Clinical usefulness of CEA-mRNA determination in minor effusion.

Malignant pleural effusion of lung cancer is an important prognostic factor, even in minor effusions. Previous studies reported that cytological examination could not detect malignant cells in pleural dissemination cases. Therefore, we used real-time PCR as a more sensitive test to detect malignant cells. The subjects were selected from 132 primary lung cancer patients and 8 benign tumor patients as negative control. These subjects had no apparent pleural effusion or distant metastasis. All subjects were negative on cytological examination and without exfoliation evidence. The follow-up duration was 18.1 +/- 7.1 months (mean +/- SD). In the real-time PCR, the CEA-mRNA and GAPDH-mRNA parameters were measured simultaneously, and the CEA-mRNA ratio was obtained as normalized values of CEA-mRNA divided by GAPDH-mRNA. The CEA-mRNA ratio in our study was correlated with lymph node metastasis (N-factor: p = 0.0948) and lymphatic invasion (Ly-factor: p = 0.0520). Using a proportional hazard model, with recurrence or death as terminal point, the CEA-mRNA ratio affected the recurrence risk by 1.920 (95% CI: 1.104-3.340) in Stage 1a. Using log rank testing, we found significant differences in the recurrence rate between the CEA-mRNA-positive and -negative cases (p = 0.0039) at cut-off point 0.1.

A randomized phase III trial of adjuvant chemotherapy with UFT for completely resected pathological stage I non-small-cell lung cancer: the West Japan Study Group for Lung Cancer Surgery (WJSG)--the 4th study.

PURPOSE: To examine the efficacy of UFT, an oral 5-fluorouracil derivative agent, as post-operative adjuvant therapy for pathologic (p-) stage I non-small-cell lung cancer (NSCLC), because a previous randomized study had suggested it was efficacious for early-stage NSCLC patients. PATIENTS AND METHODS: Patients with completely resected p-stage I, adenocarcinoma or squamous cell carcinoma were eligible. A total of 332 patients were randomized to the surgery-alone group (control group) and the treatment group (UFT 400 mg/m(2) for 1 year after surgery, UFT group) after stratification by the histologic types. RESULTS: For all patients, the 5- and 8-year survival rates for the UFT group were 82.2% and 73.0%, and those for the control group were 75.9% and 61.2%, respectively; no statistically significant improvement of survival was achieved by UFT administration (P=0.105). For Ad patients, the 5- and 8-year survival rates of the UFT group (n=120) were 85.2% and 79.5%, respectively, which seemed better than those of the control group (n=121) (79.2% and 64.0%, respectively; P=0.081). For squamous cell carcinoma patients, there was also no difference in survival between the control group (n=48) and the UFT group (n=43) (P=0.762). For all pT1 patients, the 5- and 8-year survival rates of the UFT group were 83.6% and 82.1%, respectively, significantly better than those of the control group (77.9% and 57.6%, respectively, P=0.036); UFT was not significantly effective for pT2 patients. For pT1 adenocarcinoma patients, UFT administration markedly improved the survival (P=0.011). CONCLUSION: Post-operative UFT administration did not significantly improve post-operative survival of p-stage I NSCLC patients. Subset analyses suggested that UFT might be effective in pT1N0M0 adenocarcinoma patients.

Prediction of lymph node metastasis by p53, p21(Waf1), and PCNA expression in esophageal cancer patients.

Esophageal cancer is still one of the most widespread diseases, and surgery for esophageal carcinoma is very stressful for patients. Even though lymph node metastasis occurs more frequently in cases of early esophageal cancer than it does in cases of gastric cancer, surgeons prefer to avoid lymph node dissection if possible, thereby subjecting patients to less invasion. Thus, the aim of the present study was to examine the possibility of predicting lymph node metastasis on the basis of tumor location, quantification theory II analysis of tumor expression of genetic markers in primary esophageal cancer. Surgical specimens from 63 patients of esophageal cancer with submucosal invasion were examined for the relationship between tumor location and lymph node metastasis. In 19 of these 63 patients, p53, p21(Waf1, and proliferating cell nuclear antigen (PCNA) were examined immunohistologically, and to quantify the risk of lymph node metastasis, computer analysis was performed on the basis of quantification theory II, in which pathological lymph node metastasis (pN) was the objective variable and "high" or "low" expression of each of the three markers was the predictive variable. Tumors located in the lower third of the esophagus had no lymph node metastasis to the upper mediastinal region, and were thus indicated for trans-hiatal esophagectomy. A coefficient greater than 0.91 predicted node negative disease accurately without false-negative results; false-positive results were obtained for 54.5% of patients with a coefficient less than 0.064. Thus, we found that quantification theory II may be useful when considering indications for surgery without lymph node dissection in some cases of T1 esophageal carcinoma.

