Nine-year single center experience with cervical mediastinoscopy: complications and false negative rate

Clinical Course of Patients With Mediastinal Lymph Node Tuberculosis and Risk Factors for Paradoxical Responses

BACKGROUND

Paradoxical responses (PR) occur more frequently in lymph node tuberculosis (LNTB) than in pulmonary tuberculosis and present difficulties in differential diagnosis of drug resistance, new infection, poor patient compliance, and adverse drug reactions. Although diagnosis of mediastinal LNTB has become much easier with the development of endosonography, limited information is available. The aim of this study was to investigate the clinical course of mediastinal LNTB and the risk factors associated with PR.

METHODS

Patients diagnosed with mediastinal LNTB via endosonography were evaluated retrospectively between October 2009 and December 2019. Multivariable logistic regression was applied to evaluate the risk factors associated with PR.

RESULTS

Of 9,052 patients who underwent endosonography during the study period, 158 were diagnosed with mediastinal LNTB. Of these, 55 (35%) and 41 (26%) concurrently had pulmonary tuberculosis and extrapulmonary tuberculosis other than mediastinal LNTB, respectively. Of 125 patients who completed anti-tuberculosis treatment, 21 (17%) developed PR at a median of 4.4 months after initiation of anti-tuberculosis treatment. The median duration of anti-tuberculosis treatment was 6.3 and 10.4 months in patients without and with PR, respectively. Development of PR was independently associated with age < 55 years (adjusted odds ratio [aOR], 5.72; 95% confidence interval [CI], 1.81-18.14; P = 0.003), lymphocyte count < 800/μL (aOR, 8.59; 95% CI, 1.60-46.20; P = 0.012), and short axis diameter of the largest lymph node (LN) ≥ 16 mm (aOR, 5.22; 95% CI, 1.70-16.00; P = 0.004) at the time of diagnosis of mediastinal LNTB.

CONCLUSION

As PR occurred in one of six patients with mediastinal LNTB during anti-tuberculosis treatment, physicians should pay attention to patients with risk factors (younger age, lymphocytopenia, and larger LN) at the time of diagnosis.

Clinical management of stage III non-small cell lung cancer in India: An expert consensus statement

Non-small cell lung cancer (NSCLC) is considered the most common type of lung cancer (>80% of all lung cancers); patients are often diagnosed at advanced stages of the disease. The management of NSCLC is considered challenging owing to variations in size, an extension of the tumors, involvement patterns, and classification. Although adequate literature and guidelines are available on the management of NSCLC in several countries, an Indian perspective on stage III NSCLC management is lacking. We used the modified Delphi approach to form consensus statements. A thorough literature search was done. The authors then convened and deliberated over published literature, available guidelines, and clinical judgment. Recommendation statements were formed for different clinical scenarios. These statements were sent as a form of survey to other oncologists, and their responses were recorded and mentioned. Evidence-based statements were formed for diagnosing and managing stage III NSCLC. These recommendation statements cover various aspects-surgical, radiation, and medical treatment in various clinical scenarios including adjuvant, neoadjuvant, and consolidation therapies.

What is the yield of EBUS-TBNA for re-evaluation of previously treated non-small-cell lung cancer?

BACKGROUND

Locoregional recurrence in lung cancer still remains an important problem. We aimed to indicate the effectiveness of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for reevaluation in previously treated nonsmall cell lung cancer (NSCLC).

METHODS

: NSCLC patients who underwent EBUS for rebiopsy of suspicious recurrent or progressive lesions between January 2010 and June 2017 were reviewed. Patients were categorized into two groups based on the previous treatment modalities: Group 1 (G1) consisted of patients who had been treated with chemoradiotherapy, and Group 2 (G2) consisted of patients who had undergone radical surgery.

RESULTS

Of 115 patients, 100 patients enrolled in the study. Of 26 patients with 35 lymph nodes in G1, malignant cells were identified in thirteen patients (50%). Anthracosis was detected in the remaining. Malignancy was detected in 28 patients (37.8%) in G2. Thirty-threepatients were diagnosed as benign (24 anthracosis; 8 lymphocytes, and 1 granulomatous); 8 were not sampled, and inadequate material was obtained in five. The sensitivity, specificity, negative and positive predictive value, and overall diagnostic accuracy of EBUS-TBNA for rebiopsy in G1 were 84.8%, 100%, 89.1%, 100%, and 93.2%, respectively. These values were all perfect in G2.

DISCUSSION

EBUS-TBNA could be preferred as a feasible and efficient procedure for rebiopsy in previously treated NSCLC patients.

Intraoperative ultrasound: "Alternative eye" in lymph nodal dissection in non-small cell lung cancer

INTRODUCTION

Staging of the mediastinum lymph nodes involvement in patients with non-small cell lung cancer (NSCLC) is an important prognostic factor determining the most appropriate multimodality treatment plan. The objective of this study is to assess ultrasound characteristics of mediastinal lymph nodes metastasis and effectiveness of intraoperative ultrasound-guided mediastinal nodal dissection in patients with resected NSCLC.

MATERIALS AND METHODS

All patients undergoing video-assisted thoracoscopic surgery lobectomy and pulmonary lymphadenectomy from November 2020 to March 2022 at the thoracic surgery department of the Vanvitelli University of Naples underwent intraoperative ultrasound-guided mediastinal lymph nodal dissection.

RESULTS

This study evaluates whether individual B-mode features and a compounding thereof can be used to accurately and reproducibly predict lymph node malignancy.

DISCUSSION

Intraoperative ultrasound, during systematic mediastinal lymph node dissection, is helpful in preventing lesion to mediastinal structures. Pathological nodal sonographic characteristics are round shape, short-axis diameter, echogenicity, margin, the absence or presence of coagulation necrosis sign, and the absence or presence of central hilar structure, increased color Doppler flow, the absence or presence of calcification, and nodal conglomeration. Operating time was not substantially prolonged. The procedure is simple, safe and highly accurate.

CONCLUSIONS

Ultrasonic techniques allow surgeons to detect the relationship between lymph nodes and surrounding large blood vessels during biopsy, improving the safety and simplicity of the operation, increasing the number of harvested lymph nodes, and reducing the risk of intraoperative injury; it is a fast, easily reproducible, and inexpensive method.

Interventional Pulmonology and Esophagus: Combined Endobronchial Ultrasound and Endoscopic Ultrasound for Mediastinal Staging

Endoscopic ultrasound (EUS) techniques in addition to endobronchial ultrasound (EBUS) can lead to diagnosis and complete accurate staging of the mediastinum in a single session. This allows for decreased health care costs, less delay in diagnosis and treatment, reduced patient discomfort, and decreased morbidity compared with invasive surgical staging techniques. In comparison to conventional mediastinoscopy, the cost-effectiveness and reduced complication profile of the endoscopic approach has made this a superior initial step in the staging and diagnosis of lung cancer. Moreover, compared with EBUS alone, combined EUS and EBUS has significantly increased yield, as well as diagnostic sensitivity making a combined approach preferable as the emerging gold-standard technique for initial minimally invasive mediastinal staging. We discuss the advantage of using EUS in combination with EBUS and highlight techniques, lymph node landmarks, utility in staging and restaging of the mediastinum, roles in diagnosing mediastinal infections and granulomatous lesions, and future directions in endosonography.

