[Risk factor analysis of mediastinal lymph node metastasis in non-small cell lung cancer patients and the strategy of mediastinoscopy prior to surgery].

OBJECTIVE: To discuss the strategy of mediastinoscopy for the evaluation of mediastinal lymph node status (metastasis or not) of non-small cell lung cancer (NSCLC) prior to surgery. METHODS: From October 2000 to June 2007, 152 consecutive NSCLC cases pathologically proven and clinically staged I-III were enrolled in the study. Of the 152 cases, there were 118 males and 34 females. Age ranged 24-79 years old and the median age was 58. All cases underwent CT and mediastinoscopy for the evaluation of mediastinal lymph node status prior to surgery. Compared with the results of final pathology, the positive rate of mediastinoscopy and the prevalence of mediastinal lymph node metastasis were calculated in the NSCLC patients with negative mediastinal or hilar lymph nodes on CT scan (the shortest axis of mediastinal or hilar lymph nodes <1 cm). Clinical characteristics used as predictive factor including sex, age, cancer location, type of pathology, T status, cancer type (central or peripheral), size of mediastinal lymph nodes (the shortest axis <1 cm or >1 cm) on CT scan and serum CEA level were analyzed by univariate and multivariate analysis with Binary logistic regression model to identify risk factors of mediastinal metastasis. RESULTS: The positive rate of mediastinoscopy was 11.6% (8/69) and the prevalence of mediastinal metastasis was 20.1% (14/69) in NSCLC with negative mediastinal or hilar lymph nodes on CT scan respectively. In clinical stage I (cT1-2N0M0) NSCLC the positive rate of mediastinoscopy was 11.3% (7/62), N2 accounting for 6.5% (4/62) and N3 4.8% (3/62), respectively; and the prevalence of mediastinal lymph node metastasis was 19.4% (12/62), N2 ccounting for 14.6% (9/62) and N3 4.8% (3/62), respectively. In the whole group both univariate and multivariate analysis showed that adenocarcinoma or mediastinal lymph nodes > or =1 cm in the shortest axis on CT scan was an independent risk factor to predict mediastinal lymph node metastasis. In NSCLC with negative mediastinal or hilar lymph nodes on CT scan both univariate and multivariate analysis showed that adenocarcinoma was a predictor of mediastinal lymph node metastasis. Conclusion We recommend the policy of routine mediastinoscopy in NSCLC prior to surgery if the mediastinal staging was only based on CT scan. Mediastinal lymph nodes > or =1 cm in the shortest axis on CT scan mandates preoperative mediastinoscopy. Adenocarcinoma also indicates mandatory mediastinoscopy even with negative mediastinal or hilar lymph nodes on CT scan.

[Safety and long-term outcome of sleeve lobectomy for non-small cell lung cancer].

BACKGROUND AND OBJECTIVE: Pneumonectomy has been long term used as the standard surgical procedure for central type non-small cell lung cancer (NSCLC). Sleeve lobectomy has been performed in a small number of patients meeting the indications. This study was to compare the 5-year survival rate, operation related complications and mortality of sleeve lobectomy with pneumonectomy for NSCLC, and evaluate sleeve lobectomy in the surgical treatment for NSCLC. METHODS: Ninety-three patients with NSCLC undergoing sleeve lobectomy (group A) and 571 patients with NSCLC undergoing pneumonectomy (group B) from January 1997 to December 2007 in Sun Yat-sen University Cancer Center were reviewed. The 5-year survival rate, operation related complications and mortality between the two groups were analyzed. RESULTS: The overall 5-year survival for group A and group B were 42.0% and 31.5%, respectively (P=0.015). In the subgroup analysis, the 5-year survival of N0 (P=0.007) and N1 (P=0.025) patients were significant higher in group A than in group B, while the survival were not significantly different between N2 patients (P=0.073). The 5-year survival rates for bronchial and pulmonary arterial sleeve resection (the subset of group A) and pneumonectomy were not significantly different (P=0.092). There was no significant difference in local recurrences between the groups (P=0.821). The postoperative complication rates were 11.8% in group A and 20.7% in group B (P=0.046). There was no statistically significant difference in mortality between the two groups (P=0.259). CONCLUSION: The operative safety and long term efficacy of sleeve lobectomy are superior to pneumonectomy for NSCLC.