[The stratification of surgically treated T4 (stage IIIb) primary lung cancers; analysis of cases with intrapulmonary metastases in the same lobe as the primary tumors (pm 1) and invading adjacent organs].

OBJECTIVE: The purpose of this article was to investigate the validity of T4 classification of primary non-small cell lung cancer. METHODS: We retrospectively reviewed the clinical outcome of cases with pm 1 (n = 65) and T4 tumors invading adjacent organs (n = 36). RESULTS: When the pm 1 tumors were excised completely (n = 57), the prognosis of these cases was affected by the pN factor (5-year survival rate: pN 0-1; 70.1%, pN 2-3; 7.7%, p = 0.0002) and comparable to that of T2 diseases (pN 0-1 cases: p = 0.7315). The patients who underwent complete resection for their pm 1 tumors had a significantly better prognosis than cases with disseminations or malignant pleural effusions which had the same T4 classification (p < 0.0001). The prognosis of the patients who underwent complete resection for the tumors invading adjacent organs (classified under T4) was similar to that of T3 diseases (pN 0-1 cases: p = 0.7116). CONCLUSIONS: Patients whose lung cancer is classified as T4 comprise 2 subgroups; those whose tumors can be completely resected, and those in whom complete resection is impractical. There is a significant difference in the management and the prognosis between these 2 groups although they share the same T4 classification.

[Three cases with a mediastinal neurinoma developed in a same family].

A 47-years-old woman (case 1) was admitted to our hospital because of a mediastinal mass. We performed an operation by VATS under the diagnosis of a mediastinal neurinoma. The histology of it was a neurinoma. Her father (case 2) had undergone a resection of a mediastinal neurinoma at the age of 42. Her brother (case 3) also had undergone a resection of mediastinal and intrathoracic neurinomas at the age of 37. A few years later, he underwent operations for neurinomas in limbs 2 times. We suppose patients with a mediastinal neurinoma have little complaints in many cases, so there are a number of patients who have a mediastinal neurinoma without being discovered and treated. Although the neurinoma is not considered as a hereditary disease inherently, the cases, we experienced, might have some genetic disorders. In this concern, our cases are very rare and have a great interest.

[Wedge resection for lung cancer].

The role of wedge resection in lung cancer is reviewed. In the past century, many reports appeared dealing with limited resection for lung cancer, and it is clear that wedge resection should be performed in patients who are considered at high risk for not tolerating lobectomy; still there is no prospective or even retrospective study on wedge resection carried out in candidates for lobectomy. In recent years, progress in imaging diagnostic technology using high-resolution computed tomography has increased the opportunity to diagnose early adenocarcinoma presenting as small ground-glass opacity (GGO) which could not be detected on chest radiographs. Some patients with GGO may become candidates for wedge resection in this century, if additional favorable data result from prospective studies relevant to imaging diagnosis, pathology, and prognosis.

Lung cancer treated surgically in patients <50 years of age.

STUDY OBJECTIVES: Some investigators have suggested that lung cancer in young patients has a more aggressive course and a poorer prognosis than lung cancer in older patients. The aim of this study was to determine if the basal characteristics and survival in younger patients with lung cancer undergoing surgical resection differ from those of older patients. DESIGN: Retrospective clinical study. PATIENTS: Of 1,208 consecutive patients who underwent surgery for primary lung cancer between June 1984 and March 2000, we reviewed the medical records of 110 younger patients who were < 50 years of age at the time of surgery and compared them with 1,098 older patients (> or = 50 years of age). All deaths were included. RESULTS: In the younger patient group, asymptomatic disease and adenocarcinoma was significantly more frequent, the rate of smoking was significantly higher, and the amount of smoking (Brinkman index) was significantly larger. For the 94 younger patients with complete resection, the 5-year survival rate was 61.0%, which was not significantly higher than that for the 923 older patients (57.7%). However, the 53 younger patients with stage I disease (5-year survival of 84.3%) had significantly better survival than older patients with the same condition (71.6%). Survival of patients in stage II or stage III disease was not significantly different. CONCLUSION: The younger patients had significantly better prognoses, and a statistical difference was shown especially in the early stage, while in the advanced stage the malignancy of the lung cancer itself surpassed the difference in survival.

