Surgery for non-small cell lung cancer with unsuspected metastasis to ipsilateral mediastinal or subcarinal nodes (N2 disease)

OBJECTIVE: Although the results after surgery for N2 disease aredisappointing, there seems to be a subgroup of patients which may benefitfrom primary resection. These patients have clinically unrecognized N2involvement that is discovered only at the time of thoracotomy (unsuspectedor unforeseen N2 disease). It was the aim of this retrospective study toanalyze the survival after resection for unforeseen N2 disease and toevaluate different prognostic factors. We were interested to see whetherour strategy of rigorous staging of the mediastinum with mediastinoscopy oranterior mediastinotomy had an effect on the resectability rate andsurvival of unsuspected N2 disease. METHODS: Between 1985 and 1990, 859patients with potentially operable non-small cell lung cancer were referredto our surgical department. Despite rigorous preoperative staging withcomputed tomography scan and cervical mediastinoscopy and/or anteriormediastinotomy, 103 patients (14.5%) had unsuspected N2 disease atthoracotomy. The tumor could be completely resected in 90 patients (87.5%).RESULTS: The 5-year survival after complete resection was 22%. Histology ofthe tumor, number of involved levels and extent of nodal disease had noeffect on survival. CONCLUSION: We conclude that resection is justified inpatients with unforeseen N2 disease. Rigorous staging of the mediastinum bycervical mediastinoscopy or anterior mediastinotomy results in a highresectability rate and avoids unnecessary thoracotomies. Mediastinoscopyplays a central role in the staging of patients with carcinoma of thelung.