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Treatment of Bronchogenic Carcinoma with Mediastinal Metastases
Treatment of Bronchogenic Carcinoma with Mediastinal Metastases Marvin M. Kirsh, M.D., Donald R. Kahn, M.D., Otto Gago, M.D., Isadore Lampe, M.D., Juan V. Fayos, M.D., Michael Prior, M.D., William Y. Moores, M.D., Cameron Haight, M.D.,* and Herbert Sloan, M.D. ABSTRACT Mediastinal lymph node dissection in conjunction with pulmonary resection was performed on 231 patients with bronchogenic carcinoma. Mediastinal metastases were found in 48 patients. Thirty-six of these 48 patients underwent mediastiaal irradiation in the immediate postoperative period. Seven of the 36 patients receiving postoperative irradiation lived five years (an absolute five-year survival rate of 19.5%). Of 17 patients with squamous cell carcinoma and mediastinal metastases, 5 lived five years (a five-year survival rate of 29.5%); only 1 of the 17 patients with adenocarcinoma and mediastinal metastases lived five years (an absolute survival rate of 5.9%). No patient who did not receive mediastinal irradiation postoperatively survived five years. The presence of mediastinal lymph node involvement in patients with squamous cell carcinoma of the lung is not a contraindication to resection because long-term survival can be achieved in a significant percentage of these patients.
P
ulmonary resection is generally accepted as the preferred method of treatment for bronchogenic carcinoma. However, the selection of patients for resection is still subject to debate. The spread of carcinoma to mediastinal lymph nodes is considered by many to be a contraindication to pulmonary resection because the survival rate five years following resection with mediastinal lymph node involvement has been less than 10% [Z, 11, 16, 18, 21, 231. Despite this apparently dismal outlook, we believe resection is indicated for some patients with bronchogenic carcinoma and mediastinal lymph node involvement.
Clinical Experience Mediastinal lymph node dissection in conjunction with pulmonary resection was performed on 231 patients with bronchogenic carcinoma at From the Departments of Surgery and Radiology, T h e University of Michigan Medical Center, Ann Arbor, Mich. 'Deceased. Presented a t the Seventh Annual Meeting of T h e Society of Thoracic Surgeons, Dallas, Tex., Jan. 18-20, 1971. Address reprint requests to Dr. Kirsh, T h e University of Michigan Medical Center, Ann Arbor. Mich. 48104.
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KIRSH E T AL. TABLE 1. OPERATIONS PERFORMED ON PATIENTS WITH BRONCHOGENIC CARCINOMA AND MEDIASTINAL METASTASES WITH AND WITHOUT POSTOPERATIVE IRRADIATION
Lobectomy 19 7
Postoperative Treatment Mediastinal irradiation No mediastinal irradiation
Operation Pneumonectomy 17 5
the University of Michigan Medical Center from 1959 to 1965. Anterior mediastinal exploration or mediastinoscopy was not performed preoperatively on any of these patients. Whether pneumonectomy or lobectomy was performed depended on the location of the lesion and the extent of the carcinoma. Lobectomy was carried out whenever feasible. Pneumonectomy was employed for tumors in the hilum of the lung or for those that could not be removed with a lesser procedure (Table 1). Following the resection, the mediastinal lymph nodes were removed. On the right side the superior mediastinal pleura was incised from the apex of the chest to the azygous vein, just anterior to the vagus nerve. T h e right paratracheal, anterior mediastinal, paraesophageal chain, and the subcarinal lymph nodes were completely removed. On the left side the mediastinal pleura was incised from the apex of the chest to the arch of the aorta. T h e anterior mediastinal, paraesophageal, subaortic, and subcarinal lymph node chains were removed. We considered the resection to be curative if all the gross tumor was excised. Mediastinal lymph node metastases were found i n 48 patients who survived a curative resection. T h e patients were divided into two groups. Group I consisted of 36 patients, 28 men and 8 women, who received mediastinal irradiation in the immediate postoperative period. Group I1 consisted of 12 patients, 11 men and 1 woman, who did not receive radiation therapy in the immediate postoperative period. GROUP I-POSTOPERATIVE
IRRADIATION
T h e postoperative radiotherapy in the 36 patients was carried out with cobalt 60 radiation at a distance of 75 to 80 cm. or cesium 137 radiation at a distance of 50 cm. T h e field size usually did not exceed 15 x 10 cm. In most patients, opposed anterior and posterior ports were used to provide cross fire to the mediastinum. Care was exercised to minimize the volume of pulmonary tissue irradiated in order not to further compromise pulmonary function. Both fields were irradiated daily with a midplane dose of 200 R five days a week to a total of 5,000 to 5,500 R. Three patients who also had residual microscopical tumor at the margin of the bronchial resection received a total dose of 6,000 R given to the bronchial stump by a 360degree rotational technique for a period of six to seven weeks. T h e treatment was well tolerated by most patients; skin changes were minimal. In approximately one-third of the patients roentgenograms were ob12
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tained after irradiation; all except 2 showed mild to moderate paramediastinal radiation pneumonitis. Subsequently the radiated pulmonary tissue became fibrotic and retracted toward the mediastinum. In the other patients either the follow-up period was too short or adequate chest filming was not available for determining radiation changes in pulmonary tissue. N o patient in Group I developed symptoms related to radiation pneumonitis, and no patient developed radiation myelopathy of the spinal cord. Results. Seven of the 36 patients receiving radiation therapy lived five years (an absolute five-year survival rate of 19.4%). Five of 17 patients with squamous cell carcinoma survived five years, while only 1 of 17 patients with adenocarcinoma survived five years. One of 2 patients with undifferentiated carcinoma lived free of disease for five years. T h e average mean survival of the remaining patients was 12.4 months. T h e cause of death was known in only 20 patients. Eighteen of these died of carcinomatosis, but only 2 died with evidence of recurrent disease in the thorax. Squamous Cell Carcinoma. Seventeen patients in Group I had squamous cell carcinoma. Sixteen of these patients were men. Most of the tumors were centrally located, and there was involvement of major bronchi in 14 patients. Eight of these patients had evidence of bronchial obstruction with distal atelectasis or pneumonitis. Only 3 patients had tumors arising in the more peripheral regions of the lung. Roentgenographic evidence of mediastinal involvement was not present in any of the patients. Eleven patients had superior mediastinal lymph node involvement, and in 9 there was also involvement of the hilar nodes (Table 2). Two of these who underwent lobectomy and 2 who underwent pneumonectomy have survived five years and are still living free of disease 60, 62, 74, and 124 months, respectively, following operation. There was no difference between the survivors and nonsurvivors in the number or size of nodes involved. T h e average length of survival among patients who died was 15.8 months (Table 3). Six patients had involvement of the subcarinal nodes. In addition, 5 of these patients also had hilar node metastases and 2 had superior mediastinal lymph node involvement. Only 1 patient with subcarinal spread of disease survived for five years. He died suddenly at home 75 months postoperatively, TABLE 2. LOCATION OF METASTASES IN 17 GROUP I PATIENTS WITH SQUAMOUS CELL CARCINOMA AND POSTOPERATIVE MEDIASTINAL IRRADIATION
