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Ann Thorac Surg 2000;70:1620-1623
© 2000 The Society of Thoracic Surgeons

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Original articles: general thoracic

Results of preoperative mediastinoscopy for small cell lung cancer

^a Department of Surgery, Osaka Prefectural Habikino Hospital, Osaka, Japan

Address reprint requests to Dr Inoue, Department of Surgery, Osaka Prefectural Habikino Hospital Habikino 3-7-1, Habikino-city, Osaka 583-8588, Japan
e-mail: masayoshinoue{at}aol.com

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. The significance of mediastinoscopy for small cell lung cancer is unclear owing to the small number of surgical cases.

Methods. To determine the N component of the TNM staging system, computed tomographic findings and the results of mediastinoscopy were compared with the pathologic examination of surgical specimens.

Results. Four cases among 37 patients (10.8%) were determined as inoperable by mediastinoscopy because of mediastinal lymph node metastasis. A thoracotomy was performed in 33 patients. Six patients (18.2%) who had been judged to have no metastasis by mediastinoscopy were found to have N2 disease after examination of the surgical specimens. In the identification of all mediastinal metastases, mediastinoscopy was 40.0% sensitive, 100% specific, and 83.8% accurate. When the superior mediastinal, paratracheal, pretracheal, tracheobronchial, and subcarinal lymph nodes were defined as approachable nodes, mediastinoscopy was 66.7% sensitive, 100% specific, and 94.6% accurate in the evaluation of these restricted nodes. Four cases among 8 patients with cN1 lesions resulted in a designation as pN2.

Conclusions. Mediastinoscopy is useful for the diagnosis of an approachable mediastinal lymph node in small cell lung cancer cases. This exploration is necessary for patients with small cell lung cancer who are diagnosed as cN1 before thoracotomy.

	Introduction

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Small cell lung cancer (SCLC) shows a high-grade malignancy with a rapid growth and early distant metastasis as compared with non–small cell lung cancer. Chemotherapy has been generally accepted because of its high response rate for SCLC. However, local recurrence has been frequently found even in those cases that show complete remission. Recently, operation as a locoregional treatment with combined chemotherapy has been recommended for cases of limited disease without mediastinal node metastasis [1, 2]. Therefore, it is important to determine how N2 disease can be correctly excluded from operative indication candidates. A preoperative mediastinoscopy is often performed for histologic diagnosis of mediastinal lymph node metastasis from lung cancer. However, the significance of mediastinoscopy for SCLC is unclear owing to the small number of surgical cases reported. In this study, we retrospectively analyzed SCLC cases that had been evaluated by preoperative mediastinoscopy.

	Material and methods

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A mediastinoscopy was performed for 37 SCLC patients (33 men, 4 women; age, 38 to 77 years; mean, 61.5 years) between January 1978 and December 1997 at Osaka Prefectural Habikino Hospital to determine operative indication. There were 13 patients with cancer stage IA, 12 with IB, 1 with IIA, 6 with IIB (5 with T2 N1, 1 with T3 N0), and 5 with IIIA (1 with T1 N2, 1 with T2 N2, 2 with T3 N1, 1 with T3 N2). A mediastinoscopy was not indicated for multiple or extranodal cN2 patients. Operation was indicated for the cT0 N0 M0 to cT3 N1 M0 patients after exploration by a mediastinoscopy. As for the N factor, results of the preoperative evaluation by thoracic computed tomography (CT) were compared with the results of mediastinoscopy. We defined 1 cm as the upper limit of normal for the short axis of the nodes in thoracic CT. Furthermore, surgical specimens were pathologically examined in those cases treated by thoracotomy, and the results of mediastinoscopy were reevaluated after operation. The survival period was determined from either the operative date or the beginning date of induction chemotherapy. The mean follow-up period was 137 ± 76 months. Survival was estimated according to the method of Kaplan and Meier.

	Results

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Twenty-nine patients had a premediastinoscopy diagnosis of SCLC. Among these cases, 25 patients were diagnosed by transbronchial lung biopsy, and 4 patients were diagnosed by transcutaneous needle biopsy. The remaining 8 patients did not have a diagnosis of SCLC before mediastinoscopy.

As to the number of lymph nodes, we sample all of the superior mediastinal, paratracheal, pretracheal, tracheobronchial, and subcarinal nodes in principle. If there is no distinct lymph node in these stations, we sample the connective or fatty tissue. The number of biopsies was 4.3 stations on average in this study.

