Showing papers on "Mediastinoscopy published in 2013"
TL;DR: It is demonstrated that PET scanning is more accurate than CT scanning, but tissue biopsy is still required to confirm PET scan findings, and evidence suggests that more complete staging improves patient outcomes.
1,167 citations
TL;DR: Conversion to open thoracotomy should be regarded as a means of completing resections in a traditional manner rather than as a surgical failure, with a focus on a safe and complete resection.
Abstract: Since the introduction of anatomic lung resection by video-assisted thoracoscopic surgery (VATS) was introduced 20 years ago, VATS has experienced major advances in both equipment and technique, introducing a technical challenge in the surgical treatment of both benign and malignant lung disease. The demonstrated safety, decreased morbidity, and equivalent efficacy of this minimally invasive technique has led to the acceptance of VATS as a standard surgical modality for earlystage lung cancer and increasing application to more advanced disease. However, only a minority of lobectomies are performed using the VATS technique, likely owing to concern for intraoperative complications. Optimal operative planning, including obtaining baseline pulmonary function tests with diffusion measurements, positron emission tomography and/or computed tomography scans, bronchoscopy, and endobronchial ultrasound or mediastinoscopy, can be used to anticipate and potentially prevent the occurrence of complications. With increasing focus on operative planning, as well as comfort and experience with the VATS technique, the indications for which this technique is used has grown. As such, the absolute contraindications have narrowed to inability to tolerate single lung ventilation, inability to achieve complete resection with lobectomy, T3 or T4 tumors, and N2 or N3 disease. However, as VATS lobectomy has been applied to more advanced stage disease, the rate of conversion to open thoracotomy has increased, particularly early in the surgeon’s learning curve. Causes of conversion are generally classified into four categories: intraoperative complications, technical problems, anatomical problems, and oncological conditions. Though it is difficult to anticipate which patients may require conversion, it appears that these patients do not suffer from increased morbidity or mortality as a result of conversion to open thoracotomy. Therefore, with a focus on a safe and complete resection, conversion should be regarded as a means of completing resections in a traditional manner rather than as a surgical failure.
83 citations
TL;DR: The success rate of multiple tumor genomic analyses techniques for EGFR, KRAS, and ALK gene abnormalities using routine lung cancer tissue samples obtained from hilar or mediastinal lymph nodes by means of CP-EBUS exceeds 90%, and this method of tissue acquisition is not inferior to other specimen types.
70 citations
TL;DR: Although not all the complications and costs due to CT image-guided biopsies could have been avoided, roughly two-thirds could have be eliminated by just changing the testing sequence.
43 citations
TL;DR: ROSE does not impact clinical decision making if a thorough mediastinal staging using EBUS is performed, and despite inadequate tissue sampling assessment by ROSE, a final diagnosis was made in most patients, potentially avoiding an additional surgical procedure to prove mediastsinal disease.
42 citations
TL;DR: VAMLA was associated with improved survival in NSCLC patients who had resectional surgery and the negative predictive value, sensitivity, false-negative value, and accuracy of VAMla were statistically higher in the VAMLA groups compared with those of standard mediastinoscopy.
34 citations
TL;DR: EBUS-TBNA is an accurate procedure for the diagnosis of thoracic lymph node metastases in patients with extrathoracic malignancies and should be an initial diagnostic tool in these patients.
Abstract: Intrathoracic lymph node enlargement is a common finding in patients with extrathoracic malignancies. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a technique that is commonly used for lung cancer diagnosis and staging but that has not been widely investigated for the diagnosis of enlarged mediastinal and lobar lymph nodes in patients with extrathoracic malignancies. We conducted a retrospective study of 117 patients with extrathoracic malignancies who underwent EBUS-TBNA for diagnosis of intrathoracic lymph node enlargement from October 2005 to December 2009 and compared the EBUS-TBNA findings with the final diagnoses. EBUS-TBNA diagnosed mediastinal metastases in 51 of the 117 (43.6 %) cases and gave an alternate diagnosis or ruled out the presence of malignancy in 35 (56.4 %). Fourteen of these 35 patients underwent further surgical investigation, while the remaining 21 had clinical and radiological follow-up for 18 months. No false negatives were found in the surgery group. In the follow-up group, 13 patients had stable or regressive lymphadenopathy, and eight developed clinicoradiological progression and were assumed to have been false negatives by EBUS-TBNA. The sensitivity and negative predictive value of EBUS-TBNA were 86.4 and 75 %, respectively. Immunohistochemical staining (IHC) was performed in 80.4 % of the samples obtained by EBUS-TBNA. In samples obtained from ten patients with metastatic breast cancer, estrogen receptor expression was successfully assessed in eight patients and progesterone receptor and human epidermal growth factor receptor 2 in four. EBUS-TBNA is an accurate procedure for the diagnosis of thoracic lymph node metastases in patients with extrathoracic malignancies and should be an initial diagnostic tool in these patients. Furthermore, EBUS-TBNA can obtain high-quality specimens from metastatic lymph nodes for use in molecular analyses.
