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Ann Thorac Surg 2003;75:364-366
© 2003 The Society of Thoracic Surgeons

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Original article: general thoracic

Mediastinoscopy in patients with clinical stage I non–small cell lung cancer

^a Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea

Accepted for publication September 5, 2002.

* Address reprint requests to Dr Shim, Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, 50 Ilwon Dong Kangnam Gu, Seoul, South Korea 135-710
e-mail: ymshim{at}smc.samsung.co.kr

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
BACKGROUND: The aim of this study was to investigate the significance of mediastinoscopy for clinical stage I non–small cell lung cancer.

METHODS: We reviewed 291 patients who underwent mediastinoscopy from January 1995 to December 2001 for clinical stage I non–small cell lung cancer. The patients who presented tumor-negative lymph nodes on mediastinoscopy underwent thoracotomy for pulmonary resection and mediastinal lymph node dissection in the same operative session. Mediastinoscopy-positive patients were referred for neoadjuvant therapy.

RESULTS: Of the 291 patients, 20 patients (6.9%) were found with N2 or N3 disease on mediastinoscopy. Among 271 mediastinoscopy-negative patients, thoracotomy-proven N0 was found in 201 patients (74.2%), N1 in 44 patients (16.2%), and N2 in 25 patients (9.2%). Seventeen of 25 patients with unforeseen N2 disease had positive lymph nodes in the station that could be approached by mediastinoscopy only. The positive rate of mediastinoscopy was significantly higher in the patients with nonbronchioloalveolar-type adenocarcinoma than in squamous cell carcinoma (11.5% vs 3.3%, p = 0.013). However, there was no difference in the mediastinoscopy-positive rate between clinical T1 and T2 status.

CONCLUSIONS: Though there are still controversies about routine mediastinoscopy in patients without mediastinal nodal enlargement on chest computed tomography scan, this study demonstrates that routine mediastinoscopy is necessary, especially for nonbronchioloalveolar-type adenocarcinoma patients.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
There have been studies reporting the advantage of neoadjuvant therapy in N2 disease of non–small cell lung cancer [1–5]. Accurate staging of mediastinal lymph nodes is mandatory for adequate treatment of non–small cell lung cancer. Chest computed tomography (CT) has a low sensitivity and specificity in the evaluation of mediastinal lymph nodes [6–9]. Positron emission tomography (PET) has been reported to be more accurate than CT [10, 11], but its use is limited due to the high cost. Mediastinoscopy is an invasive but safe method for the evaluation of mediastinal lymph nodes. There have been few reports on the results of mediastinoscopy for clinical stage I non–small cell lung cancer [12]. We retrospectively reviewed the results of mediastinoscopy and the status of thoracotomy-confirmed mediastinal nodal metastases of the patients who had clinical stage I lung cancers.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
From January 1995 to December 2001, cervical mediastinoscopy was performed in 291 patients with clinical stage I disease at Samsung Medical Center in Seoul, Korea. Preoperative CT scans were performed on all patients. Mediastinal lymph nodes were considered enlarged if their shortest diameter was more than 10 mm. Tissuediagnosis was obtained by flexible bronchoscopy or percutaneous needle biopsy. Our policy was to perform cervical mediastinoscopy in all patients with presumably operable lung cancer even without mediastinal nodal enlargement on CT scans. Mediastinoscopic examinations were done by the standard technique to evaluate the lymph nodes of 2R, 2L, 4R, 4L, and the subcarinal stations.

There were 203 men and 88 women ranging in age from 29 to 82 years (median, 63 years). The patients with tumor-positive mediastinal nodes on frozen biopsy were referred for neoadjuvant therapy before pulmonary resection. Neoadjuvant therapy included radiation at 4,500 cGy and one or two cycles of chemotherapy of etoposide and cisplatin regimens. Those with negative mediastinal nodes proceeded on to thoracotomy in the same operative session. If complete resection of the tumor was possible on thoracotomy, systematic dissection of mediastinal and hilar lymph nodes was routinely performed in all patients for accurate staging. Data on postoperative complications were obtained by reviewing our hospital’s chart and database. Statistical analysis was performed with SPSS 10.0 for Windows statistical software package (SPSS, Inc, Chicago, IL).

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
There was no operative mortality associated with mediastinoscopy. Mediastinoscopy-related complications were found in 6 patients (2.1%): hoarseness in 5 patients and wound infection in 1 patient. It was not clear whether hoarseness was due to mediastinoscopy or pulmonary resection and lymph node dissection. Four of 5 patients had transient hoarseness, and their voices improved during follow-up.

The tumor-positive rate of mediastinoscopy was 6.9% (20/291). Out of 20 patients, 2 had tumor-positive nodes on contralateral mediastinal nodes (N3) and were referred for curative chemoradiation. The other 18 patients were found having N2 disease and were referred for neoadjuvant therapy. Of the 18 patients, 14 patients underwent pulmonary resection 2 or 3 months after neoadjuvant therapy. Clinical T, N stage was reevaluated based on the rechecked CT scan before thoracotomy. As for T stage after neoadjuvant chemoradiation, there were partial remissions (more than 50% reduction in primary tumor size) in 10 patients and stable diseases (less than 50% reduction of primary tumor size) in 4 patients. Nodal staging of 14 patients on prethoracotomy CT scans were as follows: N0 in 9 patients, N1 in 3 patients, and N2 in 2 patients. Two patients with N2 finding had reduction in primary tumor size. Four of 18 patients did not undergo thoracotomy: death during neoadjuvant therapy, refusal of further treatment, palliative radiotherapy due to poor performance status, and follow-up loss.

