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

Abstract

Background: To assess if video-mediastinoscopy (VM) with frozen sections (FS) combined with a videoassisted thoracic surgery major pulmonary resection (VMPRS) is able to improve VATS mediastinal intraoperative staging. Methods: From June 2012 to March 2015 a total of 146 patients underwent VMPRS lymphadenectomy. NCCN guidelines were followed for pre-operative staging, including VM with FS in 27 patients (19%).Procedural time, dissected nodal stations, complications related to VM and VATS lymphadenectomy and definitive histology, were evaluated.Results: Operative time for VATS resection with VM (group 1) and VATS pulmonary resection alone (group 2) was 198±64 vs. 167±43 min (P=0.003). Mean/median numbers of dissected nodal stations were 4.93±1.1/5 (range, 4-8) in group 1 and 3.25±0.5/5 (range, 3-8) in group 2 (P<0.001). Group 1 vs. group 2 right-sided lymphadenectomy (n=86) was performed at station 2R/4R in 18 (90%) and 46 (69.7%); at station 3a/3p in 14 (51.8%) and 22 (31%); at station 7 in 18 (90%) and 44 (66.7%); at station 8/9 in 11 (55%) and 24 (36.4%) respectively. On the left side (n=60) group 1 vs. group 2 lymphadenectomy resulted at station 4 in 6 (85.7%) and 38 (71.7%); at station 5/6 in 6 (85.7%) and 26 (49%); at station 7 in 6 (85.7%) and 33 (62.3%), and at station 8/9 in 1 (14.3%) and 18 (34%). There were no early deaths and recurrent laryngeal nerve palsy occurred in 1 (0.8%) in group 2. Pathological upstaging (pN1; pN2) was found in 5 patients (17%) in group 1, and 13 (11%) in group 2 (P=0.23). About FS (n=29), formal paraffin histology resulted in 0% of both, false negative and false positive results. Conclusions: Based on our experience, the combination "VM with FS followed by VMPRS in sequence", seems to be effective and offers an alternative approach to improve intraoperative mediastinal staging.

Thoracoscopic lobectomy for locally advanced-stage non-small cell lung cancer is a feasible and safe approach: analysis from multi-institutional national database

“…Furthermore, the anatomical alterations caused by induction therapies (as calcified lymph nodes or scarring fibrous tissue strongly tightened to pulmonary artery or bronchus) lead to more complex procedures such as a broncho-vascular sleeve resection or a pneumonectomy (9).…”

“…Almost 25% of patients had chemotherapy before surgery, but in this cohort, we included different cases that could be differently evaluated on the basis of the clinical experience of the recruiting centre. The initial doubts about VATS-L oncological adequacy for early-stage NSCLC have been overcome, as demonstrated by several authoritative papers (1)(2)(3)(4)(5)(6)(7)(8)(9)(10); the minimally invasive technique and the traditional open technique have proven to be equivalent in terms of overall survival and disease free-survival also for locally advanced NSCLC (10)(11)(12)(13). Unfortunately, our study lacks of mid-and long-term survival results; however, we have some valid oncological data such as the extent of lymphadenectomy and the resection margin status.…”

“…Furthermore, several and authoritative authors demonstrated the efficacy of VATS lobectomy in terms of oncological results and validity of mediastinal intra-operative staging (7)(8)(9)(10), but the use of VATS-L for locally advanced-stage NSCLC is not well established. Some preliminary and single-centre retrospective studies have shown that VATS-L is feasible, safe and effective with long-term oncologic outcomes comparable to lobectomy via thoracotomy (11)(12)(13).…”

Hybrid treatment of T3 chest wall lung cancer lobectomy

“…Selecting the patient with precision is mandatory, considering the size of the tumor, the presence of lymphadenopathy, the possible neo-adjuvant chemotherapy or radiotherapy as in our series, which could entail more technical difficulties by addressing the VATS intervention. Obviously, a mini-invasive approach involves minor alterations of the wall muscles and the ribcage and less nervous trauma than thoracotomy, reducing postoperative pain and improving patient outcome and quality of life (QoL) (1,4,9). In our case, we can't demonstrate a real advantage of the hybrid approach to the classical one, but only its usefulness and viability, in well-selected patients, which correspond to particular surgical feasibility criteria.…”

“…Non-small cell lung cancer (NSCLC) is now widely treated in VATS, considered in selected cases as a gold standard, though not limited to this type of tumor. In selected patients, 5-year survival without lymph node invasion reaches 40-50% after tumor and chest wall resection, although this procedure may have a higher morbidity with mortality of up to 9%, higher than the simple lobectomy (1)(2)(3)(4)(5)6). Unfortunately, in aggressive cases with wall invasion, surgery often involves a potentially disruptive resection, long hospitalization, and a long and painful period of recovery.…”