34 citations
TL;DR: Despite systematic preoperative staging, there continues to be a high rate of nodal status change following surgical resection and lymph node dissection, and errors in prognosis and in determining correct adjuvant treatment may arise.
Abstract: OBJECTIVES: Lung cancer staging has improved in recent years. Assuming that contemporary detailed preoperative staging may yield a lower rate of stage change after surgery, we were interested to determine the impact of our lymph node dissections performed at the time of surgical resection. METHODS: We retrospectively analysed a database in our surgical unit that prospectively captured information on all patients assessed and treated for lung cancer. We reviewed the data on patients who underwent lung cancer surgery with curative intent between January 2006 and August 2010 so as to reflect contemporary practice. Prior to potentially curative treatment, patients systematically underwent staging computerized tomography (CT), integrated positron emission tomography (PET) with CT and brain imaging. Enlarged and/or PET-positive nodes were subject to invasive evaluation to establish the nodal status in line with the current guidelines. This was performed by needle aspiration or biopsy usually with ultrasound guidance, endobronchial or endo-oesophageal ultrasound with needle biopsy; mediastinoscopy; mediastinotomy; video-assisted or open surgery. RESULTS: Three hundred and twelve lung cancer resections were performed (a mean age of 68 years [range 42–86] and a male-tofemale ratio of 1.14:1). Despite thorough preoperative evaluations, 25.3% of patients had a change in nodal status after lung resection and lymph node dissection; of which 20.8% of patients had a nodal status upstaging. Occult N2 disease was identified in 31 (9.9%) of 312 patients. Patients with cT1 tumours showed a nodal upstaging of 12.3% compared with 25.3% in cT2 tumours. There was no difference in the rate of N2 disease for different tumour histological types. CONCLUSIONS: Despite systematic preoperative staging, there continues to be a high rate of nodal status change following surgical resection and lymph node dissection. If considering non-surgical treatments for the early stage lung cancer, the impact of this discrepancy should be considered. If not, errors in prognosis and in determining correct adjuvant treatment may arise.
24 citations
TL;DR: With advances in minimally invasive procedures and imaging, mediastinoscopy usage has declined significantly and is likely to be relevant to both clinical practice and practice guidelines.
Abstract: Lung cancer staging is essential to selecting the most effective therapy and assessing a prognosis. Since the 1950s, mediastinoscopy has been the gold standard in evaluating the presence of mediastinal nodal metastases in patients with lung cancer. Carlens first performed mediastinoscopy in the 1950s and his technique is still in use today.1 By 1964, patients were selected for the procedure if x-ray imaging demonstrated central tumors, atelectases, or oat-cell carcinoma. By that time, physicians had discovered that with mediastinoscopy, the resection rate had increased to 90%.2 By 1969, mediastinoscopy was suggested for every case of operable bronchogenic cancer because it offered histopathological evidence and reduced higher-risk thoracotomy.3 By 1976, researchers had determined that available radiographic techniques were insufficient to select patients for mediastinoscopy because of the prevalence of occult cancers.4 As a result, it was determined that histology was more important than location in diagnosing metastasis. The incidence of mediastinoscopy has increased over time, with 16% of patients undergoing the procedure from 1986–1992, 32% of whom undergoing the procedure from 1993–2001.5 In 1989, Lerut and colleagues developed video-assisted mediastinoscopy,6 which was expanded in a clinical setting by Sortini and colleagues.7
In addition to its utility in staging lung cancer, mediastinoscopy is mandatory for lung resection in some medical centers. When compared with advances in minimally invasive procedures and imaging technology, mediastinoscopy is perceived by many surgeons to be exceedingly invasive. Many practitioners believe that advances in new technology and minimally invasive techniques can replace mediastinoscopy. The present study was undertaken to assess and evaluate contemporary practices in the staging of lung cancer by describing current trends and practice patterns of mediastinoscopy usage. In addition, regional variation in usage was assessed nationally, as was practice-based learning and patient care. The hypothesis is that lessons learned during surgeries performed on patients with lung cancer and new advances can be universally applied to improve surgeons' management of patient care. We expect that our findings will be relevant to both clinical practice and practice guidelines.
20 citations
TL;DR: Five cases of mediastinal lymphadenopathy are presented here in which lymph node anthracosis was identified as the primary diagnosis using EBUS-TBNA, and it is likely that primary nodal Anthracosis will be encountered more frequently and should be considered in the differential diagnosis of those with PET/CT positive lymphadenopathies.
Abstract: Isolated mediastinal lymphadenopathy can result from a number of potentially serious aetiologies. Traditionally those presenting with mediastinal lymphadenopathy would undergo mediastinoscopy to elucidate a final diagnosis or receive empirical treatment. There is now increased utilization of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), in this setting.
