Endoscopic ultrasound in lung cancer patients with a normal mediastinum on computed tomography

BACKGROUND: Computed tomography (CT) is the most common method of staging lung cancer. We have previously shown endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) to be highly accurate in staging patients with nonsmall cell lung cancer (NSCLC) who have enlarged mediastinal lymph nodes on CT scan. In this study we report the accuracy and yield of EUS-FNA in staging patients without enlarged mediastinal lymph nodes by CT. METHODS: Patients with NSCLC and CT scan showing no enlarged mediastinal lymph nodes (> 1 cm for all nodes except > 1.2 cm for subcarinal) in the mediastinum underwent EUS. Fine needle aspiration was performed on at least one lymph node, if present, in the upper mediastinum, aortopulmonary window, subcarinal, and periesophagus regions. Each specimen was evaluated with on-site cytopathology and confirmed with complete cytopathologic examination. RESULTS: Sixty-nine patients without enlarged mediastinal lymph nodes were evaluated. Endoscopic ultrasound detected malignant mediastinal lymph nodes in 14 of 69 patients as well as other advanced (American Joint Committee on Cancer [AJCC] stage III/IV) in 3 others (1 left adrenal, and 2 with mediastinal invasion of tumor) for a total of 17 of 69 (25%, 95% confidence interval: 16% to 34%) patients. Eleven additional patients were found to have advanced disease by bronchoscopy (2), mediastinoscopy (2), and thoracotomy with mediastinal lymph node dissection (7). The sensitivity of EUS for advanced mediastinal disease was 61% (49% to 75%), and the specificity was 98% (95% to 100%). CONCLUSIONS: Endoscopic ultrasound guided fine needle aspiration can detect advanced mediastinal disease and avoid unnecessary surgical exploration in almost one of four patients who have no evidence of mediastinal disease on CT scan. In addition to previously reported results in patients with enlarged lymph nodes on CT, these data suggest that all potentially operable patients with nonmetastatic NSCLC may benefit from EUS staging.     

Does endoesophageal ultrasound-guided fine-needle aspiration replace mediastinoscopy in mediastinal staging of thoracic malignancies?

OBJECTIVE: To determine the impact of endoesophageal ultrasound-guided fine-needle aspiration (EUS-FNA) on management of thoracic malignancies. METHODS: One hundred and twenty patients referred for invasive diagnostic and resection of thoracic malignancies were studied prospectively. Negative and inconclusive EUS-FNA findings were assessed by video-assisted mediastinoscopic lymphadenectomy (VAMLA) or open lymphadenectomy. RESULTS: One hundred and twenty patients, aged 64.1 years (range 38-85) underwent 120 EUS-FNA, 53 video-assisted mediastinoscopic and 48 open lymphadenectomies for diagnosis and treatment of 99 lung carcinoma, six lung metastases, five mesothelioma, three lymphoma, and eight other conditions. EUS-FNA showed T4 in 15/120 and adrenal or hepatic metastases in 9/120 cases. Prevalence of mediastinal lymph node metastases was 51.7%. EUS-FNA false-negative rate was 25.3%. EUS-FNA sensitivity was 91.7%, 78.1% and 43.8% for bulky disease, enlarged mediastinal nodes or normal nodes on CT scan, 50% and 96.6% for right- and left-sided tumours, and 80.6%, 78.9%, 23.8% and 25.0% for the lymph node stations 7, 5/6, 4R, and 4L. A 38.3% respectively 100% cut-down of mediastinoscopies leads in 7.5% respectively 20.8% to incorrect treatment decisions. CONCLUSIONS: EUS-FNA sensitivity depends on the localisation of the primary tumour, and extent and location of mediastinal disease. For left-sided tumours, EUS-FNA improves mediastinal staging by assessing stations 5 and 6 inaccessible to conventional mediastinoscopy. For extended mediastinal disease, mediastinoscopy can be avoided or spared for restaging after neoadjuvant therapy. Exclusion of mediastinal involvement requires mediastinoscopy or open lymphadenectomy. Beyond mediastinal nodal staging, EUS-FNA may detect T4 and M1 situations. Thus, EUS-FNA is a useful supplement to and not the replacement of mediastinoscopy.     