Metastases Superior mediastinal Subcarinal Superior mediastinal and subcarinal Hilar
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KIRSH E T AL. TABLE 3. SURVlVAL ACCORDING T O OPERATION IN 17 GROUP I PATIENTS WITH SQUAMOUS CELL CARCINOMA AND POSTOPERATIVE MEDIASTINAL IRRADIATION
Operation Lobectomy Pneumonectomy
No. of Patients 9 8
5-Year Survival 3 2
following a right upper lobectomy. He was seen 3 months prior to his death and did not have any evidence of recurrent disease by either clinical or radiological examination. T h e average length of survival of those who died was 10.6 months. I t was impossible to determine in this retrospective study of all the patients whether the nodes were grossly involved at the time of thoracotomy . Adenocarcinoma. Adenocarcinoma was present in 17 patients (10 men and 7 women). Eleven of the lesions were centrally located, and in 7 patients there was evidence of bronchial obstruction with distal atelectasis or pneumonitis. Roentgenographic evidence of mediastinal widening or a mass was present in 2 patients. Peripheral or midlung masses 6 cm. or less in diameter were found in the remaining 6 patients. Eight patients had superior mediastinal involvement, and 6 had hilar metastases as well (Table 4). Nine patients had subcarinal involvement, and 6 had hilar metastases in addition. Two patients had superior mediastinal involvement as well as subcarinal metastases. Only 1 patient in this entire group is still alive and free of disease 66 months following a left upper lobectomy for a 3 x 3 cm. mass located in the midlung field. A solitary 1.5 cm. subcarinal metastasis was completely removed. None of the remaining 7 patients who underwent lobectomy and none of the 9 patients who underwent pneumonectomy survived five years. One patient died of cor pulmonale 48 months following a left pneumonectomy, but he had in addition radiological evidence of recurrent disease of the right lung. T h e average survival of the remaining patients was 11.7 months (Table 5). Undi8erentiated Carcinoma. One of 2 male patients with undifferenTABLE 4. LOCATION OF METASTASES IN 17 GROUP I PATIENTS WITH ADENOCARCINOMA AND POSTOPERATIVE MEDIASTINAL IRRADIATION
Metastases Superior mediastinal Subcarinal Superior mediastinal and subcarinal Hilar
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Treatment of Bronchogenic Carcinoma TABLE 5. SURVIVAL ACCORDING T O OPERATION IN 17 GROUP I PATIENTS WITH ADENOCARCINOMA AND POSTOPERATIVE MEDIASTINAL IRRADIATION
Operation Lobectomy Pneumonectomy
Patients
No. of
5-Year Survival
8 9
1 0
tiated carcinoma died 72 months after a right upper lobectomy and mediastinal lymph node dissection. This patient had a 6 cm. mass in the midportion of the right upper lobe and a 1.5 cm. node in the superior mediastinum. There was no clinical or roentgenographic evidence of recurrent disease. GROUP II-NO
POSTOPERATIVE IRRADIATION
Five patients with squamous cell carcinoma, 5 with adenocarcinoma, and 2 with undifferentiated carcinoma did not receive mediastinal irradiation in the immediate postoperative period. Seven of the 12 patients had centrally located lesions. Only 2 patients had bronchial obstruction with distal atelectasis or pneumonitis. Four had superior mediastinal involvement, 8 had subcarinal metastases, and 3 patients had both superior mediastinal and subcarinal involvement. Eleven of the 12 had hilar node metastases in addition. There was no difference between this group of patients and the irradiated group with respect to age, general condition, degree of differentiation of tumor, size of primary lesion, and the number and size of mediastinal metastases. N o specific reason was found upon review of their charts why these patients did not undergo mediastinal irradiation postoperatively. Five of these patients underwent pneumonectomy, and 7 underwent lobectomy as well as a mediastinal lymph node dissection. ResuEts. None of the 12 Group I1 patients survived five years, although l patient lived 28 months following operation and then died suddenly. Four months prior to his death he did not have recurrent disease either by physical examination or chest roentgenogram. Six of the remaining 11 patients developed recurrent disease. The average survival of the other 11 patients was 11.5 months.
Comment It is generally accepted that the presence and extent of metastases to lymph nodes is an important prognostic factor in bronchogenic carcinoma. When there is no lymphatic involvement at all, the five-year survival rate following resection of bronchogenic carcinoma is between 25 and 40% [46, 9, 10, 12, 15, 161. Lymphatic involvement of the intersegmental or hilar nodes has a better prognosis than mediastinal node involvement. In most VOL. 1 2 , NO. I , JULY,
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reported series, five-year survival following resection of bronchogenic carcinoma with hilar node involvement is between 15 and 20% but is less than 10% when mediastinal lymph nodes are involved. Sanger [22] had no twoyear survivors with mediastinal metastases. Jepson [13] reported a 1% threeyear survival, and Bergh and Schersten [5] had a 7% five-year survival following resection in patients with mediastinal node involvement. These authors and many others have believed that the discovery of mediastinal lymph node metastases either by mediastinoscopy or anterior mediastinal exploration meant that these patients should not undergo pulmonary resection [5, 18, 21, 231. In an effort to increase the life expectancy of these patients, preoperative radiation therapy has been tried, with little overall improvement. Local control of the disease by irradiation postoperatively has not increased survival in these patients [1, 7, 14, 19, 241. Bangma and Tonkes [3] treated alternate patients with 4,000 to 4,500 R to the hilum and mediastinum following pulmonary resection. There was no significant difference in survival when the two groups were compared. Similar studies were reported by Sherrah-Davies [24] and Patterson and Russell [17]. T h e authors did not discuss mediastinal lymph node dissection as a part of pulmonary resection. On the other hand, since 1951 Cahan and his associates [8] have been performing extensive en bloc excision of hilar and mediastinal lymph nodes in conjunction with pulmonary resection for bronchogenic carcinoma. T h e patients did not undergo postoperative mediastinal irradiation. T h e fiveyear survival in the group of patients in whom positive lymph nodes were found in the mediastinal lymphatics of the resected specimens was 21.6%. No attempt was made to correlate survival with the histological cell type
[ZOI.