Five cases of mediastinal lymphadenopathy are presented here in which lymph node anthracosis was identified as the primary diagnosis using EBUS-TBNA. They were female, non-smokers presenting with non-specific symptoms, who retrospectively reported cooking over wood fires. Four were from South Asia. Three were investigated by F-18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) scanning and increased signal was identified in the anthracotic nodes sampled.
With expansion of PET/CT and EBUS-TBNA services it is likely that primary nodal anthracosis will be encountered more frequently and should be considered in the differential diagnosis of those with PET/CT positive lymphadenopathy. It may mimic pathologies including tuberculosis and malignancy, thus accurate sampling and follow-up are essential.
20 citations
TL;DR: In patients with a high probability of mediastinal metastases, based on imaging, and negative endosonography, cervical mediastinoscopy should not be omitted, not even when the aspirate seems representative.
Abstract: OBJECTIVES: In patients with lung cancer, endosonography has emerged as a minimally invasive method to obtain cytological proof of mediastinal lymph nodes, suspicious for metastases on imaging. In case of a negative result, it is currently recommended that a cervical mediastinoscopy be performed additionally. However, in daily practice, a second procedure is often regarded superfluous. The goal of our study was to assess the additional value of a cervical mediastinoscopy, after a negative result of endosonography, in routine clinical practice. METHODS: In a retrospective cohort study, the records of 147 consecutive patients with an indication for mediastinal lymph node staging and a negative result of endosonography were analysed. As a subsequent procedure, 124 patients underwent a cervical mediastinoscopy and 23 patients were scheduled for an intended curative resection directly. The negative predictive value (NPV) for both diagnostic procedures was determined, as well as the number of patients who needed to undergo a mediastinoscopy to find one false-negative result of endosonography (number needed to treat (NNT)). Clinical data of patients with a false-negative endosonography were analysed. RESULTS: When using cervical mediastinoscopy as the gold standard, the NPV for endosonography was 88.7%, resulting in a NNT of 8.8 patients. For patients with fluoro-2-deoxyglucose positron emission tomography positive mediastinal lymph nodes, the NNT was 6.1. Overall, a futile thoracotomy could be prevented in 50% of patients by an additional mediastinoscopy. A representative lymph node aspirate, containing adequate numbers of lymphocytes, did not exclude metastases. CONCLUSIONS: In patients with a high probability of mediastinal metastases, based on imaging, and negative endosonography, cervical mediastinoscopy should not be omitted, not even when the aspirate seems representative.
TL;DR: Lung cancer was excluded during evaluation of positive screening examinations by clinical or radiographic evaluation in all but 1.4% who required a tissue biopsy, and 80% of screen-detected lung cancers were diagnosed within 6 months.
TL;DR: At threshold values of around €30,000 for cost-effectiveness, it was found to be cost-effective to send all patients to positron emission tomography-computed tomography with confirmation of positive findings on nodal involvement by endobronchial ultrasound.
Journal Article•
TL;DR: ROSE significantly impacts on the diagnostic yield, as well as on the overall management costs of patients with mediastinal lymphadenopathy, suspected for lung cancer.
Abstract: BACKGROUND The diagnostic and staging approach for the mediastinal lymphadenopathies, with or whithout pulmonary lesions endoscopically visible, is based on transbronchial needle aspiration (TBNA) during fiberoptic bronchoscopy and on mediastinoscopy. One important factor impacting on TBNA sensitivity is the rapid on site cytological examination (ROSE). AIM The aim of this study was to evaluate the economic impact of TBNA and TBNA + ROSE, in the diagnosis of these lesions. PATIENTS AND METHODS 120 patients, affected by mediastinal lymphadenopathies suspected for lung cancer, underwent TBNA during fiberoptic bronchoscopy: 60 patients without ROSE (group A) and other 60 with ROSE (group B). Whenever needle aspirations failed to provide diagnosis, the patient underwent mediastinoscopy. The economic impact of the diagnostic process was performed. RESULTS In group A, 39 patients (65%) obtained a diagnosis with TBNA while 21 patients (35%) required mediastinoscopy. In group B, 48 patients (80%) obtained a diagnosis with TBNA + ROSE, while 12 patients (20%) required mediastinoscopy. With regards to the costs of the procedures performed in the diagnostic process, the use of TBNA with ROSE as first diagnostic approach has saved a considerable amount of euros (19,413) compared to the use of TBNA without ROSE and the combined procedure increased (p < 0.02; chi square test) the sensitivity of TBNA by 15%. CONCLUSIONS ROSE significantly impacts on the diagnostic yield, as well as on the overall management costs of patients with mediastinal lymphadenopathy, suspected for lung cancer.