ESTS guidelines for preoperative lymph node staging for non-small cell lung cancer.

Accurate preoperative staging and restaging of mediastinal lymph nodes in patients with non-small cell lung cancer (NSCLC) is of paramount importance. It will guide choices of treatment and determine prognosis and outcome. Over the last years, different techniques have become available. They vary in accuracy and procedure-related morbidity. The Council of the ESTS initiated a workshop on preoperative mediastinal lymph node staging. This resulted in guidelines for primary staging and restaging. For primary staging, mediastinoscopy remains the gold standard for the superior mediastinal lymph nodes. Invasive procedures can be omitted in patients with peripheral tumors and negative mediastinal positron emission tomography (PET) images. However, in case of central tumors, PET hilar N1 disease, low fluorodeoxyglucose uptake of the primary tumor and LNs > or = 16 mm on CT scan, invasive staging remains indicated. PET positive mediastinal findings should always be cyto-histologically confirmed. Transbronchial needle aspiration (TBNA), ultrasound-guided bronchoscopy with fine needle aspiration (EBUS-FNA) and endoscopic esophageal ultrasound-guided fine needle aspiration (EUS-FNA) are new techniques that provide cyto-histological diagnosis and are minimally invasive. Their specificity is high but the negative predictive value is low. Because of this, if they yield negative results, an invasive surgical technique is indicated. However, if fine needle aspiration is positive, this result may be valid as proof for N2 or N3 disease. For restaging, invasive techniques providing cyto-histological information are advisable despite the encouraging results supported with the use of PET/CT imaging. Both endoscopic techniques and surgical procedures are available. If they yield a positive result, non-surgical treatment is indicated in most patients.     

Bronchoscopic diagnosis and staging of lung cancer.

In the past 2 decades, flexible bronchoscopy (FB) with forceps biopsy and transbronchial needle aspiration (TBNA); computed tomography (CT)-guided, transthoracic fine-needle aspiration (FNA); and endoscopic ultrasonography (EUS) have revolutionized lung cancer diagnosis and staging by facilitating precise biopsy of lung lesions and virtually all mediastinal lymph-node stations. In this article the authors present an algorithm for the diagnosis and staging of lung cancer that addresses sampling of suspicious lesions and lymph nodes by means of FB, CT, ultrasonography, fluoroscopy, and EUS, emphasizing tissue-based diagnosis and staging by means of image-guided technology with the highest diagnostic yield. They discuss the approach to the diagnosis and staging of lung cancer by techniques guided by FB, with particular attention to the increasing role of TBNA in this field. Additionally, the authors propose a rating scale based on the degree of invasiveness and diagnostic yield, comparing FB with other diagnostic techniques.     

Endoscopic ultrasound-guided fine needle aspiration for staging patients with carcinoma of the lung

Background. Endoscopic ultrasound (EUS)-guided fine needle aspiration is a safe, cost-effective procedure that can confirm the presence of mediastinal lymph node metastases and mediastinal tumor invasion. We studied the accuracy of EUS in a large population of lung cancer patients with and without enlarged mediastinal lymph nodes on computed tomographic (CT) scan.

Methods. From 1996 to 2000 all patients referred to our institution with lung tumors and no proven distant metastases were considered for EUS and surgical staging. Patients had endoscopic ultrasound with fine needle aspiration of abnormal appearing mediastinal lymph nodes and evaluation for mediastinal invasion of tumor (stage III or IV disease). Patients without confirmed stage III or IV disease had surgical staging.