Postoperative mediastinal irradiation was given to our patients because we felt that gross removal of all malignant tissue was not sufficient. In addition to improving the survival rate of patients with squamous cell carcinoma, radiation therapy to the mediastinum markedly decreased the incidence of local recurrence. In the entire group, only 2 patients treated with cobalt 60 or cesium developed local recurrence. T h e five-year survival rate of 29.5% in 17 patients with squamous cell carcinoma and mediastinal metastases treated by pulmonary resection, mediastinal lymph node dissection, and postoperative mediastinal irradiation -5 lived five years-has encouraged us to continue this program, although the number is too small to be of statistical significance. T h e results compare favorably with the 45% five-year survival rate of patients in our institution who had squamous cell carcinoma of the lung and hilar metastases treated by pulmonary resection alone. There was no difference between the survivors and the nonsurvivors in the size or location of the primary lesion, the degree of differentiation of the tumor, and the duration of preoperative symptoms. T h e presence of 16
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superior mediastinal lymph node involvement alone gave a better prognosis than if subcarinal nodes were involved, either alone or in conjunction with superior mediastinal involvement. T h e subcarinal nodes were usually larger in size than the superior mediastinal nodes. T h e subcarinal nodes averaged 3.5 cm. in size, while the superior mediastinal nodes averaged 2 cm. T h e 2 survivors with subcarinal metastases had nodes that were fewer and smaller in size than those of the nonsurvivors with subcarinal involvement. We believe that the discovery of mediastinal lymph node involvement during mediastinoscopy or exploratory thoracotomy in patients with squamous cell carcinoma of the lung is not a contraindication to resection, since these patients have had a 29.5% five-year survival rate-5 of 17 patients lived five years-when pulmonary resection and mediastinal lymph node dissection were followed by postoperative irradiation of the mediastinum. T h e patients in this series who did not receive postooerative mediastinal irradiation did not survive five years. T h e five-year survival (1 of 17, or 5.9%) in patients with adenocarcinoma of the lung and m-diastinal metastases who received postoperative irradiation does not appear to justify postoperative mediastinal irradiation in these patients. However, we believe pulmonary resection should not be denied to patients with adenocarcinoma and mediastinal metastases.
References 1. Baker, N. H., Cowley, R A., and Linberg, E. A follow-up in patients with bronchogenic carcinoma “locally cured” by preoperative irradiation. J. Thorac. Cardiovasc. Surg. 46:298, 1963. 2. Baker, R. R. The clinical management of bronchogenic carcinoma. Johns Hopkins Med. J . 121:401, 1967. 3. Bangma, P. J., and Tonkes, E. De waarde van postoperatieve roentgenbestraling bij bronchuscarcinoom. Nederl. T . Geneesk. 109:653, 1965. 4. Belcher, J. R., and Anderson, R. Surgical treatment of carcinoma of the bronchus. Brit. Med. J. 1:948, 1965. 5. Bergh, N. P., and 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. Suppl. 347: 1, 1965. 6. Boucot, K. R., Cooper, D. A., and Weiss, W. The role of surgery in the cure of lung cancer. Arch. Intern. Med. (Chicago) 120:168, 1967. 7. Bromley, L. L., and Szur, L. Combined radiotherapy and resection for carcinoma of the bronchus: Experiences with 66 patients. Lancet 2:937, 1955. 8. Cahan, W. G., Watson, W. L., and Pool, J. L. Radical pneumonectomy. J. Thorac. Surg. 22:449, 1951. 9. Churchill, E. D., Sweet, R. H., Scannell, J. G., and Wilkins, E. W., Jr. Further studies in the surgical management of carcinoma of the lung: A further study of the cases treated at the Massachusetts General Hospital from 1950 to 1957. J. Thorac. Surg. 36:301, 1958. 10. Clagett, 0. T., Allen, T. H., Payne, W. S., and Woolner, L. B. The surgical treatment of pulmonary neoplasms: A 10-year experience. J. Thorac. Cardiovasc. Surg. 48:391, 1964. VOL. 12, NO. 1, JULY,
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KIRSH E T AL. 11. Delarue, N. C., and Starr, J. A review of some important problems concerning lung cancer: 11. The importance of complete preoperative assessment in bronchogenic carcinoma. Canad. Med. Ass. J . 96:8, 1967. 12. Gibbon, J. H., Jr., Templeton, J. Y., 111, and Nealon, T. F., Jr. Factors which influence the long term survival of patients with cancer of the lung. Ann. Surg. 145:6!37, 1957. 13. Jepson, 0. Mediastinoscopy. Copenhagen: Munksgaard, 1966. 14. Krant, M. J. The question of irradiation therapy in lung cancer. J.A.M.A. 195:471, 1966. 15. Nickell, W. B., Bartley, T. D., and Wheat, M. W. Bronchogenic carcinoma: Management at University of Florida Teaching Hospital. J . Florida Med. Ass. 56:846, 1969. 16. Nohl, H. C. An investigation into the lymphatic and vascular spread of carcinoma of the bronchus. Thorax 11:172, 1956. 17. Patterson, R., and Russell, M. H. Clinical trials in malignant disease: IV. Lung cancer: Value of postoperative radiotherapy. Clin. Radiol. 13: 141, 1962. 18. Paulson, D. L. Carcinoma of the lung. Curr. Probl. Surg. (Nov.) 1967. Pp. 1-64. 19. Preoperative irradiation of cancer of the lung: Preliminary report of a therapeutic trial. A collaborative study. Cancer 23:419, 1969. 20. Ramsey, H. E., Cahan, W. G., Beattie, E. J., and Humphrey, C. The importance of radical lobectomy in lung cancer. J. Thorac. Cardiovasc. Surg. 58:225, 1969. 21. Reynders, H. The value of mediastinoscopic study in ascertaining the inoperability of pulmonary carcinoma. J. Int. Coll. Surg. 39:597, 1963. 22. Sanger, P. W. Cited by N. C. Delarue and J. Starr [lll. 23. Shah, H. H., Lambert, C. J., Paulson, D. L., McNamara, J. J., Razzuk, M. A., and Urschel, H. C., Jr. Cervical mediastinal lymph node exploration for diagnosis and determination of operability. Ann. Thorac. Surg. 5 : 15, 1968. 24. Sherrah-Davies,E. Does postoperative irradiation improve survival in lung cancer? J.A.M.A. 196:345, 1967. 25. Shimkin, M. B., Connelly, R. R., Marcus, S. C., and Cutler, S. J. Pneumonectomy and lobectomy in bronchogenic carcinoma: A comparison of and results of the Overholt and Ochsner clinics. J. Thorac. Cardiovasc. Surg. 44:503, 1962.
