Mediastinal lymph node metastasis in patients with clinical stage I peripheral non-small-cell lung cancer

Pulmonary function after segmentectomy for small peripheral carcinoma of the lung

OBJECTIVE

The aim of this study is to compare the pulmonary function after a segmentectomy with that after a lobectomy for small peripheral carcinoma of the lung.

PATIENTS AND METHODS

Between 1993 and 1996, segmentectomy and lobectomy were performed on 48 and 133 good-risk patients, respectively. Lymph node metastases were detected after the operation in 6 and 24 patients of the segmentectomy and lobectomy groups, respectively. For bias reduction in comparison with a nonrandomized control group, we paired 40 segmentectomy patients with 40 lobectomy patients using nearest available matching method on the estimated propensity score.

RESULTS

Twelve months after the operation, the segmentectomy and lobectomy groups had forced vital capacities of 2.67 +/- 0.73 L (mean +/- standard deviation) and 2.57 +/- 0.59 L, which were calculated to be 94.9% +/- 10.6% and 91.0% +/- 13.2% of the preoperative values (P =.14), respectively. The segmentectomy and lobectomy groups had postoperative 1-second forced expiratory volumes of 1.99 +/- 0.63 L and 1.95 +/- 0.49 L, which were calculated to be 93.3% +/- 10.3% and 87.3% +/- 14.0% of the preoperative values, respectively (P =.03). The multiple linear regression analysis showed that the alternative of segmentectomy or lobectomy was not a determinant for postoperative forced vital capacity but did affect postoperative 1-second forced expiratory volume.

CONCLUSION

Pulmonary function after a segmentectomy for a good-risk patient is slightly better than that after a lobectomy. However, segmentectomy should be still the surgical procedure for only poor-risk patients because of the difficulty in excluding patients with metastatic lymph nodes from the candidates for the procedure.

Extent of mediastinal node metastasis in clinical stage I non-small-cell lung cancer: the role of systematic nodal dissection

OBJECTIVE

To determine the extent of lymph node metastasis in clinical stage I non-small-cell lung cancer (NSCLC).

METHODS

We performed a retrospective review of 524 patients with clinical stage I NSCLC who underwent lobectomy with systematic nodal dissection.

RESULTS

The nodal status was N0 in 409 patients (78%), N1 in 44 (8%), N2 in 67 (13%), and N3 in four (0.8%). Thirty-six patients had single-level mediastinal nodal metastases and 35 had multi-level metastases. The incidence of N2/3 disease in patients with adenocarcinoma/squamous cell carcinoma/other histologic types according to tumor size was 0/0/0%, respectively, in tumors < or = 10 mm in diameter, 12/0/0% in tumors 11-20 mm in diameter, 14/4/23% in tumors 21-30 mm in diameter, and 26/14/20% in tumors >30 mm in diameter. Nodal metastases to the upper mediastinum from middle or lower lobe lesions were frequently observed in 51 N2 adenocarcinomas, whereas those to the lower mediastinum from upper lobe lesions were rare. Of 10 N2 squamous cell carcinomas, seven had regional and three had non-regional nodal metastases. The 5-year survival rate was 68, 43, and 30% in N0, N1, and N2, respectively (P<0.01, N0 versus N1, N0 and N2).

CONCLUSIONS

Systematic mediastinal nodal dissection should be routinely performed for clinical stage I lung cancer to ensure the correct nodal status, but it might be dispensable in the patients with peripheral squamous cell carcinoma < or = 20 mm in diameter, with central squamous cell carcinoma < or = 30 mm, and with adenocarcinoma < or = 10 mm. When systematic nodal dissection cannot be performed, the incidence and extent of nodal metastases should be taken account with respect to histologic type, size, and location of the tumor.

Lymph node metastasis in small peripheral adenocarcinoma of the lung

OBJECTIVE

Our aim in this study is to clarify the clinical and pathologic features of small peripheral adenocarcinoma of the lung with special emphasis on intraoperative identification of lymph node metastasis.

PATIENTS AND METHODS

Between 1980 and 1996, 157 patients underwent lobectomy and complete hilar/mediastinal lymphadenectomy for small (1.1 to 2.0 cm in diameter) peripheral adenocarcinoma of the lung. The intraoperative assessment, the distribution of metastatic lymph nodes, and the association between the tumor's histopathologic characteristics and lymph node metastasis were retrospectively investigated in this study.

RESULTS

Postoperative examination revealed lymph node metastasis in 27 (17%) patients. Lymph node metastases were not noticed during the operation in 19 of these 27 patients. Metastases were localized in single lymph nodes in 10 patients; the metastases were distributed over a segmental, a lobar, an interlobar, and a mediastinal lymph node. The prevalence of lymph node metastasis was as follows: Of 92 patients with well-differentiated adenocarcinoma, seven (8%) had lymph node metastases; of the 65 patients with other types of tumors, 20 (31%) had lymph node metastases. Of 120 patients without pleural involvement, 13 (11%) had lymph node metastases; of the 37 with pleural involvement, 14 (38%) had lymph node metastases. Five-year survivals were estimated at 91% +/- 6% (mean +/- 95% confidence interval) for 130 patients with N0 tumor and 30% +/- 22% for 27 patients with N1 or N2 tumor.

CONCLUSIONS

Intraoperative assessment is not reliable for identifying lymph node metastasis. Lobectomy and complete hilar/ mediastinal lymphadenectomy are necessary to determine N stage rigidly. Histologic degree of differentiation and pleural involvement are significantly associated with lymph node metastasis.