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J Thorac Cardiovasc Surg 1997;114:511
© 1997 Mosby, Inc.

LETTERS TO THE EDITOR

Mediastinal lymph node metastasis in patients with clinical stage I lung cancer

Department of Surgery
Division of Thoracic and Vascular Surgery
University Hospital of Antwerp
Wilrijkstraat 10
B-2650 Edegem, Belgium

To the Editor:

I read the recent article by Takizawa and associates ¹ regarding mediastinal lymph node metastasis in patients with clinical stage I peripheral non-small-cell lung cancer (NSCLC) with great interest. This important study in 575 patients nicely demonstrates that even in clinical stage I NSCLC, 14% of patients have N2 disease, moving them into stage IIIA. In 68% of these N2 cases, the surgeon could not detect the lymph node metastases by macroscopic examination, a fact that stresses the importance of complete nodal sampling.

However, it is surprising that in the discussion the authors do not address the role of mediastinoscopy in preoperative staging of lung cancer. When looking carefully at Tables III to VII, I observed a total of 79 patients with N2 disease; in 61 patients (77.2%) these N2 nodes were accessible by cervical mediastinoscopy and in 16 patients (20.3%) by left anterior mediastinoscopy. If routine cervical mediastinoscopy had been performed for right-sided tumors, and combined with an anterior or extended mediastinoscopy for left-sided tumors, 77 of 79 or 97.5% of these N2 metastases would have been detected before the operation. The accuracy of mediastinoscopy has been shown to be 95% for superior mediastinal involvement. ² Another advantage of mediastinoscopy is contralateral sampling of lymph nodes, which detects possible N3 disease. Inasmuch as contralateral node sampling is difficult by way of a lateral thoracotomy, some patients in the study by Takizawa's group, especially those with multilevel N2 disease, could have had N3 and thus stage IIIB disease.

Recently, the role of mediastinoscopy has become more important because surgery is no longer advocated as primary treatment for NSCLC with histologically proved N2 involvement. Because overall survival in these patients is very poor, many of them are treated by induction chemotherapy. ^3,4 It would be interesting to know the overall survival data of the 79 patients with N2 disease in the study by Takizawa's group, ¹ in which none of the patients had preoperative mediastinoscopy and all were treated by primary surgery. In my opinion, mediastinoscopy should be performed routinely for correct staging of NSCLC, because the accuracy of present-day computed tomographic scanners in mediastinal staging remains low. ⁵ Primary consideration should be given to induction chemotherapy in patients with N2 involvement, avoiding primary surgical treatment.

12/8/82762

References

1. Takizawa T, Terashima M, Koike T, Akamatsu H, Kurita Y, Yokoyama A. Mediastinal lymph node metastasis in patients with clinical stage I peripheral non-small-cell lung cancer. J Thorac Cardiovasc Surg 1997;113:248-52. [Abstract/Free Full Text]
   
2. Van Schil PEY, Van Hee RHGG, Schoofs ELG. The value of mediastinoscopy in preoperative staging of bronchogenic carcinoma. J Thorac Cardiovasc Surg 1989;97:240-4. [Abstract]
   
3. Edelman MJ, Gandara DR, Roach M III, Benfield JR. Multimodality therapy in stage III non-small cell lung cancer. Ann Thorac Surg 1996;61:1564-72. [Abstract/Free Full Text]
   
4. Albain KS, Rusch VW, Crowley JJ, Rice TW, Turrisi AT III, Weick JK, et al. Concurrent cisplatin/etoposide plus chest radiotherapy followed by surgery for stages IIIA (N2) and IIIB non-small cell lung cancer: mature results of Southwest Oncology Group phase II study 8805. J Clin Oncol 1995;13:1880-92. [Abstract/Free Full Text]
   
5. Gdeedo A, Van Schil P, Corthouts B, Van Mieghem F, Van Meerbeeck J, Van Marck E. Prospective evaluation of computed tomography and mediastinoscopy in mediastinal lymph node staging. Eur Respir J. In press.
   

This Article Alert me when this article is cited Alert me if a correction is posted 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): Paul E. Y. Van Schil Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Van Schil, P. E. Y. Search for Related Content PubMed PubMed Citation Articles by Van Schil, P. E. Y.