Bronchoscopic dye injection for localization of small pulmonary nodules in thoracoscopic surgery.

A new method of marking small pulmonary nodules situated deep within the visceral pleura using a transbronchial approach has been developed. Once the tip of the sheath catheter has passed the tumor and reached the visceral pleura, as confirmed by computed tomography fluoroscopy, indigo carmine is injected through a bronchoscope into the lung parenchyma just beneath the visceral pleura. No complications related to the procedure were experienced. The dye-marking procedure enabled the nodules to be precisely located. This technique can provide appropriate guidance when used in conjunction with video-assisted thoracic operations.

Pulmonary resection for metastases from colorectal cancer.

BACKGROUND: We reviewed our experience in the surgical treatment of 47 patients with colorectal pulmonary metastases and investigated factors affecting their survival. METHOD: From September 1986 to December 1999, 47 patients underwent 59 thoracotomies for pulmonary metastases from colorectal cancer. RESULTS: The median interval between colorectal resection and lung resection (disease-free interval [DFI]) was 33 months. Overall, 5-year survival was 48%. Five-year survival was 51% for patients with solitary metastasis (n = 30), 47% for patients with ipsilateral multiple metastases (n = 11), and 50% for patients with bilateral metastases (n = 6), and there were no significant differences. Five-year survival was 80.8% for 14 patients with DFI of < 2 years and 39.7% for 30 patients with a DFI of > 2 years (p = 0.22). Five-year survival for 11 patients with normal prethoracotomy carcinoembryonic antigen (CEA) levels was 70%, and that for 26 patients with elevated prethoracotomy CEA levels (> 5 ng/mL) was 36% (p < 0.05). Eight patients had extrathoracic disease. The median survival time after pulmonary resection was 18.5 months, and the 5-year survival was 60%. A second resection for recurrent metastases was performed in five patients, and a third resection was done in one patient. All six patients are alive. The median survival of five patients who underwent a second thoracotomy was 22 months (range, 2 to 68 months), and one patient is alive 39 months after the third resection. CONCLUSION: Pulmonary resection for metastases from colorectal cancer may help prolong survival in selected patients, even with bilateral lesions, recurrent metastasectomy, or extrathoracic disease. Prethoracotomy CEA level was found to be a significant prognostic factor.

Is segmentectomy with lymph node assessment an alternative to lobectomy for non-small cell lung cancer of 2 cm or smaller?

BACKGROUND: Lesser resection than the standard lobectomy for small-sized cT1N0M0 non-small cell lung cancers continues to be debated. METHODS: We reviewed specimens of 139 patients after lobectomy for cT1N0M0 cancer of 2 cm or less. In addition, we prospectively enrolled 70 patients able to tolerate a lobectomy, in a trial of lesser resection for these lesions. The limited procedure consisted of segmentectomy in which the resection line was delivered beyond the burdened segment, plus exploration of lymph nodes by frozen sectioning. This procedure was modified if the result was positive; this modified procedure was called extended segmentectomy. RESULTS: The nodal status after lobectomy was pN0, 107 patients; pN1, 12 patients; and pN2, 20 patients. Of the pN1 patients, 2 had only intralobar nodal involvement within the same segment of the main tumor. In the remaining 30 patients with nodal involvement, we ascertained the nodal involvement during the operation. Regarding intrapulmonary metastasis, 1 of 8 patients having this metastasis had the lesion at the segment where the main tumor was not located and had N2 disease, which was detected intraoperatively. If extended segmentectomy had been performed instead of lobectomy, the lesion could have been removed completely. The 5-year survival of patients with cT1N0M0 cancer of 2 cm or less was 87.3% after extended segmentectomy. There were no local recurrences and three noncancer-related deaths. Among patients with pT1N0M0 cancer of 2 cm or less, the 5-year survival was 87.1% in the extended segmentectomy group and 87.7% in the lobectomy group (p = 0.8008). CONCLUSIONS: Extended segmentectomy should be considered as an alternative for patients with cT1N0M0 non-small cell lung cancer of 2 cm or smaller.

Lung cancer in women: sex-associated differences in survival of patients undergoing resection for lung cancer.

