Staging of lung cancer: mediastinoscopy and VATS

doi:10.1017/CBO9781139565905.003

3 - Staging of lung cancer: mediastinoscopy and VATS

from Section I - Diagnostic work-up of the thoracic surgery patient

Published online by Cambridge University Press: 05 September 2016

Gaetano Rocco and

Edited by

Tom Routledge and

Gaetano Rocco: Affiliation:
Division of Thoracic Surgery - Department of Thoracic Surgery and Oncology, National Cancer Institute, Pascale Foundation, Naples, Italy
Giuseppe De Luca: Affiliation:
Division of Thoracic Surgery - Department of Thoracic Surgery and Oncology, National Cancer Institute, Pascale Foundation, Naples, Italy
Marco Scarci: Affiliation:
University College London Hospital
Aman Coonar: Affiliation:
Papworth Hospital
Tom Routledge: Affiliation:
Guy’s Hospital

Book contents

Get access

Summary

Mediastinoscopy and lung cancer

Mediastinoscopy serves the purpose of providing tissue for the diagnosis of masses in the mediastinum. In addition, cervical mediastinoscopy is used to access the lymph nodes located in the middle mediastinum which represent the N compartment of the modern TNM staging for lung cancer. In addition, cervical mediastinoscopy represents a valid diagnostic tool for the diagnosis of lymphoma. Less frequently, it is possible to perform an extended mediastinoscopy by which the surgeon gains access to the lymph nodes of a specific area of the anterior mediastinum, namely, the pre- and subaortic ones beyond the reach of cervical mediastinoscopy. A safe and reliable performance of the procedure also in relatively inexperienced hands has been made possible by the implementation of video-assisted mediastinoscopy. As a result, tutoring of cervical mediastinoscopy has since become routine as well as recording of the procedure for medico-legal and training purposes. Video-assisted cervical mediastinoscopy for staging requires the patient to be under general anesthesia and the surgeon to perform the procedure according to time-honoured principles.

Surgical anatomy of video-assisted mediastinoscopy. A basic knowledge of the anatomy of the mediastinum is mandatory for the trainee approaching a surgical mediastinal exploration. The corridor where the mediastinoscope needs to be inserted is a parallelepiped. The posterior face of this geometric space is the anterior wall of the trachea, and it is first visualized when the mediastinoscope is first inserted in this corridor. The anterior wall of the trachea is indeed the pavement of this corridor and represents the landmark always to be kept in sight for orientation during the procedure. Laterally, the superior vena cava and the right paratracheal nodal stations are found. On the left side, lateral to the trachea, are the left carotid artery, the paratracheal nodal stations and the left recurrent nerve. Anteriorly, the innominate artery crosses this space as it emerges from the aortic arch towards the right thoracic inlet. At the carinal level, the pulmonary artery runs anteriorly, partially hidden by the subcarinal nodes. Laterally, on the right-hand side, the azygos vein is found as it encroaches the right main stem bronchus.

Information

Type: Chapter
Information: Core Topics in Thoracic Surgery , pp. 17 - 24

DOI: https://doi.org/10.1017/CBO9781139565905.003 [Opens in a new window]

Publisher: Cambridge University Press

Print publication year: 2016

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Book purchase

Temporarily unavailable

References

1 Specht, G. Erweiterte mediastinoskopie. Thoraxchir Vask Chir. 1965; 13:401–7.Google Scholar

2 Ginsberg, RJ, Rice, TW Goldberg, M, et al. Extended cervical medistinoscopy. A single staging procedure for bronchogenic carcinoma of the left upper lobe. J Thoracic Cardiovasc Surg. 1987; 94:673–8.Google Scholar

3 Kuzdzał, J, Zieliński, M, Papla, B, et al. The transcervical extended mediastinal lymphadenectomy versus cervical mediastinoscopy in non-small cell lung cancer staging. Eur J Cardiothorac Surg. 2007 Jan; 31(1):88–94. Epub 2006 Nov 20.Google Scholar

4 Zieliński, M. Transcervical extended mediastinal lymphadenectomy: results of staging in two hundred fifty-six patients with non-small cell lung cancer. J Thorac Oncol. 2007 Apr; 2(4):370–2.Google Scholar