[Prospective comparison of CT versus mediastinoscopy in preoperative evaluation of mediastinal lymph node status in patients with non-small cell lung cancer].

OBJECTIVE: To compare the value of CT and mediastinoscopy in assessment of mediastinal lymph node status in potentially operable non-small cell lung cancer (NSCLC). METHODS: From Oct. 2000 to Jun. 2007, 152 consecutive patients with pathologically proven and stage I to approximately III NSCLC were enrolled into the study. Of the 152 cases, there were 118 males and 34 females, with a median age of 58 years (range, 24 to approximately 79 years). Compared with the final pathology, the sensitivity, specificity, positive and negative predictive values and accuracy of CT and mediastinoscopy for preoperative evaluation of mediastinal lymph node status were calculated, respectively. The accuracy and diagnostic efficacy of CT and mediastinoscopy was compared by Pearson chi(2) test and ROC curve, respectively. RESULTS: The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of detection of mediastinal metastasis was 73.8%, 70.1%, 64.9%, 78.2% and 71.7% by CT, respectively, versus 83.1%, 100.0%, 100.0%, 88.8% and 92.8% by mediastinoscopy, respectively. Both the accuracy and diagnostic efficacy of mediastinoscopy were superior to CT (Pearson chi(2) test, P < 0.001; Z test of the areas under the ROC curve, P < 0.001). The complication rate of mediastinoscopy was 4.6%, and the false negative rate was 7.2%. CONCLUSION: Mediastinoscopy is safe and effective in preoperative assessment of mediastinal lymph node status in potentially operable NSCLC, while CT alone is inadequate.

[Influence of perioperative hypertension on postoperative cardiovascular complications in chest cancer patients].

BACKGROUND & OBJECTIVE: The incidence of perioperative hypertension is increasing in recent decades. Hypertension increases the risk of anaesthesia and surgical operation, and also affects the prognosis of patients apparently. This study was to investigate the influence of perioperative hypertension on postoperative cardiovascular complications in chest cancer patients. METHODS: Clinical data of 464 chest cancer patients, received thoracotomy in Cancer Center of Sun Yat-sen University between Aug. 2005 and Dec. 2005, were analyzed. Of the 464 patients, 152 had perioperative hypertension, and 312 did not. Postoperative cardiovascular complications of the 2 groups were compared with Chi-square test. RESULTS: The 2 groups had no significant differences in age, sex, tumor type, preoperative chronic disease, and preoperative cardiovascular disease (P>0.05). Postoperative cardiovascular complications were developed in 54 patients in perioperative hypertension group (including 41 cases of arrhythmia, 8 cases of hypotension, 3 cases of heart failure, and 2 cases of cardiac ischemia) and in 53 patients in perioperative non-hypertension group (including 41 cases of arrhythmia, 9 cases of hypotension, 2 cases of heart failure, and 1 case of cardiac ischemia). The occurrence rate of postoperative cardiovascular complications was significantly higher in perioperative hypertension group than in perioperative non-hypertension group (35.53% vs. 16.99%, P<0.05). CONCLUSION: Perioperative hypertension obviously increases the incidence of postoperative cardiovascular complications in chest cancer patients after thoracotomy.

[Surgical treatment efficacy of bronchioloalveolar carcinoma: a retrospective analysis of 130 patients].

BACKGROUND & OBJECTIVE: Bronchioloalveolar carcinoma (BAC) is a well-differentiated lung adenocarcinoma occurring in the periphery of the lung and growing along an intact interstitial framework. There are controversies about the surgical treatment efficacy of BAC. This study was to explore the surgical treatment efficacy of BAC. METHODS: Data were collected from 130 patients with BAC, hospitalized in the department of Thoracic Surgery, Cancer Center of Sun Yat-sen University, diagnosed by postoperative pathology from 1985 to 2000. Clinical and histological features, approaches and outcomes of surgical treatment according to different TNM stages and clinical patterns were studied retrospectively. RESULTS: Of the 130 patients, 56.1% were men, 42.9% were women. The ratio of smoker to non-smoker was 1:1.55. Ninety-eight patients underwent complete resection and 32 underwent incomplete resection. Patients in stage I (n=54), stage II (n=15), stage III B (2/11), and stage IV (1/19) underwent complete resection, of whom the 5-year survival rates were 60.7%, 33.3%, 13.6%, and 14.0%, respectively. Patients of unifocal (96/113), multifocal (1/12), and pneumonic (1/19) patterns underwent complete resection, of whom the median survival time was 46.3, 20.6, and 5 months. The 1-, 3-, and 5-year survival rates were 96.4%, 58.6%, and 41.2% for the unifocal pattern, 91.2%, 41.7%, and 33.3% for the multifocal pattern, 20%, 0, and 0 for the pneumonic pattern. CONCLUSION: Complete surgical resection can achieve favorable survival rates for BAC in stage I/II and multifocal BAC in stage III/IV, whereas relatively poorer prognosis for pneumonic BAC.