TL;DR: Positron emission tomography/CT is an important tool for lymphatic staging and evaluation of distant metastases in cervical cancer, however, PET/CT should be interpreted cautiously for isolated mediastinal involvement; surgical evaluation is required for accurate staging and appropriate treatment decisions to achieve better outcomes.
Abstract: Objective This study aimed to evaluate the degree of mediastinal involvement in patients with cervical cancer with isolated mediastinal [18F]-fluorodeoxyglucose–positron emission tomography (FDG-PET) positivity as verified by histopathologic examination. Methods Two hundred twenty-eight patients with newly diagnosed cervical cancer and who underwent FDG-PET imaging were analyzed. Twenty-nine patients (17%) had disseminated disease detected with PET/computed tomography (CT). Only 10 patients (4%) had increased FDG uptake in mediastinal lymph nodes alone. Of the 10 patients with mediastinal disease, 2 refused surgical mediastinal lymph node biopsy and did not receive any treatment. Patients with suspected paratracheal or subcarinal lymph node metastasis detected on PET/CT underwent mediastinoscopy, and those with hilar metastasis had video-assisted mediastinal lymphadenectomy. Treatment was delivered according to final staging based on histopathologic confirmation of mediastinal lymph node involvement. Results The mean (SD) maximum standardized uptake values for primary cervical tumor and mediastinal lymph nodes were 19.7 (10.3) and 7.5 (1.6), respectively. Of 8 patients who underwent mediastinal lymph node confirmation, 6 (75%) were tumor free, demonstrating granulomatous changes, and were treated curatively. No patients had residual or recurrent disease at the primary site, and all but 1 were alive without disease. Two patients with confirmed mediastinal lymph node metastasis were treated palliatively and died between 9 and 11 months after diagnosis. Conclusions Positron emission tomography/CT is an important tool for lymphatic staging and evaluation of distant metastases in cervical cancer. However, PET/CT should be interpreted cautiously for isolated mediastinal involvement; surgical evaluation is required for accurate staging and appropriate treatment decisions to achieve better outcomes.
TL;DR: The sensitivity of PET/CT in detecting nodal metastasis in patients with adenocarcinoma is too low to avoid any further invasive staging procedure, and Ultrasound-guided needle biopsy or mediastinoscopy is still necessary in staging patients undergoing lung resection for adenOCarcinomas.
Abstract: OBJECTIVES: The aim of our study was to analyze the specificity and sensitivity of integrated positron emission tomography and computed tomography (PET/CT) in detecting nodal metastasis according to histology (adenocarcinoma vs squamous cell carcinoma), and to identify the factors related to false-negative findings. METHODS: A retrospective, single-institution review of 353 consecutive patients with suspected or pathologically proven, potentially resectable non-small-cell lung cancer (NSCLC) who had integrated PET/CT scanning at the same centre. Lymph node staging was pathologically confirmed on tissue specimens obtained at mediastinoscopy and/or thoracotomy. Statistical evaluation of PET/CT results was performed on a per-patient and per-nodal-station basis. RESULTS: A total of 2286 nodal stations (1643 mediastinal, 333 hilar and 310 intrapulmonary) were evaluated. Adenocarcinoma was the final diagnosis in 244 patients and squamous carcinoma in 109 patients. Nodes were positive for malignancy in 80 (32.8%) of 244 patients with adenocarcinoma (N1 = 31; N2 = 48 and N3 = 1) and in 32 (29.3%) of 109 with squamous carcinoma (N1 = 21 and N2 = 11). PET/CT in the adenocarcinoma group had a sensitivity, specificity and accuracy of 53.8, 91.5 and 79.1%, and in the squamous cell group, of 87.5, 81.8 and 83.5%, respectively in a per-patient analysis. In the analysis for N2 disease on a per-patient basis, the sensitivity, specificity and accuracy were 38.8, 97.4, and 85.7% for the adenocarcinoma group and 81.8, 91.8 and 90.8% in the squamous cell group. In the adenocarcinoma group, the mean diameter of false-negative lymph nodes was 7 mm (standard deviation [SD] ± 2.5 mm) compared with the diameter of true-positive lymph nodes of 12.5 (SD ± 4 mm; P < 0.00001). In the squamous cell group, the mean diameter of false-negative lymph nodes was 7.4 mm (SD ± 2.8 mm) compared with the diameter of true-positive lymph nodes of 14.7 (SD ± 6 mm; P< 0.005). In the adenocarcinoma group, false-negative lymph nodes were statistically correlated with the presence of vascular invasion and in the squamous cell group only with the maximum standardized uptake value (SUVmax) < 5.4. CONCLUSIONS: The sensitivity of PET/CT in detecting nodal metastasis in patients with adenocarcinoma is too low to avoid any further invasive staging procedure. Ultrasound-guided needle biopsy or mediastinoscopy is still necessary in staging patients undergoing lung resection for adenocarcinoma.
