Parasternal mediastinoscopy

Ultrasound Guided Tumour Biopsy in the Anterior Mediastinum

To evaluate percutaneous ultrasound (US) guided tumour biopsy of the anterior mediastinum all patients scheduled for open mediastinal biopsy were considered for percutaneous biopsy during a 2-year period. US guided biopsy was chosen when CT had shown the tumour to be in contact with the thoracic wall. US guided biopsy was performed in 23 patients on 28 occasions. The procedure was technically successful in all cases and no complications occurred. In 27 of 28 cases the biopsy diagnosis was identical to the final diagnosis. In one patient with a malignant lymphoma a false diagnosis of connective tissue remnant was reached. US guided tumour biopsy of the anterior mediastinum is a safe, cost-effective and reliable method and a good alternative to the traditional biopsy techniques via mediastinoscopy or thoracotomy.

Combined video-assisted mediastinoscopy and video-assisted thoracoscopy in the management of lung cancer

BACKGROUND

This study seeks to assess the safety and usefulness of combined video-assisted mediastinoscopy and video-assisted thoracoscopy in the management of patients with lung cancer.

METHODS

Ten consecutive patients with lung neoplasms were evaluated. Indications for this combined approach included inconclusive findings from imaging techniques concerning locoregional extension and resectability; possible involvement of different structures not accessible to a single procedure; and failure to obtain histologic diagnosis by a single technique. RESULTS; Histologic diagnosis was obtained in 6 patients without preoperative histologic typing. In 3 patients, in contrast with preoperative imaging studies, combined thoracoscopy and mediastinoscopy showed the resectability of the primary tumor and the absence of metastatic mediastinal lymph nodes. These findings were confirmed at thoracotomy. In 3 other patients prevascular lymph nodes metastases were found. They underwent neoadjuvant chemotherapy; at subsequent operation, a complete resection was possible. In the remaining four cases combined exploration proved definitive contraindications for operation (recognition of oat-cell carcinoma, n = 2; T4 status, n = 1; T3N2, n = 1).

CONCLUSIONS

Combined video-assisted mediastinoscopy and video-assisted thoracoscopy seems to be a safe and useful tool in the management of selected patients with lung neoplasms. Both the extent of primary tumor and the possible intrathoracic spread may be exhaustively evaluated. In patients with left lung cancer a complete exploration of the aortopulmonary window is possible.

Neoadjuvant therapy and surgical resection for locally advanced non-small cell lung cancer

During the past 15 years, treatment of stage IIIA (N2) non-small cell lung cancer has evolved considerably because of improvements in patients selection, staging, and combined modality therapy. Results of several clinical trials suggest that induction chemotherapy or chemoradiation and surgical resection is superior to surgery alone. However, the optimal induction regimen has not been defined. An intergroup trial is also underway to determine whether chemoradiation and surgical resection leads to better survival than chemotherapy and radiation alone. Future studies will assess ways to combine radiation and novel chemotherapeutic agents, and will identify molecular abnormalities that predict response to induction therapy.

Clinical and surgical staging of non-small cell lung cancer

The necessity for a compulsive attitude toward preoperative assessment of lung cancer is to be emphasized, since rational treatment and prognosis depend largely on the stage of disease at the time of diagnosis. In the preoperative setting, the techniques used should be sequential, logical, and help to identify patients suitable for treatment with curative intent. With regard to the primary tumor (T status), the accuracy of CT or MRI to predict the need for extended resections is limited. Similarly, all noninvasive methods to determine the nodal status (N) are valuable, but mediastinoscopy has a greater sensitivity and specificity than either CT or MRI. The role of routine organ screening for the detection of distant occult metastasis in the asymptomatic patient is still controversial. Ultimately, the prognosis of the resected patient with lung cancer is based on complete intraoperative staging, which can be done by either systematic node sampling or complete lymphadenectomy. At present, neither of these techniques has been shown to improve the quality of staging or survival.

Phase II study of neoadjuvant chemotherapy and radiation therapy with thoracotomy in the treatment of clinically staged IIIA non-small cell lung cancer

BACKGROUND

The purpose of this study was to assess the ability of administering to patients induction chemotherapy with carboplatin and etoposide (VP-16), followed by full-course radiation therapy and weekly carboplatin with tolerable toxicity as preoperative therapy to down-stage disease thus allowing the resection of clinically staged IIIA non-small cell lung cancer.