Controversies in Mediastinal Staging for Nonsmall Cell Lung Cancer

Mediastinal lymph nodal involvement in nonsmall cell lung cancer plays a crucial role in deciding treatment strategy. Survival falls markedly with increasing involvement of mediastinal nodal stations. Hence, accurate staging of the mediastinum with lowest morbidity is of utmost importance. A wide array of invasive and noninvasive modalities that complement each other in assessing the nodes are available at our disposal. Guidelines recommend noninvasive imaging as the initial step in the staging algorithm for all tumors, followed by invasive staging. No single modality has proven to be the ideal method to stage the mediastinum when used alone. In the present decade, minimally invasive endobronchial ultrasound (EBUS) has challenged the position of surgical mediastinoscopy, which has been the gold standard, historically. However, a negative EBUS needs to be confirmed by surgical mediastinoscopy. Video-assisted mediastinoscopic lymphadenectomy has also come to the forefront in last two decades and has shown exceptional results, when performed in experienced centers. This review details the various modalities of mediastinal staging and the controversies surrounding the optimal method of staging, restaging after neoadjuvant therapy, and the most cost-effective strategy.

Evaluation of mediastinoscopy in mediastinal lymph node staging for non-small-cell lung cancer

OBJECTIVES

The purpose of this study was to assess the quality of video-assisted cervical mediastinoscopy (VACM) in the staging of non-small-cell lung cancer (NSCLC) at the Antwerp University Hospital with a focus on test effectiveness indicators, morbidity and unforeseen pN2 results.

METHODS

All consecutive VACM workups of cases of NSCLC performed between January 2010 and December 2015 were included to assess overall test quality and effectiveness. Quality assurance was performed in accordance with the recommendations of the European Society of Gastrointestinal Endoscopy and European Society of Thoracic Surgeons (ESTS) where appropriate.

RESULTS

A total of 168 video-assisted cervical mediastinoscopies were included. A total of 91.7% of the procedures were performed in accordance with the ESTS guideline. An unforeseen pN2 staging was identified in 10 anatomical lung resections (8.6%). Statistical analysis showed no significant association between VACM performed in accordance with the ESTS guideline and the presence of pN2 positive lymph nodes [χ2 (1) = 0.61; P = 0.57] and no association between VACM performed in accordance with the ESTS guideline and overall futile thoracotomy [χ2 (1) = 0.76; P = 0.50]. Calculations revealed a sensitivity of 81.8 [95% confidence interval (CI) 69.1-90.9], specificity of 100%, positive predictive value of 100%, negative predictive value of 91.9% (95% CI 86.6-95.2) and diagnostic accuracy of 94.1% (95% CI 89.33-97.11).

CONCLUSIONS

Overall, 91.7% of the VACM were performed in accordance with the ESTS guideline. This process resulted in a sensitivity of 81.8%, a negative predictive value of 91.9% and an unforeseen pN2 rate of 8.6%.

Endosonography-Guided Biopsy as a First Test in the Diagnosis of Lymphoma

To evaluate the diagnostic accuracy of Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) and Endoscopic Ultrasound-guided Fine Needle Aspiration (EUS-FNA) in the diagnosis of lymphoma. A retrospective analysis of patients with suspected mediastinal lymphoproliferative disorders who underwent EBUS-TBNA, EUS-FNA or combined procedures from 2009 to 2019 was conducted using a prospectively maintained interventional thoracic endoscopy database. Demographic data, imaging, needle size, surgical biopsy, complications rate and pathology reports were reviewed. Over a 10-year period, a total of 444 patients were investigated with endosonography as the first diagnostic procedure for mediastinal adenopathy suspicious for lymphoma. Lymphoma was diagnosed in 77 patients (17.3%). In total, 68 patients (88.3%) were diagnosed using endosonographic mediastinal tissue sampling. Four patients had both lymphoproliferative disorders and lung cancer. Nine patients (11.7%) required a surgical biopsy to confirm the lymphoma diagnosis (6 non-diagnostic; 3 inadequate samples from endosonographic biopsies). In patients with adequate biopsies via endosonography, the sensitivity for the diagnosis of lymphoma, was 91.9% (n = 68/74). The histopathologic subtype of lymphoma was determined by endosonographic biopsies in 61 patients (89.7%) with an increased sensitivity (92.6%) for low grade Non-Hodgkin lymphoma (NHL). No acute complication related to endosonography was observed. Endosonographic biopsy (EBUS and/or EUS) of mediastinal adenopathy in patients with suspected lymphoma is a highly sensitive and safe diagnostic test. Endosonography should be the first test in the diagnosis of suspicious mediastinal lymphoma and should be followed by surgical biopsy in cases of insufficient sampling or indefinite diagnosis.

Mediastinal lymphadenopathy: a practical approach

Introduction: Mediastinal lymphadenopathy is secondary to various benign and malignant etiologies. There is a variation in the underlying cause in different demographic settings. The initial clue to the presence of enlarged mediastinal lymph nodes is through thoracic imaging modalities. Malignancy (Lung cancer, lymphoma, and extrathoracic cancer) and granulomatous conditions (sarcoidosis and tuberculosis) are the most common causes. For a confident diagnosis, the clinician must choose from several available options and integrate the clinical, radiological, and pathology findings. An accurate diagnosis is necessary for optimal management.Areas covered: We performed a search of the PUBMED database to identify relevant articles on the causes, imaging modalities, and interventional modalities to diagnose these conditions. We discuss a practical approach toward the evaluation of a patient with mediastinal lymphadenopathy.Expert opinion: Mediastinal lymphadenopathy is a commonly encountered clinical problem. Treating physicians need to be aware of the clinico-radiological manifestations of the common diagnostic entities. Selecting an appropriate tissue diagnosis modality is crucial, with an intent to use the least invasive technique with good diagnostic yield. Endosonographic modalities (EBUS-TBNA, EUS-FNA, and EUS-B-FNA) have emerged as the cornerstone to most patients' diagnosis. An accurate diagnosis translates into favorable treatment outcomes.

Impact of 18F-FDG PET/CT, CT and EBUS/TBNA on preoperative mediastinal nodal staging of NSCLC

BACKGROUND

Staging of non-small-cell lung cancer (NSCLC) is a multidisciplinary process involving imaging, endoscopic and surgical techniques. This study aims at investigating the diagnostic accuracy of ¹⁸F-FDG PET/CT, CT scan, and endobronchial ultrasound/transbronchial needle aspirate (EBUS/TBNA) in preoperative mediastinal lymph nodes (MLNs) staging of NSCLC.