TL;DR: RT-PCR analysis of fluorodeoxyglucose-avid lymph nodes results in up-staging a patient's cancer, and micrometastases correlate with the expression of VEGF in lymph nodes in patients with NSCLC.
TL;DR: The case of a 71‐year‐old male with a smoking history who presented to dermatology department with a violaceous nodule of the right sideburn skin illustrates the opportunity of considering metastatic thyroid carcinoma to skin even in cases which lack the classic cytologic and architectural features of papillary thyroid carcinomas follicular variant.
Abstract: Cutaneous metastasis of visceral tumors accounts for 2% of skin tumors. We report the case of a 71-year-old male with a smoking history who presented to dermatology department with a violaceous nodule of the right sideburn skin. The lesion was interpreted as an adenocarcinoma that was completely excised and was suspicious for a metastasis. There was a recommendation for additional work-up. At a different institution, a positron emission tomography scan showed a left hilar mass and uptake in the right thyroid. He was then referred to our hospital for tissue diagnosis. Mediastinoscopy with biopsy of the left hilar mass showed metastatic follicular thyroid carcinoma. Subsequently, a thyroid fine needle aspirate showed suspicion for malignancy with similar morphology. Thyroidectomy and central neck dissection showed right thyroid papillary carcinoma extending to one margin and involving the lymph nodes. The left hilar metastasis mass resection showed similar lymph node findings. A re-review of the sideburn excision revealed similar histopathology to the thyroid and mediastinal resection. This case illustrates the opportunity of considering metastatic thyroid carcinoma to skin even in cases which lack the classic cytologic and architectural features of papillary thyroid carcinoma follicular variant.
TL;DR: A case of false positive metastatic mediastinal lymph nodes that were diagnosed by 18F-FDG PET CT in a 40-year-old breast cancer patient who had undergone preoperative evaluation is reported.
Abstract: Breast cancer is the most frequently diagnosed cancer among females. It is accepted that lymph node involvement with metastatic tumor and the presence of distant metastasis are the most important prognostic factors. Accurate staging is important in determining prognosis and appropriate treatment. Positron emission tomography with computed tomography detects malignancies using 2-[18F]-fluoro-2-deoxy-d-glucose (18F-FDG PET CT) with high accuracy and they contribute to decisions regarding diagnosis, staging, recurrence, and treatment response. Here, we report a case of false positive metastatic mediastinal lymph nodes that were diagnosed by 18F-FDG PET CT in a 40-year-old breast cancer patient who had undergone preoperative evaluation. Right paratracheal, prevascular, aorticopulmonary, precarinal, subcarinal, hilar, and subhilar multiple conglomerated mediastinal lymph nodes were revealed in addition to left breast mass and axillary lymph nodes. Mediastinoscopy was performed with biopsy and pathology was reported as granulomatous lymphadenitis. In conclusion, any abnormal FDG accumulation in unusual lymph nodes must be evaluated carefully and confirmed histopathologically.
TL;DR: Agarwal et al. as mentioned in this paper found that whole-body F-18 fluorodeoxyglucose positron emission tomography/computed tomography is useful in patients with complex and multisystem forms of sarcoidosis.
Abstract: Sarcoidosis is a chronic granulomatous disease of unknown origin. There are several modalities for diagnosis, staging and therapeutic management of patients with sarcoidosis. Among these, whole-body F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography is found to useful in patients with complex and multisystem forms of sarcoidosis. Other modalities include Gallium scanning, assesment of angiotensin converting enzyme levels in blood, chest radiography, mediastinoscopy etcetera.
TL;DR: Conventional (without ultrasound) transbronchial needle aspiration (TBNA) still has a useful role in lung cancer staging, especially where EBUS-TBNA is not available; it can help avoid unnecessary mediastinoscopies.
Abstract: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an increasingly used technique by the interventional pulmonologist in lung cancer staging and diagnosis of both malignant and benign mediastinal lymphadenopathy amongst other applications. There are increasing data to support the use of EBUS-TBNA over mediastinoscopy as a first staging or diagnostic procedure in defined situations. In this review, the technique of EBUS-TBNA is briefly discussed with a more extended discussion around comparative studies of mediastinal staging techniques, with an emphasis on the recent ASTER trial as well as impending trials and diagnostic performance studies of EBUS-TBNA in sarcoidosis.
TL;DR: TBNA is a clinically useful, cost-effective technique in patients with BC and mediastinal or hilar lymphadenopathies and should be performed on a regular basis during diagnostic bronchoscopy of these patients.
