MEDIASTINAL LYMPH NODE DISSECTION IN A MULTIMODAL APPROACH
TO THE MANAGEMENT OF LUNG CANCER.
E. Shaughnessy, K. Clarke, T. OdomMaryon, N. Vora, L. Wagman, F. Grannis,Jr.. City of Hope National Medical Center, Duarte, CA. Resection and radical mediastinal lymph node dissection (MLND) have been employed in the management of NSCLC for the past ten years at the City of Hope, with the addition of radiotherapy for N1N2 node positive disease. A retrospective analysis of over 150 patients diagnosed and treated between 1987 and 1996 examined patterns of failure, perioperative patient and tumor characteristics, as well as morbidity, mortality and survival. 15 (10%) patients were found to be unresectable at surgery, leaving over 125 evaluable patients resected by lobectomy(s) or pneumonectomy and systematic MLND by one surgeon (FG). Preoperative radiotherapy was provided only to patients with superior sulcus tumors; patients with N1 or N2 nodal disease underwent postoperative radiotherapy. Two patients received neoadjuvant chemotherapy on protocol. Median followup was 20.3 mos (range 0.299.2 mos). The stage distribution as well as fiveyear overall and diseasefree survivals can be found in the following table:
Actuarial 5year OS was 32% for patients with N2 NSCLC and 39% for patients with T3 NSCLC. There were no survivors with T3N2 stage IIIA NSCLC. Local control remained high for all resected, ranging 56.373.1%. The degree of metastatic mediastinal involvement, in terms of lymph node number and nodal stations, significantly correlated with OS, as did the status of the surgical margin. These factors also correlated with DFS. Perioperative morbidity (34%) included arrthymia (14%), pneumonia (4%), pulmonary edema (2%), and empyema (1%). 60day mortality was 2.4%, occurring in patients who underwent pneumonectomy for stage III disease. 24% received transfusions, but none required reoperation for hemorrhage. Median hospital stay was 8 days, with a median 2 days in the ICU. The inclusion of systematic MLND in the surgical management of NSCLC, combined with radical resection, appears to be safe and without longterm adverse effects. In the context of a multimodal approach, resection with MLND plus radiotherapy for N1N2 nodal disease improves survival in NSCLC patients as compared to historical controls.
Frederic W. Grannis Jr. M.D If you have trouble contacting me with the address above, I may also be reached at 76516,2333@compuserve.com and at fgrannis@cris.com |