91

after 30 days of either placebo (P) or HS (60 mg, 3 x/day, po) administration. A to- tal of 51 pts had initial evaluation with a comparable percentage of HS and P treat- ed pts being repeat study. Pretreatment clinical and nutritional parameters were similar in 26 HS and 9 P patients having repeat evaluation with overall pretreat- ment evaluation weight loss of 16%. After 1 month therapy, 83% of HS and only 33% of P patients maintained or increased their weight (p<0.05). Increased caloric intake was associated with weight gain in 94% of lung cancer patients receiving HS compared to only 50% of those receiving P (p<0.05). In 12 pts HS levels were measured using a spectrofluorometric assay after 30 days of therapy with samples taken as a morning fasting level 9 hours after their last dose. Mean maintenance circulatory level was 45 ng/ml (range 8-89 ng/ml). This level of hydrazine was comparable to that asso- ciated with cytotoxicity against malig- nant Ll210 leukemia cells evaluated in a flask culture system where growth inhibi- tion at 28 ng/ml was seen. Taken together, these results give a rationale for clini- cal trials evaluating efficacy of HS addi- tion to standard chemotherapeutic regimens in patients with non-small cell lung cancer,

Surveillance CT Scans of Brain, Chest and Abdomen Following Resection for Non Small Cell Lung Cancer: Relapse Patterns: Impli- cations for Adjuvant Therapy. Goldstraw, P., Grant, D., Edwards, D. Uni- versity College Hospital, Gower Street, London.

Forty-five patients undergoing pulmona- ry resection were subsequently followed at 6, 12, 18 and 24 months by CT scans of brain, chest and abdomen on a Phillips Tomoscan 350 with a 4.8 second scan time. Isotope scans and mediastinal exploration were undertaken where appropriate. No pa- tient assessed as N2 underwent thoracoto- my. Intraoperative staging included routi- ne mediastinal node sampling. Twenty-eight patients had squamous carcinoma, 13 ade~ nocarcinoma, 2 large cell carcinoma and 2 adenosquamous carcinoma, pTNM staging found 8 patients to be TIN0, 16 T2N0, 4 T3N0, I TIN1, 4 T2NI and 12 T2N2. Thirty-four patients have proceeded beyond their 6 month scan, 12 beyond 12 months, ii beyond 18 months and 4 patients have completed the study at 2 years. There have been 13 relapses and l0 of these patients have died. One TIN0 patient has relapsed with cerebral metastases at 9 months, having had a normal CT scan of the brain at 6 months. Three T2N0 patients have relapsed, 1 in the mediastinum and 2 at distant si- res. One T3N0 patient has relapsed locally

and in cervical glands and bones. No pa-

tient with N1 disease has so far relapsed. Of the 12 patients with N2 disease 8 have relap-

sed, only 1 of whom has isolated mediastinal node disease, the rest having distant metasta- ses.

The routine post-operative use of CT scan would appear to have little therapeutic benefit as relapse occurred in organs recently assessed by CT scan. Where CT scan detected occult meta- stases clinical symptoms followed within a few weeks. The frequency of relapse varied with cell type, but the pattern showed no difference for cell type or pTNM staging. Adjuvant media- stinal irradiation for pTNM N2 disease can on- ly be expected to help a small minority of such patients.

Mediastinoscopy vs Computed T0mography as Pre- operative Staging of Lung Cancer. Rocmans, P., Kuhn, G., Francquen, Ph.de, Brion, J.P., Depauw, L., Struyven, J. Hopital Erasme, Universit~ Libre de Bruxelles, Brussels, Bel- gium.

A prospective study 1982-1984 on 222 patients with presumably operable lung cancer evaluates computed tomography (CT 5 sec. scanning time, contiguous 9mm-thick sections, with contrast) vs routine cervical mediastinoscopy (MEDSC) vs thoracotomy after negative mediastinoscopy (THOR) in the staging of mediastinal lymph nodes (N~ vs N ). 120 tumors are in the right lung, 102 in t~e left lung (squamous 116, adenocarcino- ma 73, large cell 22, small cell 2). All nodes larger than 5 mm on CT are considered as poten- tially metastatic.

Final Staging CT MEDSC Thoracotomy N O 132 70 132 132 N 2 90 71 54 36

8 MEDSC positive after normal CT concern 4 small cell c., 2 adenocarcinoma, 2 large cell but no squamous c. (4 left primary tumors). 2 thoracotomy-discovered N 2 cases after negative CT and negative MEDSC concern mainly squamous and adenocarcinoma. The false negative rate is 21% for CT and 40% for MEDSC.

Nodes with size ranging 5-10 mm, 10-20 mm and over 20 mm have respectively 19%, 40% and 55% of metastatic spread. Enlarged non-metasta- tic nodes disclose anthracosis or reactive hy- perplasia. CT often misinterpretes T3N 1 and T_N_ cases. Z ~DSC may be usnecessary for squamous cell

carcinoma without enlarged nodes on CT. However, MEDSC is still advocated in the presence of me- diastinal nodes larger than 5 ~a~ on a CT used as a screening method and, whatever the size of nodes, in all left lung tumors.

Should Mediastinoscopy be Done Routinely in Lung Cancer Patients. Schr6der, D., Thermann, M., Hamelmann, H. De- partment of Gen. Surgery, University of Kiel, Department of Surgery, Comm. Hospital Bielefeld,

Fed. Rep. Germany.

