Abstract:Background: The current preferred approach for surgical mediastinal staging of non-small-cell lung carcinoma is video-assisted mediastinoscopy. An alternative technique in which lymph nodes are resected instead of biopsied is video-assisted mediastinoscopic lymphadenectomy (VAMLA) that is suggested to be superior in detecting N2 disease. Yet, evidence is conflicting and furthermore limited by sample size. The objective was to compare mediastinal staging through VAMLA and video-assisted mediastinoscopy.Methods:… Show more
“…The high diagnostic ability of the endoscopic mediastinal LN staging techniques using endobronchial ultrasonography and endoscopic ultrasound has been reported (35); however, at present, it is spread is insufficient. Video-assisted mediastinoscopic lymphadenectomy (36) not only allows bilateral mediastinal LN evaluation but also demonstrates superior sensitivity and negative predictive value relative to the currently prevalent endobronchial ultrasonography. If the procedure is devised to improve the high complication rate, there is a possibility that it is also more effective than the combined use of mediastinal LN dissection from the thoracic cavity side and conventional mediastinoscopy.…”
Background: Mediastinal lymph node (LN) dissection during lung resection is essential for accurate staging. Station 4L dissection is anatomically difficult. Therefore, care should be taken to avoid complications. We investigated the importance of mediastinal LN dissection in left upper lobe lung cancer and evaluated intraoperative videos to identify relevant steps during dissection.Methods: We retrospectively reviewed 151 consecutive patients with left upper lobe lung cancer. Finally, 139 patients were enrolled to examine the survival effects of clinical factors of metastatic LN stations. The association between risk factors or surgical procedures and recurrent laryngeal nerve palsy was analyzed.Results: LN dissection of the left upper lobe revealed station 4L LN metastasis in nine patients, three of whom were node-negative on mediastinoscopy. Station 4L LN status was confirmed intraoperatively in 12 of 33 patients. Twenty patients had recurrent laryngeal nerve palsy, four of whom were complicated with aspiration pneumonia. Station 4L LN dissection was an independent risk factor for recurrent laryngeal nerve palsy (P=0.03). The use of an energy device near the recurrent laryngeal nerve was a significant risk factor for recurrent laryngeal nerve palsy. Incidentally, pathological N stage ≥2 was an independent prognostic factor for disease-free survival (DFS) (P=0.005) herein.
Conclusions:In patients with left upper lobe lung cancer, pathological N2 disease is an important predictor of recurrence. Therefore, accurate mediastinal LN dissection, including at station 4L, should be performed. We propose to standardize the dissection procedure at each institution to avoid complications, such as recurrent laryngeal nerve palsy.
“…The high diagnostic ability of the endoscopic mediastinal LN staging techniques using endobronchial ultrasonography and endoscopic ultrasound has been reported (35); however, at present, it is spread is insufficient. Video-assisted mediastinoscopic lymphadenectomy (36) not only allows bilateral mediastinal LN evaluation but also demonstrates superior sensitivity and negative predictive value relative to the currently prevalent endobronchial ultrasonography. If the procedure is devised to improve the high complication rate, there is a possibility that it is also more effective than the combined use of mediastinal LN dissection from the thoracic cavity side and conventional mediastinoscopy.…”
Background: Mediastinal lymph node (LN) dissection during lung resection is essential for accurate staging. Station 4L dissection is anatomically difficult. Therefore, care should be taken to avoid complications. We investigated the importance of mediastinal LN dissection in left upper lobe lung cancer and evaluated intraoperative videos to identify relevant steps during dissection.Methods: We retrospectively reviewed 151 consecutive patients with left upper lobe lung cancer. Finally, 139 patients were enrolled to examine the survival effects of clinical factors of metastatic LN stations. The association between risk factors or surgical procedures and recurrent laryngeal nerve palsy was analyzed.Results: LN dissection of the left upper lobe revealed station 4L LN metastasis in nine patients, three of whom were node-negative on mediastinoscopy. Station 4L LN status was confirmed intraoperatively in 12 of 33 patients. Twenty patients had recurrent laryngeal nerve palsy, four of whom were complicated with aspiration pneumonia. Station 4L LN dissection was an independent risk factor for recurrent laryngeal nerve palsy (P=0.03). The use of an energy device near the recurrent laryngeal nerve was a significant risk factor for recurrent laryngeal nerve palsy. Incidentally, pathological N stage ≥2 was an independent prognostic factor for disease-free survival (DFS) (P=0.005) herein.
Conclusions:In patients with left upper lobe lung cancer, pathological N2 disease is an important predictor of recurrence. Therefore, accurate mediastinal LN dissection, including at station 4L, should be performed. We propose to standardize the dissection procedure at each institution to avoid complications, such as recurrent laryngeal nerve palsy.
“… Fig. 2 The extent of the resected mediastinal lymph nodes included the following nodal stations: 2L, 2R, 4L, 4R, 5, 6, 7, 10L, and 10R (outlined via red circles) and both 11L and 12L (not part of the illustration; illustration courtesy taken from [ 3 ]) …”
Section: Discussionmentioning
confidence: 99%
“…Video-assisted mediastinoscopic lymphadenectomy (VAMLA) is broadly accepted as the most precise combined staging and therapeutic intervention in the context of non-small cell lung cancer (NSCLC) [ 1 – 3 ]. As the regional lymphatic network of the left lung increases the likelihood of mediastinal lymph node metastases, VAMLA is an indispensable tool for left-sided NSCLCs [ 4 – 6 ].…”
Background
Video-assisted mediastinoscopic lymphadenectomy (VAMLA) is the most precise approach combining staging and therapeutic interventions in non-small cell lung cancer (NSCLC). In the case of left-sided NSCLC, the likelihood of mediastinal lymph node metastases depends on the involvement of the left lung regional lymphatic network. As such, it appears obvious – at least for selected patients with mediastinal staging by either PET-CT or EBUS-TBNA ± EUS-FNA and with cN ≤ 2 – to merge VAMLA and left-sided video-assisted thoracoscopic (VAT) lobectomy for a single-stage therapeutical procedure.
Case presentation
We present the clinical course of an 83-year-old patient following simultaneous VAMLA and VAT-lobectomy for invasive mucinous adenocarcinoma of the left upper lobe with a provisional cT3cN0cM0 stage. The patient developed a clinically relevant postoperative pneumothorax due to a persistent parenchymal air leak. CT scan revealed a substantial pneumomediastinum and showed the capability of VAMLAs range for mediastinal lymph node dissection in a unique way. Following the prompt insertion of a second chest tube, the situation was stabilized with an unremarkable further in-hospital stay. The patient remains free of tumor recurrence or distant metastases at a one-year follow-up.
Conclusion
Presenting this aperçu, we encourage reviving the debate on (1) precise mediastinal staging in general and (2) VAMLA’s important role as a diagnostic and therapeutic tool.
“…Furthermore, it is worth noticing that the survey by Wiesel and colleagues ( 6 ) did not include any data on VAMLA or transcervical extended mediastinal lymphadenectomy (TEMLA), where complete resection of targeted mediastinal nodes with surrounding adipose tissue is achieved. Compared to nodal biopsy with EBUS and mediastinoscopy, accuracy of both VAMLA ( 7 ) and TEMLA ( 8 ) are higher, although at the cost of higher morbidity and mortality rates.…”
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