Discussion DR. DONALDL. PAULSON (Dallas, Tex.): W e agree with Dr. Kirsh that operation is indicated for some patients with bronchogenic carcinoma and mediastinal lymph node involvement. But we cannot agree that it is indicated in all patients or as part of a generalized, unselective operative approach. W e believe that the problem is one of selection-of selectivity based on careful evaluation by means of mediastinoscopy. O u r experience consists of 251 operations performed for Stage 3 lesions (those with mediastinal nodes involved) from 1950 to 1969, and it includes 56 exploratory thoracotomies-and these should be included with operative figures because the intent is to resect-and 195 resections. T h e total operative mortality was 8% and the five-year survival 7%, a standoff in surgical 18
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salvage rate-surgical salvage being defined as the five-year survival figure minus the operative mortality. These results are in agreement with those of others for unselected series, notably Noh1 1161 in England and Bergh and Schersten [5] in Scandinavia. In our experience there was no significant difference in cell type; preoperative or postoperative irradiation; or extent of resection, whether it was lobectomy or pneumonectomy, once the mediastinal lymph nodes were involved. The operative mortality was 7% for 56 exploratory thoracotomies, and this is a figure that should be included. Although mediastinal lymph nodes can be resected, the results do not justify the means employed except on a selective basis. I believe that Dr. Kirsh’s series is somewhat selective, and the results must be interpreted in that light. In his paper I believe the statement was made that there was no roentgenographic evidence of mediastinal lymph node involvement prior to operation, which in itself is a selective factor. There are other factors to be considered in evaluating the patient with a stage 3 lesion. First there is the location of the node other than simply superior mediastinal. This should be defined as high paratracheal, low paratracheal, azygous node, subcarinal node, and so forth, or a node at the tracheobronchial angle. The prognosis is extremely poor for high paratracheal, contralateral, or bilateral lymph node involvement. Also the extent of involvement of the node is significant. Massive perinodal and localized intranodal involvement are two entirely different things. Bergh and Schersten [5]have reported a 43% survival over two and a half years following resection for intranodal metastases in contrast to 4% for resection for perinodal metastases, that is, metastases which have broken through the capsule of the lymph node. The surgical mortality was five times greater for patients with perinodal metastases, or 24%, as compared to 5% for those with intranodal metastases. The epidermoid cell type appears to be the cell type most favorable for survival, probably because it has a lower percentage of contralateral and bilateral mediastinal lymph node metastases and perhaps a higher incidence of intranodal involvement. I suspect that a similar explanation might apply to the poorer results with subcarinal lymph node involvement in that contralateral involvement is more apt to be associated with this location. The same explanation may be applied to the poorer results in treating adenoid and undifferentiated types of carcinoma, as there is a higher percentage of contralateral or bilateral involvement found in addition to a higher percentage of mediastinal lymph node involvement. The surgical problem then is one of selection based on cell type, location, and stage of lymph node involvement. By refining our indications on a selective basis and with the aid of mediastinoscopy (we think this should be employed routinely), we are more likely to accomplish our aim of increasing surgical survival than we are by applying a generalized, unselective approach. VOL. 12, NO. 1, JULY, 1 9 7 1
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DR. PAULA. KIRSCHNER(New York, N.Y.): We agree with Dr. Paulson that mediastinoscopy is the focal point in the preoperative assessment of lung cancer patients, those with positive nodes being considered nonresectable in most instances. Since 1965 we have performed mediastinoscopies in more than 350 patients at T h e Mount Sinai Hospital, New York, 188 of whom had bronchogenic carcinoma. Positive biopsies were found in 48% of the 188. At first we employed mediastinoscopy selectively; now it is practically routine. Mediastinal lymph nodes were positive in 60% of right-sided tumors but only 27% of left-sided tumors, the discrepancy being due to the anatomical interposition of the aortic arch on the left. However, of 21 positive studies in the latter group, 7 were obtained from the right side of the trachea, showing the futility of so-called radical mediastinal dissection. T h e converse was much less common (2 in 66). When biopsies were negative, 35 of 37 (95%) of right-sided tumors were resectable as opposed to only 30 of 41 (73%) on the left, the discrepancy again being due to the position of the aortic arch. I n selected patients with positive biopsies we have administered radiation followed by resection. T e n of l l such patients ultimately explored underwent resection, 8 by lobectomy and 2 by pneumonectomy. T h e primary tumor was still positive in 7, the nodes being positive in just 4. Following combined treatment 4 patients were alive and well respectively 4% years, 3% years, 2% years (with left recurrent nerve involvement initially), and 1‘/2 years (with contralateral nodes positive) after resection. Recurrences in the other patients were systemic, not local. DR. WILLIAMG. CAHAN(New York, N.Y.): And so the battle of the mediastinal lymph nodes continues! One of the first guns fired in this battle was at the meeting of the American Association for Thoracic Surgery in 1950, when we reported a step-by-step procedure called radical pneumonectomy. T e n years later we described a radical lobectomy in that society’s journal. In both presentations we seemed to make very few friends and influence very few people, for the mediastinum was considered to be a morass and, therefore, it was pointless to try to find one’s way therein. There were even counterattacks: “What is the point of doing a mediastinal lymph node dissection if so many cancers of the lung invade blood vessels, making such a dissection superfluous?” Or, “If you select one lymph node at the time of thoracotomy and it proves to be negative, that indicates that all others in the mediastinum are negative; or, if it is positive, there is no point in dissecting the rest as it is hopeless to do so.” So the situation continued until two years ago when, before the Association, Drs. Ramsey, Beattie, Humphrey, and I presented a paper (Journal of Thoracic and Cardiovascular Surgery 58:225, 1969) describing some of the results of radical pneumonectomy and radical lobectomy at Memorial 20
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Cancer Center. We reported that 18 patients in whom positive mediastinal lymph nodes had been found in the resected specimen lived five or more years. This has encouraged us to continue exploring the value of a mediastinal dissection. It also suggests that if at mediastinoscopy a positive lymph node is found ipsilateral with the primary lung cancer, this does not denote a hopeless prognosis or negate resection. Parenthetically, may I make a plea that the traditional terms radical or simple be scrupulously adhered to to clarify the extent of the lymphatic dissection combined with the removal of lobes or lung? T o distinguish the procedures in this way may well have its own prognostic and statistical significance. We welcome our new allies and want to congratulate them on their survival figures. Time does not permit a discussion of the value of postop erative irradiation in this series. DR. SLOAN:Most of you know of Dr. Haight’s sad death a few months ago. The study was started by him, and he first urged us to carry out this form of therapy in patients with carcinoma of the lung. Dr. PauIson raised some questions which deserve answers from us. The resectability rate in this group of patients was 90%, which indicates a con. siderable amount of selection. There was an 8% operative mortality for pneumonectomy and a 4% mortality for lobectomy. Unfortunately, in a retrospective study such as this we were not able to find data about intranodal and perinodal metastases. We want to give Dr. Cahan credit, as we have in this paper, for his contributions to this field [8]. We don’t have anything against mediastinoscopy; it so happens that in the group of patients presented we were not using the procedure. We have one simple message to leave with you. In squamous cell carcinoma the presence of mediastinal metastases should not contraindicate an operation, and with postoperative irradiation one can expect a reasonable salvage rate.
