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Parasternal mediastinoscopy
J
THORAC CARDIOVASC SURG
1988;95:298-302
Parasternal mediastinoscopy Assessment of operability in left upper lobe lung cancer: A prospective analysis Between 1976 and 1984,242 patients with presumably operable lung cancer were treated surgicaUy. In the Canisius Wilhelmina Hospital, Nijmegen, The Netherlands, in the period 1976 to 1980, 109 of 131 (83.2 %) patients underwent cervical mediastinoscopy to assess operability. They were studied retrospectively. During this examination, lymph node metastasis was demonstrated in three of 19 (15.8 %) patients with left upper lobe lung cancer. At thoracotomy after a normal cervical mediastinoscopic study or no mediastinoscopic study, periaortic lymph node metastases were found in eight of 34 (23.5 %) patients with left upper lobe lung cancer. In the period 1981 to 1984, the value of left parasternal mediastinoscopy was studied prospectively in patients with left lung cancer in the Canisius Wilhelmina Hospital, Nijmegen; in the Lung Centre of the Radboud University Hospital, Nijmegen; and in the Lung Center of the Dekkerswald Medical Centre, Groesbeek. Cervical or cervical and parasternal mediastinoscopy were performed in 69 of III (62.2 %) patients. At parasternal mediastinoscopy performed after a normal cervical mediastinoscopic study, periaortic lymph node metastases were found in seven of 31 (22.6%) patients with left upper lobe lung cancer. AU periaortic lymph node metastases showed intranodal and extranodal growth. The resectability rate in left upper lobe lung cancer was 79.4 % in the retrospective group and 96.5 % in the prospective group. There were no serious complications after parasternal mediastinoscopy. These data point to the reliability of parasternal mediastinoscopy in the assessment of left upper lobe lung cancer. The study provides essential information for the staging and treatment of non-smaU ceU lung cancer of the left upper lobe.
Hans H. J. Schreinemakers, MD: Harry J. M. Joosten, MD,b Marcel Mravunac, MD,c and Leon K. Lacquet, MD: Nijmegen, The Netherlands
In cases of non-small cell lung cancer, surgical therapy offers the best chance for cure. At surgical exploration in patients considered clinically to have operable diseases the tumor often proves unresectable or a curative resection appears virtually impossible because of metastasis to the mediastinum. Before mediastinoscopy was introduced, the number of exploratory thoracot-
From the Department of Thoracic, Cardiac, and Vascular Surgery (Head Prof. Dr. L. K. Lacquet), Radboud University Hospital; and the Departments of General and Thoracic Surgery' and Pathology,' the Canisius Wilhelmina Hospital, Nijmegen, The Netherlands. Received for publication July 18, 1986. Accepted for publication Feb. 5, 1987. Address for reprints: Hans H. J. Schreinemakers, MD, Radboud University Hospital, Department of Thoracic, Cardiac, and Vascular Surgery, Geert Grooteplein 10, 6525 GH Nijmegen, The Netherlands.
298
omies was high, making up about 40% of the total number of thoracotomies. I. 2 During the past 20 years the operative mortality has remained remarkably constant: about 5% in the group in which mediastinoscopic studies were performed preoperatively to determine operability. Since exploratory thoracotomy and palliative resection do not prolong life expectancy, it is essential to determine the operability of a tumor as accurately as possible." After cervical mediastinoscopy was introduced, the percentage of exploratory thoracotomies dropped considerably, ranging now from 1.7% to 23.9%.6-14 The lymph nodes in the periaortic region cannot be reached during cervical mediastinoscopic examinations. These, however, form an important lymph drainage pathway for the upper lobe of the left lung. Cordier, Papamiltiades, and Cedard" refined the lymphatic system of the lungs set up by Rouviere" by examining the separate lung segments. They established
Volume 95 Number 2 February 1988
that the apical, dorsal, and ventral segments of the left upper lobe and the cranial and caudal segments of the lingula drain to the left anterior mediastinal lymph node chain. Others support these findings.":" In 1966 McNeill and Chamberlain'? first described the technique of anterior mediastinotomy, and in 1980 Jolly," Page", and their associates described the technique of left parasternal mediastinoscopy. In the prospective part of our study, left parasternal mediastinoscopy was used to provide a more accurate staging of left upper lobe lung cancer. After cervical mediastinoscopy was performed, revealing no abnormalities, the nodes of the left anterior lymph node chain were examined by left parasternal mediastinoscopy in patients with cancer of the left lung and particularly of the left upper lobe. In the case of metastatic lymph node involvement, special attention was paid to intranodal and extranodal growth. Thus parasternal and cervical mediastinoscopy are performed on the anatomic basis of lymph drainage pathways of the left upper lung lobe.