Results. Two hundred seventy-seven patients met the inclusion criteria, including 121 who had EUS. Endoscopic ultrasound and fine needle aspiration detected stage III or IV disease in 85 of 121 (70%). Among patients with enlarged lymph nodes on CT, 75 of 97 (77%) had stage III or IV disease detected by EUS. Among a small cohort of patients without enlarged mediastinal lymph nodes on CT, 10 of 24 (42%) had stage III or IV disease detected by EUS. For mediastinal lymph nodes only, the sensitivity of endoscopic ultrasound and CT was 87%. The specificity of EUS (100%) was superior to that of CT (32%) (p < 0.001).

Conclusions. Endoscopic ultrasound with fine needle aspiration identified and histologically confirmed mediastinal disease in more than two thirds of patients with carcinoma of the lung who have abnormal mediastinal CT scans. Although mediastinal disease was more likely in patients with an abnormal mediastinal CT, EUS also detected mediastinal disease in more than one third of patients with a normal mediastinal CT and deserves further study. Endoscopic ultrasound should be considered a first line method of presurgical evaluation of patients with tumors of the lung.     

Current concepts in the mediastinal lymph node staging of nonsmall cell lung cancer

OBJECTIVE: To review the current concepts in the mediastinal staging of nonsmall cell lung cancer (NSCLC), evaluating traditional and modern staging modalities. SUMMARY BACKGROUND DATA: Staging of NSCLC includes the assessment of mediastinal lymph nodes. Traditionally, computed tomography (CT) and mediastinoscopy are used. Modern staging modalities include magnetic resonance imaging (MRI), positron emission tomography (PET), and endoscopic ultrasound with fine-needle aspiration (EUS-FNA) METHODS: Literature was searched with PubMed and SUMSearch for original, peer-reviewed, full-length articles. Studies were evaluated on inclusion criteria, sample size, and operating characteristics. Endpoints were accuracy, safety, and applicability of the staging methods. RESULTS: CT had moderate sensitivities and specificities. With few exceptions magnetic resonance imaging (MRI) offered no advantages when compared with CT, against higher costs. PET was significantly more accurate than CT. Mediastinoscopy and its variants were widely used as gold standard, although meta-analyses were absent. Percutaneous transthoracic needle biopsy (PTNB) and transbronchial needle biopsy (TBNA) were moderately sensitive and specific. EUS-FNA had high sensitivity and specificity, is a safe and fast procedure, and is cost-effective. EUS-FNA evaluates largely a nonoverlapping mediastinal area compared with mediastinoscopy. CONCLUSIONS: PET has the highest accuracy in the mediastinal staging of NSCLC, but is not generally used yet. EUS-FNA has the potential to perform mediastinal tissue sampling more accurate than TBNA, PTNB, and mediastinoscopy, with fewer complications and costs. Although promising, EUS-FNA is still experimental. Mediastinoscopy is still considered as gold standard for mediastinal staging of NSCLC.     

Study of mediastinal lymph nodes in lung cancer using transesophageal ultrasonography]

Evaluation of mediastinal lymph nodes in patients with lung cancer is fundamental for their treatment and prognosis. Chest computed tomography (CT) is presently the most utilized diagnostic modality. In recent years endoscopic ultrasound (EUS) is being employed for this purpose. We retrospectively compared the results of CT and EUS staging of 35 selected patients with postsurgical stage. A total of 175 lymph node sites were examined. Results CT vs EUS were as follows: specificity 92% vs 98%, sensitivity 88% vs 84%, positive predicted accuracy 80% vs 96%, negative predicted accuracy 95% vs 94%, overall accuracy 92% vs 95%. The region most accessible by EUS evaluation were the paraesophageal lymph nodes; the most difficult were the right superior mediastinal nodes which cannot be imaged for anatomic reasons. EUS not only allows one to arrive at correct diagnosis with less false positive results, but also permits evaluation of lymph nodes which are not enlarged. We think that EUS, in combination with CT, is an appropriate modality for staging of mediastinal lymph nodes in patients with lung cancer.     

