The selection of patients with bronchogenic carcinoma for mediastinoscopy

The prognostic significance of preoperative assessment of mediastinal lymph nodes in patients with lung cancer

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.

Comparative studies of computerized tomography and mediastinoscopy for the staging of bronchogenic carcinoma

The accuracy of mediastinal computerized tomographic scans for the staging of bronchogenic carcinoma varies between institutions. In the present study, the sensitivity rate was 57 percent, the specificity rate 69 percent, and the overall accuracy rate 64 percent, all of which were generally lower than rates reported in the recent literature. Different scanning equipment, diagnostic criteria, and patient populations may all contribute to this variance. The data in this report suggest that tumor histologic type and location also influenced the accuracy of computerized tomography. On the basis of this study and review of the literature, it is recommended that any given institution assess the accuracy of its own computerized tomographic mediastinal scans before substituting scanning for mediastinoscopy in the preoperative staging of bronchogenic carcinoma.

Mediastinal assessment for staging and treatment of carcinoma of the lung

Invasive diagnostic procedures for mediastinal assessment, such as mediastinoscopy, are necessitated by the importance of staging lung cancers, both to plan the treatment and to estimate the prognosis. Other noninvasive techniques may complement or be substituted for mediastinoscopy under certain specific clinical settings. Thus with the introduction of newer diagnostic technologies, such as computed axial tomography, the strategy for mediastinal assessment should be continually reevaluated. In this review, the diagnostic sensitivity, specificity, and overall accuracy of various techniques reported in the literature are examined to elucidate their current roles in assessing the mediastinal involvement in patients with lung cancer.

The role of gallium-67 in the clinical evaluation of cancer

This review is based primarily on historic data, and it examines the indications for and limitations of gallium-67 scanning in the evaluation of patients with neoplasms. The use of gallium-67 scans is discussed according to tumor type, and data from the most representative and comprehensive studies are included. The results described, some of which were obtained primarily with older imaging techniques, should be regarded as representing the minimum that can be expected from application of this imaging procedure.

Oblique hilar tomography and mediastinoscopy. A correlative prospective study in 100 patients with bronchogenic carcinoma

One hundred patients with bronchogenic carcinoma had oblique hilar tomography preoperatively to evaluate the pulmonary hila. Subsequently, all of these patients underwent mediastinoscopy or thoracotomy or both. Hilar and mediastinal nodes were evaluated for the presence of metastasis. These findings were then correlated with the radiographic findings of oblique hilar tomography. We found oblique hilar tomography to be a useful method of selecting patients for mediastinoscopy. The negative predictive value of oblique hilar tomography for mediastinal involvement was 95 percent, while the positive predictive value was 75 percent. Thus, patients with negative findings on oblique hilar tomography need not undergo mediastinoscopic examination prior to thoracotomy.

Pre-operative mediastinal evaluation in primary bronchial carcinoma--a review of staging investigations

A review of staging investigations in the preoperative evaluation of mediastinal involvement in primary bronchial carcinoma is presented. The following conclusions are offered as guidelines for the use of mediastinal staging procedures in clinical practice: Surgical staging methods have the over-riding advantage of superior specificity over indirect imaging techniques. Where 67Ga-imaging or CT scanning are not available, routine pre-operative mediastinoscopy or, when appropriate, mediastinotomy will identify most patients with non-resectable disease but this approach entails a high proportion of true negative examinations. Radioisotope ventilation and perfusion lung imaging has no place in the pre-operative staging of lung cancer. Where the techniques are available, 67Ga-imaging and CT scanning have a use in selecting patients for mediastinal exploration. A negative mediastinal 67Ga scan or a negative CT examination suggest that mediastinal exploration will be unrewarding in the vast majority of cases and may be omitted prior to thoracotomy. A positive mediastinal 67Ga scan or the demonstration of abnormal mediastinal nodes by CT is an indication for mediastinal exploration which, if negative should be followed by thoracotomy.