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P
ulmonary resection is generally accepted as the preferred method of treatment for bronchogenic carcinoma. However, the selection of patients for resection is still subject to debate. The spread of carcinoma to mediastinal lymph nodes is considered by many to be a contraindication to pulmonary resection because the survival rate five years following resection with mediastinal lymph node involvement has been less than 10% [Z, 11, 16, 18, 21, 231. Despite this apparently dismal outlook, we believe resection is indicated for some patients with bronchogenic carcinoma and mediastinal lymph node involvement.
Clinical Experience Mediastinal lymph node dissection in conjunction with pulmonary resection was performed on 231 patients with bronchogenic carcinoma at From the Departments of Surgery and Radiology, T h e University of Michigan Medical Center, Ann Arbor, Mich. 'Deceased. Presented a t the Seventh Annual Meeting of T h e Society of Thoracic Surgeons, Dallas, Tex., Jan. 18-20, 1971. Address reprint requests to Dr. Kirsh, T h e University of Michigan Medical Center, Ann Arbor. Mich. 48104.
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KIRSH E T AL. TABLE 1. OPERATIONS PERFORMED ON PATIENTS WITH BRONCHOGENIC CARCINOMA AND MEDIASTINAL METASTASES WITH AND WITHOUT POSTOPERATIVE IRRADIATION
Lobectomy 19 7
Postoperative Treatment Mediastinal irradiation No mediastinal irradiation
Operation Pneumonectomy 17 5
the University of Michigan Medical Center from 1959 to 1965. Anterior mediastinal exploration or mediastinoscopy was not performed preoperatively on any of these patients. Whether pneumonectomy or lobectomy was performed depended on the location of the lesion and the extent of the carcinoma. Lobectomy was carried out whenever feasible. Pneumonectomy was employed for tumors in the hilum of the lung or for those that could not be removed with a lesser procedure (Table 1). Following the resection, the mediastinal lymph nodes were removed. On the right side the superior mediastinal pleura was incised from the apex of the chest to the azygous vein, just anterior to the vagus nerve. T h e right paratracheal, anterior mediastinal, paraesophageal chain, and the subcarinal lymph nodes were completely removed. On the left side the mediastinal pleura was incised from the apex of the chest to the arch of the aorta. T h e anterior mediastinal, paraesophageal, subaortic, and subcarinal lymph node chains were removed. We considered the resection to be curative if all the gross tumor was excised. Mediastinal lymph node metastases were found i n 48 patients who survived a curative resection. T h e patients were divided into two groups. Group I consisted of 36 patients, 28 men and 8 women, who received mediastinal irradiation in the immediate postoperative period. Group I1 consisted of 12 patients, 11 men and 1 woman, who did not receive radiation therapy in the immediate postoperative period. GROUP I-POSTOPERATIVE
IRRADIATION
T h e postoperative radiotherapy in the 36 patients was carried out with cobalt 60 radiation at a distance of 75 to 80 cm. or cesium 137 radiation at a distance of 50 cm. T h e field size usually did not exceed 15 x 10 cm. In most patients, opposed anterior and posterior ports were used to provide cross fire to the mediastinum. Care was exercised to minimize the volume of pulmonary tissue irradiated in order not to further compromise pulmonary function. Both fields were irradiated daily with a midplane dose of 200 R five days a week to a total of 5,000 to 5,500 R. Three patients who also had residual microscopical tumor at the margin of the bronchial resection received a total dose of 6,000 R given to the bronchial stump by a 360degree rotational technique for a period of six to seven weeks. T h e treatment was well tolerated by most patients; skin changes were minimal. In approximately one-third of the patients roentgenograms were ob12
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tained after irradiation; all except 2 showed mild to moderate paramediastinal radiation pneumonitis. Subsequently the radiated pulmonary tissue became fibrotic and retracted toward the mediastinum. In the other patients either the follow-up period was too short or adequate chest filming was not available for determining radiation changes in pulmonary tissue. N o patient in Group I developed symptoms related to radiation pneumonitis, and no patient developed radiation myelopathy of the spinal cord. Results. Seven of the 36 patients receiving radiation therapy lived five years (an absolute five-year survival rate of 19.4%). Five of 17 patients with squamous cell carcinoma survived five years, while only 1 of 17 patients with adenocarcinoma survived five years. One of 2 patients with undifferentiated carcinoma lived free of disease for five years. T h e average mean survival of the remaining patients was 12.4 months. T h e cause of death was known in only 20 patients. Eighteen of these died of carcinomatosis, but only 2 died with evidence of recurrent disease in the thorax. Squamous Cell Carcinoma. Seventeen patients in Group I had squamous cell carcinoma. Sixteen of these patients were men. Most of the tumors were centrally located, and there was involvement of major bronchi in 14 patients. Eight of these patients had evidence of bronchial obstruction with distal atelectasis or pneumonitis. Only 3 patients had tumors arising in the more peripheral regions of the lung. Roentgenographic evidence of mediastinal involvement was not present in any of the patients. Eleven patients had superior mediastinal lymph node involvement, and in 9 there was also involvement of the hilar nodes (Table 2). Two of these who underwent lobectomy and 2 who underwent pneumonectomy have survived five years and are still living free of disease 60, 62, 74, and 124 months, respectively, following operation. There was no difference between the survivors and nonsurvivors in the number or size of nodes involved. T h e average length of survival among patients who died was 15.8 months (Table 3). Six patients had involvement of the subcarinal nodes. In addition, 5 of these patients also had hilar node metastases and 2 had superior mediastinal lymph node involvement. Only 1 patient with subcarinal spread of disease survived for five years. He died suddenly at home 75 months postoperatively, TABLE 2. LOCATION OF METASTASES IN 17 GROUP I PATIENTS WITH SQUAMOUS CELL CARCINOMA AND POSTOPERATIVE MEDIASTINAL IRRADIATION
Metastases Superior mediastinal Subcarinal Superior mediastinal and subcarinal Hilar