METHODS

We identified all patients who were diagnosed with NSCLC at the King Hussein Cancer Center in Amman, Jordan, between July 2011 and December 2017. We collected their relevant clinical, radiological, and histopathological findings. The per-patient analysis was performed on all patients (N = 101) and then on those with histopathological confirmation (N = 57), followed by a per-lymph-node-station basis overall, and then according to distinct N-stage categories.

RESULTS

¹⁸F-FDG PET/CT, in comparison to CT, had a better sensitivity (90.5% vs. 75%, p = 0.04) overall and in patients with histopathological confirmation (83.3% vs. 54.6%), and better specificity (60.5% vs. 43.6%, p = 0.01) overall and in patients with histopathological confirmation in MLN staging (60.6% vs. 38.2%). Negative predictive value of mediastinoscopy, EBUS/TBNA, and ¹⁸F-FDG PET/CT were (87.1%), (90.91%), and (83.33%) respectively. The overall accuracy was highest for mediastinoscopy (88.6%) and EBUS/TBNA (88.2%), followed by ¹⁸F-FDG PET/CT (70.2%). Dividing patients into N1 disease vs. those with N2/N3 disease yielded similar findings. Comparison between ¹⁸F-FDG PET/CT and EBUS/TBNA in patients with histopathological confirmation shows 28 correlated true positive and true negative findings with final N-staging. In four patients, ¹⁸F-FDG PET/CT detected metastatic MLNs that would have otherwise remained undiscovered by EBUS/TBNA alone. Lymph nodes with a maximal standardized uptake value (SUVmax) more than 3 were significantly more likely to be true-positive.

CONCLUSION

Multimodality staging of the MLNs in NSCLC is essential to provide accurate staging and the appropriate treatment. ¹⁸F-FDG PET/CT has better overall diagnostic utility when compared to the CT scan. The NPV of ¹⁸F-FDG PET/CT in MLNs is reliable and comparable to the NPV of EBUS/TBNA. SUVmax of MLNs can help in predicting metastases, but nevertheless, a positive ¹⁸F-FDG PET/CT MLNs particularly if such a result would change the treatment plan, should be verified histopathologically.

Innominate Artery Dissection Caused by Video-Mediastinoscopy

Mediastinoscopy is considered a safe technique to biopsy mediastinal lesions. Among its complications, vascular ones are the most common. We present a rare case of intimal dissection of the innominate artery during the performance of a mediastinoscopy that caused an ischemic attack from which the patient recovered completely without long-term sequelae. We analyze the possible causes and risk factors of this complication.

Surgical Experience of Video-Assisted Mediastinoscopy for Nonlung Cancer Diseases

BACKGROUND

Video-assisted mediastinoscopy (VAM) is a valuable method in the investigation of diseases with mediastinal lymphadenopathy or those localized in the mediastinum. The aim of this study was to determine the diagnostic value of VAM in the investigation of mediastinal involvement of nonlung cancer diseases and to describe our institutional surgical experience.

METHODS

Clinical parameters such as age, sex, histological diagnosis, morbidity, and mortality of all patients who underwent VAM for the investigation of mediastinal involvement of diseases except lung cancer between January 2006 and July 2018 were retrospectively reviewed, and the diagnostic efficacy of VAM was determined statistically.

RESULTS

During the study period, 388 patients underwent VAM, and 536 lymph nodes were sampled for histopathological evaluation of mediastinum due to mediastinal lymphadenopathy or paratracheal lesions. The most common diagnoses were sarcoidosis (n = 178 [45.9%]), tuberculous lymphadenitis (n = 108 [27.8%]), lymphadenitis with anthracosis (n = 72 [18.6%]), and lymphoma (n = 15 [3.9%]).

CONCLUSION

The results of the study show that VAM should be used because of its high diagnostic benefit in mediastinal lymphadenopathies, which are difficult to diagnose, or mediastinal lesions located in the paratracheal region. Despite the increase in the number of new diagnostic modalities, VAM is still the most effective method and a gold standard.

Diagnosis and Detection of Sarcoidosis. An Official American Thoracic Society Clinical Practice Guideline

Background: The diagnosis of sarcoidosis is not standardized but is based on three major criteria: a compatible clinical presentation, finding nonnecrotizing granulomatous inflammation in one or more tissue samples, and the exclusion of alternative causes of granulomatous disease. There are no universally accepted measures to determine if each diagnostic criterion has been satisfied; therefore, the diagnosis of sarcoidosis is never fully secure.

Methods: Systematic reviews and, when appropriate, meta-analyses were performed to summarize the best available evidence. The evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation approach and then discussed by a multidisciplinary panel. Recommendations for or against various diagnostic tests were formulated and graded after the expert panel weighed desirable and undesirable consequences, certainty of estimates, feasibility, and acceptability.

Results: The clinical presentation, histopathology, and exclusion of alternative diagnoses were summarized. On the basis of the available evidence, the expert committee made 1 strong recommendation for baseline serum calcium testing, 13 conditional recommendations, and 1 best practice statement. All evidence was very low quality.

Conclusions: The panel used systematic reviews of the evidence to inform clinical recommendations in favor of or against various diagnostic tests in patients with suspected or known sarcoidosis. The evidence and recommendations should be revisited as new evidence becomes available.

Diagnostic value and complication rate of ultrasound-guided transthoracic core needle biopsy in mediastinal lesions

BACKGROUND

Ultrasound-guided transthoracic core needle biopsy (US-TCNB) is a promising method for establishing the correct diagnosis of mediastinal masses. However, the existing studies in this area are scant and with small samples.

PURPOSE

To evaluate the diagnostic value and the complication rate of US-TCNB, particularly large bore cutting biopsy in patients with mediastinal lesions.

MATERIAL AND METHODS

This retrospective study includes 566 patients with mediastinal lesions suspicious of malignancy evaluated between March 2004 and December 2018. Inclusion criteria: 1. Patients with mediastinal lesions detected on thoracic CT scan; 2. Lesions more than 15 mm; 3. Negative histological diagnosis after bronchoscopic biopsy; 4. Normal coagulation status; 5. Cooperative patient; 6. Written informed consent. US visualization of the mediastinal lesions was successful in 308 (54.4%). In all of them, US-TCNB was performed. All patients with mediastinal lesions unsuitable for US visualization were evaluated for a CT-guided transthoracic needle biopsy (CT-TTNB), which was done if the presence of a safe trajectory was available (n = 41, 7.2%). All patients inappropriate for image-guided TTNB were referred to primary surgical diagnostic procedures (n = 217, 38.3%).

RESULTS

The US-TCNB is a highly effective (accuracy 96%, sensitivity 95%) and safe tool (2.6% complications) in the diagnosis of all subgroups mediastinal lesions. It is non-inferior to CT-TTNB (90%) and comes close to the effectiveness of surgical biopsy techniques (98.4%), but is less invasive and with a lower complication rate.

CONCLUSION

US-TCNB of mediastinal lesions is highly effective and safe tool which is particularly helpful in critically ill patients.

