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J Thorac Cardiovasc Surg 1997;114:511-512
© 1997 Mosby, Inc.

LETTERS TO THE EDITOR

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

Department of Thoracic Surgery
Niigata Cancer Center Hospital
Niigata, Japan

Reply to the Editor:

We appreciate Dr. Van Schil's investigation of the data with regard to our patients with N2 disease. His investigation shows us that 97.5% of the N2 metastases of our patients would have been detected in the preoperative period if cervical or anterior mediastinoscopy had been performed. We realize that Dr. Van Schil recommends performing mediastinoscopy to detect N2 disease before thoracotomies. We do not agree with his recommendation. We did not perform mediastinoscopy in our patients with clinical stage I lung cancer because the negative predictive accuracy for mediastinal lymph node metastasis with the use of computed tomography is high. ^{1, 2} Each patient in our article had clinical stage I lung cancer, which was assessed through computed tomography. No patients had enlarged mediastinal lymph nodes suggestive of N2 disease. We would have had to perform mediastinoscopy on all patients with clinical stage I lung cancer to detect N2 disease. We would have had to perform mediastinoscopy on all patients with clinical stage I lung cancer to detect N2 disease among them. If we had done so, 496 of 575 patients (86%) would have been subjected to a needless invasive operation. Therefore we think that the practicality of performing mediastinoscopy on all patients with clinical stage I lung cancer merits further debate.

Dr. Van Schil asked about the overall survival data of the 79 patients with N2 disease in our study. We followed up all of our 79 patients with N2 disease. Their overall survival, calculated by means of the Kaplan-Meier method, was estimated to be 26% at 5 years. Each death decreased the proportion surviving in our calculations, regardless of the cause of death. Although we believe that our surgical treatment for patients with N2 disease is justified, we need to implement induction chemotherapy to improve the survival of patients with N2 disease.

We agree with Dr. Van Schil's opinion: "Primary consideration should be given to induction chemotherapy in patients with N2 involvement, avoiding primary surgical treatment." The problem is how to detect N2 disease in patients with clinical stage I lung cancer before thoracotomies. We have recently performed video-assisted thoracoscopic sampling of mediastinal lymph nodes just before thoracotomy in patients with clinical stage I lung cancer. We detected N2 disease in some patients and treated them with induction chemotherapy. We are preparing to publish our methods and results of this study.

12/8/82761

References

1. Lewis JW Jr, Pealberg JL, Beute AM, Kvale PA, Magilligan DJ Jr. Can computed tomography of the chest stage lung cancer? Yes and no. Ann Thorac Surg 1990;49:591-6. [Abstract]
   
2. Izbicki JR, Thetter O, Karg O, et al. Accuracy of computed tomographic scan and surgical assessment for staging of bronchial carcinoma. J Thorac Cardiovasc Surg 1992;104:413-20.[Abstract]
   

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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Takizawa, T. Articles by Terashima, M. Search for Related Content PubMed Articles by Takizawa, T. Articles by Terashima, M.