5 Witte, B, Hürtgen, M. Video-assisted mediastinoscopic lymphadenectomy (VAMLA). J Thorac Oncol. 2007 Apr; 2(4):367–9.Google Scholar

6 Hürtgen, M, Friedel, G, Witte, B, et al. Systematic Video-Assisted Mediastinoscopic Lymphadenectomy (VAMLA). Thorac Surg Sci. 2005 Nov 9; 2:Doc02.Google Scholar

7 Leschber, G, Holinka, G, Linder, A. Video-assisted mediastinoscopic lymphadenectomy (VAMLA)–a method for systematic mediastinal lymphnode dissection. Eur J Cardiothorac Surg. 2003 Aug; 24(2):192–5.Google Scholar

8 Leschber, G, Sperling, D, Klemm, W, Merk, J. Does video-mediastinoscopy improve the results of conventional mediastinoscopy? Eur J Cardiothorac Surg. 2008 Feb; 33(2):289–93. Epub 2007 Dec 3.Google Scholar

9 Yendamuri, S, Demmy, TL. Is VAMLA/TEMLA the new standard of preresection staging of non small lung cancer? J Thorac Cardiovasc Surg. 2012 Sep; 144(3):S14–7. doi: 10.1016/j.jtcvs.2012.03.038. Epub 2012 Apr 13.CrossRef Google Scholar

10 Bolton, WD, Johnson, R, Banks, E, et al. Utility and accuracy of endobronchial ultrasound as a diagnostic and staging tool for the evaluation of mediastinal adenopathy. Surg Endosc. 2013 Apr; 27(4):1119–23.Google Scholar

11 Zhang, R, Mietchen, C, Krüger, M, et al. Endobronchial ultrasound guided fine needle aspiration versus transcervical mediastinoscopy in nodal staging of non small cell lung cancer: a prospective comparison study. J Cardiothorac Surg. 2012 Jun 6; 7:51.Google Scholar

12 Sharples, LD, Jackson, C, Wheaton, E, et al. Clinical effectiveness and cost-effectiveness of endobronchial and endoscopic ultrasound relative to surgical staging in potentially resectable lung cancer: results from the ASTER randomised controlled trial. Health Technol Assess. 2012; 16(18):1–75.Google Scholar

13 Sivrikoz, CM, Ak, I, Simsek, FS, et al. Is mediastinoscopy still the gold standard to evaluate mediastinal lymph nodes in patients with non-small cell lung carcinoma? Thorac Cardiovasc Surg. 2012 Mar; 60(2):116–21.Google Scholar

14 Shrager, JB. Mediastinoscopy: still the gold standard. Ann Thorac Surg. 2010 Jun; 89(6):S2084-9.Google Scholar

15 Zhang, R, Ying, K, Shi, L, et al. Combined endobronchial and endoscopic ultrasound-guided fine needle aspiration for mediastinal lymph node staging of lung cancer: A meta-analysis. Eur J Cancer. 2013 May; 49(8):1860–7.Google Scholar

16 Kambartel, K, Krbek, T, Voshaar, T. Comparison of endobronchial ultrasound (EBUS) and mediastinoscopy (MS) for staging lung cancer. Pneumologie. 2012 Jul; 66(7):426–31.Google Scholar

17 Medford, AR, Bennett, JA, Free, CM, Agrawal, S. Mediastinal staging procedures in lung cancer: EBUS, TBNA and mediastinoscopy. Curr Opin Pulm Med. 2009 Jul; 15(4):334–42.Google Scholar

18 Defranchi, SA, Edell, ES, Daniels, CE, et al. Mediastinoscopy in patients with lung cancer and negative endobronchial ultrasound guided needle aspiration. Ann Thorac Surg. 2010 Dec; 90(6):1753–7.Google Scholar

19 Rocco, G. Operative VATS: the need for a different intrathoracic approach. Eur J Cardiothorac Surg. 2005 Aug; 28(2):358.Google Scholar