Is mediastinoscopy an effective diagnostic method in mediastinal area evaluation in pediatric patients?

BACKGROUND

The purpose of the study was to discuss the effectiveness of mediastinoscopy for pediatric patients as the use of EBUS-EUS (Endobronchial Ultrasound-Endoscopic Ultrasound) has replaced mediastinoscopy for adult patients in evaluation of the mediastinal area.

METHODS

The records of patients subject to cervical and anterior mediastinoscopy at our clinic from January 1, 2000 to June 1, 2019 were examined and patients aged 18 years or less were included in the study. Data were acquired on the demographic characteristics of the patients, type of surgery, complications, operation times, and histopathologic diagnoses.

RESULTS

Of the 1505 patients subject to intervention by mediastinoscopy at our clinic from January 1, 2000 to June 1, 2019, only 22 (1.46%) were pediatric patients aged 18 years or less. Cervical and anterior mediastinoscopies were performed on 16 and six patients, respectively. Histopathological tissue diagnoses via mediastinoscopy were obtained for 19 (86.3%) of 22 patients. The most frequently observed diagnoses were sarcoidosis (n = 10), lymphoma (n = 4), thymoma (n = 1), tuberculosis (n = 1), undifferentiated round cell sarcoma (n = 1), and reactive lymph node (n = 2); three patients could not be diagnosed. Mortality was not detected. There were no major complications requiring thoracotomy or sternotomy and none of the patients were subject to tube thoracostomy as a result of surgery.

CONCLUSION

Pediatric age mediastinoscopy may be the first method of diagnosis due to low complication rates and high diagnosis rates in mediastinal area.

Safety and Costs of Endobronchial Ultrasound-Guided Nodal Aspiration and Mediastinoscopy

BACKGROUND

There remains debate over the best invasive diagnostic modality for mediastinal nodal evaluation. Prior studies have limited generalizability and insufficient power to detect differences in rare adverse events. We compared the risks and costs of endobronchial ultrasound (EBUS)-guided nodal aspiration and mediastinoscopy performed for any indication in a large national cohort.

METHODS

We conducted a retrospective study (2007-2015) with MarketScan, a claims database of individuals with employer-provided insurance in the United States. Patients who underwent multimodality mediastinal evaluation (n = 1,396) or same-day pulmonary resection (n = 2,130) were excluded. Regression models were used to evaluate associations between diagnostic modalities and risks and costs while adjusting for patient characteristics, year, concomitant bronchoscopic procedures, and lung cancer diagnosis.

RESULTS

Among 30,570 patients, 49% underwent EBUS. Severe adverse events-pneumothorax, hemothorax, airway/vascular injuries, or death-were rare and invariant between EBUS and mediastinoscopy (0.3% vs 0.4%; P = .189). The rate of vocal cord paralysis was lower for EBUS (1.4% vs 2.2%; P < .001). EBUS was associated with a lower adjusted risk of severe adverse events (OR, 0.42; 95% CI, 0.32-0.55) and vocal cord paralysis (OR, 0.57; 95% CI, 0.54-0.60). The mean cost of EBUS was $2,211 less than mediastinoscopy ($6,816 vs $9,023; P < .001). After adjustment this difference decreased to $1,650 (95% CI, $1,525-$1,776).

CONCLUSIONS

When performed as isolated procedures, EBUS is associated with lower risks and costs compared with mediastinoscopy. Future studies comparing the effectiveness of EBUS vs mediastinoscopy in the community at large will help determine which procedure is superior or if trade-offs exist.

Mediastinal lymph node staging for lung cancer

Mediastinal lymph node staging is crucial in deciding the treatment strategy for lung carcinoma. The diagnosis rate of computed tomography is not high; however, it is a standard examination. Although the contrast computed tomography is necessary for an accurate diagnosis, images from the positron emission tomography are excellent, and these two technologies are independent and complementary. Positron emission tomography has a disadvantage of false positives and false negatives, but it should also be used in cases where lymph node diameters are 1 cm or more. However, image-based diagnostic methods are not an alternative to histological examination. The results of a transbronchial needle biopsy are extremely dependent on the inspection method, the diagnostic ability of the physician, and the staging of the case. The transesophageal ultrasound endoscope is useful for reaching parts inaccessible by a mediastinoscope. Although its employment requires technical training, it is becoming popular as a minimally invasive method of obtaining cell and the tissue samples. A thoracoscopic biopsy is considered as a last resort for mediastinal lymph node diagnosis. Carefully-chosen invasive procedures are necessary to diagnose swollen lymph nodes. Although mediastinoscopy is still considered as the gold standard, most procedures will be replaced by a comparatively minimally invasive method in the future.

Multidisciplinary consensus statement on the clinical management of patients with stage III non-small cell lung cancer

Stage III non-small cell lung cancer (NSCLC) is a very heterogeneous disease that encompasses patients with resected, potentially resectable and unresectable tumours. To improve the prognostic capacity of the TNM classification, it has been agreed to divide stage III into sub-stages IIIA, IIIB and IIIC that have very different 5-year survival rates (36, 26 and 13%, respectively). Currently, it is considered that both staging and optimal treatment of stage III NSCLC requires the joint work of a multidisciplinary team of expert physicians within the tumour committee. To improve the care of patients with stage III NSCLC, different scientific societies involved in the diagnosis and treatment of this disease have agreed to issue a series of recommendations that can contribute to homogenise the management of this disease, and ultimately to improve patient care.

Prediction Model for Nodal Disease Among Patients With Non-Small Cell Lung Cancer

BACKGROUND

We characterized the performance characteristics of guideline-recommended invasive mediastinal staging (IMS) for lung cancer and developed a prediction model for nodal disease as a potential alternative approach to staging.

METHODS

We conducted a prospective cohort study of adults with suspected/confirmed non-small cell lung cancer without evidence of distant metastatic disease (by computed tomography/positron emission tomography) who underwent nodal evaluation by IMS and/or at the time of resection. The true-positive rate was the proportion of patients with true nodal disease selected to undergo IMS based on guideline recommendations, and the false-positive rate was the proportion of patients without true nodal disease selected to undergo IMS. Logistic regression was used to predict nodal disease using radiographic predictors.

RESULTS

Among 123 eligible subjects, 31 (25%) had pathologically confirmed nodal disease. A guideline-recommended invasive staging strategy had a true-positive rate and false-positive rate of 100% and 65%, respectively. The prediction model fit the data well (goodness-of-fit test, p = 0.55) and had excellent discrimination (optimism corrected c-statistic, 0.78; 95% confidence interval, 0.72 to 0.89). Exploratory analysis revealed that use of the prediction model could achieve a false-positive rate of 44% and a true-positive rate of 97%.

CONCLUSIONS

A guideline-recommended strategy for IMS selects all patients with true nodal disease and most patients without nodal disease for IMS. Our prediction model appears to maintain (within a margin of error) the sensitivity of a guideline-recommended invasive staging strategy and has the potential to reduce the use of invasive procedures.