Abstract: Objectives To analyse the clinical utility and economic impact of conventional transbronchial needle aspiration (TBNA) in patients with diagnosis of bronchogenic carcinoma (BC) and mediastinal lymphadenopathies in thoracic computed tomography (CT). To assess the predictive factors of valid aspirations. Patients and methods Retrospective observational study between 2006 and 2011 of all TBNA performed in patients with final diagnosis of BC and accessible hilar or mediastinal lymphadenopathies on thoracic CT. Results We performed TBNA on 267 lymphadenopathies of 192 patients. In 34.9% of patients, two or more lymph nodes were biopsied. Valid aspirations were obtained in 153 patients (79.7%) that were diagnostic in 124 patients (64.6%). Multivariate analysis showed that factors associated with valid or diagnostic results are the diameter of the lymph node and the number of lymph nodes explored. TBNA was the only endoscopic technique that provided the diagnosis of BC in 54 patients (28.1%). Staging mediastinoscopy was avoided in 67.6% of patients. The prevalence of mediastinal lymph node involvement was 74.4%, sensitivity of TBNA was 86.2% and negative predictive value was 63.6%. Including mediastinoscopy and other avoided diagnostic techniques, TBNA saved 451.57 € per patient. Conclusions TBNA is a clinically useful, cost-effective technique in patients with BC and mediastinal or hilar lymphadenopathies. It should therefore be performed on a regular basis during diagnostic bronchoscopy of these patients.
TL;DR: The video-assisted technique can significantly improve the results of mediastinoscopy and a thorough education on the modern video- assisted technique is mandatory for thoracic surgeons until they can fully exhaust its potential.
Abstract: OBJECTIVES Mediastinoscopy represents the gold standard for invasive mediastinal staging. While learning and teaching the surgical technique are challenging due to the limited accessibility of the operation field, both benefited from the implementation of video-assisted techniques. However, it has not been established yet whether video-assisted mediastinoscopy improves the mediastinal staging in itself. METHODS Retrospective single-centre cohort analysis of 657 mediastinoscopies performed at a specialized tertiary care thoracic surgery unit from 1994 to 2006. The number of specimens obtained per procedure and per lymph node station (2, 4, 7, 8 for mediastinoscopy and 2-9 for open lymphadenectomy), the number of lymph node stations examined, sensitivity and negative predictive value with a focus on the technique employed (video-assisted vs standard technique) and the surgeon's experience were calculated. RESULTS Overall sensitivity was 60%, accuracy was 90% and negative predictive value 88%. With the conventional technique, experience alone improved sensitivity from 49 to 57% and it was predominant at the paratracheal right region (from 62 to 82%). But with the video-assisted technique, experienced surgeons rose sensitivity from 57 to 79% in contrast to inexperienced surgeons who lowered sensitivity from 49 to 33%. We found significant differences concerning (i) the total number of specimens taken, (ii) the amount of lymph node stations examined, (iii) the number of specimens taken per lymph node station and (iv) true positive mediastinoscopies. CONCLUSIONS The video-assisted technique can significantly improve the results of mediastinoscopy. A thorough education on the modern video-assisted technique is mandatory for thoracic surgeons until they can fully exhaust its potential.
TL;DR: This study demonstrates that the CT-based image registration system (IRS) appears feasible in natural orifice transluminal endoscopic surgery MED and suggests that IRS guidance might be useful for selected procedures.
TL;DR: Perfusion characteristics of mediastinal metastatic and non-metastatic lymph nodes in untreated lung cancer show considerable overlap, so that a reliable differentiation via VPCT is not possible.
Abstract: Objectives: To compare the perfusion characteristics of mediastinal lymph node metastases with those of non-metastatic nodes in patients with newly diagnosed lung cancer using volume perfusion computed tomography (VPCT). Materials and methods: Between January 2010 and October 2011, 101 patients with histologically confirmed, untreated lung cancer received a 40-s VPCT of the tumor bulk; 32/101 patients had evident hilar/mediastinal metastatic disease and 17/101 patients had proven non-metastasized lymph nodes within the VPCT scan range. Validation or exclusion of metastatic node involvement was proven by mediastinoscopy, biopsy, positron emission tomography imaging and/or unequivocal volume dynamics on follow-up computed tomography. A total of 45 metastases and 23 non-metastatic lymph nodes were found within the scan range and subsequently evaluated. Blood flow (BF), blood volume (BV) and Ktrans were determined. Tumor volume was recorded as whole tumor volume. Results: In a comparison between metastatic and non-metastatic lymph nodes, we controlled for age, lymph node volume, lung tumor volume, lung tumor location, and histologic type effects and found no significant differences with respect to BF, BV, Ktrans or heterogeneity in nodal perfusion (P > 0.05, respectively), even after adjusting lymph node perfusion values to the perfusion parameters of the primary tumor (P > 0.05, respectively). Metastatic lymph node volume had a significant increasing effect on perfusion heterogeneity (P < 0.05, respectively) and BV in the primary was a highly significant factor for BV in metastatic disease (P < 0.001). Conclusion: Perfusion characteristics of mediastinal metastatic and non-metastatic lymph nodes in untreated lung cancer show considerable overlap, so that a reliable differentiation via VPCT is not possible.