[Methods of preserving intercostobrachial nerve during breast cancer operation and its clinical value].

OBJECTIVE: To study the methods and the clinical value of preserving intercostobrachial nerve during the axillary lymph nodes excision in breast cancer operations. METHODS: One hundred and sixty-two cases of stages I, II, IIIa breast cancer patients were divided into experimental group and control group respectively. The intercostobrachial nerves were preserved in experimental group and not in control group. Both groups were treated following the practice guideline of breast cancer, and found no recurrence during 4 to 36 months following up. RESULTS: The postoperative arm sensory disturbance was 22.2% in the experimental group, which was significantly different from that of the control group 73.3% (chi(2) = 41.80, P < 0.01), the incidence of pain is 12.5% in experimental group, which was also significantly different from that of control group 31.1% (chi(2) = 7.86, P < 0.01). CONCLUSION: Preserving intercostobrachial nerves may significantly decrease the postoperative morbidity of arm sensory disturbance and pain during axillary excision of stage I, II, IIIa breast cancer patients.

[Clinical analysis of resectable breast cancer: a report of 6 263 cases].

BACKGROUND & OBJECTIVE: In Europe and America, breast cancer commonly occurs in women of middle and old age, the median age of patients is about 57 years old. Modified radical mastectomy has taken the place of traditional radical mastectomy, and is called standard radical mastectomy. Patients with breast cancer of early stage commonly receive breast conservative therapy. TNM stage (especially the lymph node status) affects the prognosis, and adjuvant therapy can improve the survival. In China, just a few clinical researches of large amounts of breast cancer patients have been reported. This study was to analyze clinical feature, surgical patterns, treatment outcome of resectable breast cancer, and explore prognostic factors and the effect of adjuvant therapy, for the sake of improving the levels of diagnosis and treatment. METHODS: Records of 6 263 patients with resectable breast cancer, admitted in our hospital from Jun. 1963 to Jun. 2003, were analyzed retrospectively. RESULTS: Of the 6 263 patients, 98.8% were women. Breast cancer occurred most frequently in patients of 40-49 years old (41.0%), especially in patients of 45-49 years old (25.2%). Breast lump was the main clinical manifestation, and occurred in 96.2% of the patients. The 5-, and 10-year survival rates of all patients were 75.2%, and 40.4%. Of the patients in TNM stages 0-I,II, and III, the 5-year survival rates were 96.8%, 73.7%, and 46.4%, respectively the 10-year survival rates were 78.7%, 64.6%, and 33.5%, respectively. The 5-, and 10-year survival rates were higher in lymph node negative group than in lymph node positive group (80.3% vs. 55.6%, and 59.2% vs. 31.9%, P<0.01). There was no significant difference in survival rates of patients received radical mastectomy and modified radical mastectomy since 1980's (P>0.05). Of the 73 patients received breast conservative therapy, no local recurrence or metastasis occurred, with the maximal follow-up of 17 years. Of the patients in stage T2 -T4, the 5-, and 10-year survival rates were significantly higher in adjuvant chemotherapy group than in non-chemotherapy group (78.2% vs. 60.1%, and 48.9% vs. 30.7%, P<0.01). CONCLUSIONS: According to our data, breast cancer most frequently occurred in patients of 45-49 years old. TNM stage (especially the axillary lymph node status)relates to prognosis of breast cancer. The prognosis was worse in the patients with positive lymph node than in the patients with negative Lymph node. The efficacy of modified radical mastectomy equals to that of radical mastectomy, breast conservative therapy can be applied to patients in early stage. Adjuvant chemotherapy and endocrine therapy can improve the survival of resectable breast cancer patients.