Vocal Fold Paralysis/Paresis as a Marker for Poor Swallowing Outcomes After Thoracic Surgery Procedures

(1) To examine the association between vocal fold paresis/paralysis (VFP) and poor swallowing outcomes in a thoracic surgery cohort at the population level, and (2) to assess utilization of ENT/speech-language pathology intervention in these cases. The National Inpatient Sample (NIS) represents a 20% stratified sample of discharges from US hospitals. Using ICD-9 codes, discharges undergoing general thoracic surgical procedures between 2008 and 2013 were identified in the NIS. Sub-cohorts of discharges with VFP and those who utilized ENT/SLP services were also identified. Weighted logistic regression models were used to compare binary outcomes such as dysphagia, aspiration pneumonia, and other complications; generalized linear models with generalized estimating equations (GEE) were used to compare total hospital costs and length of stay (LOS). We identified a weighted estimate of 673,940 discharges following general thoracic surgery procedures. The weighted frequency of VFP was 3738 (0.55%). Compared to those without VFP, patients who discharged with VFP had increased odds of dysphagia (6.56, 95% CI 5.07-8.47), aspiration pneumonia (2.54, 95% CI 1.74-3.70), post-operative tracheotomy (3.10, 95% CI 2.16-4.45), and gastrostomy tube requirement (2.46, 95% CI 1.66-3.64). Discharges with VFP also had a longer length of stay and total hospital costs. Of the discharges with VFP, 15.7% received ENT/SLP intervention. VFP after general thoracic procedures is associated with negative swallowing-related health outcomes and higher costs. Despite these negative impacts, most patients with VFP do not receive ENT/SLP intervention, identifying a potential opportunity for improving adverse swallowing-related outcomes.

Endobronchial ultrasound-guided transbronchial needle aspiration mediastinal lymph node staging in malignant pleural mesothelioma

Background

Given poor survival of patients with malignant pleural mesothelioma (MPM) and extrapleural nodal metastasis, pre-operative mediastinal lymph node (LN) staging has been advocated. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) may be a useful pre-operative adjunct in patients with MPM. This study aims to assess performance of EBUS-TBNA for mediastinal LN staging in MPM.

Methods

A retrospective chart review of patients with diagnosis of MPM referred to the mesothelioma program at a tertiary Canadian cancer center between January 1, 2012 and December 31, 2014 who received mediastinal LN staging with EBUS-TBNA.

Results

Forty-eight patients were included. Average age was 70 years (range, 48-84 years). Mesothelioma subtypes were as follows: epithelioid 34/48 (70.8%), sarcomatoid 4/48 (8.3%), biphasic 7/48 (14.6%) and other 3/48 (6.3%). Stage distribution was as follows: I 18.8%, II 10.4%, III 47.9%, and IV 22.9%. On average 3.4 LNs were sampled per patient (range, 1-5). The mean short axis of a sampled LN was 6.8±3.8 mm. Rapid on Site Evaluation (ROSE) was available in 75.0% (36/48) of the assessments. Prevalence of N2/N3 disease was 35.4% (17/48). EBUS-TBNA sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy were: 16.7%, 100%, 100%, 68.8%, and 70.6%, respectively. EBUS-TBNA mediastinal LN staging prevented unnecessary surgery in 18.8% (9/48 patients) by detection of N2/N3 disease (8 patients) and metastatic secondary malignancy (1 patient). There were no EBUS-TBNA related complications.

Conclusions

EBUS-TBNA mediastinal LN staging may impact significantly management of patients with MPM by detecting mediastinal metastatic disease, therefore, preventing morbidity and mortality of surgical management.

Routinely staging gastric cancer with 18F-FDG PET-CT detects additional metastases and predicts early recurrence and death after surgery

Objectives

Fluorodeoxyglucose (FDG) positron emission tomography–computed tomography (PET-CT) is typically considered to have minimal yield in gastric cancer, and so is not consistently recommended by international guidelines. However, its yield is considerable in esophageal and junctional cancer, identifying unsuspected metastases and risk-stratifying patients using metabolic nodal stage (mN). We aimed to determine the contemporary utility of routine ¹⁸F-FDG PET-CT in gastric cancer.

Methods

We routinely stage patients with non-junctional gastric cancer with PET-CT, provided initial CT does not demonstrate unequivocal metastases. We performed a retrospective study of all such patients staged in our institution from January 2007 to July 2016. Our primary endpoint was detection of incurable disease. Our secondary endpoint was disease-free survival following gastrectomy. Decision theory, economic, and predictive models were generated.

Results

The primary tumor was FDG-avid in 225/279 patients (80.6%). Seventy-two (25.8%) had FDG-avid nodes (resectable by D2 lymphadenectomy). This was not influenced by the Lauren classification. Unsuspected metastases were identified in 20 patients (7.2%). In 13 (4.7%), these would not have been otherwise identified. Decision theory and economic modeling supported routine PET-CT. Patients with FDG-avid nodes were more likely to have incurable disease (51.4% versus 15.5%; p < 0.001), and a worse prognosis if not: multivariate hazard ratio 2.19 (1.23–3.91; p = 0.008). Prognosis worsened with mN stage.

Conclusions

PET-CT appears useful when used routinely for non-junctional gastric cancer, and should be considered in international recommendations. Any extra costs appear small and offset by avoiding futile investigations and radical treatment. mN stage identifies patients at risk of early recurrence and death.

Key Points

• PET-CT is typically not considered useful when staging gastric cancer. We describe a retrospective study of 279 patients routinely staged with PET-CT in the absence of metastases on CT.

• The primary tumor was avid in 80% of patients. Twenty-five percent had resectable avid nodes. PET-CT identified previously unsuspected metastases in 7% of patients, which would likely not have been identified by conventional staging without PET-CT in 5%. These patients were much more likely to have avid nodes.

• Beyond avoiding futile investigations and radical treatment in this 5%, we found patients with FDG-avid nodes (metabolic nodal stage, mN) to have a worse disease-free survival after gastrectomy.

Electronic supplementary material

The online version of this article (10.1007/s00330-018-5904-2) contains supplementary material, which is available to authorized users.

Surgical experience and patient-related restrictions predict the adequacy of cervical mediastinoscopy in non-small cell lung carcinoma lymph node staging

BACKGROUND

Until recently, cervical mediastinoscopy was considered to be the reference standard for mediastinal staging for Non-Small Cell Lung Carcinoma (NSCLC). In the absence of metastases, mediastinal lymph node involvement is the most important prognostic factor and as such it determines therapeutic strategies. In this study we evaluated the adequacy of cervical mediastinoscopy in NSCLC lymph node staging in a large university hospital over more than a decade. In addition, we determined the influence of: (1) surgeon's experience (2) video-assisted mediastinoscopy (VAM) and (3) patient-related restrictions (PRR) on the adequacy of lymph node sampling.

