Radical Surgery for N2 Disease

Cancer Center Hospital, Tokyo, and there were 1,492 resected cases. The cases have been classified in accordance with Lymph Node Mapping. Our preoperative diagnosis of N, disease has been based on radiography including standard tomography and oblique tomography. Since 1980, computed tomography (Cf) has been also employed. Staging is determined at the weekly conference, where chest groups staffof surgeons, physicians, radiologists and pathologists, as well as residents are present. Although the standards to determine whether or not metastasis in lymph nodes has occurred should be modified in the future according to the sites of tumor, the diagnosis by cr depends on whether the lymph.node size is 1cm or more. Mediastinoscopy is not routinely used for N, disease diagnosis. The prospective study results concerning 109 cases of non-small cell carcinoma resected from 1980 to 1984 are as follows: Diagnosis Accuracy Sensitivity

Specificity

Positive predictive index Negative predictive index

Standard

cr

sa-cr

38%

81%

73% 62% 79%

48%

57%

48%

74%

82%

82%

Rad

68%

67% 68% 67%

The original lymph node map was completed in 1967 by surgical and pathologic examinations of 100resected cases of lung cancer and in 1977with the addition of 348 cases, it was slightly revised into the form of the present map. Regarding the 473 NtMo non-small cell carcinoma patients, there were 181 patients (38%) who had complete potentially curative resection with mediastinal lymph node dissection. The 5-year survival rates were 15.7% (squamous cell carcinoma 24.2% adenocarcinoma 14.3%). REFERENCES

Naruke 1: The spread of lung cancer and its relevance to surgery. Japan Surg Soc (in Japanese) 1967; 11:16-7 Naruke T, et ale Surgical treatment for lung cancer with metastasis to mediastinal lymph nodes. J Thorac Cardiovasc Surg 1976; 71:279-85 Kirsh MM, Potman H, Argenta L, Bove E, Cimmino ~ Tashian J, et ale Carcinoma of the lung. Results of treatment over ten years. Ann Thorac Surg 1976; 21:371-77 Kirshner PA. Surgical significance of mediastinal lymph node metastases. NY State J Med 1979; 79:2036-39 Smith FA. The importance of mediastinal lymph node invasion by pulmonary carcinoma in selection of patients for resection. Ann Thorac Surg 1978; 25:5-11 Naruke 1: Results of treatment of N-2 lung cancer 11th MSKCCNCCH Cooperative Study, Lung Cancer, 1980 Pearson FG. Use of mediastinoscopy in selection of patients for lung cancer operations. Ann Thorac Surg 1980; 30:205-07 Pearson FG, Delarue NC, Uves F, Todd TFJ, 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 Martini N, Flehinger BJ, .Zaman MB, Beattie EJ Jr. Results of resection in non-oat cell carcinoma of the lung with mediastinal lymph node metastases. Ann Surg 1983; 198:386-97 Daly BD, et ale Computed tomography: an effective technique for mediastinal staging in lung cancer. J Thorac Cardiovasc Surg 1984;

88:486-94 Naruke 1: et ale Lymph node mapping and curability at various levels of metastasis in resected lung cancer. J Thorae Cardiovasc Surg 1978; 76:833-39

Radical Surgery for N2 Disease F. G. Pearson, M.D., F.C.C.l, University ofToronto, Canada

prognosis for resectable lung cancer with metastases T hein mediastinal nodes remains controversial. Twelvepub-