[Predictive value of detection of sentinel lymph nodes on lymphatic metastasis of non-small cell lung cancer].

BACKGROUND & OBJECTIVE: The metastasis status of regional lymph node is an important prognostic factor of non-small cell lung cancer (NSCLC). Sentinel lymph node (SLN) mapping and biopsy is a quick and high efficient technique to intraoperatively detect occult micrometastatic disease, however, its application in NSCLC is immature. This study was designed to investigate the feasibility of detecting SLN in patients with NSCLC during radical surgery, and to evaluate its accuracy of predicting metastasis status of regional lymph node. METHODS: Fifty patients with NSCLC underwent SLN detection. During radical operation, 4 ml of 1% isosulfan blue was injected into the lung tissue around the tumor at 3, 6, 9, and 12 o'clock sites. Location and number of blue dyed SLNs were recorded, and compared with pathologic results to calculate the accuracy and false negative rate of SLN detection. RESULTS: Blue dyed SLNs were seen in 33 patients with a detection rate of 66.0%. SLNs located in N1 lymph node of 24 patients (72.7%), in N2 lymph node of 6 patients (18.2%), in both N1 and N2 lymph nodes of 3 patients (9.1%). Approved by pathology, the accuracy of SLN detection was 87.9% (29/33), the sensibility was 73.3% (11/15), the false negative rate was 26.7% (4/15). CONCLUSION: SLN detection is valuable for predicting hilar and mediastinal lymph nodes metastases in NSCLC.

[Shrinkage of resected specimens of esophageal carcinoma].

BACKGROUND & OBJECTIVE: There are some kinds of shrinkage in resected specimens of esophageal carcinoma; however,there were few reports on its regularity. This study was designed to investigate the degree of shrinkage in resected specimens of esophageal carcinoma. METHODS: Specimens of seventy patients with esophageal squamous cell carcinoma who underwent resections in Cancer Center, Sun Yat-Sen University were collected. The length of the upper margin,the tumor,and the lower margin were measured with a ruler during operation before the esophagus was removed (in situ). After the esophagus was removed, the specimens were cut longitudinally on the side opposite the tumor, then the length of the upper margin, the tumor, and the lower margin were measured again without retraction. After 48 h fixation of 10% formalin (fixed), the length of the upper margin, the tumor, and the lower margin were measured again. RESULTS: After resection,the shrinkage rates of the upper margin, the tumor,and the lower margin were (40.71+/-10.02)%,(83.59+/-16.57)%, and (58.41+/-12.03)% of their in situ length; after 48 h fixation of 10% formalin, the shrinkage rates of the upper margin,the tumor, and the lower margin were (40.06+/-10.50)%, (80.92+/-15.88)%, and (54.83+/-11.29)% of their in situ length (P< 0.05). CONCLUSION: The specimens of esophageal carcinoma shrink remarkably after removed and after formalin fixation.

[Combined surgical treatment for limited small cell lung cancer: clinical analysis of 51 cases].

BACKGROUND & OBJECTIVE: Small cell lung cancer (SCLC) is usually widely disseminated at the time of diagnosis due to its rapid growth. Therefore chemotherapy is the predominant form of treatment for SCLC. However, chemotherapy normally ended in failure as a consequence of recurrence of primary tumor or mediastinal lymphatic nodes. The objective of this study was to investigate whether combined surgical treatment for SCLC can control primary tumor more effectively and increase the survival of the patients. METHODS: Fifty-one cases of limited SCLC treated with surgery from May 1981 to May 2001 in Cancer Center, Sun Yat-sen University were reviewed retrospectively. RESULTS: According to 1997 international staging system, there were 7 patients with stage IB(13.7%), 5 with stage IIA(9.8%), 15 with stage IIB (29.4%), 20 with stage IIIA (39.2%) and 4 with stage IIIB (7.8%). Twelve patients received pneumonectomy, 35 lobectomy, 3 segmentectomy, and 1 exploration. Thirteen patients were treated with surgery alone and 38 of them combined with 2-6 cycles of pre- or post- operative chemotherapy. The median survival time was 20.8 months. The overall 1-, 3-, and 5-year survival rates were 43.0%, 25.9%, and 20.1%, respectively. The 1-, 3-, and 5-year survival rates for patients with stage IB were 100.0%, 80.0%, and 30.0% respectively, with stage II were 79.7%, 39.8%, and 34.5%, respectively, with stage III were 52.4%, 21.8%, and 5.46%, respectively. The 1-,3-, and 5-year survival rates for patients treated by surgery combined with chemotherapy were 77.5%, 38.5%, and 23.8% and that of surgery alone were 41.7%, 16.7%, and 8.3%, respectively (P< 0.01). CONCLUSION: Combined surgical treatment can increase the survival rate of SCLC more effectively and should be considered as an important modality in multi-disciplinary treatment of limited small cell lung cancer.