Is sampling really effective in staging non-small cell lung cancer? A prospective study

Is sampling really effective in staging non-small cell lung cancer? The aim of the study was to assess if systematic nodal dissection is necessary in order to stage non-small cell lung cancer correctly or whether mediastinal lymph node sampling can be used and whether in selected cases it could replace systematic nodal dissection for the treatment of lung cancer. A prospective study was conducted in 94 patients affected by clinically resectable non-small cell lung cancer (stages I-IIIB) who were surgically treated by the same team of surgeons. During surgery mediastinal lymph node sampling was done first and then another surgeon completed the systematic nodal dissection and performed the lung resection. One hundred and ninety-three mediastinal nodal stations were investigated using the American Thoracic Society lymph node map to identify them. On analysing the 193 mediastinal nodal stations investigated, it emerged that in 181 cases (94%) mediastinal lymph node sampling and systematic nodal dissection yielded the same histopathological findings, whereas in 12 cases (6%) there was no agreement between the two techniques. The negative predictive value of mediastinal lymph node sampling was 92.8% (103/111). The results of the study show no statistical difference between mediastinal lymph node sampling and systematic nodal dissection in staging non-small cell lung cancer. However, it is possible that in a limited percentage of cases a nodal station could be understaged and thus the surgical resection could prove incomplete if mediastinal lymph node sampling alone is performed. Moreover, in those cases where mediastinal lymph node sampling detects N2 disease and systematic nodal dissection has not been completed, the intervention cannot be considered radical.     

Cervical Mediastinoscopy Versus Computed Tomography for Detecting Enlarged Mediastinal Lymph Nodes in Non-Cancerous Lung Diseases

Cervical mediastinoscopy (CM) is considered to be the gold standard for evaluating mediastinal lymph nodes. The aim of this study was to determine the diagnostic yield of computed tomography (CT) and CM for detecting enlarged mediastinal lymph nodes in non-malignant pulmonary diseases. We retrospectively investigated the correlation and differentiation between chest CT and CM findings in terms of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), in 30 patients with granulomatous lung disease diagnosed by CM and isolated enlarged lymph nodes seen on CT scans. Biopsy tissues from the lymph nodes in stations right, 1, 2, 3, 4, and 7, were obtained for pathological examination. The 30 patients comprised 11 men (mean age 47.1 ± 18.4 years) and 19 women (mean age 44.2 ± 14.0 years). Radiological examination showed that the diagnostic value of stations 2 and 4 was particularly high. Thus, when CM is used for diagnostic purposes, the small lymph nodes in station 1, obtained by careful dissection of the higher mediastinal region, can be helpful. Generally, there is no absolute consistency between the findings of CM and CT. For this reason, obtaining samples from each station regardless of CT findings is recommended.     

气道超声在肺部疾病中的临床应用及进展

气道内超声(EBUS)已成为各种肺部疾病重要的诊断工具。EBUS可指导肺外周病变经支气管肺活检(TBB),同时也可指导肺门纵隔淋巴结或肿块进行经支气管针吸活检术(TBNA),因此EBUS-TBB和EBUS-TBNA对于肺部疾病良恶性诊断至关重要。EBUS属微创侵入性检查,肺癌纵隔淋巴结分期中被推荐为首选的诊断方法。此外,EBUS可以评估恶性肿瘤对支气管壁的浸润程度。本文对EBUS在肺部疾病中的临床应用及进展进行综述。     

