary resection was carried out in 638 patients. Five-year survival in the series was 24.5% and 10-year survival (based on 104 eligible patients), 16.3%, including the operative mortality of 5.5%. Mediastinoscopy has not improved long-term survival to any great extent. However, it has raised the rate of resectability to 97.1% and lowered the operative mortality without denying the patient a chance of cure.

Resectional surgery in the treatment of primary carcinoma of the lung with mediastinal lymph node metastases

Between 1966 and 1970 we reviewed 46 consecutive patients undergoing resection for primary carcinoma of the lung, in whom mediastinal lymph node metastases were found at operation. There was one operative death. Five of the remaining 45 patients survived five years--one of 10 cases of large cell carcinoma, one of 19 cases of adenocarcinoma, and three of 12 cases of epidermoid carcinoma. We believe that mediastinal lymph node metastases are not per se a contraindication to resection of epidermoid carcinoma of the lung.

Lung cancer

Only patients with localized lung cancer benefit from curative resection. Curative radiotherapy is recommended in patients with a resectable tumor in whom surgery is precluded for medical reasons. Adjuvant preoperative or postoperative therapy of any type does not improve the results of surgery except in patients with Pancoast tumor. Therapy for nonlocalized tumors does not affect survival. Radiotherapy has a palliative effect in 50 to 75 per cent of patients presenting with symptoms from either a primary lesion or metastases and should therefore be recommended in symptomatic patients. The palliative effect of chemotherapy is limited in lung cancers other than small cell carcinomas. However, chemotherapy alone or in association with radiotherapy produces remarkable tumor regression and some improvement of survival in small cell carcinoma. The use of immunotherapy in the treatment of lung cancer is still under evaluation.

Mediastinoscopy

A series of 150 mediastinoscopic examinations, performed at The Prince Charles Hospital, Brisbane, is reported. The procedure was employed as a diagnostic aid in the care of patients known to be suffering from disease processes involving the superior mediastinum, and as a preoperative assessment in a group of patients known to have, or suspected of having, bronchogenic carcinoma, There was no mortality. The morbidity rate was 2%.

Is mediastinoscopy necessary in the evaluation of lung cancer?

The records of 96 consecutive patients who underwent mediastinoscopy and were ultimately shown to have bronchogenic carcinoma were reviewed. Indirect tests for mediastinal tumor metastases in these patients included bronchoscopy and chest roentgenograms in all 96, mediastinal laminagrams in 65, esophagograms in 27, carinal biopsy in 23, bronchograms in 5, pulmonary angiograms in 5, azygograms in 2, and aortograms in 2 patients. Of the 43 patients in this series in whom all indirect tests revealed no metastases, mediastinoscopy showed nodal involvement in 11 (28%), who were thus spared unnecessary thoracotomy. On the other hand, if negative mediastinoscopy had not cast doubt on the validity of indirect tests that seemed to show metastases, an operation might actuallly have been denied to 14 patients who were ultimately proved to have anatomically resectable disease.