20 Rocco, G, Internullo, E, Cassivi, SD, et al. The variability of practice in minimally invasive thoracic surgery for pulmonary resections. Thorac Surg Clin. 2008 Aug; 18(3):235–47.Google Scholar

21 Rocco, G. One-port (uniportal) Video-assisted thoracic surgical resections. A clear advance. J Thorac Cardiovasc Surg. 2012 Sep; 144(3):S27-31.Google Scholar

22 Howington, JA. The role of VATS for staging and diagnosis in patients with non-small cell lung cancer. Semin Thorac Cardiovasc Surg. 2007 Fall; 19(3):212–6.Google Scholar

23 Thomas, P, Massard, G, Giudicelli, R, et al. Role of video-thoracoscopy in the pretreatment evaluation of lung carcinoma. Rev Med Interne. 1999 Dec; 20(12):1093–8.Google Scholar

24 Menzies, R Charbonneau, M. Thoracoscopy for the diagnosis of pleural disease. Ann Intern Med 1991; 114:271.Google Scholar

25 Antunes, G, Neville, E, Duffy, J, et al. BTS guidelines for the management of malignant pleural effusions. Thorax. 2003 May; 58 Suppl 2:ii29–38.Google Scholar

26 Roberts, ME, Neville, E, Berrisford, RG, et al. Management of a malignant pleural effusion: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010 Aug; 65 Suppl 2:ii32–40.Google Scholar

27 Katlic, MR, Facktor, MA. Video-assisted thoracic surgery utilizing local anesthesia and sedation: 384 consecutive cases. Ann Thorac Surg. 2010 Jul; 90(1):240–5.Google Scholar

28 Katlic, MR. Video-assisted thoracic surgery utilizing local anesthesia and sedation. Eur J Cardiothorac Surg. 2006 Sep; 30(3):529–32.Google Scholar

29 Khullar, OV, Gangadharan, SP. Video-assisted thoracoscopic mediastinal lymph node dissection. J Thorac Cardiovasc Surg. 2012 Sep; 144(3):S32–4.Google Scholar

30 Baisi, A, Rizzi, A, Raveglia, F, Cioffi, U. Video-assisted thoracic surgery is effective in systemic lymph node dissection. Eur J Cardiothorac Surg. 2013 Nov; 44(5):966. doi: 10.1093/ejcts/ezt235. Epub 2013 May 3.CrossRef Google Scholar

31 Rocco, G, Brunelli, A, Jutley, R, et al. Uniportal VATS for mediastinal nodal diagnosis and staging. Interact Cardiovasc Thorac Surg. 2006 Aug; 5(4):430–2.Google Scholar

32 Salati, M, Brunelli, A, Rocco, G. Uniportal video-assisted thoracic surgery for diagnosis and treatment of intrathoracic conditions. Thorac Surg Clin. 2008 Aug; 18(3):305–10.Google Scholar

33 Muhammad, MI. The pericardial window: is a video-assisted thoracoscopy approach better than a surgical approach? Interact Cardiovasc Thorac Surg. 2011 Feb; 12(2):174–8.Google Scholar

34 Rocco, G, Rocca, A La, Manna, C La, et al. Uniportal video-assisted thoracoscopic surgery pericardial window. J Thorac Cardiovasc Surg. 2006 Apr; 131(4):921–2.Google Scholar

35 Rocco, G. VATS lung biopsy: the uniportal technique. Multimed Man Cardiothorac Surg. 2005 Jan 1; 2005(121):mmcts.2004.000356. doi: 10.1510/mmcts.2004.000356.CrossRef Google Scholar

36 Rocco, G, Martin-Ucar, A, Passera, E. Uniportal VATS wedge pulmonary resections. Ann Thorac Surg. 2004 Feb; 77(2):726–8.Google Scholar

37 Rocco, G, Cicalese, M, Manna, C La, et al. Ultrasonographic identification of peripheral pulmonary nodules through uniportal video-assisted thoracic surgery. Ann Thorac Surg. 2011 Sep; 92(3):1099–101.Google Scholar

Accessibility standard: Unknown

Accessibility compliance for the PDF of this book is currently unknown and may be updated in the future.