92

In a previous study it could be shown that routine mediastinoscopy for preopera-

tive N 2 staging results in an inadequate high rate of unnecessary or unhelpful me- diastinoscopies.

In a consecutive prospective study started in 1983, preoperative mediastino- scopy in patients with suspected or proved bronchial carcinoma only was performed when x ray tomography or CT scanning of the me-

diastinum gave evidence of N 2 metastasis. If both methods were negative or no oat cell tumor was found, thoracotomy was per- formed. We combined lung resection with

mediastinal lymphadenectomy for exact N 2 staging.

In 99 consecutive patients 6 dropped out for not forfilling the criterias. 23 of the remaining 93 patients underwent media-

stinoscopy, in 14 N 2 disease with peri- nodal involvement was found and the patients declared not radical operable. 79 patients were operated, in 14 cases the suspected tumor was no bronchial carcinoma. In 12 of 65 patients with bronchial carcinoma declared operable by staging procedures N 2 disease was found by postoperative staging nevertheless. In 6 cases solitary N 2 nodes were found in left sited tumors apparent- ly not accessible by our mediastinoscopy technique.

By this we could have saved 6 not radical resections or probatory thoracotomies using mediastinoscopy routinely, but we saved 63 unnecessary or unhelpful mediastinosco- pies.

So it semms acceptable to perform medi- astinoscopy only if x ray tomography or CT of the mediastinum gives evidence for

N 2 disease.

Should Subcarinal Lymph Nodes be Routine- ly Examined in Patients with Non-Small Cell Lung Cancer? The Lung Cancer Study Group (LCSG): prepa- red by Thomas, P.A., Illinois Cancer Coun- cil, and Mountain, C.F., Reference Center for Anatomic and Pathologic Classification of Lung Cancer, M.D. Anderson Hospital.

In the LCSG Reference Center 234 patients were reviewed prior to 12/31/83 who under- went complete or incomplete resection with and without adjuvant therapy for stage III non-small cell lung cancer; 176 had con- firmation of N2 disease. Documentation by the LCSG submitting pathologists of the lymph node mapping at operation showed that the most frequent sites of mediasti- nal node metastasis were the subcarinal (61), upper paratracheal (40), lower paratracheal (33) and subaortic (25). Smaller numbers of patients had involvement of the retro~ tracheal, para-aortio, para-esophageal and inferior pulmonary ligament nodes. Consi-

dering subcarinal nodes as an isolated va-

riable the cumulative survival of patients with

N2 disease was better if subcarinal nodes were not involved.

S u b c a r i n a l lymph No. o f Cumula t ive Percent $ u ~ l v i n s ~ d e S t a t u e P t l . 12 ~ . 2& ~ . 36 ~ . &8 ~ .

P o s i t ~ e 61 5 8 . 8 4 3 . 0 3 1 , 7 2 1 , 1 N e g a t i v e 115 75.1 ~ 9 . $ 3 9 . 5 3 2 . 5

The survival difference was significant for the entire group (p = .03) and for patients with adenocarcinoma (p = .04). A non-signifi- cant trend was noted for patients with squamous carcinoma (p = .ii). This study illustrates the importance of full nodal sampling of the mediastinum and recording sites of tumor meta- stases. The data emphasize the high frequency of subcarinal lymph node involvement and the guarded prognostic implications for patients with such finding.

Prospective Evaluation of Mediastinoscopy for Assessment of The Lung. Cooper, J.D., Luke, W.P., Pearson, F.G., Todd, T.R., Patterson, G.A. Thoracic Surgery Division, Toronto General Hospital, University of Toronto.

Between 1979 and 1984 cervical mediastino- scopy was carried out on 960 (61.5%) of the 1559 patients admitted to the Thoracic Surgical Service of the Toronto General Hospital with a diagnosis of lung cancer. In 127 cases, conco- mitant anterior mediastinoscopy was also per- formed, Positive nodes were found in 286 pati- ents (30%). There was an overall 2% complica- tion rate with no mortality. Positive mediasti- hal nodes were found in 17% of squamous carci- nomas, 23% adenocarcinomas, 49% small cell, 30% large cell undifferentiated and 9% broncho- alveolar. Positive mediastinal nodes were found with equal frequency in right and left sided tumours and occurred in 34% of tumours of the main bronchus, 26% of upper lobe tumours and 17% of lower lobe tumours. Of the 674 negative mediastinoscopies, 562 patients (83%) came to thoracotomy, at which time 58 patients (10%) were found to have positive mediastinal nodes. Overall resectability rate was 93% (86% cura- tive, 7% palliative). Twenty per cent of the re- sections were pneumonectomies. Fifty-five (19%) of the 268 positive mediastinoscopy patients were selected for thoracotomy. In this group, resectability rate was 85% (67% curative, 18% palliative). Pneumonectomy rate was 34%. Follow- up data is complete for 925 of 960 patients with a mean follow-up of 36 months.

A=tuarial Survi~l i Y___~r. 2 Yr_____ss. 5 Y~. -~ msdlastinoscc~y ~ thora~tcmy 58% 52% 33% +ve medi~tlnoscopy c thora~tcmy 26% 16% -- +re m~dlastinos~ s thora~tomy 19% 4% --

We conclude that routine mediastinoscopy can be done with negligible morbidity and provides essential information for the management of pa- tients with lung cancer.

Extended Cervical Mediastinoscopy - A Single Procedure for Staging Left Upper Lobe Carcino- mas.

Rice, T.W., Goldberg, M., Waters, P.F., LeClerc,