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J Thorac Cardiovasc Surg 2004;127:1587-1592
© 2004 The American Association for Thoracic Surgery

General thoracic surgery

Prognostic value of visceral pleural invasion in resected non–small cell lung cancer diagnosed by using a jet stream of saline solution

^a Department of Thoracic Oncology, National Kyushu Cancer Center, Fukuoka, Japan

Received for publication October 28, 2003; revisions received January 8, 2004; accepted for publication February 4, 2004.

^* Address for reprints: Riichiroh Maruyama, MD, Department of Thoracic Oncology, National Kyushu Cancer Center, 3-1-1, Notame, Minami-ku, Fukuoka 811-1395, Japan
rmaruyama{at}nk-cc.go.jp

OBJECTIVE: Visceral pleural invasion caused by non–small cell lung cancer is a factor in the poor prognosis of patients with that disease. We investigated the relationship between the diagnosis of visceral pleural invasion by using a jet stream of saline solution, which was previously reported as a new cytologic method to more accurately detect the presence of visceral pleural invasion, and prognosis.

METHODS: From January 1992 through December 1998, 143 consecutive patients with peripheral non–small cell lung cancer that appeared to reach the visceral pleura underwent a surgical resection at the Department of Thoracic Oncology, National Kyushu Cancer Center. The surface of the visceral pleura in patients undergoing lung cancer resection was irrigated with a jet stream of saline solution. The diagnosis of visceral pleural invasion was determined by means of either a pathologic examination or by means of a jet stream of saline solution. In addition, a cytologic examination of the pleural lavage fluid obtained immediately after a thoracotomy was evaluated.

RESULTS: Forty-nine (34%) resected tumors were identified as having visceral pleural invasion. The diagnosis of visceral pleural invasion in 31, 6, and 12 patients was determined by using a jet stream of saline solution alone, pathologic examination alone, or both, respectively. The visceral pleural invasion and positive findings of intrapleural lavage cytology were linked. Although there was no significant difference between the incidence of distant metastases in the patients with visceral pleural invasion and those without visceral pleural invasion, the incidence of local recurrence, especially regarding carcinomatous pleuritis (malignant pleural effusion, pleural dissemination, or both), in the patients with visceral pleural invasion was significantly higher than in those without visceral pleural invasion. The recurrence-free survival of patients with visceral pleural invasion was significantly shorter than that of patients without visceral pleural invasion (P = .004), even patients with stage I disease (P = .02). There was also a significant difference between the patients with or without visceral pleural invasion in the overall survival (P = .02). Visceral pleural invasion was independently associated with a poor recurrence-free survival on the basis of multivariate analyses (P = .03), as were sex (P = .03), age (P = 002), and the stage of the disease (P < .0001).

CONCLUSIONS: This study confirmed that the jet stream of saline solution method in addition to ordinary pathologic examination was useful for detecting visceral pleural invasion, which is considered to be one of the causes of local recurrence, especially in carcinomatous pleuritis.