Video-assisted mediastinoscopic lymphadenectomy (VAMLA) for staging & treatment of non-small cell lung cancer (NSCLC)

Abstract

Precise preoperative staging and restaging of mediastinal lymph nodes in patients with potentially resectable non-small cell lung cancer (NSCLC) is of supreme importance. Over the last years, algorithms on preoperative mediastinal staging incorporating imaging, endoscopic and surgical techniques have been widely published, offering more evidence concerning different mediastinal staging techniques. Current guidelines well define when and how to receive tissue confirmation in case of computed tomography (CT)-enlarged or positron emission tomography (PET)-positive mediastinal lymph nodes. Endosonography [(endoscopic bronchial ultrasonography/oesophageal ultrasonography (EBUS/EUS)] with fine needle aspiration still is the first choice (when accessible) since it is minimally invasive and has a high sensitivity to confirm mediastinal nodal disease. If negative, surgical staging with nodal dissection or biopsy is indicated. Video-assisted mediastinoscopic lymphadenectomy (VAMLA) and transcervical extended mediastinal lymphadenectomy (TEMLA) are preferred over conventional mediastinoscopy if a mediastinal R0-resection can be achieved. The mutual use of endoscopic and surgical staging effects highest accuracy. Straight surgical resection of tumors ≤3 cm (located within the external third of the lung) with systematic nodal dissection is justified as soon as there are no enlarged lymph nodes on CT-scan and once there is no nodal uptake on PET-CT. In case of central tumors and enlarged or FDG avid nodes regardless of cytological result, preoperative invasive mediastinal staging is indicated to rule out mediastinal nodal spread. However, accuracy needed in preoperative nodal staging has been under continuous debate ever since and with the advent of immunotherapy is right now intensely revived. During the last two decades VAMLA has been growing up from being a merely staging tool to an expert-recognized therapeutic tool in the context of minimal invasive lung cancer resection.

Endobronchial Ultrasound/Transbronchial Needle Aspiration-Biopsy for Systematic Mediastinal lymph Node Staging of Non-Small Cell Lung Cancer in Patients Eligible for Surgery: A Prospective Multicenter Study

“…The authors concluded that confirmatory mediastinoscopy can be omitted in patients with resectable NSCLC, also reducing delays in treatment. Based on these considerations, the use of video-assisted mediastinoscopic lymphadenectomy (VAMLA) or transcervical extended mediastinal lymphadenectomy (TEMLA) [ 19 , 20 ] does not appear justified due to the continuous search for minimally invasive diagnostic and surgical approaches; hence, the need for a re-evaluation of the indications is imperative in order to tailor the procedures on each patient. This concept is stressed by Mullins et al [ 21 ] regarding early-stage inoperable NSCLC patients, who underwent stereotactic body radiotherapy (SBRT) after CT-guided needle biopsy (Group 1: 79 patients) and navigational bronchoscopy with EBUS for hilar and mediastinal staging (Group 2: 79 patients).…”

Video-Assisted Mediastinoscopic Lymphadenectomy (VAMLA): Recipe and Cooking Secrets (a Tutorial)

“…We have to bring 2 aspects to mind: (1) the ancient but still present definition of an N3-status meaning surgically not accessible and (2) it is becoming increasingly clear that the percentage of positive lymph nodes (the so called "node ratio") depict the clinically relevant tumor stadium more accurate than the anatomical N2/3 categorization. [14][15][16][17][18][19][20] Both keynotes will be translated into the upcoming 9th edition of the Union for International Cancer Control staging system for lung cancer-as well as being basis for ongoing research as clinical investigators increasingly lift out the lively character of a tumor instead of its strict compartmentation. So after more than 60 years of great facility and constant advancements the golden age of up-to-date mediastinoscopy-which is called VAMLA for nearly 20 years-is not over for a long time yet.…”

Enhancing Patient Selection in Stage IIIA-IIIB NSCLC: Invasive Lymph Node Restaging after Neoadjuvant Therapy

“…EBUS and EUS are complementary techniques that allow for visualization and biopsy of most of the mediastinal nodes [14]. Notably, TEMLA, a relatively novel technique involving the complete removal of the mediastinal nodes and surrounding adipose tissue, aims to enhance the accuracy of NSCLC staging and restaging after neoadjuvant treatment [10,15,16].…”