STUDY OBJECTIVES: The aim of this study was to analyze various characteristics and survival in female patients treated surgically for lung cancer. DESIGN: Retrospective clinical study. PATIENTS: From 1,242 consecutive cases of primary non-small cell lung cancer treated with pulmonary resection between June 1984 and December 1998, 337 female patients (27.1%) were chosen. RESULTS: Female patients had the following characteristics: a significantly younger age at onset (62.5 +/- 0.56 years vs 64.1 +/- 0.31 years for men), a higher frequency of adenocarcinoma (86.0% vs 48.3% for men), and smaller tumors (32.7 mm vs 38.3 mm in diameter for men). Peripheral tumors were significantly more common in women than men (71.8% vs 50.6%, respectively). Among 686 patients with a history of smoking, the women smoked significantly less often (12.8% vs 91.4% for men). Complete resection was achieved significantly less often in women (79.6% vs 85.2% for men); however, women having complete resection survived significantly longer than their male counterparts. Women with a postoperative negative carcinoembryonic antigen (CEA) had a significantly better prognosis than men; however, women with a postoperative positive CEA did not. Women > or = 60 years old survived significantly longer than their male counterparts, while women < 60 years old did not. CONCLUSIONS: Once the tumor was resected completely, women survived longer, partly due to the influence of life expectancy. However, the incidence of malignant effusion was higher and the rate of complete resection was lower in women.

An improved method for distinguishing the intersegmental plane of the lung.

An improved technique for distinguishing the intersegmental plane of the lung was developed as follows. After the involved bronchus is identified, the lobe is inflated and the segmental bronchus is then tied to maintain gas inside of the segments that will be removed, and thereafter is severed at a point proximal to the tie. When almost done closing the stump, a line will develop between the deflated and the inflated area, which represents the intersegmental plane to be operated on. This technique is therefore completely different from the technique described in textbooks, in which the preserved segment is kept inflated while the resected one is kept deflated. Once the line develops, one can operate just on the line using either electrocautery under adequate tension or staples between the collapsed and inflated segments. The cutting surface is so close to the real intersegmental plane that the amounts of air leak and bleeding are negligible.

[Extended segmentectomy for small lung tumors].

UNLABELLED: To identify the benefits of limited surgery on small-sized lung tumors, the following subjects are discussed: 1) an updated report from a prospective group study (January 1992-December 1994) for extended segmentectomy for small lung tumors (n = 55); 2) a histopathological study of resected adenocarcinoma specimens less than 2 cm in size (n = 94), proposed by Noguchi; and 3) lung function after limited surgery and the quality of video-assisted thoracoscopic surgery. RESULTS: 1) Among 10 deaths, 4 patients died of their disease including one with local recurrence. The survival rate at 5 years was 91%, not including 6 unrelated deaths. 2) Of 94 patients, twelve with localized bronchioalveolar tumors (type A and B), and 23 of 57 patients with active fibroblastic proliferation (type C), underwent extended segmentectomy. Those 35 patients are all free of disease. The remaining 59 patients had a 70% 5-year survival rate. 3) Forced vital capacity was maintained at 92% of the preoperative level, which was much better than 81% for patients undergoing lobectomy. Card-sized thoracotomy using a thoracoscope was carried out in 92 patients, including 21 patients who underwent segmentectomy, in a series of 175 consecutive lung cancer operations. This approach resulted in less bleeding, the same operating time, and better preservation of vital capacity. CONCLUSIONS: Extended segmentectomy for small lung tumors did not affect the prognosis, and was associated with a better quality of life postoperatively.

Surgical treatment for chronic pleural empyema.

Various surgical procedures have been developed in an attempt to alleviate the significant problems caused by chronic pleural empyema. The present study evaluates our 11-year experience of employing a number of therapeutic approaches for chronic empyema. Between 1987 and 1997, 45 consecutive patients underwent treatment for chronic empyema at our hospitals. They comprised 21 patients (47%) presenting with post-tuberculosis, 11 (24%) receiving cancer therapy including pulmonary resection, and 13 (29%) with postpneumonic empyema. Omentopexy, lung resection, and thoracoscopic surgery were performed in 10 (22%), 5 (11%), and 4 (9%) patients, respectively. Poor results of treatment were observed in two of the patients with post-tuberculous empyema, and three of the patients treated for cancer died of recurrence. The other 40 patients remain symptom-free. An improvement in quality of postoperative life was revealed by the exercise test rather than by static spirometry. Optimal therapy for chronic empyema requires selection of the most appropriate first and staged procedures for each patient. Moreover, lung resection should be minimal. In a critical state, open thoracostomy must be performed as the first procedure, while omentopexy or thoracoplasty should be restricted to selected cases. Dead space and minor air leakage may safely be left behind. A video-assisted procedure can be selected for postpneumonia empyema.

