Chest
Volume 93, Issue 4, April 1988, Pages 807-813
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The Prognostic Significance of Preoperative Assessment of Mediastinal Lymph Nodes in Patients with Lung Cancer

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In order to evaluate the prognostic significance of the preoperative assessment of mediastinal lymph nodes, 100 patients with potentially operable lung cancer underwent two-plane tomography, computed tomography (CT), transbronchial needle aspiration (TBNA; 47 patients), and cervical mediastinoscopy. Mediastinoscopy proved to be the most accurate staging procedure. Tomography was less specific, detecting only advanced mediastinal node involvement, and CT was as sensitive as mediastinoscopy but sensibly less specific. TBNA gave no false positive results but a false negative rate of 25.5 percent. Accurate preoperative staging of mediastinal nodes is mandatory to optimize the resectability rate of lung cancer. Where metastatic involvement of mediastinal nodes was preoperatively documented at more than one level, tumors were invariably unresectable. Mediastinoscopic demonstration of intracapsular metastases at only one level did not preclude complete resection. Before thoracotomy, confirmation of neoplastic spread to mediastinal nodes suggests very low survival rates, especially in patients with incomplete removal of tumors.

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Patient Selection

One hundred patients (89 men and 11 women), aged 39 to 76 years (mean age, 57.7 years) with known or presumptive bronchogenic carcinoma were entered into this prospective study. The pathologic diagnosis of bronchogenic carcinoma was ultimately confirmed in all cases. Diagnostic fiberoptic bronchoscopic study, two-plane roentgenograms of the chest, radioisotope scans of bone and brain, and CT of the upper abdomen, from the diaphragmatic dome to the adrenal glands, were performed in all cases.

RESULTS

Sensitivity, specificity, and accuracy of the applied diagnostic techniques of mediastinal exploration are listed in Table 1. No side- or lobe-related significant differences were observed.

CT scan proved more sensitive than either tomography or TBNA and as sensitive as mediastinoscopy in detecting mediastinal node metastases. Tomography failed in 13 patients in whom the tumor-containing nodes did not deform the normal mediastinal contours or were masked by contiguous pulmonary lesions. TBNA

DISCUSSION

There is increasing evidence in the literature that a number of variables may influence the resectability rate of lung cancer other than mediastinal node involvement.6 Further, mediastinal node involvement may not be considered an absolute sign of unresectability, even though the value of such resection remains uncertain. Consequently, the need for an extensive mediastinal investigation before thoracotomy is not accepted by all surgeons, as shown by the results of a questionnaire published by

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