Selective preoperative evaluation for possible N2 disease in carcinoma of the lung

The efficacy of computed tomography and surgical mediastinal exploration in determining tumor resectability were retrospectively evaluated in 92 consecutive patients with non-small cell lung carcinoma. Status of mediastinal nodes was ultimately determined by surgical mediastinal exploration or thoracotomy. Patients were divided into three groups on the basis of chest roentgenography: Group I comprised 30 patients with peripheral T1 or T2 lesions with normal hilar and mediastinal shadows. Only one patient was found to have an involved node. Chest roentgenography had an accuracy rate of 96% and computed tomography, 93%. Thoracotomy is recommended without either computed tomography or surgical mediastinal exploration in this group. Group II comprised 47 patients with T1 or T2 lesions with an abnormal hilus, an abnormal mediastinal shadow, or either the hilus or mediastinum obscured by overlying parenchymal disease. Computed tomography revealed mediastinal nodes 1 cm or greater in size (abnormal node group) in 21 patients (45%) and smaller than 1 cm (normal node group) in 26 patients (55%). Surgical mediastinal exploration was performed in the abnormal node group and involved nodes were found in 17 of 21 patients (81%). In the normal node group, thoracotomy only was performed and no involved nodes were found. Computed tomography is recommended in all patients in Group II. Patients in the normal node group may be subjected to thoracotomy only and those in the abnormal node group should undergo surgical mediastinal exploration as the next diagnostic step before thoracotomy. Group III comprised 15 patients with grossly abnormal mediastinal shadows. Findings from computed tomography were abnormal in all 10 patients in whom it was done. Surgical mediastinal exploration was done in all 15 and yielded abnormal results in 14. It is recommended in this group that computed tomography is unnecessary and surgical mediastinal exploration should be the only diagnostic procedure. Thus, in potentially resectable non-small cell lung carcinoma, the use of computed tomography and surgical mediastinal exploration should be selective and should be determined by appropriate initial interpretation of the chest roentgenogram.