Clinical staging of esophageal carcinoma. CT, EUS, and PET

CT is readily available to all patients. It is relatively inexpensive and fees are usually reimbursed. It provides exquisite anatomic detail of the chest and abdomen in patients with esophageal cancer. The only reliable use of CT in the determination of T is the exclusion of T4 tumors, which is suggested by the preservation of fat planes. Enlarged lymph nodes are suspicious for metastatic disease but require further study or tissue sampling if nodal metastases will determine treatment. Its major use is in the detection of distant metastatic disease; however, 30% to 60% of distant metastases may be radiographically occult. There is a significant learning curve for EUS staging of esophageal cancer. It is suggested that this study be performed at institutions where there is a dedicated, experienced endoscopic ultrasonographer with adequate instrumentation that allows specialty imaging and EUS-FNA. EUS is the best means of clinically determining T. The addition of EUS-FNA to routine EUS evaluation of lymph nodes allows an accuracy similar to the EUS determination of T. EUS has no purpose in assessment of non-nodal distant metastatic disease; however, the serendipitous finding of distant metastases in adjacent structures visualized during the evaluation of the primary tumor and lymph nodes has, on occasion, detected M1b disease. FDG-PET represents an advance over CT scanning in the screening for distant metastases. The major problems with FDG-PET staging of esophageal cancer is failure to detect metastatic deposits less than 1 cm in diameter and lack of anatomic definition. It is unable to determine T and has been inaccurate in the detection of lymph node metastases. Because this test is not readily available, is expensive, and is not routinely reimbursed, its use in staging esophageal cancer continues to be limited. Today, CT and EUS are the mainstays in the clinical staging of esophageal carcinoma. When possible, FDG-PET should be added to CT to improve the evaluation of non-nodal M1b disease. Results of these studies should determine the necessity for invasive staging techniques and direct their use.     

New Endoscopic Ultrasound (EUS) Applications in Lung Cancer: Evaluation of Patients With Negative Mediastinal CT and Re-Staging After Neoadjuvant Treatment

The main purpose of staging in non-small cell lung cancer (NSCLC) is to assess mediastinal lymph node involvement, with thoracic CT being the main non-invasive test for this. However, given that up to 15% of patients who show no mediastinal lymph node involvement in the CT has lymph node metastasis during surgery, other examinations are required. Endoscopic ultrasonography guided fine-needle aspiration (EUS-FNA) was shown to be able to detect advanced disease (metastatic mediastinal lymph nodes, adrenal metastasis, mediastinal invasion by the tumor) in approximately 25% of patients with a CT that suggested a non-advanced disease.Another situation in which CT has a very limited value is in the evaluation of the response to induction therapy, with its most limiting factor being its intrinsic inability to distinguish between a tumor and necrosis. In this context, EUS-FNA was shown to have a good performance, with a sensitivity, negative predictive value and precision of 75%, 67%, and 83%, respectively.In conclusion, EUS-FNA may be considered a good alternative in the pre-operative staging of patients with NSCLC, with and without diseased mediastinal lymph nodes in CT, and could play an important role in the mediastinal re-staging of these patients by identifying a patient sub-group who might benefit from additional surgical treatment.     

Mediastinal Staging Prior to Surgical Resection

In our current conception of cancer, lymph nodes represent a pivotal transition between a primary tumor treated by surgical therapy alone and metastatic disease treated by an evolving combination of multimodality therapy. Invasive mediastinal staging provides an opportunity for pre-resectional histologic examination of these pivotal lymph nodes. The disadvantages of mediastinoscopy is that it requires general anesthesia and, in many cases, a delay in surgical resection. The advantages of mediastinoscopy are that it is safe and effective.¹⁶ In patients with suspected mediastinal lung cancer (stage III), mediastinoscopy provides lymph node staging and histologic confirmation of tumor type. In these selected patients, we perform sufficiently extensive mediastinal sampling that it is impractical to examine the entire specimen by frozen section. The price of a thorough examination of the lymph nodes is that the therapeutic resection may be delayed a week; nonetheless, the mediastinoscopy is low risk and can be performed as an outpatient procedure. In appropriately selected patients, invasive mediastinal staging provides important histologic information with minimal morbidity.     

