Journal of Chest Surgery

The Korean Society for Thoracic and Cardiovascular Surgery (대한심장혈관흉부외과학회)
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The Clinical Value of Mediastinoscopy in Preoperative Staging of Non-small Cell Lung Cancer

폐암 환자의 수술 전 병기 결정에서 종격동경의 임상적 의의

  • Haam, Seok-Jin (Department of Thoracic and Cardiovascular Surgery, Yongdong Severance Hospital, Yonsei University College of Medicine) ;
  • Kim, Do-Hyung (Department of Thoracic and Cardiovascular Surgery, Eulji University Hospital, Eulji University College of Medicine) ;
  • Jeon, Se-Eun (Department of Thoracic and Cardiovascular Surgery, Yongdong Severance Hospital, Yonsei University College of Medicine) ;
  • Lee, Doo-Yun (Department of Thoracic and Cardiovascular Surgery, Yongdong Severance Hospital, Yonsei University College of Medicine) ;
  • Paik, Hyo-Chae (Department of Thoracic and Cardiovascular Surgery, Yongdong Severance Hospital, Yonsei University College of Medicine)
  • 함석진 (연세대학교 의과대학 영동세브란스병원 흉부외과학교실) ;
  • 김도형 (을지대학교 의과대학 을지대학교병원 흉부외과학교실) ;
  • 전세은 (연세대학교 의과대학 영동세브란스병원 흉부외과학교실) ;
  • 이두연 (연세대학교 의과대학 영동세브란스병원 흉부외과학교실) ;
  • 백효채 (연세대학교 의과대학 영동세브란스병원 흉부외과학교실)
  • Published : 2007.11.05
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Abstract

Background: Mediastinoscopy is generally performed to confirm mediastinal lymph node metastasis in lung cancer patients. It still remains controversial whether mediastinoscopy should be performed in all patients with resectable non-small cell lung cancer (NSCLC). We studied the clinical value of mediastinoscopy in preoperative staging in NSCLC. Material and Method: We retrospectively studied 90 NSCLC patients who underwent radiological evaluation and mediastinoscopy followed by surgical resection from March 2002 to December 2004. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of each evaluation method were assessed and compared. Result: Specificity, PPV, NPV, and accuracy of mediastinoscopy were superior to those of radiological evaluation, but there was no significant difference in sensitivity. The sensitivity of mediastinoscopy was 28.6% in 62 patients with radiological N0/1 disease and 72.7% in 28 patients with radiological N2/3 disease. Seven of eight patients in whom positive nodes were not detected by the mediastinoscopy had subcarinal lymph node metastasis. Conclusion: Considering its invasiveness, the difficulty to reach certain node stations, and its low sensitivity in radiological N0/1 disease, mediastinoscopy should be selectively performed in radiological N2/3 disease rather than in all radiological cancer stages.

배경: 폐암환자에서 수술 전에 종격동 림프절의 전이 여부를 확인하기 위해 종격동경이 많이 이용되고 있으나 수술의 적응이 되는 모든 환자에서 종격동경을 시행할 것인지에 대해서는 논란의 여지가 있다. 이에 본 연구에서는 모든 비소세포성폐암 환자에서 통상적으로 종격동경을 시행하는 것이 임상적으로 의미가 있는지 살펴보고자 하였다. 대상 및 방법: 2002년 3월부터 2004년 12월까지 비소세포성폐암으로 진단받고 수술을 시행한 90명의 환자를 대상으로 방사선학적 검사와 종격동 검사를 시행하여 각 검사의 민감도, 특이도, 양성예측치, 음성예측치, 정확도를 비교하였고 방사선학적 N0/1기군과 N2/3기군에서 이들 수치를 분석하여 각 군에서 종격동경 검사가 임상적으로 의미를 가지는가를 후향적으로 분석하였다. 결과: 방사선학적 검사와 종격동경의 민감도, 특이도, 정확도를 비교하였을 때 민감도에는 차이가 없었으나 특이도, 정확도는 종격동경 검사가 우수하였다. 방사선학적 N0/1기군은 62명으로 이 군에서 시행한 종격동경의 민감도는 28.6%였고 방사선학적 N2/3기군은 28명으로 이 군에서의 종격동경의 민감도는 72.7%로 방사선학적 N0/1기군에서의 민감도가 N2/3군에 비해 아주 낮았다. 종격동경으로 진단이 되지 못한 N2/3 양성인 환자 8명 중 7명의 환자에서 수술 시 용골하 림프절의 전이가 확인되었다. 결론: 술 전 병기결정에 종격동경이 종격동 림프절의 전이를 진단하는 가장 정확한 방법이지만 침습적 방법이라는 점과 일부 림프절만이 검사가 가능하다는 점, 방사선학적 N0/1기군에서 특히 낮은 민감도를 고려할 때 모든 군에서 종격동경을 시행하는 것은 임상적 의미를 찾기 어려웠으며 방사선학적 병기 N2/3군에서 선택적으로 종격동경 검사를 시행하는 것이 유용할 것으로 생각한다.