METHODS

Twenty-eight eligible patients with good performance status and previously untreated, marginally resectable stage IIIA non-small cell lung cancer received induction chemotherapy with carboplatin (dosed per the Egorin formulation), and VP-16 (100 mg/m2) followed by 6000 cGy of chest radiotherapy over six weeks administered concurrently with weekly doses of 100 mg/m2 of carboplatin. Patients who had either responsive or stable disease underwent thoracotomy, with attempted surgical resection of the primary lung lesion and the areas of abnormal adenopathy. Procedures involving less than a pneumonectomy were used whenever feasible.

RESULTS

Fifty-two cycles of induction chemotherapy were administered. The average initial dose of carboplatin was 407 mg/m2. Toxicity was tolerable with grade 3-4 neutropenia and/or thrombocytopenia in 48 and 27% of the patients. There were no septic deaths. Full-dose radiotherapy was administered to 82% of patients, with 73% receiving at least five weekly doses of carboplatin. The radiographically assessed response rate to the neoadjuvant treatment was 64% (partial response, 46%; minimal response, 18%). Sixteen patients underwent gross tumor resection with 12 (43%) having negative pathologic margins. Six patients had pneumonectomy. There were three perioperative deaths (19%); two were secondary to respiratory failure after the patients underwent a pneumonectomy. The median survival for all 28 patients was 15 months, and for the 16 patients undergoing thoracotomy was 23 months. Eight patients were alive and in remission, with follow-up ranging from 8 to 31 months.

CONCLUSIONS

The authors conclude that (1) carboplatin and VP-16, followed by full-dose radiotherapy with weekly carboplatin administration, is a well tolerated and effective regimen in the treatment of patients with marginally resectable stage IIIA non-small cell lung cancer; and (2) full-course radiotherapy can be administered before surgical resection without additional surgical morbidity or mortality.

Extended cervical mediastinoscopy: prospective study of fifty cases

To assess the usefulness of extended cervical mediastinoscopy (ECM) in the staging of bronchogenic carcinoma, an ECM was performed prospectively in 50 patients with bronchogenic carcinoma of the left lung. The ECM was used after evaluation of disease operability and computed tomographic findings, and was performed simultaneously with standard cervical mediastinoscopy. In ECM, using the same cervical incision as in a standard cervical mediastinoscopy, dissection is performed behind the anterior face of the sternum. The aortic arch is reached at the level of the origin of the innominate artery. The mediastinoscope is then passed by sliding it along the left anterolateral face of the aortic arch until it reaches the aortopulmonary window. Extended cervical mediastinoscopy was considered positive when a nodal biopsy result consistent with a neoformative process or direct invasion of the mediastinal structures was found. Four patients with positive standard cervical mediastinoscopy and negative ECM were excluded. A false negative ECM was defined as the presence of infiltrated adenopathies at the paraaortic level detected on postoperative histologic study. The ECM was positive in 5 patients in whom operation was contraindicated. Resectability in the remaining 41 patients was 97.6%. Postoperative pathologic study showed infiltrated adenopathy in 3 patients (2 subcarinal, 1 subaortic) accounting for 40 true negatives (the subcarinal group is inaccessible by ECM). This study suggests that ECM has outstanding specificity (100%), sensitivity of 83.3%, and a diagnostic accuracy of 97.8%. A positive predictive value of 100% and a negative predictive value of 97.5% were also identified by this study.(ABSTRACT TRUNCATED AT 250 WORDS)

Carcinoma of the lung. Who will benefit from surgery?

The present staging methods for non-small-cell lung cancer provide little more than epidemiologic assessment of prognosis for grossly defined groups of patients. Except in extreme instances, physicians can tell patients very little about their prognosis or the need for supplemental therapy. More effective and less toxic chemotherapeutic agents are needed to treat this disease. Although improved results have been attained with combination therapy in patients with good functional status and less advanced disease, little help is available for lung cancer patients with advanced disease. Treating this large group of patients remains a great challenge for the surgical and medical oncologist.