[Giant pathologic section in the study of optimal length of surgical resection for esophageal carcinoma].

OBJECTIVE: To study the optimal surgical resection length for esophageal carcinoma. METHODS: Specimens of seventy patients with esophageal squamous cell carcinoma resected and collected in our hospital were made into pathologic giant sections. Direct intramural infiltration, multicentric carcinogenic lesion and leaping metastasis were observed in the large slice by microscope. The actual length during the operation was calculated by the ratio of shrinkage. RESULTS: Direct intramural infiltration was found in 51 (72.9%) patients, 39 proximal and 36 distal to the tumor. The mean length of direct intramural infiltration was 0.9 +/- 0.8 cm (4.0 cm maximum) proximally and 0.5 +/- 0.3 cm (2.0 cm maximum) distally. Multicentric carcinogenic lesion was found in 11 (15.7%) patients, 5 proximally, 8 distally and 2 on both sides. Proximal to the tumor, the mean distance between the multicentric carcinogenic lesion and the main lesion plus the length of the multiple carcinogenic lesion was 3.2 +/- 1.5 cm (4.7 cm maximum). Distal to the tumor, it was 3.6 +/- 2.4 cm (9.1 cm maximum). Leaping metastasis was found in 9 (12.9%) patients, 7 proximally and 4 distally. The mean distance between the leaping metastasis and the main lesion plus the length of the leaping metastatic lesion was 1.9 +/- 0.6 cm (2.9 cm maximum) proximally and 1.4 +/- 1.0 cm (2.7 cm in maximum) distally. CONCLUSION: The optimal surgical resection length for esophageal carcinoma should be at least 5 cm proximal to the tumor and total length on the distal side.

A randomized trial of systematic nodal dissection in resectable non-small cell lung cancer.

PURPOSE: We conducted a randomized trial to investigate whether systematic nodal dissection (SND) is superior to mediastinal lymph nodal sampling (MLS) in surgical treatment of non-small cell lung cancer (NSCLC). METHODS: The patients resectable clinical Stage I-IIIA NSCLC were randomly assigned to lung resection combined with SND or lung resection combined with MLS. After postoperative pathological re-staging, eligible cases were followed up until 30 November 2000. The Kaplan-Meier method was used for survival analysis. COX proportional hazards model was used for prognostic analysis. RESULTS: Of the 532 patients who were enrolled in the study, 268 patients were assigned to lung resection combined with SND and 264 were assigned to lung resection combined with MLS. After surgical restaging only 471 cases were eligible for follow-up. The median survival was 59 months in the group given SND and 34 months in the group given MLS (P=0.0000 by the log rank test). There was significant difference in survival in Stage I (5-year survival 82.16 vs. 57.49%) and Stage IIIA (26.98 vs. 6.18%) by the log rank test and Breslow test. There was no significant yet marginal difference in survival by log rank test (10-year survival 32.04 vs. 26.92%, P=0.0523) but significant difference in survival by Breslow test (5-year survival 50.42 vs. 34.05%, P=0.0284) in Stage II. Types of mediastinal lymph node dissection, pTNM stage, tumor size and number of lymph node metastasis were four factors that influenced long-term survival rate by multivariate analysis. CONCLUSIONS: As compared with MLS, lobectomy (pneumonectomy) combined with SND can improve survival in resectable NSCLC.