Parasternal mediastinoscopy
299
Table I. Retrospective group Left lung Central MS No MS Peripheral MS No MS Total
Left upper lobe Central MS NoMS Peripheral MS No MS Total
N
eM
33
10 (33.3%)
14
11 58
19
3(15.8%)
12
7 38
Legend: N, Total number of patients with central or peripheral left lung cancer, with or without mediastinoscopy. Clvl, The number of abnormal cervical mediastinoscopic studies. The results of mediastinoscopy in patients with left upper lobe lung cancer are mentioned separately. No MS, No mediastinoscopic study performed.
Patients and methods In the Canisius Wilhelmina Hospital, Nijmegen, The Netherlands, between J976 and J980, cervical mediastinoscopic studies were performed in 109 of 131 (83.2%) patients with clinically operable lung cancer. Of the 109 patients in this retrospective study group, 62 had right-sided tumors and 47 had left-sided tumors. The location and extent of mediastinal metastases identified at thoracotomy (after cervical mediastinoscopy showed no abnormalities) were studied with special attention to the periaortic lymph nodes and were compared with literature data on left lung cancer. Of the 131 patients, 81 (61.8%) had centrally located lung cancer. Between 1981 and 1984, III patients with presumably operable left lung cancer were studied prospectively in the Canisius Wilhelmina Hospital, Nijmegen; in the Lung Centre of Radboud University Hospital, Nijmegen; and in the Lung Centre of the Dekkerswald Medical Centre, Groesbeek. A cervical mediastinoscopic examination was performed in 64 of III (57.7%) patients with left lung cancer. This study showed no abnormalities in 40 of the patients, and they were then subjected to a parasternal mediastinoscopic examination. The tumor was centrally located in 61 of III (54.9%) patients with left lung cancer and more specified in 38 of 71 (53.5%) patients with left upper lobe lung cancer. In all patients staging was done before and after thoracotomy according to the TNM classification of the American Joint Committee for Cancer Staging and End Results Reporting." At thoracotomy, hilar and mediastinal lymph nodes were sampled and mapped according to the American Joint Committee on Cancer Classification of regional lymph nodes." The results were entered into a previously established data base. In the retrospective and prospective analyses, the histologic diagnoses of all patients were verified and confirmed by one of us (M.M.). There were 223 men and 19 women. The mean age was in the seventh decade of life. We perform cervical mediastinoscopic studies in all patients with a clinically operable central lung cancer and in selected
patients with a peripheral lung cancer with T2 or T3 status. A left parasternal mediastinoscopic study is performed only if findings of the cervical examination are normal in patients with left lung cancer, especially left upper lobe cancer. We use the criteria of Paulson and Urschel? to determine operability in patients with metastatic lymph node involvement demonstrated by cervical or parasternal mediastinoscopy.
Results In the present series of 242 patients, a cervical mediastinoscopic examination was performed in 178 patients with 'inically resectable lung cancer. A parasternal mediasunoscopic study, after the cervical examination showed no abnormalities, was performed in 31 patients with left upper lobe lung cancer. The series is divided into a retrospective part of 131 patients with right or left lung cancer, comprising 38 patients with left upper lobe lung cancer, and a prospective part of 111 patients with left lung cancer, comprising 71 patients with left upper lobe lung cancer. Retrospective study (1976 to 1980). The percentage of metastatically involved lymph nodes found during cervical mediastinoscopy for right and left lung cancer is lower in patients with left lung cancer and is lowest in those with left upper lobe lung cancer, ranging from 19.7% to 50% in the literature.v-" The results will vary with the selection criteria. Our retrospective study deals with 38 (65.5%) patients in whom lung cancer spread from the left upper lobe. Of 38 patients, 31 (81.6%) underwent a cervical mediastinoscopic examination. Abnormalities were detected in
The Journal of
3 00
Schreinemakers et al.
Thoracic and Cardiovascular Surgery
Table II. Prospective group Left lung Central MS No MS Peripheral MS NoMS Total Left upper lobe Central MS NoMS Peripheral MS No MS Total
N
CM+PM
53 8
24 (45.3%)
16 34 III
35 3 8 25 71
5
14 (40%)
4
Legend: N, Total number of patients with central or peripheral left lung cancer. with or without mediastinoscopy. CM + PM. The number of combined abnormal mediastinoscopic studies. The results of combined mediastinoscopy in patients with left upper lobe lung cancer are mentioned separately. CM. Abnormal cervical mediastinoscopic study. PM. Abnormal parasternal mediastinoscopic study. No MS. No mediastinoscopic study performed.