超声内镜诊断肺癌纵隔淋巴结转移

目的：探讨超声内镜（EUS）对肺癌纵隔淋巴结转移的诊断价值。方法：21例肺癌患者术前行EUS检查,分别统计EUS检出及手术切除的纵隔淋巴结个数;对EUS发现,手术切除并行病理检查的103枚淋巴结的声像图进行分析,寻找EUS下恶性淋巴结的特征及诊断方法。并与CT诊断的准确性比较。结果：EUS对第5、7、8、9组转移淋巴结的检出率高于非转移淋巴结（χ^2=11.752.P=0.01),EUS发现的恶性淋巴结较良性淋巴结大（二者短径相比：t=4541,P=0.000,长径相比：t=3.278,P=0.002),恶性淋巴结的特征有：短径≥1．0cm,长径≥1．5cm,边界清楚,应用公式：P（1）＝1／[1 e-(-2.963 2.041 x1 1.681 x2)],以P（1）≥0．5作为恶性淋巴结诊断标准,其准确率,灵敏度,特异度分别为72．8％,72．7％,72．9％;EUS对第5、7、8、9组纵隔淋巴结诊断的准确性高于CT（χ^2=6.812,P=0.013),以病理检查结果为金标准,EUS诊断肺癌纵隔淋巴结转移的准确率,灵敏度,特异度分别为83．9％,80．0％,87．5％（χ^2=21.218,P=0.000)。结论：EUS可以帮助诊断肺癌纵隔淋巴结转移。     

Section III: endoscopic and other staging techniques

Accurate staging of esophageal cancer is important as disease survival closely correlates with TNM stage. The optimal management of patients with esophageal cancer utilizes stage-dependent algorithms. The primary diagnosis of esophageal cancer is established by upper endoscopy and biopsy. Computed tomography (CT) is typically the next test performed and is most valuable at detecting metastatic (M) distant disease, particularly in the liver, lungs, and bone. Positron emission tomography (PET) scanning with 18-fluorodeoxyglucose also is useful in detecting distant disease. Endoscopic ultrasound (EUS) combines endoscopy with high-frequency ultrasonography to obtain detailed images of the tumor and surrounding structures. EUS is the most accurate technique for the locoregional (T and N) staging of esophageal cancer. The recent availability of EUS-directed fine needle aspiration (FNA) has allowed a tissue diagnosis of lymph nodes both periesophageal and in the celiac axis. EUS-FNA can also sample liver metastases. Laparoscopic and thoracoscopic techniques can also be used to sample thoracic and celiac axis lymph nodes. Optimal staging strategies for esophageal cancer combine EUS FNA with either CT or PET scans.     

Oesophageal endoscopic ultrasound with fine needle aspiration improves and simplifies the staging of lung cancer

BACKGROUND: Positron emission tomography (PET) is accurate for mediastinal staging of lung cancer but has a moderate positive predictive value, necessitating pathological verification. Endoscopic ultrasonography with fine needle aspiration (EUS-FNA) is a technique for tissue verification of mediastinal and upper retroperitoneal abnormalities. The use of EUS-FNA may decrease the number of surgical procedures and thereby staging costs. METHODS: EUS-FNA was used prospectively for the cytological assessment of mediastinal and/or upper retroperitoneal PET hot spots in patients with suspected lung cancer. Only if EUS-FNA was positive for malignancy was subsequent mediastinoscopy or exploratory thoracotomy cancelled. The cost effectiveness of EUS-FNA was determined. RESULTS: Of 488 consecutive patients with suspected lung cancer, 81 were enrolled with mediastinal and/or upper retroperitoneal PET hot spots. EUS-FNA was positive in 50 (62%) patients, negative in six, and inconclusive in 25. Of the 31 negative or inconclusive patients, 26 underwent surgical staging (resulting in 14 patients with and 12 without mediastinal malignancy), while five patients had mediastinal metastases during follow up. No EUS-FNA related morbidity or mortality was encountered. The accuracy of the decision to proceed to surgery (or not) on the basis of EUS-FNA was 77% (95% CI 68 to 86). EUS-FNA detected more mediastinal abnormalities than PET except for the upper mediastinal region. Addition of EUS-FNA to conventional lung cancer staging reduced staging costs by 40% per patient, mainly due to a decrease in surgical staging procedures. CONCLUSION: EUS-FNA can replace more than half of the surgical staging procedures in lung cancer patients with mediastinal and/or upper retroperitoneal PET hot spots, thereby saving 40% of staging costs.     