lications report results in such cases, and in these studies the 5-year survival rates range from 0 to 30%.1.12 In many of these reports, the data are entirely retrospective, the precise location of mediastinal nodes is not identified, and the label of mediastinal node was probably frequently obtained only from the pathologist's review and report. In some of these reports, the nodes were identified at mediastinoscopy prior to thoracotomy. In the majority, however, mediastinal nodes were identified only at the time of thoracotomy and resection. Furthermore, only complete and potentially curative resections are included in the survival data in most publications, and there is no indication of the incidence of exploratory thoracotomy without resection, or survival data in patients undergoing incomplete on noncurative resections. We have reviewed our experience in 141 patients with mediastinal nodes who were managed by surgical resection. 13 These patients were divided into 2 groups: Group 1: There were 79 patients in whom metastatic tumor was identified in superior mediastinal nodes at preoperative mediastinoscopy. These were a highly selected subset of patients who had ipsilateral superior mediastinal metastases, and in whom a curative resection was deemed possible. This subset represents only one-fifth of our patients with presumably operable lung cancer in whom the N, status wasdefined as positive at staging mediastinoscopy. The actuarial 5-year survival for all 79 patients was 9%. The 5-year survival rate in 51 patients with curative resections was 18%, and no patient with a palliative resection survived 5 years. Group 2: Those with "mediastinoscopy-negative nodes" in whom metastases were found in mediastinal nodes only at subsequent thoracotomy comprised 62 patients. The actuarial5-year survival rate was 24% for all 62 patients, 41%for the 25 curative resections, and 14% for the 22 palliative resections. Recent data have been reported by the North American Lung Cancer Study Group (sponsored by the National Institutes of Health) on survival followingcomplete resection in patients with N, disease." The 5-year actuarial survival in 43 patients surviving a complete resection for squamous cell carcinoma with metastases in mediastinal nodes is 48%. The actuarial5-yeat survival in 55 patients with adenocarcinoma and large cell carcinoma who survived a complete resection of the primary and involved mediastinal nodes is 26%. CURRENT APPROACH 10 MANAGEMENT OF N 2 TUMORS

The following is an outline for our current approach to the management of patients with primary lung cancer and resectable Nt disease. We continue to recommend preoperative mediastinoscopy in most cases. Patients with small peripheral lesions less than CHEST / 89 / 4 / APRIL, 1986 / SUpplement

3398

2 em in diameter are excluded. As CT scanning of the mediastinum becomes more sophisticated, we are increasingly willing to proceed directly to thoracotomy in patients whose preoperative scan is "negative for N, disease-no demonstrable adenopathy greater than 2 em in diameter" In patients with tumors of the left upper lobe or left hilum, an anterior mediastinotomy may be added for evaluation. In such cases a conventional cervical mediastinoscopy is done first, nodal biopsies are assessed by frozen section and if the findings at cervical mediastinoscopy are negative, we proceed to left anterior mediastinotomy. Patients with certain types of N, disease identified at mediastinoscopy or anterior mediastinotomy are clearly excluded from surgical treatment. These exclusions comprise contralateral node involvement, small cell carcinoma, extranodal extension of cancer that precludes a complete resection, and patients with high paratracheal involvement. Patients with N, disease identified at the time of thoracotomy undergo resection if technically possible. This approach requires accurate intraoperative staging and dependable frozen section assessment. The role which adjuvant therapy plays in modifying prognosis for patients with resected N, disease is uncertain. Nevertheless, it is still our policy to recommend adjuvant therapy in all' patients with resected N, lesions. These adjuvant treatments include radiotherapy and combination chemotherapy, and are under evaluation in trials currently conducted by the North American Lung Cancer Study Group. A clearer definition of the indications for resection in patients with N, disease awaits information that will only come from a standardized nomenclature for mediastinal nodes, accurate intraoperative and postoperative staging, and the type of evaluation· provided by randomized prospective trials. REFERENCES