three of 19 (15.8%) patients with central tumor of the left upper lobe. The results of cervical mediastinoscopy and the total number of patients with left upper lobe lung cancer are listed in Table I. At thoracotomy after a normal cervical mediastinascopic study or no mediastinoscopic study, metastatic involvement in the periaortic lymph nodes was found in 10 of 47 (21.3%) patients with left lung cancer. Of those 10 patients, eight had a left upper lobe cancer and six a centrally located left lung cancer. In the literature, this percentage ranges from 7.7% to 50% for the left lung and from 23% to 83.3% for the left upper lobe. 12. 22. 32·41 Primary tumors and their metastases were classified according to cell type. The distribution of the various histologic cell types among the 242 patients is squamous cell carcinoma 69.8% (169), adenocarcinoma 12.4% (30), undifferentiated small cell carcinoma 8.7% (21), and other histologic cell types 9.1% (22). The distribution is similar in the retrospective and prospective groups. Prospective study (1981 to 1984). The prospective part deals with 111 patients with left lung cancer. There were 71 (64.0%) patients in whom lung cancer had spread from the left upper lobe. Of these 71 patients, 43 (60.6%) underwent cervical or cervical and parasternal mediastinoscopy. The cervical mediastinoscopic examination detected abnormalities in nine of 35 patients (25.7%) with central left upper lobe cancer. The 26 with normal findings were subjected to a parasternal media-
stinoscopic study, and this revealed nodal disease in five patients (19.2%). The number of abnormal results of combined cervical and parasternal mediastinoscopic examinations in centrally located left upper lobe lung cancer was 14 of 35 cases (40.0%). The results of mediastinoscopy in left upper lobe lung cancer are listed in Table II. Surgical intervention in the retrospective and prospective studies (1976 to 1984). Of 242 patients, 178 underwent cervical or parasternal mediastinoscopy and 54 of them proved to have metastatically involved lymph nodes in the mediastinum. These 54 were rejected for thoracotomy on the basis of criteria developed by Paulson and Urschel." Two patients were refused for thoracotomy for cardiac reasons, and two proved to have distant metastases. Thoracotomy was performed in 184 patients. The resectability rates in the retrospective and prospective parts of the study were 80.8% (80/99) and 92.9% (79/85), respectively. The resectability rates for left upper lobe lung cancer increased from 79.4% (27/34) in the retrospective study to 96.5% (55/57) in the prospective study. Of 159 resections for lung cancer, there were 19 (11.9%) palliative resections and 140 (88.1 %) curative resections. The pneumonectomy rate was 42.8%.
Discussion According to Paulson and Urschel," cervical mediastinoscopy increases the resectability rate and the survival rate after resection for lung cancer. The left anterior lymph node chain (involving the periaortic and aortic window lymph nodes) is not accessible via the cervical mediastinoscopic route. Cordier, Papamiltiades, and Cedard" refined the classification system of anatomic lymph drainage pathways, set up by Rouviere," by examining the lung segments separately. They established that the apical, dorsal, and ventral segments of the left upper lobe and the cranial and caudal segments of the lingula drain to the left anterior lymph node chain. Others support these findings. 17·19 Also, exact knowledge of lymph drainage pathways of the left lung is the scientific basis for the combined cervical and parasternal exploration by mediastinoscopy in left upper lobe lung cancer. We do not agree with Jolly, Li, and Anderson," who examined left lung cancer by parasternal mediastinoscopy alone. After finding no abnormal nodes by a cervical mediastinoscopic study in left upper lobe cancer, we perform a left parasternal mediastinoscopic examination, as do Luke and his colleagues." On the basis of the usual clinical criteria, all patients in the present series were regarded as having curatively operable disease. We and others believe that mediastinal
Volume 95 Number 2
Parasternal mediastinoscopy 3 0 1
February 1988
lymph node invasion is a contraindication to resection of lung cancer, 4.9.18.38.40.43.44 with a few exceptions according to Paulson and Urschel." Such an exception may be ipsilateral intranodal invasion at a low tracheobronchial level in a case of squamous cell carcinoma. We also accept the operability of squamous cell carcinoma of the left upper lobe with metastatic intra nodal involvement in the aortic window, found during a left parasternal mediastinoscopic examination. On the basis of these criteria, none of the 54 patients with mediastinoscopically detected N2 disease was selected for further surgical intervention. This study has shown that left parasternal mediastinoscopy, when performed after normal cervical mediastinoscopy in left upper lobe lung cancer, is an accurate predictor of operability. In the retrospective part of the study, eight of 34 (23.5%) patients with left upper lobe cancer had metastatically involved lymph nodes in the periaortic region found at thoracotomy, whereas in the prospective part, seven of 31 (22.6%) patients with left upper lobe cancer had metastatically involved lymph nodes in the periaortic region found at parasternal mediastinoscopy after normal cervical mediastinoscopy. In the prospective series, unwarranted thoracotomies were avoided in eight of 40 patients. In other studies, parasternal mediastinotomy is performed in left upper lobe cancer with similar results. There were very few minor complications. We advocate both mediastinoscopic procedures if necessary in the evaluation of mediastinallymph nodes in cases of left upper lobe lung cancer. Left parasternal mediastinoscopy has proved to have a high degree of accuracy with a negligible complication rate. In a collective review, Unruh and Chiu" compared the role of mediastinoscopy with that of other noninvasive methods, including chest roentgenography, tomography, pulmonary angiography, gallium scintigraphy, and computed tomography. At present, mediastinoscopy seems to be the most accurate procedure for staging even limited mediastinal metastasis, and as such it spares those who would have little or no chance of benefiting from thoracotomy. We agree with Unruh and Chiu" that other noninvasive developments, such as scanning radioactive tumor-specific monoclonal antibodies, will eliminate the need for invasive staging of the mediastinum in the near future.