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KIRSH E T AL. TABLE 3. SURVlVAL ACCORDING T O OPERATION IN 17 GROUP I PATIENTS WITH SQUAMOUS CELL CARCINOMA AND POSTOPERATIVE MEDIASTINAL IRRADIATION
Operation Lobectomy Pneumonectomy
No. of Patients 9 8
5-Year Survival 3 2
following a right upper lobectomy. He was seen 3 months prior to his death and did not have any evidence of recurrent disease by either clinical or radiological examination. T h e average length of survival of those who died was 10.6 months. I t was impossible to determine in this retrospective study of all the patients whether the nodes were grossly involved at the time of thoracotomy . Adenocarcinoma. Adenocarcinoma was present in 17 patients (10 men and 7 women). Eleven of the lesions were centrally located, and in 7 patients there was evidence of bronchial obstruction with distal atelectasis or pneumonitis. Roentgenographic evidence of mediastinal widening or a mass was present in 2 patients. Peripheral or midlung masses 6 cm. or less in diameter were found in the remaining 6 patients. Eight patients had superior mediastinal involvement, and 6 had hilar metastases as well (Table 4). Nine patients had subcarinal involvement, and 6 had hilar metastases in addition. Two patients had superior mediastinal involvement as well as subcarinal metastases. Only 1 patient in this entire group is still alive and free of disease 66 months following a left upper lobectomy for a 3 x 3 cm. mass located in the midlung field. A solitary 1.5 cm. subcarinal metastasis was completely removed. None of the remaining 7 patients who underwent lobectomy and none of the 9 patients who underwent pneumonectomy survived five years. One patient died of cor pulmonale 48 months following a left pneumonectomy, but he had in addition radiological evidence of recurrent disease of the right lung. T h e average survival of the remaining patients was 11.7 months (Table 5). Undi8erentiated Carcinoma. One of 2 male patients with undifferenTABLE 4. LOCATION OF METASTASES IN 17 GROUP I PATIENTS WITH ADENOCARCINOMA AND POSTOPERATIVE MEDIASTINAL IRRADIATION
Metastases Superior mediastinal Subcarinal Superior mediastinal and subcarinal Hilar
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Treatment of Bronchogenic Carcinoma TABLE 5. SURVIVAL ACCORDING T O OPERATION IN 17 GROUP I PATIENTS WITH ADENOCARCINOMA AND POSTOPERATIVE MEDIASTINAL IRRADIATION
Operation Lobectomy Pneumonectomy
Patients
No. of
5-Year Survival
8 9
1 0
tiated carcinoma died 72 months after a right upper lobectomy and mediastinal lymph node dissection. This patient had a 6 cm. mass in the midportion of the right upper lobe and a 1.5 cm. node in the superior mediastinum. There was no clinical or roentgenographic evidence of recurrent disease. GROUP II-NO
POSTOPERATIVE IRRADIATION
Five patients with squamous cell carcinoma, 5 with adenocarcinoma, and 2 with undifferentiated carcinoma did not receive mediastinal irradiation in the immediate postoperative period. Seven of the 12 patients had centrally located lesions. Only 2 patients had bronchial obstruction with distal atelectasis or pneumonitis. Four had superior mediastinal involvement, 8 had subcarinal metastases, and 3 patients had both superior mediastinal and subcarinal involvement. Eleven of the 12 had hilar node metastases in addition. There was no difference between this group of patients and the irradiated group with respect to age, general condition, degree of differentiation of tumor, size of primary lesion, and the number and size of mediastinal metastases. N o specific reason was found upon review of their charts why these patients did not undergo mediastinal irradiation postoperatively. Five of these patients underwent pneumonectomy, and 7 underwent lobectomy as well as a mediastinal lymph node dissection. ResuEts. None of the 12 Group I1 patients survived five years, although l patient lived 28 months following operation and then died suddenly. Four months prior to his death he did not have recurrent disease either by physical examination or chest roentgenogram. Six of the remaining 11 patients developed recurrent disease. The average survival of the other 11 patients was 11.5 months.
Comment It is generally accepted that the presence and extent of metastases to lymph nodes is an important prognostic factor in bronchogenic carcinoma. When there is no lymphatic involvement at all, the five-year survival rate following resection of bronchogenic carcinoma is between 25 and 40% [46, 9, 10, 12, 15, 161. Lymphatic involvement of the intersegmental or hilar nodes has a better prognosis than mediastinal node involvement. In most VOL. 1 2 , NO. I , JULY,
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reported series, five-year survival following resection of bronchogenic carcinoma with hilar node involvement is between 15 and 20% but is less than 10% when mediastinal lymph nodes are involved. Sanger [22] had no twoyear survivors with mediastinal metastases. Jepson [13] reported a 1% threeyear survival, and Bergh and Schersten [5] had a 7% five-year survival following resection in patients with mediastinal node involvement. These authors and many others have believed that the discovery of mediastinal lymph node metastases either by mediastinoscopy or anterior mediastinal exploration meant that these patients should not undergo pulmonary resection [5, 18, 21, 231. In an effort to increase the life expectancy of these patients, preoperative radiation therapy has been tried, with little overall improvement. Local control of the disease by irradiation postoperatively has not increased survival in these patients [1, 7, 14, 19, 241. Bangma and Tonkes [3] treated alternate patients with 4,000 to 4,500 R to the hilum and mediastinum following pulmonary resection. There was no significant difference in survival when the two groups were compared. Similar studies were reported by Sherrah-Davies [24] and Patterson and Russell [17]. T h e authors did not discuss mediastinal lymph node dissection as a part of pulmonary resection. On the other hand, since 1951 Cahan and his associates [8] have been performing extensive en bloc excision of hilar and mediastinal lymph nodes in conjunction with pulmonary resection for bronchogenic carcinoma. T h e patients did not undergo postoperative mediastinal irradiation. T h e fiveyear survival in the group of patients in whom positive lymph nodes were found in the mediastinal lymphatics of the resected specimens was 21.6%. No attempt was made to correlate survival with the histological cell type
[ZOI.
