Combined videothoracoscopic and videomediastinoscopic approach improves radicality of minimally invasive mediastinal lymphadenectomy for early stage lung carcinoma☆

Abstract

A combined approach by VATS and VAMLA improves radicality of minimally invasive mediastinal lymphadenectomy without increase in operation time, morbidity, and drainage time.

Pros: should a patient with stage IA non-small cell lung cancer undergo invasive mediastinal staging?

“…The role of transcervical lymphadenectomies in early stage lung cancer has been described, showing better staging values than standard mediastinoscopy and endoscopic ultrasound fine needle aspiration techniques (14)(15)(16)(17)(18). Therefore, in case of central tumours, the accuracy of these techniques adds value to rule out mediastinal disease, enhancing, therefore, clinical staging.…”

“…Other challenging situations like bilateral synchronous lung cancer (16,19) and elderly patients or patients with poor performance status (16) can benefit from VAMLA/TEMLA in order to avoid unnecessary lung resections and its complications. Finally, these pre-resectional lymphadenectomies can be indicated in cIA tumours located in the left lung or in combination with VATS lobectomy to achieve a radical lymphadenectomy, even better than by open surgery (16,17).…”

“…These are the described indications for VAMLA which also includes cIA NSCLC: central tumours, left sided tumours, bilateral synchronous lung cancer, preresectional lymphadenectomy in video-assisted thoracoscopic lobectomy (17) and in elderly patients and patients with poor performance status (16). In all these situations, VAMLA provides an accurate preoperative mediastinal staging and lymphadenectomy.…”

Does videomediastinoscopy with frozen sections improve mediastinal staging during video-assisted thoracic surgery pulmonary resections?

“…As an exception, Witte et al (11) evaluated the feasibility and radicality of a combined thoracoscopic and mediastinoscopic approach to improve minimally invasive mediastinal LN dissection: they compared the number of dissected stations and sample weight in a group of 14 patients who underwent VATS lobectomy alone versus a group of 18 patients who underwent a combined VAMLA and VATS lobectomy. They concluded that VAMLA improves radicality of minimally invasive mediastinal lymphadenectomy without increasing operation time, morbidity, and drainage time.…”

“…A combined mediastinoscopic approach [video-assisted mediastinoscopic lymphadenectomy (VAMLA)] has been advocated to achieve a more satisfying radical minimally invasive lymphadenectomy during VATS lobectomy (11). However, VAMLA is not universally performed and it is a safe procedure only in experienced hands.…”