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8. 9.
10.
11. 12.
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16. 17.
18.
19. 20.
REFERENCES 1. Barrett RJ, Day JC, O'Rourke PV, et al. Primary carcinoma of the lung: experience with 1,312 patients. J THORAC CARDIOVASC SURG 1963;46:292-7. 2. Sensenig DM, Rossi NP, Ehrenhaft JL. Results of the
21.
surgical treatment of bronchogenic carcinoma. Surg Gynecol Obstet 1963;116:279-84. Larsson S. Mediastinoscopy in bronchogenic carcinoma. Scand J Thorac Cardiovasc Surg 1976;Suppl 19:5-23. Lacquet LK, Mertens A, van Kleef J, Jongerius CM. Mediastinoscopy and bronchial carcinoma: experience with 600 mediastinoscopies. Thorax 1975;30:141-5. Carlens E, Larsson S. Mediastinoscopy in lung cancer. Sem Resp Med 1982;3:176-83. Larsson S. Pretreatment classification and staging of bronchogenic carcinoma. Scand J Thorac Cardiovasc Surg 1973;Suppl 10:5-140. Bergh NP, Schersten T. Bronchogenic carcinoma: a follow-up study of a surgically treated series with special reference to the prognostic significance of lymph node metastases. Acta Chir Scand 1965;Suppl 347:1-42. PaIva T, Viikari S, Inberg M. Pulmonary carcinoma. Chest 1969;56:156-8. Paulson DL, Urschel H. Selectivity in the surgical treatment of bronchogenic carcinoma. J THORAC CARDIOVASC SURG 1971;62:554-62. Pearson FG, Nelems JM, Henderson RD, Delarue Ne. The role of mediastinoscopy in the selection of treatment for bronchial carcinoma with involvement of superior mediastinal lymph nodes. J THORAC CARDIOVASC SURG 1972;64:382-90. Freise G, Gabler A, Liebig S. Bronchial carcinoma and long-term survival. Thorax 1978;33:228-34. Lacquet LK. La valeur de la mediastinoscopie et de la mediastinotomie dans la selection preoperatoire des malades avec cancer pulmonaire. Rev Mediterran Sci Med 1978;Suppl 4:32-3. Nohl-Oser He. The long-term survival of patients with lung cancer treated surgically after selection by mediastinoscopy. Thorac Cardiovasc Surg 1980;28: 158-61. van den Bosch JMM, Gelissen HJ, Wagenaar SS. Exploratory thoracotomy in bronchial carcinoma. J THORAC CARDIOVASC SURG 1983;85:733-7. Cordier G, Papamiltiades M, Cedard e. Les Iymphatiques des bronches et des segments pulmonaires. Bronches 1958;8:8-52. Rouviere H. Les Iymphatiques de I'homme. Paris: Masson & Cie, 1932:168-89. Munka W. Das Lymphgefass-Systern der Lungen vom Standpunkt ihrer Segmentstruktur. Bioi Prace Bratislava 1964. Ref.: Zbl Tuberk Forschung 1963;94: 131-40. Nohl-Oser He. Lymphatics of the lung. In: Shields TW, ed. General Thoracic Surgery, 2nd ed. Philadelphia: Lea & Febiger, 1983:72-81. Sarrazin R, Dyon JF. Les lymphatiques du poumon. Bull Assoc Anat 1974;58:1043-59. McNeill T, Chamberlain JM. Diagnostic anterior mediastinotomy. Ann Thorac Surg 1966;2:532-9. Jolly PC, Li W, Anderson RP. Anterior and cervical mediastinoscopy for determining operability and predicting resectability in lung cancer. J THORAC CARDIOVASC SURG 1980;79:366-71.