Postoperative mediastinal irradiation was given to our patients because we felt that gross removal of all malignant tissue was not sufficient. In addition to improving the survival rate of patients with squamous cell carcinoma, radiation therapy to the mediastinum markedly decreased the incidence of local recurrence. In the entire group, only 2 patients treated with cobalt 60 or cesium developed local recurrence. T h e five-year survival rate of 29.5% in 17 patients with squamous cell carcinoma and mediastinal metastases treated by pulmonary resection, mediastinal lymph node dissection, and postoperative mediastinal irradiation -5 lived five years-has encouraged us to continue this program, although the number is too small to be of statistical significance. T h e results compare favorably with the 45% five-year survival rate of patients in our institution who had squamous cell carcinoma of the lung and hilar metastases treated by pulmonary resection alone. There was no difference between the survivors and the nonsurvivors in the size or location of the primary lesion, the degree of differentiation of the tumor, and the duration of preoperative symptoms. T h e presence of 16
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superior mediastinal lymph node involvement alone gave a better prognosis than if subcarinal nodes were involved, either alone or in conjunction with superior mediastinal involvement. T h e subcarinal nodes were usually larger in size than the superior mediastinal nodes. T h e subcarinal nodes averaged 3.5 cm. in size, while the superior mediastinal nodes averaged 2 cm. T h e 2 survivors with subcarinal metastases had nodes that were fewer and smaller in size than those of the nonsurvivors with subcarinal involvement. We believe that the discovery of mediastinal lymph node involvement during mediastinoscopy or exploratory thoracotomy in patients with squamous cell carcinoma of the lung is not a contraindication to resection, since these patients have had a 29.5% five-year survival rate-5 of 17 patients lived five years-when pulmonary resection and mediastinal lymph node dissection were followed by postoperative irradiation of the mediastinum. T h e patients in this series who did not receive postooerative mediastinal irradiation did not survive five years. T h e five-year survival (1 of 17, or 5.9%) in patients with adenocarcinoma of the lung and m-diastinal metastases who received postoperative irradiation does not appear to justify postoperative mediastinal irradiation in these patients. However, we believe pulmonary resection should not be denied to patients with adenocarcinoma and mediastinal metastases.
References 1. Baker, N. H., Cowley, R A., and Linberg, E. A follow-up in patients with bronchogenic carcinoma “locally cured” by preoperative irradiation. J. Thorac. Cardiovasc. Surg. 46:298, 1963. 2. Baker, R. R. The clinical management of bronchogenic carcinoma. Johns Hopkins Med. J . 121:401, 1967. 3. Bangma, P. J., and Tonkes, E. De waarde van postoperatieve roentgenbestraling bij bronchuscarcinoom. Nederl. T . Geneesk. 109:653, 1965. 4. Belcher, J. R., and Anderson, R. Surgical treatment of carcinoma of the bronchus. Brit. Med. J. 1:948, 1965. 5. Bergh, N. P., and 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. Suppl. 347: 1, 1965. 6. Boucot, K. R., Cooper, D. A., and Weiss, W. The role of surgery in the cure of lung cancer. Arch. Intern. Med. (Chicago) 120:168, 1967. 7. Bromley, L. L., and Szur, L. Combined radiotherapy and resection for carcinoma of the bronchus: Experiences with 66 patients. Lancet 2:937, 1955. 8. Cahan, W. G., Watson, W. L., and Pool, J. L. Radical pneumonectomy. J. Thorac. Surg. 22:449, 1951. 9. Churchill, E. D., Sweet, R. H., Scannell, J. G., and Wilkins, E. W., Jr. Further studies in the surgical management of carcinoma of the lung: A further study of the cases treated at the Massachusetts General Hospital from 1950 to 1957. J. Thorac. Surg. 36:301, 1958. 10. Clagett, 0. T., Allen, T. H., Payne, W. S., and Woolner, L. B. The surgical treatment of pulmonary neoplasms: A 10-year experience. J. Thorac. Cardiovasc. Surg. 48:391, 1964. VOL. 12, NO. 1, JULY,
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KIRSH E T AL. 11. Delarue, N. C., and Starr, J. A review of some important problems concerning lung cancer: 11. The importance of complete preoperative assessment in bronchogenic carcinoma. Canad. Med. Ass. J . 96:8, 1967. 12. Gibbon, J. H., Jr., Templeton, J. Y., 111, and Nealon, T. F., Jr. Factors which influence the long term survival of patients with cancer of the lung. Ann. Surg. 145:6!37, 1957. 13. Jepson, 0. Mediastinoscopy. Copenhagen: Munksgaard, 1966. 14. Krant, M. J. The question of irradiation therapy in lung cancer. J.A.M.A. 195:471, 1966. 15. Nickell, W. B., Bartley, T. D., and Wheat, M. W. Bronchogenic carcinoma: Management at University of Florida Teaching Hospital. J . Florida Med. Ass. 56:846, 1969. 16. Nohl, H. C. An investigation into the lymphatic and vascular spread of carcinoma of the bronchus. Thorax 11:172, 1956. 17. Patterson, R., and Russell, M. H. Clinical trials in malignant disease: IV. Lung cancer: Value of postoperative radiotherapy. Clin. Radiol. 13: 141, 1962. 18. Paulson, D. L. Carcinoma of the lung. Curr. Probl. Surg. (Nov.) 1967. Pp. 1-64. 19. Preoperative irradiation of cancer of the lung: Preliminary report of a therapeutic trial. A collaborative study. Cancer 23:419, 1969. 20. Ramsey, H. E., Cahan, W. G., Beattie, E. J., and Humphrey, C. The importance of radical lobectomy in lung cancer. J. Thorac. Cardiovasc. Surg. 58:225, 1969. 21. Reynders, H. The value of mediastinoscopic study in ascertaining the inoperability of pulmonary carcinoma. J. Int. Coll. Surg. 39:597, 1963. 22. Sanger, P. W. Cited by N. C. Delarue and J. Starr [lll. 23. Shah, H. H., Lambert, C. J., Paulson, D. L., McNamara, J. J., Razzuk, M. A., and Urschel, H. C., Jr. Cervical mediastinal lymph node exploration for diagnosis and determination of operability. Ann. Thorac. Surg. 5 : 15, 1968. 24. Sherrah-Davies,E. Does postoperative irradiation improve survival in lung cancer? J.A.M.A. 196:345, 1967. 25. Shimkin, M. B., Connelly, R. R., Marcus, S. C., and Cutler, S. J. Pneumonectomy and lobectomy in bronchogenic carcinoma: A comparison of and results of the Overholt and Ochsner clinics. J. Thorac. Cardiovasc. Surg. 44:503, 1962.