TL;DR: Endobronchial ultrasound (EBUS) in recent years has become a routine diagnostic procedure in bronchology and is mainly used for nodal evaluation in lung cancer, but has also proven to be efficient in diagnostic evaluation of mediastinal masses.
Abstract: Endobronchial ultrasound (EBUS) in recent years has become a routine diagnostic procedure in bronchology. Linear EBUS shows high diagnostic yield in evaluation of mediastinal lymph nodes. It is mainly used for nodal evaluation in lung cancer, but has also proven to be efficient in diagnostic evaluation of mediastinal masses. This technique has been shown to be complementary to mediastinoscopy. In combination with PET and rapid on site cytology (ROSE), the diagnostic yield of EBUS is significantly higher. Radial EBUS is used for diagnosis of peripheral lung lesions. This technique facilitates evaluation of bronchial wall in central lung cancer lesions, enabling differentiation between early and invasive lung cancer. The diagnostic yield of radial EBUS in the diagnostics of peripheral lung lesions is high, reducing the number of diagnostic thoracotomies. The application of miniature radial EBUS probes, together with guiding sheaths and other guiding accessories, allow the access to smaller and more peripheral lung lesions. In addition, EBUS bronchoscopy can be utilized for the placement of brachytherapy catheters, or evaluation of the distal bronchi in order to chose between different therapeutic bronchoscopic techniques for desobstruction. An experienced bronchoscopist, availability of ROSE and additional guiding devices might be necessary to accomplish the best possible results of EBUS bronchoscopy.
TL;DR: The authors report their retrospective experience with 19 patients who underwent bilateral thoracoscopic mediastinal nodal dissection compared with 25 unilateral dissection, suggesting that BMD correlates with a better survival and that N3 skip micrometastases do not contraindicate surgery.
Abstract: We have read with interest the article by Anami et al. [1], which focused on skip micrometastasis in left lung cancer. The authors report their retrospective experience with 19 patients who underwent bilateral thoracoscopic mediastinal nodal dissection (BMD) compared with 25 unilateral dissection (UMD). Considering that the unsatisfactory survival observed in Stage I, left-sided, non-small-cell lung cancer (NSCLC) is most likely related to a higher incidence of occult controlateral nodal involvement (N3), many authors have suggested complete clinical staging with right nodal biopsies. We routinely sample right paratracheal nodes in left upper NSCLC with mediastinoscopy since this allows us to turn the patient just once intraoperatively, avoiding the need for bilateral chest tubes. However, we congratulate the authors because there were no significant differences between the groups regardless of the bilateral approach used. The authors have reported on two topics already separately investigated, namely micrometastases and skip metastases, although uniquely focusing on the selective population with both N3 skip nodal involvement and micrometastases. We would like to highlight some points concerning their findings. First, only 1 of the 19 patients was upstaged at pathological examination, but molecular studies revealed that 11 of the 19 were affected by micrometastases, determining a further upstaging. The possibility of controlateral nodal involvement has been already demonstrated, with an incidence of 21–44%, concurring with the 8 of 19 cases. However, it is remarkable that in 7, there were skip micrometastases. This suggests that controlateral nodal involvement is rarely predicted by pN1/N2 and that its evaluation based on routine pathological investigation may lead to downstaging. Consequently, controlateral nodal biopsies should always be performed, and in particular molecular studies encouraged, leading to the result that bilateral surgical staging and resection should always be done at two different times. The other topic is the relevance of N3 skip metastasis to prognosis. There are contrasting opinions on the significance of N2 skip metastases on survival and no data on N3 skip micrometastases. However, it has been reported that patients staged as pN0/N1 with micrometastases have the same survival as pN2 [2, 3] and that micrometastases strongly correlate with prognosis [4]. Patients with BMD had better overall and disease-free survival than UMD, although not statistically significant. Nevertheless, patients with skip N3 micrometastases are all alive without disease recurrence, while 5 of 25 UMD died due to cancer relapse (pTNM of this last group is not reported). This suggests that BMD correlates with a better survival and that N3 skip micrometastases do not contraindicate surgery. Unfortunately, the authors did not report if N3 skip micrometastases involved one or multiple nodes [5] and if patients underwent adjuvant chemotherapy. These limitations and the small population of the study do not allow for conclusions to be drawn, however, their data encourage better investigation of some topics. Does N3 skip micrometastases detection guarantee a more efficient preoperative prognostic staging? Does an N3 micrometastatic finding contraindicate surgery or should nodal dissection be considered therapeutic? We congratulate the authors for this interesting paper giving the cue for further studies.
Journal Article•
TL;DR: Two novel, minimally-invasive techniques have emerged for the evaluation of the mediastinum: endoscopic (transesophageal) and endobronchial ultrasound--both performed using a dedicated echoendoscope, facilitating the ultrasound-guided, real-time aspiration of mediastinal lymph nodes.