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22. Page A, Mercier C, Verdant A, Cossette R, Dontigny L, Pelletier LC. Parasternal mediastinoscopy in bronchial carcinoma of the left upper lobe. Can J Surg 1980;23: 171-2. 23. American Joint Committee on Cancer. Manual for staging of cancer. Beahrs OH, Myers MH, eds. Philadelphia: JB Lippincott, 1983:99-105. 24. Akovbiantz A. Die Mediastinoskopie. Bern: Huber, 1977: 53-66. 25. Maassen W, Kirsch M, Thiimmler M. Indikationen und vorlaufige Ergebnisse bei 300 Mediastinoskopien. Prax Pneumol 1964;18:65-77. 26. Jepsen 0: Mediastinoscopy. New York: Harper & Row, Publishers, 1980:1-23. 27. Maassen W. Results of routine mediastinoscopy in bronchial carcinoma. In: Jepsen 0, Sprensen HR, eds. Mediastinoscopy. Odense: University Press, 1971:31-42. 28. Sarrazin R, Voog R. Mediastinoscopy and bronchogenic carcinoma. In: Jepsen 0, Sprensen HR, eds. Mediastinoscopy. Odense: University Press, 197 I :43-52. 29. Jolly PC, Hill LD, Lawless PA, West TL. Parasternal mediastinotomy and mediastinoscopy.J THORAC CARDIOVASC SURG 1973;66:549-56. 30. Paiva T, Karja J, Paiva A. Mediastinoscopic observations of metastatic spread in pulmonary carcinoma. Acta Otolaryngol 1973;73:443-7. 31. Goldberg EH, Chapiro CH, Glicksman AS. Mediastinoscopy for assessing mediastinal spread in clinical staging of lung carcinoma. Sem Oncol 1974;1:205-15. 32. Roukema JA, Prins JG. The value of cervical mediastinoscopy. Neth J Surg 1983;35:48-51. 33. Evans DS, Hall JH, Harrison GK. Anterior mediastinotomy. Thorax 1973;28:444-7. 34. Murray GF, Wilcox BR, Starek PJK, Williams LE. Mediastinoscopy in the assessment of operability of bronchogenic carcinoma. NC Med J 1975;36:164-6.
The Journal of Thoracic and Cardiovascular Surgery
35. Gardner MAH, Lomas C. Mediastinoscopy. Med J Aust 1976;2:437-9. 36. Bowen TE, Zajtchuk R, Green DC, Brott WHo Value of anterior mediastinotomy in bronchogenic carcinoma of the left upper lobe. J THORAC CARDIOVASC SURG 1978; 76:269-71. 37. Deneffe G, Daenen W, Stalpaert G. Experience with 100 consecutive anterior mediastinotomies in lung cancer. Acta Chir Belg 1982;82:509-13. 38. Pearson FG, Delarue NC, lives R, Todd TRJ, Cooper JD. Significance of positive superior mediastinal nodes identified at mediastinoscopy in patients with resectable cancer of the lung. J THORAC CARDIOVASC SURG 1982; 83:1-11. 39. Smith STR, Hooper RG, Beechler CR, Whitcomb MF. Indications for mediastinal lymph node evaluation. Chest 1982;81 :599-604. 40. Deneffe G, Lacquet LM, Gijselen A. Cervical mediastinoscopy and anterior mediastinotomy in patients with lung cancer and radiologically normal mediastinum. Eur J Respir Dis 1983;64:613-9. 41. Pot JH, van Velthoven PCM. The value of parasternal mediastinotomy. Neth J Surg 1983;35:52-4. 42. Luke WP, Pearson FG, Todd TRJ, Patterson GA, Cooper JD. Prospective evaluation of mediastinoscopy for assessment of carcinoma of the lung. J THORAC CARDIOVASC SURG 1986;91:53-6. 43. Greschuchna D, Maassen W. Uber die intrapulmonalen und mediastinalen Ausbreitungswege des Bronchialkarzinoms. Thoraxchir Vask Chir 1971;19:434-7. 44. Schreinemakers JHJ: Parasternal mediastinoscopy. Wageningen: Veenman, 1985:1-77. 45. Unruh H, Chiu RC-J. Mediastinal assessment for staging and treatment of carcinoma of the lung. Ann Thorac Surg 1986;41 :224-9.