Discussion DR. DONALDL. PAULSON (Dallas, Tex.): W e agree with Dr. Kirsh that operation is indicated for some patients with bronchogenic carcinoma and mediastinal lymph node involvement. But we cannot agree that it is indicated in all patients or as part of a generalized, unselective operative approach. W e believe that the problem is one of selection-of selectivity based on careful evaluation by means of mediastinoscopy. O u r experience consists of 251 operations performed for Stage 3 lesions (those with mediastinal nodes involved) from 1950 to 1969, and it includes 56 exploratory thoracotomies-and these should be included with operative figures because the intent is to resect-and 195 resections. T h e total operative mortality was 8% and the five-year survival 7%, a standoff in surgical 18
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salvage rate-surgical salvage being defined as the five-year survival figure minus the operative mortality. These results are in agreement with those of others for unselected series, notably Noh1 1161 in England and Bergh and Schersten [5] in Scandinavia. In our experience there was no significant difference in cell type; preoperative or postoperative irradiation; or extent of resection, whether it was lobectomy or pneumonectomy, once the mediastinal lymph nodes were involved. The operative mortality was 7% for 56 exploratory thoracotomies, and this is a figure that should be included. Although mediastinal lymph nodes can be resected, the results do not justify the means employed except on a selective basis. I believe that Dr. Kirsh’s series is somewhat selective, and the results must be interpreted in that light. In his paper I believe the statement was made that there was no roentgenographic evidence of mediastinal lymph node involvement prior to operation, which in itself is a selective factor. There are other factors to be considered in evaluating the patient with a stage 3 lesion. First there is the location of the node other than simply superior mediastinal. This should be defined as high paratracheal, low paratracheal, azygous node, subcarinal node, and so forth, or a node at the tracheobronchial angle. The prognosis is extremely poor for high paratracheal, contralateral, or bilateral lymph node involvement. Also the extent of involvement of the node is significant. Massive perinodal and localized intranodal involvement are two entirely different things. Bergh and Schersten [5]have reported a 43% survival over two and a half years following resection for intranodal metastases in contrast to 4% for resection for perinodal metastases, that is, metastases which have broken through the capsule of the lymph node. The surgical mortality was five times greater for patients with perinodal metastases, or 24%, as compared to 5% for those with intranodal metastases. The epidermoid cell type appears to be the cell type most favorable for survival, probably because it has a lower percentage of contralateral and bilateral mediastinal lymph node metastases and perhaps a higher incidence of intranodal involvement. I suspect that a similar explanation might apply to the poorer results with subcarinal lymph node involvement in that contralateral involvement is more apt to be associated with this location. The same explanation may be applied to the poorer results in treating adenoid and undifferentiated types of carcinoma, as there is a higher percentage of contralateral or bilateral involvement found in addition to a higher percentage of mediastinal lymph node involvement. The surgical problem then is one of selection based on cell type, location, and stage of lymph node involvement. By refining our indications on a selective basis and with the aid of mediastinoscopy (we think this should be employed routinely), we are more likely to accomplish our aim of increasing surgical survival than we are by applying a generalized, unselective approach. VOL. 12, NO. 1, JULY, 1 9 7 1
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DR. PAULA. KIRSCHNER(New York, N.Y.): We agree with Dr. Paulson that mediastinoscopy is the focal point in the preoperative assessment of lung cancer patients, those with positive nodes being considered nonresectable in most instances. Since 1965 we have performed mediastinoscopies in more than 350 patients at T h e Mount Sinai Hospital, New York, 188 of whom had bronchogenic carcinoma. Positive biopsies were found in 48% of the 188. At first we employed mediastinoscopy selectively; now it is practically routine. Mediastinal lymph nodes were positive in 60% of right-sided tumors but only 27% of left-sided tumors, the discrepancy being due to the anatomical interposition of the aortic arch on the left. However, of 21 positive studies in the latter group, 7 were obtained from the right side of the trachea, showing the futility of so-called radical mediastinal dissection. T h e converse was much less common (2 in 66). When biopsies were negative, 35 of 37 (95%) of right-sided tumors were resectable as opposed to only 30 of 41 (73%) on the left, the discrepancy again being due to the position of the aortic arch. I n selected patients with positive biopsies we have administered radiation followed by resection. T e n of l l such patients ultimately explored underwent resection, 8 by lobectomy and 2 by pneumonectomy. T h e primary tumor was still positive in 7, the nodes being positive in just 4. Following combined treatment 4 patients were alive and well respectively 4% years, 3% years, 2% years (with left recurrent nerve involvement initially), and 1‘/2 years (with contralateral nodes positive) after resection. Recurrences in the other patients were systemic, not local. DR. WILLIAMG. CAHAN(New York, N.Y.): And so the battle of the mediastinal lymph nodes continues! One of the first guns fired in this battle was at the meeting of the American Association for Thoracic Surgery in 1950, when we reported a step-by-step procedure called radical pneumonectomy. T e n years later we described a radical lobectomy in that society’s journal. In both presentations we seemed to make very few friends and influence very few people, for the mediastinum was considered to be a morass and, therefore, it was pointless to try to find one’s way therein. There were even counterattacks: “What is the point of doing a mediastinal lymph node dissection if so many cancers of the lung invade blood vessels, making such a dissection superfluous?” Or, “If you select one lymph node at the time of thoracotomy and it proves to be negative, that indicates that all others in the mediastinum are negative; or, if it is positive, there is no point in dissecting the rest as it is hopeless to do so.” So the situation continued until two years ago when, before the Association, Drs. Ramsey, Beattie, Humphrey, and I presented a paper (Journal of Thoracic and Cardiovascular Surgery 58:225, 1969) describing some of the results of radical pneumonectomy and radical lobectomy at Memorial 20
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Cancer Center. We reported that 18 patients in whom positive mediastinal lymph nodes had been found in the resected specimen lived five or more years. This has encouraged us to continue exploring the value of a mediastinal dissection. It also suggests that if at mediastinoscopy a positive lymph node is found ipsilateral with the primary lung cancer, this does not denote a hopeless prognosis or negate resection. Parenthetically, may I make a plea that the traditional terms radical or simple be scrupulously adhered to to clarify the extent of the lymphatic dissection combined with the removal of lobes or lung? T o distinguish the procedures in this way may well have its own prognostic and statistical significance. We welcome our new allies and want to congratulate them on their survival figures. Time does not permit a discussion of the value of postop erative irradiation in this series. DR. SLOAN:Most of you know of Dr. Haight’s sad death a few months ago. The study was started by him, and he first urged us to carry out this form of therapy in patients with carcinoma of the lung. Dr. PauIson raised some questions which deserve answers from us. The resectability rate in this group of patients was 90%, which indicates a con. siderable amount of selection. There was an 8% operative mortality for pneumonectomy and a 4% mortality for lobectomy. Unfortunately, in a retrospective study such as this we were not able to find data about intranodal and perinodal metastases. We want to give Dr. Cahan credit, as we have in this paper, for his contributions to this field [8]. We don’t have anything against mediastinoscopy; it so happens that in the group of patients presented we were not using the procedure. We have one simple message to leave with you. In squamous cell carcinoma the presence of mediastinal metastases should not contraindicate an operation, and with postoperative irradiation one can expect a reasonable salvage rate.
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