Clinical feasibility and surgical benefits of video-assisted mediastinoscopic lymphadenectomy in the treatment of resectable lung cancer

Objective: This study was performed to assess the clinical feasibility and surgical outcomes of video-assisted mediastinoscopic lymphadenectomy in the treatment of resectable lung cancer. Methods: Between July 2004 and December 2009, we retrospectively analyzed 108 consecutive video-assisted mediastinoscopic lymphadenectomies in lung cancer patients from a prospectively collected database. Ninety-seven (89.8%) patients underwent combined operation during the same anesthesia and six (5.3%) patients underwent a staged operation for the resection of lung cancer and systematic lymphadenectomy. We reviewed the indication and duration of video-assisted mediastinoscopic lymphadenectomy, its complication, combined or staged operation type, the number of dissected lymph nodes and nodal stations, and pathologic staging of the mediastinal node. Results: Mean operative time of video-assisted mediastinoscopic lymphadenectomy was 39.8 ± 12.3 min (range of 14–85 min). Mean number of resected lymph nodes was 16.0 ± 7.7 (range of 3–37). In video-assisted mediastinoscopic lymphadenectomy, the rates of lymph node dissection of stations 4R, 4L, and 7 were 71.3%, 88.0%, and 100%, respectively, whereas the rates of dissection of lymph nodes in station 2R and 2L were only 22.2% and 17.6%, respectively. There was no operative mortality. We identified five complications of recurrent nerve palsy. Conclusions: Video-assisted mediastinoscopic lymphadenectomy is a clinically feasible procedure with acceptable complication rate and provides more accurate staging of mediastinal node in lung cancer patients. It may be also an excellent supplementary technique used for complete mediastinal node dissection at minimal invasive surgery for cancer resection, especially with left-sided video-assisted thoracoscopic lobectomy.     

Transcervical extended mediastinal lymphadenectomy--the new operative technique and early results in lung cancer staging.

OBJECTIVE: Mediastinal staging is one of the most important problems in thoracic surgery. Although the pathological examination is a generally accepted standard, none of the currently used techniques enables complete removal of all lymph node stations of the mediastinum. The aim of the study is to present a new technique of transcervical extended mediastinal lymphadenctomy (TEMLA) and to analyze its value in lung cancer staging. METHODS: In the prospective study of consecutive group of non-small cell lung cancer (NSCLC) patients, operated on between January and August 2004, we evaluated the usefulness of this original technique of bilateral mediastinal lymphadenectomy, assessing its accuracy and safety. The operations were performed through the transcervical approach, were videomediastinoscopy-assisted, with sternum elevation. Lymph node stations 1, 2R, 2L, 3a, 4R, 4L, 5, 6, 7 and 8 were removed. In patients without mediastinal metastases thoracotomy with pulmonary resection was performed and mediastinum searched for any missed lymph nodes. RESULTS: There were 83 patients operated on with the TEMLA technique. The mean number of nodes removed was 43 (range: 26-85). The sensitivity, specificity and accuracy of the presented method in detecting mediastinal node metastases were: 90, 100, and 96%, respectively, whereas the positive and negative predictive values were: 100 and 95%, respectively. CONCLUSIONS: The TEMLA technique is a safe and highly accurate method of mediastinal staging in NSCLC.     

Does the extent of lymph node dissection influence outcome in patients with stage I non-small-cell lung cancer?