THORAC CARDIOVASC SURG
1988;95:298-302
Parasternal mediastinoscopy Assessment of operability in left upper lobe lung cancer: A prospective analysis Between 1976 and 1984,242 patients with presumably operable lung cancer were treated surgicaUy. In the Canisius Wilhelmina Hospital, Nijmegen, The Netherlands, in the period 1976 to 1980, 109 of 131 (83.2 %) patients underwent cervical mediastinoscopy to assess operability. They were studied retrospectively. During this examination, lymph node metastasis was demonstrated in three of 19 (15.8 %) patients with left upper lobe lung cancer. At thoracotomy after a normal cervical mediastinoscopic study or no mediastinoscopic study, periaortic lymph node metastases were found in eight of 34 (23.5 %) patients with left upper lobe lung cancer. In the period 1981 to 1984, the value of left parasternal mediastinoscopy was studied prospectively in patients with left lung cancer in the Canisius Wilhelmina Hospital, Nijmegen; in the Lung Centre of the Radboud University Hospital, Nijmegen; and in the Lung Center of the Dekkerswald Medical Centre, Groesbeek. Cervical or cervical and parasternal mediastinoscopy were performed in 69 of III (62.2 %) patients. At parasternal mediastinoscopy performed after a normal cervical mediastinoscopic study, periaortic lymph node metastases were found in seven of 31 (22.6%) patients with left upper lobe lung cancer. AU periaortic lymph node metastases showed intranodal and extranodal growth. The resectability rate in left upper lobe lung cancer was 79.4 % in the retrospective group and 96.5 % in the prospective group. There were no serious complications after parasternal mediastinoscopy. These data point to the reliability of parasternal mediastinoscopy in the assessment of left upper lobe lung cancer. The study provides essential information for the staging and treatment of non-smaU ceU lung cancer of the left upper lobe.
Hans H. J. Schreinemakers, MD: Harry J. M. Joosten, MD,b Marcel Mravunac, MD,c and Leon K. Lacquet, MD: Nijmegen, The Netherlands
In cases of non-small cell lung cancer, surgical therapy offers the best chance for cure. At surgical exploration in patients considered clinically to have operable diseases the tumor often proves unresectable or a curative resection appears virtually impossible because of metastasis to the mediastinum. Before mediastinoscopy was introduced, the number of exploratory thoracot-
From the Department of Thoracic, Cardiac, and Vascular Surgery (Head Prof. Dr. L. K. Lacquet), Radboud University Hospital; and the Departments of General and Thoracic Surgery' and Pathology,' the Canisius Wilhelmina Hospital, Nijmegen, The Netherlands. Received for publication July 18, 1986. Accepted for publication Feb. 5, 1987. Address for reprints: Hans H. J. Schreinemakers, MD, Radboud University Hospital, Department of Thoracic, Cardiac, and Vascular Surgery, Geert Grooteplein 10, 6525 GH Nijmegen, The Netherlands.
298
omies was high, making up about 40% of the total number of thoracotomies. I. 2 During the past 20 years the operative mortality has remained remarkably constant: about 5% in the group in which mediastinoscopic studies were performed preoperatively to determine operability. Since exploratory thoracotomy and palliative resection do not prolong life expectancy, it is essential to determine the operability of a tumor as accurately as possible." After cervical mediastinoscopy was introduced, the percentage of exploratory thoracotomies dropped considerably, ranging now from 1.7% to 23.9%.6-14 The lymph nodes in the periaortic region cannot be reached during cervical mediastinoscopic examinations. These, however, form an important lymph drainage pathway for the upper lobe of the left lung. Cordier, Papamiltiades, and Cedard" refined the lymphatic system of the lungs set up by Rouviere" by examining the separate lung segments. They established
Volume 95 Number 2 February 1988
that the apical, dorsal, and ventral segments of the left upper lobe and the cranial and caudal segments of the lingula drain to the left anterior mediastinal lymph node chain. Others support these findings.":" In 1966 McNeill and Chamberlain'? first described the technique of anterior mediastinotomy, and in 1980 Jolly," Page", and their associates described the technique of left parasternal mediastinoscopy. In the prospective part of our study, left parasternal mediastinoscopy was used to provide a more accurate staging of left upper lobe lung cancer. After cervical mediastinoscopy was performed, revealing no abnormalities, the nodes of the left anterior lymph node chain were examined by left parasternal mediastinoscopy in patients with cancer of the left lung and particularly of the left upper lobe. In the case of metastatic lymph node involvement, special attention was paid to intranodal and extranodal growth. Thus parasternal and cervical mediastinoscopy are performed on the anatomic basis of lymph drainage pathways of the left upper lung lobe.
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299
Table I. Retrospective group Left lung Central MS No MS Peripheral MS No MS Total
Left upper lobe Central MS NoMS Peripheral MS No MS Total
N
eM
33
10 (33.3%)
14
11 58
19
3(15.8%)
12
7 38
Legend: N, Total number of patients with central or peripheral left lung cancer, with or without mediastinoscopy. Clvl, The number of abnormal cervical mediastinoscopic studies. The results of mediastinoscopy in patients with left upper lobe lung cancer are mentioned separately. No MS, No mediastinoscopic study performed.