METHODS

Between January 2001 and December 2014, 225 patients underwent cervical mediastinoscopy for lymph node staging. Surgical and histological data were reviewed. Thirty-day follow-up was available for all patients. Lymph node sampling was considered adequate when stations 4 L, 4R and 7 were sampled (ESTS guidelines). A surgeon was considered to be experienced when he or she performed at least 40 procedures during the study-period.

RESULTS

Intraoperative mortality was 0%. Thirty-day mortality was 1.3%. Overall adequacy of lymph node sampling was 56%. Univariate and multivariate logistic regression analyses of lymph node sampling adequacy revealed level of surgical experience and PRR as independent predictors of lymph node sampling adequacy.

CONCLUSIONS

Surgical experience and PRR independently predict the adequacy of cervical mediastinoscopy in NSCLC lymph node staging. VAM does not independently predict the adequacy of mediastinal lymph node sampling. In light of the expected further decline in mediastinoscopy numbers, we recommend to limit this procedure exclusively to the armamentarium of the experienced thoracic surgeon.

[What contribution for mediastinoscopy in non-tumor specific mediastinal lesions?]

INTRODUCTION

The aim of our study was to assess the interest of cervical mediastinoscopy in the management of benign mediastinal lymphadenopathy.

METHOD

We performed a single-center retrospective descriptive study over a period of 5 years (2013-2017) in the department of thoracic surgery of university hospital Hassan II of Fez.

RESULTS

During this period, a total of 137 cervical mediastinoscopies were performed among which 68 for a benign disease. This represents a frequency of 49.63 %. There were 22 men and 46 women with a mean age of 43.76 years±17.08. Chest CT showed isolated mediastinal lymphadenopathy in 52 %, associated with pulmonary images in 35 %. Cervical mediastinoscopy led to pathological diagnosis in 94 %. The pathological results showed a sarcoidosis in 51.5 %, tuberculosis in 41.2 % and a lymph node echinococcosis in 1 case.

CONCLUSION

Cervical mediastinoscopy remains a low risk modality in expert hands, which allows pathological diagnosis with excellent sensitivity, acceptable morbidity and no mortality in our experience.

Fundamental and Practical Aspects of Airway Anatomy: From Glottis to Segmental Bronchus

The surgical anatomy of the airways from the glottis to segmental bronchi is reviewed with a focused review on pertinent anatomic findings surrounding common surgical procedures. The knowledge of the anatomy of the trachea while performing tracheostomy, tracheal and sleeve carinal resection, and bronchoplastic procedures is addressed. Pertinent anatomic relationships as evident on common computed tomographic imagery are emphasized.

Concomitant Mediastinoscopy Increases the Risk of Postoperative Pneumonia After Pulmonary Lobectomy

BACKGROUND

Mediastinoscopy is considered the gold standard for preresectional staging of lung cancer. We sought to examine the effect of concomitant mediastinoscopy on postoperative pneumonia (POP) in patients undergoing lobectomy.

METHODS

All patients in our institutional database (2008-2015) undergoing lobectomy who did not receive neoadjuvant therapy were included in our study. The relationship between mediastinoscopy and POP was examined using univariate (Chi square) and multivariate analyses (binary logistic regression). In order to validate our institutional findings, lobectomy data in the National Surgical Quality Improvement Program (NSQIP) from 2005 to 2014 were analyzed for these associations.

RESULTS

Of 810 patients who underwent a lobectomy at our institution, 741 (91.5%) surgeries were performed by video-assisted thoracic surgery (VATS) and 487 (60.1%) patients underwent concomitant mediastinoscopy. Univariate analysis demonstrated an association between mediastinoscopy and POP in patients undergoing VATS [odds ratio (OR) 1.80; p = 0.003], but not open lobectomy. Multivariate analysis retained mediastinoscopy as a variable, although the relationship showed only a trend (OR 1.64; p = 0.1). In the NSQIP cohort (N = 12,562), concomitant mediastinoscopy was performed in 9.0% of patients, with 44.5% of all the lobectomies performed by VATS. Mediastinoscopy was associated with POP in patients having both open (OR1.69; p < 0.001) and VATS lobectomy (OR 1.72; p = 0.002). This effect remained in multivariate analysis in both the open and VATS lobectomy groups (OR 1.46, p = 0.003; and 1.53, p = 0.02, respectively).

CONCLUSIONS

Mediastinoscopy may be associated with an increased risk of POP after pulmonary lobectomy. This observation should be examined in other datasets as it potentially impacts preresectional staging algorithms for patients with lung cancer.

Anesthetic Considerations for Mediastinal Staging Procedures for Lung Cancer

Tumor staging is critical for the treatment of lung malignancies. Invasive techniques of lung tumor staging can be accomplished via mediastinoscopy, endobronchial ultrasound, and video-assisted thoracoscopy. Anesthesiologists taking care of patients undergoing mediastinal staging procedures might face different challenges. In this narrative review, the authors summarize the literature on the anesthetic considerations for mediastinal staging procedures.

Early diagnosis and effective treatment regimens are the keys to tackle antimicrobial resistance in tuberculosis (TB): A report from Euroscicon's international TB Summit 2016

To say that tuberculosis (TB) has regained a strong foothold in the global human health and wellbeing scenario would be an understatement. Ranking alongside HIV/AIDS as the top reason for mortality due to a single infectious disease, the impact of TB extends far into socio-economic context worldwide. As global efforts led by experts and political bodies converge to mitigate the predicted outcome of growing antimicrobial resistance, the academic community of students, practitioners and researchers have mobilised to develop integrated, inter-disciplinary programmes to bring the plans of the former to fruition. Enabling this crucial requirement for unimpeded dissemination of scientific discovery was the TB Summit 2016, held in London, United Kingdom. This report critically discusses the recent breakthroughs made in diagnostics and treatment while bringing to light the major hurdles in the control of the disease as discussed in the course of the 3-day international event. Conferences and symposia such as these are the breeding grounds for successful local and global collaborations and therefore must be supported to expand the understanding and outreach of basic science research.

The role of mediastinoscopy in the diagnosis of non-lung cancer diseases

BACKGROUND

Mediastinoscopy is a good method to evaluate mediastinal lesions. We sought to determine the current role of mediastinoscopy in the investigation of non-lung cancer patients with mediastinal lymphadenopathy.

MATERIALS AND METHODS

We retrospectively reviewed clinical parameters (age, gender, histological diagnosis, morbidity, mortality) of all patients without lung cancer who consecutively underwent mediastinoscopy in Hospital of Faculty of Medicine of Dicle University between June 2003 and December 2016.

RESULTS

Two-hundred twenty nine patients without lung cancer who underwent mediastinoscopy for the pathological evaluation of mediastinum during the study period were included. There were 156 female (68%) and 73 male (32%) patients. Mean age was 52.6 years (range, 16 to 85 years). Mean operative time was 41 minutes (range, 25 to 90 minutes). Mean number of biopsies was 9.3 (range, 5 to 24). Totally, 45 patients (19.6%) had previously undergone a nondiagnostic bronchoscopic biopsy such as transbronchial needle aspiration or endobronchial ultrasound-guided transbronchial needle aspiration. Mediastinoscopy was diagnostic for all patients. Diagnosis included sarcoidosis (n=100), tuberculous lymphadenitis (n=66), anthracosis lymphadenitis (n=44), lymphoma (n=11) metastatic carcinoma (n=5), and Castleman's disease (n=1); there was a diagnosis of silicosis in one patient and tymoma in one patient. Neither operative mortality nor major complication developed. The only minor complication was wound infection which was detected in three patients.