Those 271 patients who had tumor-negative nodes on mediastinoscopy underwent thoracotomy under single anesthesia. Lobectomy including sleeve resection was performed in 250 patients, wedge resection in 1 patient, and pneumonectomy in 19 patients. One patient underwent exploratory thoracotomy due to multiple pleural seeding of the tumor. Pathologic staging was obtained after evaluation of the resected primary tumor and mediastinal lymph nodes. With regard to the accuracy of frozen sections by mediastinoscopy, two cases of false-negative findings were found, but no false-positive cases were found.

TNM staging in this study was based upon the revised TNM classification in 1997 [13]. Among 271 patients who underwent thoracotomy, 184 patients (67.9%) showed no change in clinical stage, whereas 87 patients (32.1%) were found to have progressive disease: pathologic IIA (13 patients), IIB (33 patients), IIIA (24 patients), IIIB (14 patients), or IV (3 patients). Pathologic N0 was found in 201 patients (74.2%), N1 in 44 patients (16.2%), and N2 in 25 patients (9.2%). Out of 25 patients with N2 disease, 23 patients were also found with N1 disease. Eight patients had N2 disease beyond the reach of standard mediastinoscopy: inferior pulmonary ligament (2 patients) and subaortic station (6 patients). Seventeen of the 25 N2 patients had positive nodes in the station that could be approached by mediastinoscopy only, including subcarinal station (13 patients). Finally, the rate of unforeseen N2 disease was 9.2% (25/271) after CT and mediastinoscopy. The sensitivity and specificity of mediastinoscopy for clinical N0 disease were found to be 44.4% (20/45) and 100% (246/246), respectively.

Comparison of mediastinoscopy-positive rate was made according to the cell type, T status, laterality, and upper or lower lobe lesion. Table 1 shows the results of positive mediastinoscopy according to the cell type. Nonbronchioloalveolar-type adenocarcinoma had a more positive rate than squamous cell carcinoma (11.5% vs 3.3%, p = 0.013). Clinical T1 or T2 status made no difference in the mediastinoscopy-positive rate, as shown in Table 2 (7.8% vs 6.1%, p = 0.413). Laterality (right-side tumor [8.9%] vs left-side tumor [3.6%], p = 0.083) showed no significant difference. The upper (5.1%) and lower-lobe lesions (9.6%, p = 0.133) had no significant difference either (Table 3).

	Comment

Top Abstract Introduction Patients and methods Results Comment References

Many thoracic surgeons may hesitate to perform mediastinoscopy in patients who have no enlarged mediastinal nodes on preoperative CT scans. Some authors have reported the results of mediastinoscopy performed in the early stage of non–small cell lung cancer. De Leyn and associates reviewed 253 patients without enlarged mediastinal lymph nodes on CT scan [12]. Mediastinoscopy was positive in 9.5% of cT1N0 and 17.7% of cT2N0 lesions. Their report demonstrated that the prevalence of positive mediastinoscopy was statistically higher in cT1N0 adenocarcinoma than cT1N0 squamous cell carcinoma. Funatsu and associates reported that the mediastinoscopic positive rate was 9% in T1 cases, but no major difference existed between the two histologic types [15]. According to Tahara and associates’ report, 3 out of 27 (11%) patients with peripheral cT1N0 had mediastinoscopy-positive results [16]. Our results showed that 6.9% of mediastinoscopy was positive in clinical T1 to 2N0. After negative mediastinoscopy, N2 disease was found in another 9.2% by mediastinal lymphadenectomy. Thus, we demonstrated that mediastinal nodes were positive in 16.1%, even in clinical stage I tumors. The prevalence of positive mediastinoscopy is affected by some factors. Adenocarcinoma is more likely to be node positive than squamous cell carcinoma [17]. Our results also suggest that the mediastinoscopy-positive rate is higher in nonbronchioloalveloar-type adenocarcinoma than in squamous cell carcinoma. T1 or T2 status showed no difference in the mediastinoscopy-positive rate.

Gephardt and Rice conducted a retrospective analysis of the utility of frozen section diagnoses in determining lymph node status [18]. The false-negative rate of frozen section evaluation was 1.6%, and this suggests that frozen section evaluation is reliable, thus enabling the physician to decide whether to proceed to thoracotomy.

The rate of unforeseen N2 disease was 9.2% after chest CT and mediastinoscopy. Unforeseen N2 disease results from unreachable nodes, sampling error of reachable nodes, and error on frozen section [19]. We missed 22 patients who had positive mediastinal nodes within the range of mediastinoscopy. Among the reachable nodes, subcarinal lymph nodes were likely to be tumor positive after thoracotomy because the posterior portion of the subcarinal nodes could escape from the mediastinoscopic approach. The false-negative rate of mediastinoscopy can be minimized by experienced surgeons.

In conclusion, mediastinoscopy is necessary in clinical stage I non–small cell lung cancer, especially in nonbronchioloalveolar-type adenocarcinoma. This study also shows that there are still uncertainties as to whether routine mediastinoscopy should be performed on every patient, even those without mediastinal nodal enlargement on CT scans. Other methods (PET, etc) may be needed for accurate mediastinal nodal staging. Different patterns of nodal metastases between squamous cell carcinoma and adenocarcinoma warrant further studies on the biology of non–small cell lung cancer according to the cell type.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Young Mog Shim Jhingook Kim Kwhanmien Kim Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Choi, Y. S. Articles by Kim, K. Search for Related Content PubMed PubMed Citation Articles by Choi, Y. S. Articles by Kim, K. Related Collections Lung - cancer