Improved staging using intraoperative ultrasound for mediastinal lymphadenectomy in non-small lung cancer surgery

Abstract

From 23rd World Congress of the World Society of Cardio-Thoracic Surgeons Split, Croatia. 12-15 September 2013 ObjectivesThe extend of lymph node involvement in patients NSCLC is the cornerstone of staging and influences both multimodality treatment and final outcome. We studied safety, accuracy and characteristics of intraoperative ultrasound guided systematic mediastinal nodal dissection in patients with resected NSCLC. MethodsProspective randomized trial of intraoperative surgical staging after radical surgery for NSCLC was carried out. Intraoperative hand held ultrasound probe was used in systematic mediastinal nodal dissection in 124 patients after radical surgery for NSCLC and compared with 120 patients who underwent radical surgery followed by standard systematic mediastinal nodal dissection. Mapping of the lymph nodes by their number and sation followed by histopathologic evaluation was performed. Patients data were statistically analyzed. ResultsThe surgical procedure used was comparable in both groups of patients. Operating time was prolonged for 10 (6-20) minutes in patients with US guided mediastinal nodal dissection, but number and stations of evaluated lymph nodes were significantly higher (p < 0.001) at the same group of patients. Skip nodal metasteses were found in 24 % of patients without N1 nodal involvement. We upstaged 12 (10 %) patients using US guided mediastinal lyphadenectomy. Median follow-up was 38 (range 10-52) months. Standard staging system seemed to be improved in US guided mediastinal lyphadenecetomy patients.Complication rate showed no difference between analyzed groups of patients. ConclusionHigher number and location of analyzed mediastinal nodal stations in patients with resected NSCLC using hand held ultrasound probe siggested to be of great oncological significance. Procedure showed absolute safety and high accuracy. Our results indicate that intraoperative US may have important staging implication. Further clinical studies should be performed in order to improve intraoperative staging in NSCLC patients.

Intraoperative ultrasound: “Alternative eye” in lymph nodal dissection in non‐small cell lung cancer

“…Interlobar lymph nodes drain at first into the hilar nodes and after to the mediastinum 21 . Less frequently, an atypical drainage pattern can be present; it bypasses the intrapulmonary and hilar lymph nodes and proceeds directly to the mediastinal nodes, known as skip metastases 22 . However, mediastinal drainage tends to be lobe dependent; for this reason, the location of the primary tumor may help to detect the mediastinal lymph node stations interested 23,24 .…”

“…The presence of N2 and N3 disease is one of the most important factors influencing prognosis and therapeutic strategies. 31 Only one article concerning the use of intraoperative US in the detection of pathological lymph nodes has been reported in literature by Juricic et al 22 They used intraoperative US for mediastinal lymphadenectomy in NSCLC surgery in thoracotomy. We performed intraoperative US in VATS with a laparoscopic probe.…”

“…21 Less frequently, an atypical drainage pattern can be present; it bypasses the intrapulmonary and hilar lymph nodes and proceeds directly to the mediastinal nodes, known as skip metastases. 22 However, mediastinal drainage tends to be lobe dependent; for this reason, the location of the primary tumor may help to detect the mediastinal lymph node stations interested. 23 , 24 RUL tumors, commonly metastasizes to the lower paratracheal (station 4) and pretracheal (station 3) nodes, when a single station N2 disease is present.…”

An “alternative finger” in robotic-assisted thoracic surgery: intraoperative ultrasound localization of pulmonary nodules

“…Furthermore, as the main endpoint was an initial assessment of the value of intraoperative ultrasonography for lesion localization during RATS, the sample size was not sufficiently large to analyze the ultrasonographic properties and thus infer the pathological nature of nodules [8,29]. A semi-quantitative diagnostic model, such as a nomogram, should be established to determine whether a lesion is benign or malignant, based on the ultrasonographic properties of a particular nodule [30].…”