Induction therapy for non-small cell lung cancer with involved mediastinal nodes in multiple stations.

BACKGROUND: Metastasis to multiple stations of mediastinal nodes is associated with a poor prognosis. OBJECTIVE: : We prospectively examined the efficacy of induction therapy plus surgery in patients with non-small cell lung cancer and metastases at multiple stations of mediastinal (N2) lymph nodes. METHODS: Among the 1,085 patients who underwent surgery for primary non-small cell lung carcinoma from 1985 to 1997, those with clinical N2 disease of involved multiple stations, defined as bulky, mediastinal, lymph node metastases on CT scans, received induction therapy, consisting of cisplatin-based chemotherapy and radiation of 40 Gy. RESULTS: Of the 88 eligible patients entered into the study, 51 (58%) had multiple stations of N2 nodes affected preoperatively, as demonstrated by pathologic examination. Neither operative mortality nor fatal, treatment-related complications occurred during hospitalization. Patients who underwent complete resection had significantly longer survivals than did those who underwent incomplete resection (p = 0. 001). Among patients who underwent complete resection, the survival rate for patients with pathologically downstaged disease was significantly higher than that for patients whose disease was not downstaged (p = 0.009). Among patients with multiple stations of pN2 nodes involved who had undergone complete resection, those who received induction therapy for bulky N2 disease had a significantly better prognosis than did those undergoing surgery alone for nonbulky N2 disease (p = 0.03). CONCLUSIONS: Induction therapy prolonged the survival of patients with non-small cell lung cancer and mediastinal nodes involved at multiple stations. Survival was better when complete resection and downstaging of the disease were achieved after induction therapy.

A role for heterologous gap junctions between melanoma and endothelial cells in metastasis.

F10 and BL6 sublines of B16 mouse melanoma cells are metastatic after intravenous injection, but only BL6 cells are metastatic after subcutaneous injection. We found that connexin (Cx) 26 is upregulated in BL6 cells. To examine gap junction formation, we devised a coculture system, in which an opened vein segment was placed at the bottom of a culture dish and then dye-labeled melanoma cells were seeded onto it. Immunohistochemistry indicated that the vein segment preserved the integrity of the endothelial monolayer. In this system, BL6 cells could transfer dye into endothelial cells but F10 cells could not. Transfection with wild-type Cx26 rendered F10 cells competent for coupling with endothelial cells and as spontaneously metastatic as BL6 cells. Conversely, transfection with a dominant-negative form of Cx26 rendered BL6 cells deficient in coupling and less metastatic. In human melanoma lesions, the level of Cx26 expression was low in melanoma cells residing in the basal layer, but significantly upregulated in melanoma cells invading the dermis. The results suggested that Cx26 plays a role in intravasation and extravasation of tumor cells through heterologous gap junction formation with endothelial cells.

Survival related to lymph node involvement in lung cancer after sleeve lobectomy compared with pneumonectomy.

OBJECTIVE: The purpose of this study was to compare the outcomes after sleeve lobectomy and pneumonectomy for patients with non-small cell lung cancer distributed according to their nodal involvement status. METHODS: Of 1172 patients in whom primary non-small cell lung carcinoma, including mediastinal lymph nodes, was completely excised, 151 patients underwent sleeve lobectomy and 60 underwent pneumonectomy. For bias reduction in comparison with a nonrandomized control group, we paired 60 patients undergoing sleeve lobectomy with 60 patients undergoing pneumonectomy by using the nearest available matching method. RESULTS: The 30-day postoperative mortality was 2% (1/60) in the pneumonectomy group and 0% in the sleeve lobectomy group. Postoperative complications occurred in 13% of patients in the sleeve lobectomy group and in 22% of those in the pneumonectomy group. Local recurrences occurred in 8% of patients in the sleeve lobectomy group and in 10% of those in the pneumonectomy group. The overall 5- and 10-year survivals for the sleeve lobectomy group were 48% and 36%, respectively, whereas those for the pneumonectomy group were 28% and 19%, respectively (P =.005). Multivariable analysis showed that the operative procedure, T factor, and N factor were significant independent prognostic factors and revealed that survival after sleeve lobectomy was significantly longer than that after pneumonectomy (P =.03). CONCLUSIONS: These data suggest that sleeve lobectomy should be performed instead of pneumonectomy in patients with non-small cell lung cancer regardless of their nodal status whenever complete resection can be achieved because this is a lung-saving procedure with lower postoperative risks and is as curative as pneumonectomy.