Four cases among 37 patients (10.8%) were determined as inoperable by mediastinoscopy because of mediastinal lymph node metastasis (N2 to N3; Table 1). There was 1 from the 26 patients designated as cN0, 1 from the 8 patients designated as cN1, and 2 from the 3 patients designated as cN2. A thoracotomy was performed in 33 patients. One patient underwent an exploratory thoracotomy because of an invasion by the pulmonary ligament lymph node into the left atrium. A pulmonary resection was performed in the remaining 32 cases. There were 2 patients with pathologic stage 0, 10 with IA, 8 with IB, 3 with IIA, 2 with IIB, 4 with IIIA, and 4 with IIIB. Of these patients, 6 (18.2%) who had been judged to have no metastasis in the mediastinal lymph node by mediastinoscopy were found to have N2 disease after examination of the surgical specimens after thoracotomy (Table 1). In detail, there were 2 patients with cN0, 3 with cN1, and 1 with cN2 in whom we were unable to diagnose N2 disease before the thoracotomy. In the patient designated as cN2, induction chemotherapy was performed. The diagnosis was subsequently reduced to yN0, and there was no lymph node metastasis by prethoracotomy mediastinoscopy. However, a micrometastatic node was found in the subcarinal region by postoperative pathologic examination. Thus, in the identification of all mediastinal lymph node metastases, mediastinoscopy was 40.0% sensitive, 100% specific, and 83.8% accurate in SCLC. When the superior mediastinal, paratracheal, pretracheal, tracheobronchial, and subcarinal lymph nodes were defined as approachable nodes, mediastinoscopy was 66.7% sensitive, 100% specific, and 94.6% accurate in the evaluation of these restricted mediastinal lymph nodes. It should also be emphasized that 4 of the 8 patients designated as cN1 in this study resulted in pN2. There were two pT0 N0 M0 cases in this series. They were diagnosed as cT1 N0 M0 and cT2 N0 M0 by CT findings. Both of these patients were treated by preoperative chemotherapy and postoperative prophylactic cranial irradiation.

View larger version (13K): [in this window] [in a new window]   Fig 1. Overall survival of 33 patients with SCLC who were treated by thoracotomy. Five-year overall probability of survival was 33.3%, and median survival time was 25 months.

	Comment

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In this study, it should be noted that 4 of the 8 patients designated as cN1 and all of the 3 patients designated as cN2 resulted in pN2 diagnosis. Thus, cN1 seen on a chest CT might suggest pN2, and cN2 shows probably as pN2 disease in SCLC. We suggest that prethoracotomy mediastinoscopy should be performed for patients with SCLC designated as cN1 to determine operative indication, although it might not be necessary for patients designated as cN2 with the histologic diagnosis of SCLC. There were 2 patients diagnosed as pN2 and 1 patient diagnosed as pN3 among 26 patients designated as cN0. The pN2 patients had been diagnosed as cT1 N0 M0 and cT2 N0 M0, and the pN3 patient was diagnosed as cT2 N0 M0. We suggest that a mediastinoscopy might be necessary for the patients with cN0, especially cancer stage IB, although early treatment is desirable for SCLC. It may be an option to sequentially perform mediastinoscopy and thoracotomy on the same operating day.

There were 9 patients treated by operation without mediastinoscopy during the same period of this study. Among these, 6 patients (4 with cT1 N0 M0, 2 with cT2 N0 M0) had a histologic diagnosis of SCLC preoperatively. Induction chemotherapy was administered to 4 patients (3 with cT1 N0 M0, 1 with cT2 N0 M0) without mediastinoscopy by the judgment of attending physicians. All of these 4 patients were diagnosed as pT1 N0 M0 by surgery. In the remaining 2 patients (1 with cT1 N0 M0, 1 with cT2 N0 M0), an initial operation without mediastinoscopy was performed. The patient designated as cT1 N0 M0 underwent a curative resection (pT2 N0 M0), and the other patient designated as cT2 N0 M0 underwent an exploratory thoracotomy (pT4 N2 M0). Thus, a mediastinoscopy is recommended for the patients with cancer stage IB.

As for survival period, the patient who had undergone an exploratory thoracotomy and a patient who was inoperable because of pN2 by mediastinoscopy survived for 46 and 53 months, respectively, with a good response to chemotherapy. The prognosis was very poor in the patients with pN2 who were treated by pulmonary resection. We suggest that a pulmonary resection should be avoided if pN2 is found at thoracotomy.

In summary, mediastinoscopy is useful for the diagnosis of an approachable mediastinal lymph node in patients with SCLC, whereas an unapproachable station should be explored by other methods. Although a decision of therapy for SCLC should be made promptly because of such biologic characteristics as rapid growth and metastasis, a sufficient evaluation of a mediastinal lymph node and an accurate exclusion of N2 disease from the surgical candidates would clarify the significance of surgical treatment for SCLC.

	References

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