The value of radical systematic lymphadenectomy in the treatment of bronchial carcinoma is controversial. In a randomized controlled clinical trial, radical lymphadenectomy was compared with conventional node dissection in 182 patients with non-small cell lung cancer. Comparison of short-term results revealed a sigdflcantly longer operating time in those undergoing systematic lymphadenectomy, but overall morbidity and mortality rates were comparable between groups. However, there were compli-The only treatment with a chance of cure for patients with localized non-small cell lung cancer is a radical operation such as classical lobectomy or pneumonectomy. To what extent lymphadenectomy contributes to the chance of cure remains controversial.Some authors' ' advocate radical systematic mediastinal lymphadenectomy as a conditio sine qua non; it is even claimed3s4 that pulmonary resection without mediastinal lymph node dissection has to be considered a palliative operation, denying the patient a chance of cure. In some centres this treatment policy has led to ultraradical operations, mostly in left-sided lung cancers, where bilateral mediastinal lymphadenectomy via a median sternotomy is combined with the classical tumour operation3s5. Other surgeons, such as those of the American Lung Cancer Study Group, have advocated nodal sampling onlyG8 to avoid increasing the morbidity and mortality rates because of the extent of operation. A firm rational basis for extensive systematic lymph node dissection of the ipsilateral thoracic cavity does not emerge from the literat~re~.'~. Benefit has been shown only against historical controls or patients who were excluded from the treatment for other medical reasons3. Since it is unclear which patient categories will benefit from this extensive operation, McKneallyg has emphasized the need for a randomized controlled trial to evaluate the therapeutic efficacy of systematic lymph node dissection. Such a trial was devised to compare the results of conventional lymph node dissection with those of radical systematic lymphadenectomy in patients undergoing curative resection of non-small cell lung cancer. Patients and methodsThe trial was approved by the Ethical Research Committee of the Medical Faculty, University of Munich. Patients were evaluated, randomized, treated and followed up at the Department of Surgery, University of Munich, and the Division of Thoracic Surgery and Department of Pulmonary Medicine, Central Hospital Gauting.Paper accepted 11 July 1993 cations associated with radical lymphadenectomy such as prolonged air leakage and haemorrhage. Interim analysis of results at a median follow-up of 26.8 months showed no significant influence of radical lymphadenectomy on local recurrence-free interval, metastasis-free interval or cancer-related survival. In conclusion, radical systematic lymphadenectomy is a safe operation that leads to a better staging of non-small cell lung cancer, but its prognostic benefit k questionable. Eligibility criteriaPatients of any age and sex with a c...

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Although locally advanced lung cancer frequently necessitates extended resections to preserve a chance for cure, a higher morbidity is associated with extended resections. It is not known whether the increased morbidity is of relevance for the long-term outcome. It also remains unclear whether exclusion of certain patients according to their risk factors can diminish mortality in these patients. This study therefore investigated whether certain risk factors predispose patients undergoing extended pulmonary resections to increased morbidity or mortality. It also assessed the long-term survival. The cases of 126 consecutive patients with locally advanced lung cancer (stage T3 or T4) were prospectively documented. Seventy-five percent of the patients required an extended resection and 25% a nonextended resection. Extended resections were associated with a significantly increased overall morbidity (p < 0.002). However, mortality, severe complications, or multiple complications were not significantly increased after extended resections. No risk factor predisposed to an increased mortality. Risk factors that were associated with particular postoperative complications were pathologic ergonometry (p < 0.002), a positive cardiac score (p < 0.003), coronary artery disease (p = 0.021), and an increased pulmonary risk score (p < 0.05). Overall 3-year survival was 31%. Patients undergoing extended resections for stage T3 or T4 tumors with no residual tumor (70% of the patients) showed a 3-year survival of 33%. We conclude that postoperative mortality cannot be reduced by excluding patients on the basis of particular risk factors from operations that require extended resections. If a patient is considered to be eligible to undergo pulmonary resection, he or she can be considered to be eligible to undergo extended pulmonary resection. Because prognosis is dismal in nonresected locally advanced lung cancer, we recommend an aggressive surgical approach.

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Re-expansion edema is a rare, potentially life-threatening complication of the drainage of a spontaneous pneumothorax. With early recognition and timely treatment, complete resolution can be achieved. Risk factors include rapid re-expansion of the lung, young patient age, and a large pneumothorax persisting longer than 24 hours. If these risk factors are present, the chest tube should be inserted without primary suction. Doing so allows the lung to re-expand more slowly and may prevent this severe complication.