Ingested ring-pull causing bronchoesophageal fistula and transection of the left main bronchus: successful salvage of the left lung and esophagus five years after injury.

A 6-year-old girl with a history of ingestion of a ring-pull of a can and a transient episode of stridor had been asymptomatic 3 years before admission when left lung atelectasis with severe respiratory distress developed. Fluoroscopy and 3-dimensional computed tomography scan showed bronchoesophageal fistula and the ring-pull around the left main bronchus. At operation, the ring-pull, which transected the left main bronchus, was extracted. The left main bronchus was reconstructed by end-to-end anastomosis in spite of insufficient inflation of the collapsed left lung. The esophageal defect was repaired. The patient's respiratory distress gradually disappeared, and the x-ray films 3 months after operation showed complete expansion of the left lung. This case shows the risk of the long-term retained esophageal foreign body and the possibility of pulmonary salvage after long-term total atelectasis of the lung.

Extended sleeve lobectomy for lung cancer: the avoidance of pneumonectomy.

OBJECTIVE: We have tried atypical bronchoplasties in patients with noncompromised lung function with centrally located cancers to avoid pneumonectomy. We evaluated the efficacy of extended sleeve lobectomy in such patients. METHODS: Among 157 patients undergoing bronchoplasty for primary non-small cell lung carcinoma, 15 patients underwent extended sleeve lobectomy. RESULTS: According to the mode of reconstruction, the 15 patients were classified into 3 groups: (A) anastomosis between the right main and lower bronchi with resection of the upper and middle lobes (n = 6), (B) anastomosis between the left main and basal segmental bronchi with resection of the upper lobe and superior segment of the lower lobe (n = 4), and (C) anastomosis between the left main and upper division bronchi with resection of the lingular segment and lower lobe (n = 5). The tumors were completely resected in all patients. Pulmonary angioplasty was carried out in 8 patients. Bronchial reconstruction was successful in all patients. Pulmonary vein thrombosis resulting from overstretching of the inferior pulmonary vein occurred in 1 patient of group A and was relieved by completion pneumonectomy. There was neither operative mortality nor local recurrence. Although all patients with stage IIB disease and half of patients with stage IIIA disease were alive without recurrence (12-106 months), half of the patients with stage IIIA disease died of distant metastases within 1 year. CONCLUSIONS: We suggest that this extended sleeve lobectomy, which is technically demanding, should be considered in patients with centrally located lung cancer, because this lung-saving operation is safer than pneumonectomy and is equally curative.

Evaluation of TMN classification for lung carcinoma with ipsilateral intrapulmonary metastasis.

BACKGROUND: Staging for lung cancer based on the TNM classification is an important predictive factor for prognosis. Recently, lung cancer with ipsilateral intrapulmonary metastasis (PM) was reclassified according to the revision of the TNM classification. To evaluate the prognostic importance of the new staging system for PM, we analyzed the postoperative survival of patients with non-small cell lung carcinoma. METHODS: Of 1,002 consecutive patients who underwent operation for primary lung cancer between June 1984 and December 1996, we reviewed the medical record of 889 patients who underwent complete resection for non-small cell lung cancer. RESULTS: We considered 89 patients (10.0%) to have synchronous ipsilateral PM. After reclassification to the former staging system revised in 1992, 5 patients were classified as stage I, 29 as stage IIIA, 48 as stage IIIB, and 7 as stage IV. In the new staging system revised in 1997, 48 patients were recategorized as stage IIIB, and 41 as stage IV. The 5-year survival of patients without PM (49.5%) was significantly better than that of patients with PM in primary-tumor lobe (29.6%, p = 0.002) or in nonprimary-tumor ipsilateral lobe (23.4%, p = 0.0002). Although the survival of patients with stage IV cancer without PM was significantly worse than that of patients with the new (1997) stage IV cancer with PM (p = 0.02), it was similar to that of patients with the former (1992) stage IV cancer with PM. The survival of PM patients with N0 or N1 disease was significantly better than that of PM patients with N2 or N3 disease (p = 0.001). Furthermore, in patients with the new (1997) stage IIIB cancer, the survival of N0 disease was better than that of N2 disease (p = 0.007). CONCLUSIONS: Inasmuch as the prognosis of non-small cell carcinoma in patients with PM strongly correlated with N factor rather than PM factor, N factor should be reflected in a staging designation. We therefore consider the new TNM classification for PM reclassified in 1997 to be less acceptable for surgical-pathologic staging than the revision in 1992.