Abstract: Invasive staging of mediastinal lymph nodes is recommended for the majority of patients with potentially resectable non-small cell lung cancer. In the past, 'blind' transbronchial needle aspiration during bronchoscopy and mediastinoscopy, a surgical procedure conducted under general anesthesia, were the only diagnostic methods. The latter is still considered the 'gold standard'; however, two novel, minimally-invasive techniques have emerged for the evaluation of the mediastinum: endoscopic (transesophageal) and endobronchial ultrasound--both performed using a dedicated echoendoscope, facilitating the ultrasound-guided, real-time aspiration of mediastinal lymph nodes. These methods are well-tolerated under local anesthesia and moderate sedation, with very low complication rates. Current guidelines on the invasive mediastinal staging of lung cancer still state that a negative needle aspiration result from these methods should be confirmed by mediastinoscopy. As more experience is gathered and echoendoscopes evolve, a thorough endosonographic evaluation of the mediastinum by both techniques, will obviate the need for surgical staging in the vast majority of patients and reduce the number of futile thoracotomies.
TL;DR: Video-assisted mediastinoscopy (VAM) allows higher rates of sampling of mediastinal LN stations and station 7, although it did not improve staging of subcarinal LNs.
Abstract: OBJECTIVES Theoretically, video-assisted mediastinoscopy (VAM) offers improved staging of subcarinal lymph nodes (LNs) compared with standard cervical mediastinoscopy (SCM). Materials and METHODS Between 2006 and 2011, 553 patients (SCM, n = 293; VAM, n = 260) with non-small cell lung carcinoma who underwent mediastinoscopy were investigated. Mediastinoscopy was performed only in select patients based on computed tomography (CT) or positron emission tomography CT scans in our center. RESULTS The mean number of LNs and stations sampled per case was significantly higher with VAM (n = 7.65 ± 1.68 and n = 4.22 ± 0.83) than with SCM (n = 6.91 ± 1.65 and 3.92 ± 86.4; p < 0.001). The percentage of patients sampled in station 7 was significantly higher with VAM (98.8%) than with SCM (93.8%; p = 0.002). Mediastinal LN metastasis was observed in 114 patients by mediastinoscopy. The remaining 439 patients (203 patients in VAM and 236 in SCM) underwent thoracotomy and systematic mediastinal lymphadenectomy (SML). SML showed mediastinal nodal disease in 23 patients (false-negative [FN] rate, 5.2%). The FN rate was higher with SCM (n = 14, 5.9%) than with VAM (n = 9, 4.4%), although this difference was not statistically significant (p = 0.490). Station 7 was the most predominant station for FN results (n = 15). The FN rate of station 7 was found to be higher with SCM (n = 9, 3.8%) than with the VAM group (n = 6, 2.9%; p = 0.623). CONCLUSION FN were more common in mediastinoscopy of subcarinal LNs. VAM allows higher rates of sampling of mediastinal LN stations and station 7, although it did not improve staging of subcarinal LNs.
TL;DR: Extended cervical mediastinoscopy is a method for staging lung carcinoma and the impact of ECM in the staging of lung carcinomas is demonstrated.
Abstract: Background: Extended cervical mediastinoscopy (ECM) is a method for staging lungcarcinoma.Weaimedtodemonstratetheimpactof ECMinthestagingof lung carcinoma. Methods: Between 1998 and 2011, 159 patients with left lung carcinoma who underwent ECM simultaneously with standard cervical mediastinoscopy (SCM), were retrospectively analyzed. Until 2006, ECM had been performed routinely (n = 90, routine ECM), however, after 2006 ECM was performed only in patients selected based on computed tomography and positron emission tomography scans (n =69,selective ECM). Results: Mediastinallymphnodemetastasiswaspresentin36patientsbymediastinoscopy.Aortopulmonarywindow(APW)lymphnodemetastasiswaspresentin26 patients (10 in the routine group,16 in the selective group),whereas the 10 patients who had mediastinal lymph node metastasis that could only be accessed by SCM, buthadnoAPWlymphnodemetastasis,wereexcluded.Theremaining123patients (72 in the routine group, 51 in the selective group) were identified as cN0/N1 by SCM/ECM, and lobectomy, pneumonectomy, and exploratory thoracotomy were performed on 64, 43, and 16 of these patients, respectively. According to the lymphadenectomy,APWlymphnodemetastasiswasdeterminedin11patients(sevenin the routine group,four in the selective group).Sensitivity,negative predictive value (NPV), and accuracy of ECM were calculated as 0.70, 0.90, and 0.92, respectively. Staging values of routine/selective ECM protocols were 0.58/0.80, 0.89/0.91 and 0.91/0.94,respectively.The complication rate was 5% (n =8). Conclusions: ECM has an adequate NPV and accuracy in determining metastasis to the APW lymph nodes in patients with left lung carcinoma.