Patients and methods In the Canisius Wilhelmina Hospital, Nijmegen, The Netherlands, between J976 and J980, cervical mediastinoscopic studies were performed in 109 of 131 (83.2%) patients with clinically operable lung cancer. Of the 109 patients in this retrospective study group, 62 had right-sided tumors and 47 had left-sided tumors. The location and extent of mediastinal metastases identified at thoracotomy (after cervical mediastinoscopy showed no abnormalities) were studied with special attention to the periaortic lymph nodes and were compared with literature data on left lung cancer. Of the 131 patients, 81 (61.8%) had centrally located lung cancer. Between 1981 and 1984, III patients with presumably operable left lung cancer were studied prospectively in the Canisius Wilhelmina Hospital, Nijmegen; in the Lung Centre of Radboud University Hospital, Nijmegen; and in the Lung Centre of the Dekkerswald Medical Centre, Groesbeek. A cervical mediastinoscopic examination was performed in 64 of III (57.7%) patients with left lung cancer. This study showed no abnormalities in 40 of the patients, and they were then subjected to a parasternal mediastinoscopic examination. The tumor was centrally located in 61 of III (54.9%) patients with left lung cancer and more specified in 38 of 71 (53.5%) patients with left upper lobe lung cancer. In all patients staging was done before and after thoracotomy according to the TNM classification of the American Joint Committee for Cancer Staging and End Results Reporting." At thoracotomy, hilar and mediastinal lymph nodes were sampled and mapped according to the American Joint Committee on Cancer Classification of regional lymph nodes." The results were entered into a previously established data base. In the retrospective and prospective analyses, the histologic diagnoses of all patients were verified and confirmed by one of us (M.M.). There were 223 men and 19 women. The mean age was in the seventh decade of life. We perform cervical mediastinoscopic studies in all patients with a clinically operable central lung cancer and in selected
patients with a peripheral lung cancer with T2 or T3 status. A left parasternal mediastinoscopic study is performed only if findings of the cervical examination are normal in patients with left lung cancer, especially left upper lobe cancer. We use the criteria of Paulson and Urschel? to determine operability in patients with metastatic lymph node involvement demonstrated by cervical or parasternal mediastinoscopy.
Results In the present series of 242 patients, a cervical mediastinoscopic examination was performed in 178 patients with 'inically resectable lung cancer. A parasternal mediasunoscopic study, after the cervical examination showed no abnormalities, was performed in 31 patients with left upper lobe lung cancer. The series is divided into a retrospective part of 131 patients with right or left lung cancer, comprising 38 patients with left upper lobe lung cancer, and a prospective part of 111 patients with left lung cancer, comprising 71 patients with left upper lobe lung cancer. Retrospective study (1976 to 1980). The percentage of metastatically involved lymph nodes found during cervical mediastinoscopy for right and left lung cancer is lower in patients with left lung cancer and is lowest in those with left upper lobe lung cancer, ranging from 19.7% to 50% in the literature.v-" The results will vary with the selection criteria. Our retrospective study deals with 38 (65.5%) patients in whom lung cancer spread from the left upper lobe. Of 38 patients, 31 (81.6%) underwent a cervical mediastinoscopic examination. Abnormalities were detected in
The Journal of
3 00
Schreinemakers et al.
Thoracic and Cardiovascular Surgery
Table II. Prospective group Left lung Central MS No MS Peripheral MS NoMS Total Left upper lobe Central MS NoMS Peripheral MS No MS Total
N
CM+PM
53 8
24 (45.3%)
16 34 III
35 3 8 25 71
5
14 (40%)
4
Legend: N, Total number of patients with central or peripheral left lung cancer. with or without mediastinoscopy. CM + PM. The number of combined abnormal mediastinoscopic studies. The results of combined mediastinoscopy in patients with left upper lobe lung cancer are mentioned separately. CM. Abnormal cervical mediastinoscopic study. PM. Abnormal parasternal mediastinoscopic study. No MS. No mediastinoscopic study performed.