Keywords

References

  1. Okada M, Tsubota N, Yoshimura M, Miyamoto Y, Matsuoka H. Induction therapy for non-small cell lung cancer with involved mediastinal nodes in multiple stations. Chest 2000;118:123-8 https://doi.org/10.1378/chest.118.1.123
  2. Betticher DC, Hsu Schmitz SF, Totsch M, et al. Mediastinal lymph node clearance after docetaxel-cisplatin neoadjuvant chemotherapy is prognostic of survival in patients with stage IIIA pN2 non-small-cell lung cancer: a multicenter phase II trial. J Clin Oncol 2003;21:1752-9 https://doi.org/10.1200/JCO.2003.11.040
  3. Burfeind WR Jr, Harpole DH Jr. Surgical strategies and outcomes after induction therapy for non-small cell lung cancer. Semin Thorac Cardiovasc Surg 2005;17:186-90 https://doi.org/10.1053/j.semtcvs.2005.06.015
  4. Cybulsky IJ, Lanza LA, Ryan MB, Putnam JB Jr, Mc- Murtrey MM, Roth JA. Prognostic significance of computed tomography in resected N2 lung cancer. Ann Thorac Surg 1992;54:533-7 https://doi.org/10.1016/0003-4975(92)90449-E
  5. Pearson FG. Staging of the mediastinum. Role of mediastinoscopy and computed tomography. Chest 1993;103: 346S-8S https://doi.org/10.1378/chest.103.4_Supplement.346S
  6. Seely JM, Mayo JR, Miller RR, Muller NL. T1 lung cancer: prevalence of mediastinal nodal metastases and diagnostic accuracy of CT. Radiology 1993;186:129-32 https://doi.org/10.1148/radiology.186.1.8416552
  7. Dillemans B, Deneffe G, Verschakelen J, Decramer M. Value of computed tomography and mediastinoscopy in preoperative evaluation of mediastinal nodes in non-small cell lung cancer. A study of 569 patients. Eur J Cardiothorac Surg 1994;8:37-42 https://doi.org/10.1016/1010-7940(94)90131-7
  8. Poncelet AJ, Lonneux M, Cochec E, Weynand B, Noirhomme P. Groupe d'Oncologie Thoracique des Cliniques Saint-Luc. PET-FDG scan enhances but does not replace preoperative surgical staging in non-small cell lung carcinoma. Eur J Cardiothorac Surg 2001;20:468-75 https://doi.org/10.1016/S1010-7940(01)00827-2
  9. Fritscher-Ravens A, Davidson BL, Hauber HP, et al. Endoscopic ultrasound, positron emission tomography, and computerized tomography for lung cancer. Am J Respir Crit Care Med 2003;168:1293-7 https://doi.org/10.1164/rccm.200301-050OC
  10. Hammoud ZT, Anderson RC, Meyers BF, et al. The current role of mediastinoscopy in the evaluation of thoracic disease. J Thorac Cardiovasc Surg 1999;118:894-9 https://doi.org/10.1016/S0022-5223(99)70059-0
  11. de Langen AJ, Raijmakers P, Riphagen I, Paul MA, Hoekstra OS. The size of mediastinal lymph nodes and its relation with metastatic involvement: a meta-analysis. Eur J Cardiothorac Surg 2006;29:26-9 https://doi.org/10.1016/j.ejcts.2005.10.002
  12. Kimura H, Iwai N, Ando S, et al. A prospective study of indications for mediastinoscopy in lung cancer with CT findings, tumor size, and tumor markers. Ann Thorac Surg 2003;75:1734-9 https://doi.org/10.1016/S0003-4975(03)00035-3
  13. Travis WD, Brambilla E, Muller-Hermelink HK, Harris CC. The world health organizatiion classification of tumours. Tumours of the lung, pleura, thymus and heart. 1st ed. Lyon: IARC Press. 2004;10-1
  14. Mountain CF. Revisions in the international system for staging lung cancer. Chest 1997;111:1710-7 https://doi.org/10.1378/chest.111.6_Supplement.111S
  15. Naruke T, Suemasu K, Ishikawa S. Lymph node mapping and curability at various levels of metastasis in resected lung cancer. J Thorac Cardiovasc Surg 1978;76:833-9
  16. Libshitz HI, McKenna RJ Jr. Mediastinal lymph node size in lung cancer. Am J Roentgenol 1984;143:715-8 https://doi.org/10.2214/ajr.143.4.715
  17. Libshitz HI, McKenna RJ Jr, Haynie TP, McMurtrey MJ, Mountain CT. Mediastinal evaluation in lung cancer. Radiology 1984;151:295-9 https://doi.org/10.1148/radiology.151.2.6709895
  18. Gross BH, Glazer GM, Orringer MB, Spizarny DL, Flint A. Bronchogenic carcinoma metastatic to normal-sized lymph nodes: frequency and significance. Radiology 1988; 166:71-4 https://doi.org/10.1148/radiology.166.1.3336704
  19. Dwamena BA, Sonnad SS, Angobaldo JO, Wahl RL. Metastases from non-small cell lung cancer: mediastinal staging in the 1990s- meta-analytic comparison of PET and CT. Radiology 1999;213:530-6 https://doi.org/10.1148/radiology.213.2.r99nv46530
  20. Pieterman RM, van Putten JW, Meuzelaar JJ, et al. Preoperative staging of non-small-cell lung cancer with positron-emission tomography. N Engl J Med 2000;343: 254-61 https://doi.org/10.1056/NEJM200007273430404
  21. Toloza EM, Harpole L, McCrory DC. Noninvasive staging of non-small cell lung cancer: a review of the current evidence. Chest 2003;123:137S-46S https://doi.org/10.1378/chest.123.1_suppl.137S
  22. Toloza EM, Harpole L, Detterbeck F, McCrory DC. Invasive staging of non-small cell lung cancer: a review of the current evidence. Chest 2003;123:157S-66S https://doi.org/10.1378/chest.123.1_suppl.157S
  23. Jolly PC, Hutchinson CH, Detterbeck F, Guyton SW, Hofer B, Anderson RP. Routine computed tomographic scans, selective mediastinoscopy, and other factors in evaluation of lung cancer. J Thorac Cardiovasc Surg 1991;102:266-70