CONCLUSION

Although newer diagnostic modalities are being increasingly used to diagnose mediastinal diseases, mediastinoscopy continues to be a reliable method for the investigation of mediastinal lesions.

Surgical treatment for mediastinal abscess induced by endobronchial ultrasound-guided transbronchial needle aspiration: a case report and literature review

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a useful and less invasive procedure for the definitive diagnosis of mediastinal and hilar lymph nodes. However, infectious complications can occur after EBUS-TBNA, although they are extremely rare.

CASE PRESENTATION

A 66-year-old man with necrotic and swollen lower paratracheal lymph nodes underwent EBUS-TBNA. A mediastinal abscess developed 9 days post-procedure. Surgical drainage and debridement of the abscess were performed along with lymph node biopsy followed by daily washing of the thoracic cavity. Surgical treatment was effective, leading to remission of the abscess. Biopsy revealed that the tumor was squamous cell carcinoma with no radiologically detected cancer elsewhere in the body. Mediastinal lung cancer was thus confirmed. Subsequent chemoradiotherapy led to the remission of the tumor.

CONCLUSIONS

Mediastinitis after EBUS-TBNA is rare but should be considered, particularly if the target lymph nodes are necrotic. Mediastinitis can lead to serious and rapid deterioration of the patient's condition, for which surgical intervention is the treatment of choice.

Transient Aphonia After Mediastinoscopy

The most common adverse event after cervical mediastinoscopy is recurrent laryngeal nerve (RLN) injury, which has an incidence of 0.6% [1]. We report the case of a 68-year-old man with non-small cell lung cancer (NSCLC) who experienced transient bilateral vocal cord paralysis after mediastinoscopy, which manifested in complete aphonia. This patient's ability to maintain his airway was carefully followed up, but neither endotracheal intubation nor tracheostomy was required. The vocal cord paralysis resolved without intervention after 5 hours. To our knowledge, this is the first reported case in which bupivicaine used at the end of a cervical mediastinoscopy diffused through the freshly dissected planes to paralyze both RLNs along the tracheoesophageal grooves.

The role of endobronchial ultrasound versus mediastinoscopy for non-small cell lung cancer

This review provides an update on the current role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and mediastinoscopy (Med) in assessment of patients with non-small cell lung cancer (NSCLC). Invasive mediastinal lymph node (LN) staging is the major application for both of these techniques. Up until recently, Med was the gold standard for invasive mediastinal LN staging in NSCLC. However, EBUS-TBNA has shown to be equivalent, and in some studies better than Med for invasive staging of lung cancer. EBUS-TBNA offers access to N1 LNs and development of the thin convex probe EBUS (TCP-EBUS) will expand EBUS-TBNA access from the paratracheal region and central airways to more distal parabronchial regions allowing for more extensive N1 LN assessment and sampling more distal lung tumors. EBUS-TBNA is more cost-effective than Med and it is currently recommended as the test of first choice for invasive mediastinal LN staging in lung cancer. Confirmatory Med should be performed selectively in patients with high pretest probability of metastatic disease. Addition of esophageal ultrasound fine needle aspiration (EUS-FNA) may increase diagnostic yield of EBUS-TBNA mediastinal staging. Both Med and EBUS-TBNA can be used in primary lung cancer diagnosis, restaging of the mediastinum following neoadjuvant therapy and in diagnosis of lung cancer recurrence. In the future, a combination of EBUS-TBNA with or without EUS-FNA and Med is most likely going to provide the most optimal invasive assessment of the mediastinum in patients with lung cancer. The decision on test choice and sequence should be made on a case-by-case basis and factoring in local resources and expertise.

Mediastinal Staging: Endosonographic Ultrasound Lymph Node Biopsy or Mediastinoscopy

Combined endosonographic lymph node biopsy techniques are a minimally invasive alternative to surgical staging in non-small cell lung cancer and may be superior to standard mediastinoscopy and surgical mediastinal staging techniques. Endosonography allows for the biopsy of lymph nodes and metastases unattainable with standard mediastinoscopy. Standard cervical mediastinoscopy is an invasive procedure, which requires general anesthesia and is associated with higher risk, cost, and major complication rates compared with minimally invasive endosonographic biopsy techniques. Combined endosonographic procedures are the new gold standard in staging of non-small cell lung cancer when performed by an experienced operator.

The Role of Fluorodeoxy-D-glucose Positron Emission Tomography/Computed Tomography in Nodal Staging of Nonsmall Cell Lung Cancer in Sequential Surgical Algorithm

With nonsmall cell lung cancer (NSCLC), accurate mediastinal nodal staging is crucial to determine whether a patient is or is not a surgical candidate. Traditionally, computed tomography (CT) and fluorodeoxy-D-glucose (FDG) positron emission tomography (PET)/CT are the initial steps followed by tissue sampling through mediastinoscopy and/or thoracotomy, which are invasive procedures. There is controversy regarding the possibility of omission of the invasive diagnostic procedures and solely relying on noninvasive presurgical staging CT and FDG PET/CT results. Eighty-three patients who had PET/CT, mediastinoscopy, and thoracotomy for NSCLC were analyzed. For all lymph nodes that may be sampled by mediastinoscopy, PET/CT sensitivity was 80%, specificity was 86%, positive predictive value was 47%, and negative predictive value (NPV) was 97%; and for those in this group whose clinical stage was T1/T2 M0, sensitivity was 100% and specificity was 84%. For lymph nodes accessible only at thoracotomy, sensitivity was 42% and specificity was 88%. FDG PET/CT is accurate in assessing stations 2R/L, 4R/L, and 7 nodes and has the potential to replace mediastinoscopy in the treatment algorithm of T1/T2 M0 disease. A negative PET/CT may potentially prevent the patient from invasive mediastinoscopy given its high NPV. However, a patient with positive PET/CT should undergo tissue biopsy with pathology confirmation.

Transoral endoscopic mediastinal surgery (TOEMS)-results of a first clinical study for scarless mediastinal lymph node biopsies

BACKGROUND

Video-assisted mediastinoscopy (VAM) represents the standard procedure for mediastinal lymph node biopsies. This operation results in a scar at prominent position at the anterior neck. Since there is a trend to less invasive procedures, natural orifice transluminal endoscopic surgery (NOTES) was introduced to different fields of surgery. Based on NOTES we developed a new approach for mediastinoscopy: transoral endoscopic mediastinal surgery (TOEMS). In previous studies using human cadavers and living pigs the feasibility of TOEMS was shown. It was unclear whether TOEMS could be safely applied in patients requiring mediastinal lymph node biopsies.