three of 19 (15.8%) patients with central tumor of the left upper lobe. The results of cervical mediastinoscopy and the total number of patients with left upper lobe lung cancer are listed in Table I. At thoracotomy after a normal cervical mediastinascopic study or no mediastinoscopic study, metastatic involvement in the periaortic lymph nodes was found in 10 of 47 (21.3%) patients with left lung cancer. Of those 10 patients, eight had a left upper lobe cancer and six a centrally located left lung cancer. In the literature, this percentage ranges from 7.7% to 50% for the left lung and from 23% to 83.3% for the left upper lobe. 12. 22. 32·41 Primary tumors and their metastases were classified according to cell type. The distribution of the various histologic cell types among the 242 patients is squamous cell carcinoma 69.8% (169), adenocarcinoma 12.4% (30), undifferentiated small cell carcinoma 8.7% (21), and other histologic cell types 9.1% (22). The distribution is similar in the retrospective and prospective groups. Prospective study (1981 to 1984). The prospective part deals with 111 patients with left lung cancer. There were 71 (64.0%) patients in whom lung cancer had spread from the left upper lobe. Of these 71 patients, 43 (60.6%) underwent cervical or cervical and parasternal mediastinoscopy. The cervical mediastinoscopic examination detected abnormalities in nine of 35 patients (25.7%) with central left upper lobe cancer. The 26 with normal findings were subjected to a parasternal media-
stinoscopic study, and this revealed nodal disease in five patients (19.2%). The number of abnormal results of combined cervical and parasternal mediastinoscopic examinations in centrally located left upper lobe lung cancer was 14 of 35 cases (40.0%). The results of mediastinoscopy in left upper lobe lung cancer are listed in Table II. Surgical intervention in the retrospective and prospective studies (1976 to 1984). Of 242 patients, 178 underwent cervical or parasternal mediastinoscopy and 54 of them proved to have metastatically involved lymph nodes in the mediastinum. These 54 were rejected for thoracotomy on the basis of criteria developed by Paulson and Urschel." Two patients were refused for thoracotomy for cardiac reasons, and two proved to have distant metastases. Thoracotomy was performed in 184 patients. The resectability rates in the retrospective and prospective parts of the study were 80.8% (80/99) and 92.9% (79/85), respectively. The resectability rates for left upper lobe lung cancer increased from 79.4% (27/34) in the retrospective study to 96.5% (55/57) in the prospective study. Of 159 resections for lung cancer, there were 19 (11.9%) palliative resections and 140 (88.1 %) curative resections. The pneumonectomy rate was 42.8%.
Discussion According to Paulson and Urschel," cervical mediastinoscopy increases the resectability rate and the survival rate after resection for lung cancer. The left anterior lymph node chain (involving the periaortic and aortic window lymph nodes) is not accessible via the cervical mediastinoscopic route. Cordier, Papamiltiades, and Cedard" refined the classification system of anatomic lymph drainage pathways, set up by Rouviere," by examining the lung segments separately. They established that the apical, dorsal, and ventral segments of the left upper lobe and the cranial and caudal segments of the lingula drain to the left anterior lymph node chain. Others support these findings. 17·19 Also, exact knowledge of lymph drainage pathways of the left lung is the scientific basis for the combined cervical and parasternal exploration by mediastinoscopy in left upper lobe lung cancer. We do not agree with Jolly, Li, and Anderson," who examined left lung cancer by parasternal mediastinoscopy alone. After finding no abnormal nodes by a cervical mediastinoscopic study in left upper lobe cancer, we perform a left parasternal mediastinoscopic examination, as do Luke and his colleagues." On the basis of the usual clinical criteria, all patients in the present series were regarded as having curatively operable disease. We and others believe that mediastinal
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February 1988
lymph node invasion is a contraindication to resection of lung cancer, 4.9.18.38.40.43.44 with a few exceptions according to Paulson and Urschel." Such an exception may be ipsilateral intranodal invasion at a low tracheobronchial level in a case of squamous cell carcinoma. We also accept the operability of squamous cell carcinoma of the left upper lobe with metastatic intra nodal involvement in the aortic window, found during a left parasternal mediastinoscopic examination. On the basis of these criteria, none of the 54 patients with mediastinoscopically detected N2 disease was selected for further surgical intervention. This study has shown that left parasternal mediastinoscopy, when performed after normal cervical mediastinoscopy in left upper lobe lung cancer, is an accurate predictor of operability. In the retrospective part of the study, eight of 34 (23.5%) patients with left upper lobe cancer had metastatically involved lymph nodes in the periaortic region found at thoracotomy, whereas in the prospective part, seven of 31 (22.6%) patients with left upper lobe cancer had metastatically involved lymph nodes in the periaortic region found at parasternal mediastinoscopy after normal cervical mediastinoscopy. In the prospective series, unwarranted thoracotomies were avoided in eight of 40 patients. In other studies, parasternal mediastinotomy is performed in left upper lobe cancer with similar results. There were very few minor complications. We advocate both mediastinoscopic procedures if necessary in the evaluation of mediastinallymph nodes in cases of left upper lobe lung cancer. Left parasternal mediastinoscopy has proved to have a high degree of accuracy with a negligible complication rate. In a collective review, Unruh and Chiu" compared the role of mediastinoscopy with that of other noninvasive methods, including chest roentgenography, tomography, pulmonary angiography, gallium scintigraphy, and computed tomography. At present, mediastinoscopy seems to be the most accurate procedure for staging even limited mediastinal metastasis, and as such it spares those who would have little or no chance of benefiting from thoracotomy. We agree with Unruh and Chiu" that other noninvasive developments, such as scanning radioactive tumor-specific monoclonal antibodies, will eliminate the need for invasive staging of the mediastinum in the near future.
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