Prognosis of N2 Disease

Surgery tor N2 Disease Cha'mJlJn: Jean Deslauriers, M.D.

Prognosis of Na Disease Prof Dr: Med. Michael ThemJIJnn, Ch'rorgische Klinic, Bielefeld, West Germany

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t is generally accepted that mediastinal lymph node metastases (NJ severely worsen the prognosis ror patients with lung cancel: Five-year survival of Nopatients resected for lung cancer is about 50%, while it ranges from 8%-24% in N2 cases depending on selection and perhaps on adjuvant therapy. Discussing the prognosis of N, patients, the following questions arise: 1. By which methods can N2 metastasis be established? 2. What causes the death of N, patients? 3. Can the prognosis of Nt patients be influenced by a) histologic type of tumor? b) localization of the N2 metastases? c) manner of tumor growth in the lymph nodes? 4. Is improvement of the prognosis possible by a) surgical procedures? b) adjuvant therapy?

Diagnosis Several studies underline that N. metastasis suspected on x-ray film often is a sign of inoperability; therefore, many thoracic surgeons decline direct thoracotomy in these cases. If N. metastases are established by mediastinoscopy and thoracotomy is only performed in selected cases, the results are still far worse compared to patients negative at mediastinoscopy but found positive in subsequent thoracotomy. 1

Causes

ofDeath

Although exact figures are not available, it is to be expected that the majority of the patients surviving less than 5 years succumb to the tumor. It should be mentioned, however; that surgery plus adjuvant therapy can also lead to a fatal outcome. I

Prognosis Hmology: Oat cell carcinoma with N1 metastasis has a very poor prognosis and should not be operated on. Whether adenocarcinoma or squamous cell carcinoma with N 2 dissemination has a different outcome remains unclear and results appear contradictory. Perhaps it depends on the varying effectivity of adjuvant radiotherapy. 3,4 Level ofnodes: The level of N2 metastasis seems to be of interest for the prognosis. Metastasis oftbe subcarinal nodes has an unfavorable outcome, as is also the case for metastases in other areas. 5,&

lntranodal V8 Extranodal Some investigators emphasize that the manner of local tumor growth is also an important factor; Small intranodal metastases seems to result in a much better prognosis compared with perinodal growth into the mediastinum. 7.8 338S

Improvement

ofprognosis

Surgery: The question often discussed by thoracic surgeons remains the influence of mediastinal lymph node dissection. Weiss et al" have written the provocative sentence: "Local therapy aimed at lymph nodes themselves will no more effectively control (distant) metastases than removal of the speedometer from a ear will reduce its speed." Cady" entitled an article: "Lymph node metastases-indicators, but not governors of survival." It remains unclear whether lymph node dissection is more than a staging procedure. No evidence has yet been produced to show whether lymph node dissection per se has a favorable effect on survival. Adjuvant therapy: A further point of contention is whether adjuvant therapy in N2 disease improves the outcome. Only 1 prospective trial showed an improved 3 year survival in N 1 + N2 patients with additional radiotherapy," There is indeed no doubt that immunotherapy or chemotherapy is ineffective in controlling tumor growth in non oat cell carcinoma. REFERENCES 1 Pearson FG, Delarue NC, Ilves R, Todd TR), Cooper JD. Significance of positive superior mediastinal nodes identi6ed at mediastinoscopy in patients with resectable cancer of the lung. J Thorac Cardiovasc Surg 1982; 83:1-11 2 Hamelmann H, Thermann M, Mulle r-Schwefe 1: Schniirer C, 'Iroidl H. Surgically treated bronchial carcinoma patientsResults of systematic follow up. Thor Cardiov Surgeon 1983; 31:41-44 3 Beattie EJ. Lung cancer. World J Surg 1981; 5:661-62 4 Mountain CF, Hermes ICE. Management implications of surgical staging studies. Lung Cancer 1979; 233-42 5 Naruke 1: Suemasu K, Ishikawa S. Lymph node mapping and curability at various levels of metastasis in resected lung cancer. J Thor Cardiovasc Surg 1978; 76:832-39 6 Martini N, Flehinger B), Nagasaki F, Hart B. Prognostic signmcance ofN 1 disease in carcinoma of the lung. J Thorac Cardiovasc Surg 1983; 86:646-53 7 Berg N, Schersten '[ Bronchogenic carcinoma. Acta Chir Scand 1965; 347(Suppl):3 8 Martini N, Flehinger B), Zaman MB, Beattie EJ. Results of surgical treabnent in N.lung cancer. World J Surg 1981; 5:663-66 9 Weiss L. in: Weiss L, Gilbert RA, Ballon SC, (ed). Lymphatic system metastases. Boston: G.K. Hall, 1980; 2-40 10 Cady B. Lymph node metastases. Arch Surg 1984; 119:1067-72 11 Israel L, Bonadonna G, Sylvester R. Controlled study with adjuvant radiotherapy, chemotherapy, immunotherapy, and chemoimmunotherapy in operable squamous carcinoma of the lung. Lung Cancer 1979; 443-52

Staging of Nt Disease T: Naroke, M.D., F.C.C.P., NationalCancer Center Hospital, Tokyo, Japan

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here are a great number of factors which influence the prognosis of lung cancel: Above all, the presence of mediastinal lymph node metastasis is one of the most important factors and the operative indication for them has been controversial. From May 1962 till December 1983, 3,181 patients with primary carcinoma of the lung were admitted to the National IV World Conference on lung Cancer