Indications for mediastinal lymph node evaluation

Successful surgical therapy for bronchogenic carcinoma depends upon an accurate lymph node assessment. Criteria were developed and reported to identify patients who would benefit from mediastinoscopy prior to thoracotomy. This report summarizes the prospective use of the criteria between 1974 and 1977 and the total experience from 1970 to 1977. Selection of patients for prethoracotomy mediastinal evaluation is primarily based on chest roentgenogram and cell type. Left upper lobe lesions meeting the criteria were submitted to mediastinotomy if mediastinoscopy was negative. Eighty-seven potentially resectable lesions were evaluated prospectively, and the total experience included 202 patients. Mediastinal metastasis occurred in 39 patients of the current and 82 patients of the total series. When metastases to the mediastinum were documented, roentgenographic evidence of metastasis was seen in 20 of 39 (51 percent) of the current and 44 of 82 (54 percent) of the total series. There was roentgenographic evidence of metastasis in central lesions, peripheral masses, and small peripheral lesions with mediastinal metastases in 50 percent, 25 percent, and 78 percent of the cases, respectively. Mediastinal metastases were reported 80 percent of the time before thoracotomy using these criteria. The use of mediastinotomy on left upper lobe lesions identified six of seven of the unresectable cases missed by the mediastinoscopy. The criteria will identify patients at high risk for mediastinal metastases who benefit from prethoracotomy surgical evaluation.

Scalene node biopsy in pulmonary carcinoma: when is it indicated?

While there is universal agreement that palpable scalene lymph nodes should be biopsied in the preoperative evaluation of patients with carcinoma of the lung, the role of biopsy of nonpalpable scalene nodes remains unclear. This report evaluates the results of biopsy of nonpalpable scalene lymph nodes in 101 consecutive patients with bronchogenic carcinoma otherwise deemed candidates for pulmonary resection. The overall incidence of biopsy positive for metastatic disease was 8.9%. No patient with a peripheral primary lesion, regardless of size or cell type, had metastasis to scalene nodes. Six of 15 patients with centrally located adenocarcinomas showed scalene node metastasis, while only 1 of 40 patients with central squamous cell carcinomas had a positive scalene biopsy. Bilateral biopsy was no more likely to yield positive information than ipsilateral biopsy alone. We now recommend preoperative biopsy of nonpalpable scalene nodes only in patients with central lesions in whom the cell type is adenocarcinoma or unknown.

Noninvasive evaluation of mediastinal metastases in bronchogenic carcinoma: a prospective comparison of chest radiography and gallium-67 scanning

Evaluation of regional node involvement in patients with bronchogenic carcinoma is a crucial step in determining therapy and prognosis. Mediastinoscopy has been recommended for staging all potentially operable cases, but technical limitations and the need for anesthesia make this impractical. Gallium-67 scanning and chest radiography were prospectively compared as noninvasive means of evaluating spread to regional nodes in 75 patients with bronchogenic carcinoma in whom histologic evaluation of hilar and mediastinal nodes was performed. Gallium scanning was more accurate than chest radiography in assessing regional nodes (overall accuracy 85.3% vs. 56%, P less than 0.05). When positive, both procedures correctly indicate malignant involvement of regional nodes (85% vs. 87.3%). A negative gallium scan, however, was significantly more accurate in predicting the absence of such involvement (80% vs. 40%, P less than 0.01). Gallium scanning appears to be a reliable, noninvasive means of assessing mediastinal spread of bronchogenic carcinoma and when used in conjunction with radiographic findings, allows selection of appropriate patients for surgical staging procedures.

Carcinoma of the lung: a clinical review

Records of 702 patients with carcinoma of the lung seen from 1960 through 1970 were reviewed. The efficacy of various diagnostic and therapeutic procedures was assessed. Salient findings were as follows: Biopsy of nonpalpable ipsilateral supraclavicular lymph nodes was positive for carcinoma in 63 of 286 patients (22%). Even more surprising, biopsy of nonpalpable contralateral supraclavicular lymph nodes was positive for carcinoma in 9 of 38 patients (24%). Accordingly, the importance of biopsy of nonpalpable supraclavicular nodes is to be stressed. Squamous cell carcinoma was the most common type, but adenocarcinoma was more common in women and nonsmokers. Among the 702 patients, 48 (6.8%) were nonsmokers. The 5-year survival for 92 patients treated by lobectomy was 21%; the 5-year survival for 77 patients treated by pneumonectomy was 19%; the 5-year survival among 18 patients have resection of the chest wall in addition to resection of the primary lesion was 22%. Of 12 patients with small cell carcinoma of the lung treated by resection, there was 1 5-year survivor. The overall 5-year survival in the 702 patients was 6.6%.