Lung cancer found unresectable at thoracotomy: Reappraisal of an old problem

We review our experience with unresectable non-small cell lung cancer, afte r adoption of a more aggressive surgical approach, including mediastinal ly mph node dissection. Cases with enlarged mediastinal lymph nodes (MLNs, cN( 2)) that were predicted to be resectable were included. Our objective was t o identify preoperative findings to prevent unnecessary thoracotomy. In 198 8-1997, 192 patients had thoracotomy for non-small cell lung cancer, Fiftee n cases (7.7%) were found unresectable at thoracotomy. CT scans demonstrate d enlarged MLNs in 7 of 15 and enlarged hilar lymph nodes in 6 of 15 cases. The tumor abutted the hilum in 5 of 15, chest wall in 2 of 15, and mediast inal structures in 7 of 15 cases. Atelectasis was seen in 3 of 15 cases. Du ring the same period, 63 patients with stage III disease, including 39 pati ents with enlarged MLNs, were resected. The unresectability rate for cN(2) patients was 15.2 per cent. Five (33%) patients were physiologically unable to tolerate the required pneumonectomy [forced expiratory volume in 1 seco nd, 1.65 liters (range, 1.15-2.07)]. There were three (20%) esophageal inva sions, two (13.3%) mediastinal invasions, two (13.3%) aortic invasions, two (13.3%) metastases to the diaphragm, and one (6.6%) invasion of proximal p ulmonary artery. Median survival was 4 months. Two-year actuarial survival was 8 per cent. We conclude that careful palpation and dissection were requ ired to establish unresectability. Preliminary thoracoscopy would have prev ented thoracotomy in two cases (13.3%) of diaphragmatic metastases but woul d not reliably establish unresectable invasion of mediastinal structures.