The complete resectability and long-term survival of patients with non-small cell lung cancer (NSCLC) with preoperatively diagnosed involved ipsilateral mediastinal lymph nodes (N2 disease) is low. Several phase II trials and three small randomised studies indicate that chemotherapy prior to resection improves the results. However, in several of these studies, pathologic proof on N2 disease was not mandatory at the onset of chemotherapy and the results of cervical mediastinoscopy are not described in detail. Because of this, correlation between downstaging and survival is difficult to make and conflicting data are reported in the literature. In this study, all patients underwent a rigorously performed cervical mediastinoscopy. The aim was to correlate downstaging with survival.
Between June 1995 and August 1998, 60 consecutive patients with pathology proven N2 disease were treated with 3 cycles of Vindesine-Ifosfamide-Platinum (VIP). In 46 patients, the cervical mediastinoscopy was performed in our hospital and these patients are further evaluated in this study. There were no major complications of the chemotherapy. The response rate to chemotherapy was 56% (26 patients). Resection was complete in 23 patients (88,5%). Pneumonectomy was performed in 16 patients. In these patients the bronchial stump was covered with intercostal muscle (12) or pericardial fat flap (4). There were no in-hospital deaths. The mean hospital stay was 13,6 days. Three patients developed respiratory insufficiency with prolonged ventilation requiring tracheostomy in one patient.
In one patient, there was a complete sterilisation (T0N0). In 11 patients (42,9%) the mediastinal nodes (which were positive at mediastinoscopy) were negative at the time of thoracotomy (downstaging group). In two patients, no viable tumour was found in the lung while the mediastinal nodes remained positive. The projected 2-year survival of resected patients is 41%. Patients with downstaging of nodes had no better survival compared to patients with no downstaging. Findings at pretreatment mediastinoscopy proved to be the most important prognostic factor.
We conclude that surgery in N2 patients responsive to induction chemotherapy results in a high complete resectability rate. Downstaging of the mediastinal nodes was found in 42%. Resection could be performed with very acceptable morbidity.