METHODS

We conducted a clinical phase I study recruiting ten patients with unclear mediastinal lymphadenopathy not resolved by prior bronchoscopy. All patients underwent TOEMS for mediastinal lymph node biopsy. The duration of the procedure and complications were monitored. In addition, all patients were examined for pain, swallowing dysfunction and sensation disturbance.

RESULTS

TOEMS was accomplished in eight patients. In two patients operation was converted to VAM due to technical problems. Mediastinal lymph nodes were dissected in all patients who finished with TOEMS. On average, two separate lymph stations were reached by TOEMS. Duration of the procedure was 159±22 min. Permanent palsy of the right recurrent laryngeal nerve was noticed in one patient postoperatively.

CONCLUSIONS

This is the first report for a human application of NOTES in thoracic surgery. In fact, transoral endoscopic surgery seems to be a feasible approach for mediastinal lymph node biopsies. Further studies are needed to show whether this procedure has an advantage over VAM in terms of pain, complications and accessibility of mediastinal lymph node stations.

Great Vessel Injury in Thoracic Surgery

The potential for intraoperative bleeding is inherent to the practice of thoracic surgery due to the presence of multiple vital vascular structures, complex anatomy, and constant cardiorespiratory motion. Careful and detailed preoperative evaluation and planning, comprehensive review of imaging studies, and a thorough knowledge of the operative procedure, anatomic relationships, and potential complications are of the highest importance in prevention and avoidance of bleeding complications. Preparation with a clear crisis management plan ensures an effective and expedited response when intraoperative bleeding occurs.

The incidence of hoarseness after mediastinoscopy and outcome of video-assisted versus conventional mediastinoscopy in lung cancer staging

Objectives Theoretically, video-assisted mediastinoscopy (VM) should provide a decrease in the incidence of hoarseness in comparison with conventional mediastinoscopy (CM). Methods An investigation of 448 patients with the NSCLC who underwent mediastinoscopy (n = 261 VM, n = 187 CM) between 2006 and 2010. Results With VM, the mean number of sampled LNs and of stations per case were both significantly higher (n = 7.91 ± 1.97 and n = 4.29 ± 0.81) than they were for CM (n = 6.65 ± 1.79 and n = 4.14 ± 0.84) (p < 0.001 and p = 0.06). Hoarseness was reported in 24 patients (5.4%) with VM procedures resulting in a higher incidence of hoarseness than did CM procedures (6.9% and 3.2%) (p = 0.08). The incidence of hoarseness was observed to be more frequent in patients with left-lung carcinoma who had undergone a mediastinoscopy (p = 0.03). Hoarseness developed in 6% of the patients sampled at station 4L, whereas this ratio was 0% in patients who were not sampled at 4L (p = 0.07). A multivariate analysis showed that the presence of a tumor in the left lung is the only independent risk factor indicating hoarseness (p = 0.09). The sensitivity, NPV, and accuracy of VM were calculated as to be 0.87, 0.95, and 0.96, respectively. The same staging values for CM were 0.83, 0.94, and 0.95, respectively. Conclusion VM, the presence of a tumor in the left-lung, and 4L sampling via mediastinoscopy are risk factors for subsequent hoarseness. Probably due to a wider area of dissection, VM can lead to more frequent hoarseness.

Surgical Treatment of Lung Cancer

In this chapter, we discuss the preoperative evaluation that is necessary prior to surgical resection, stage-specific surgical management of lung cancer, and the procedural steps as well as the indications to a variety of surgical approaches to lung resection.

Vascular endothelial growth factor C complements the ability of positron emission tomography to predict nodal disease in lung cancer

OBJECTIVE

Vascular endothelial growth factors (VEGFs) C and D are biologically rational markers of nodal disease that could improve the accuracy of lung cancer staging. We hypothesized that these biomarkers would improve the ability of positron emission tomography (PET) to predict nodal disease among patients with suspected or confirmed non-small cell lung cancer (NSCLC).

METHODS

A cross-sectional study (2010-2013) was performed of patients prospectively enrolled in a lung nodule biorepository, staged by computed tomography (CT) and PET, and who underwent pathologic nodal evaluation. Enzyme-linked immunosorbent assay was used to measure biomarker levels in plasma from blood drawn before anesthesia. Likelihood ratio testing was used to compare the following logistic regression prediction models: ModelPET, ModelPET/VEGF-C, ModelPET/VEGF-D, and ModelPET/VEGF-C/VEGF-D. To account for 5 planned pairwise comparisons, P values <.01 were considered significant.

RESULTS

Among 62 patients (median age, 67 years; 48% men; 87% white; and 84% NSCLC), 58% had fluorodeoxyglucose uptake in hilar and/or mediastinal lymph nodes. The prevalence of pathologically confirmed lymph node metastases was 40%. Comparisons of prediction models revealed the following: ModelPET/VEGF-C versus ModelPET (P = .0069), ModelPET/VEGF-D versus ModelPET (P = .1886), ModelPET/VEGF-C/VEGF-D versus ModelPET (P = .0146), ModelPET/VEGF-C/VEGF-D versus ModelPET/VEGF-C (P = .2818), and ModelPET/VEGF-C/VEGF-D versus ModelPET/VEGF-D (P = .0095). In ModelPET/VEGF-C, higher VEGF-C levels were associated with an increased risk of nodal disease (odds ratio, 2.96; 95% confidence interval, 1.26-6.90).

CONCLUSIONS

Plasma levels of VEGF-C complemented the ability of PET to predict nodal disease among patients with suspected or confirmed NSCLC. VEGF-D did not improve prediction.

Current methods of staging and restaging of the mediastinal nodes in non-small-cell lung cancer

To analyze the current methods of primary staging and repeated staging (restaging) of the mediastinal nodes in non-small-cell lung cancer (NSCLC), all methods currently used for staging of NSCLC are analyzed. These methods include imaging techniques [computer tomography (CT), positron emission tomography (PET) combined with CT (PET/CT)], endoscopic/ultrasound techniques (endobronchial ultrasound/transbronchial needle aspiration) and endoscopic ultrasound/fine needle aspiration and surgical techniques [standard cervical mediastinoscopy, video-assisted mediastinoscopy, extended mediastinoscopy, video-assisted mediastinoscopic lymphadenectomy, transcervical extended mediastinal lymphadenectomy, anterior mediastinotomy (Chamberlain procedure) and video-assisted thoracic surgery]. The diagnostic yield of Chest CT is regarded insufficient for both, primary staging and restaging. The PET/CT became a standard imaging technique preceding curative surgery of radical chemo-radiotherapy. The issue of intraoperative staging is also described. Finally, the author’s proposed algorithm of staging, both for primary staging and restaging after neoadjuvant therapy is presented. Detailed staging of NSCLC enables selection of patients with early stage disease for curative surgical/multimodality treatment and helps to avoid unnecessary surgery in advanced disease.