OBJECTIVE: To assess the therapeutic effect of the extent of lymph node dissection performed in patients with a stage pI non-small-cell lung cancer (NSCLC). METHODS: We analysed data on 465 patients with stage I NSCLC who were treated with surgical resection and some form of lymph node sampling. The median number of lymph node sampled was 10 and the median number of ipsilateral mediastinal lymph node stations sampled was two. We chose to define a procedure that harvested 10 or more lymph nodes and sampled two or more ipsilateral mediastinal stations as a lymphadenectomy, by contrast with sampling when one or both criteria were not satisfied. The effect of the surgical techniques: lymph node sampling (LS; n=207) vs. lymphadenectomy (LA; n=258) on 30-day mortality and overall survival were investigated. RESULTS: A total of 6244 lymph nodes was examined, including 4306 mediastinal lymph nodes. The mean (+/-SD) numbers of removed lymph nodes were 7+/-6.1 per patient following LS vs.18.6+/-9.3 following LA (P=0.001). An average mean of 1+/-0.90 mediastinal lymph node station per patient was sampled following LS vs. 2.7+/-0.8 following LA (P<10(-6)). Overall 30-day mortality rates were 2.4 and 3.1%, respectively. LA was disclosed as a favourable prognosticator at multivariate analysis (Hazard Risk: 1.43; 95% Confidence Interval: 1.00-2.04; P=0.048), together with younger patient age, absence of blood vessels invasion, and smaller tumour size. CONCLUSIONS: Importance of lymph node dissection affects patients outcome, while it does not enhance the operative mortality. A minimum of 10 lymph nodes assessed, and two mediastinal stations sampled are suggested as possible pragmatic markers of the quality of lymphadenectomy.     

Video-assisted mediastinoscopic lymphadenectomy (VAMLA)--a method for systematic mediastinal lymphnode dissection.

OBJECTIVE: Video-assisted mediastinal lymphadenectomy (VAMLA) increases quality of mediastinal lymph node staging in bronchial carcinoma. The video-mediastinoscope allows systematic lymphadenectomy by bimanual preparation. Complete bilateral resection of lymph nodes in stations 1, 2, 3, 4 and 7 (Naruke) can safely be done after visualization of limiting structures (trachea, main bronchi, oesophagus, pericardium, pulmonary artery, aorta, upper vena cava and azygos vein). In this initial study, we compared histopathological findings from VAMLA with final lymph node staging from subsequent thoracotomy. METHODS: Between January 2001 and December 2001, 25 patients were operated by VAMLA (among 162 mediastinoscopies), two patients for diagnostic purposes and 23 for staging of bronchial carcinoma. Eighteen patients underwent subsequent thoracotomy for tumor resection and systematic lymphadenectomy. Pathological findings were reviewed. RESULTS: In VAMLA, lymph node dissection of station 2R, 2L and 4R was achieved in 96, 28 and 92%, respectively, whereas resection of lymph nodes in station 7 and 4L was performed in 100%. Other locations were dissected in 44%. A mean of 8.6 lymph nodes were removed in each patient. No residual lymph node tissue was found in the subcarinal compartment at open surgery. When comparing histopathological staging from VAMLA with final pathology, there were no false negative results. Seventeen patients who had N0 disease at VAMLA proved to be N0 or N1 at thoracotomy, one patient diagnosed as N2 at mediastinoscopy had N2 disease at final pathology. The only complication observed in VAMLA was a blood loss of >100 ml in 12% of patients without need for transfusion or surgical intervention. CONCLUSION: Mediastinal lymph node staging is improved by VAMLA. A systematic lymphadenectomy is performed bimanually through the video mediastinoscope. The number of lymph nodes removed is doubled compared to standard mediastinoscopy. There were no false negative results at final pathology. This new technique presents the basis for video-assisted thoracic surgery (VATS) lobectomy because complete resection of the mediastinal lymph nodes can be achieved by VAMLA. Potential complications of VAMLA such as injury of major mediastinal vessels, airways, pneumothorax or recurrent laryngeal nerve injury indicate the need for a full thoracic surgical infrastructure.