1 Pearson FG, Nelems JM, Henderson RD, Delarue NC. 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 2 Gibbons JRE The value of mediastinoscopy in assessing operability in carcinoma of the lung. Br J Dis Chest 1972; 66:162-66 3 Viikari SJ, Inberg M~ Puhakka H, et ale The role of mediastinoscopy in the treatment oflung carcinoma: Bull Soc Int Coo 1974; 2:119-26 4 Fosburg RG, O'Sullivan MJ, Ah-Tye ~ et ale Positive mediastinoscopy.: an ominous finding. Ann Thorac Surg 1974; 18:346-56 5 Kirschner PA. Lung cancer-Preoperative radiation therapy and surgery. NY State J Moo 1981; 198:339-42 6 Bergh N~ Schersten 1: Bronchogenic carcinoma. A follow-up study of a surgically treated series with special reference to the prognostic significance of lymph node metastases. Acta Coo Scan (Suppl) 1965; 347:1-42 7 Ramsey HE, Cahan WG, Beattie EJ, Humphrey C. The importance of radical lobectomy in lung cancer. J Thorac Cardiovasc Surg 1969; 58:225-30 8 Paulson DL, Urschel HC Jr. Selectivity in the surgical treatment of bronchogenic carcinoma. J Thorac Cardiovasc Surg 1971; 62:554-62 9 Kirsh MM, Kahn DR, Gago 0, et ale Treatment of bronchogenic carcinoma with mediastinal metastases. Ann Thorac Surg 1971; 12:11-21

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10 Abbey Smith R. The importance of mediastinal lymph node invasion by pulmonary carcinoma in selection of patients for resection. Ann Thorac Surg 1978; 25:5-11 11 Naruke T, Suemasu K, Ishikawa S. Lymph node mapping and curability at various levels of metastasis in resected lung cancer. J Thorac Cardiovasc Surg 1978; 76:832-39 12 Martini N, Flehinger BJ, Zaman MB, Beattie EJ Jr. Prospective study of 445 lung carcinomas with mediastinal lymph node metastases. J Thorac Cardiovasc Surg 1980; 80:390-99 13 PearsonFG, DelarueNC, IlvesR, ToddTRJ, CooperJD. Significance ofpositive superior mediastinal nodes identified at mediastinoscopy in patients with resectable cancer of the lung. J Thorac Cardiovasc Surg 1982; 83:1-11 14 Proceedings of the Lung Cancer Study Group. Annual Meeting, Santa Fe, New Mexico, May, 1985

Summary: Jean Deslauriers, M.D. recent years, pulmonary oncologists and thoracic surI ngeons have agreed that accurate evaluation of the medi-

astinum is an essential prerequisite to management of primary lung cancel: There is ample evidence in the medical literature that nodal involvement adversely influences prognosis and may influence choice of therapy. 1-3 There is considerable disagreement, however, as to which method provides the most accurate information concerning operability of the cancer. At present, no staging technique has been clearly proven to be superior to the others. Examination of the standard chest roentgenogram has an overall sensitivity of 75% and is more accurate when normal than when abnormal." If the neoplasm is central or if the hilum and/or mediastinum are abnormal on x-ray, a staging mediastinoscopy should be performed (25-30% positivity)." cr scanning can detect abnormalities in mediastinal lymph nodes not identified by other radiographic measures." In several comparative studies, the CT scan has a sensitivity of 80-95% and a specificity of 68 to 100%. It is recommended that patients with a positive CT scan should have pathologic confirmation of metastatic disease. 7 Mediastinoscopy is a more invasive technique involving an operation usually done under general anesthesia. In patients with positive nodes, it gives a precise definition of histology, site, extent of disease and degree of invasiveness (intranodal or extranodal) of the cancel: It is routinely recommended for all patients by Dr. Pearson. 8 All patients undergoing thoracotomy should have intraoperative staging with sampling of nodes in the bronchopulmonary area, hilum and mediastinum. These nodes should be recorded clearly on Dr. Narukes lymph node map (location of the node and degree of invasiveness). If a prethoracotomy mediastinoscopy has not been done, it may be necessary to do a radical mediastinal dissection in every case." More than 1 level of positive mediastinal nodes seems to influence adversely the prognosis.":" Precise definition of nodal status will become more and more important with the advent of adjuvant therapy. If positive nodes are identified in the superior mediastinum, a curative resection is generally not possible and IV World Conference on LungCancer