Endobronchial ultrasound (EBUS) with tranbronchial needle aspiration (TBNA) versus mediastinoscopy for mediastinal staging in non-small cell lung cancer (NSCLC) thoracic cancer

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.

Convex probe endobronchial ultrasound: historical, contemporary, and cutting-edge applications

The use of convex-probe endobronchial ultrasound (CP-EBUS) has revolutionized bronchoscopy. It has provided the option of a relatively safe, minimally invasive approach for the assessment of various intrathoracic diseases. In current practice, its most dramatic impact has been on the diagnosing and staging of lung cancer. It has served as an invaluable tool that has replaced mediastinoscopy in a variety of clinical scenarios. Many pulmonologists and thoracic surgeons consider CP-EBUS the most significant milestone in bronchoscopy after the development of the flexible bronchoscope itself. In this review, we summarize the historical aspects, current indications, technical approach, and future direction of CP-EBUS.

Patterns of Practice in Mediastinal Lymph Node Staging for Non-Small Cell Lung Cancer in Canada

BACKGROUND

Assessment of mediastinal lymph nodes is integral in staging patients with non-small cell lung cancer (NSCLC). This study delineated the lymph node staging practices of Canadian thoracic surgeons in patients with potentially resectable NSCLC.

METHODS

A questionnaire was distributed to Canadian Association of Thoracic Surgeons members (n = 86). Items addressed the use of imaging, thresholds/methods for preoperative invasive staging, and intraoperative node staging. Comparison was made against Canadian, American, and European guidelines.

RESULTS

Forty-seven surgeons (55%) responded. Although most stated they derived practices from published guidelines, a significant proportion did not reflect those recommendations. Most respondents ordered a positron emission tomography scan for every patient (87.2%), and the same proportion (87.2%) performed invasive staging selectively, with a wide range of indications. The most common thresholds were suspicious nodes on imaging (80.5%), tumor within the central third of the lung (67.5%), and tumor exceeding 3 cm (34.2%). Endobronchial ultrasound, alone or with endoscopic ultrasound, was selected as the initial staging procedure of choice by 47.9%, and 43.5% selected mediastinoscopy first. Of surgeons selecting mediastinoscopy, 61.9% reported some barriers to performing endobronchial ultrasound. There was variability, between surgeons and between lobes, in which nodes respondents harvested intraoperatively for given lobectomies. A sizeable minority (13%) did not routinely harvest lymph nodes intraoperatively.

CONCLUSIONS

Determining the appropriate treatment and prognosis of NSCLC patients relies on proper staging. Significant variability exists in node staging practices in Canada as well as divergence from guidelines. This may result in understaging or overstaging patients and inappropriate care.

Endosonography Versus Mediastinoscopy in Mediastinal Staging of Lung Cancer: Systematic Review and Meta-Analysis

Whether endosonography can replace mediastinoscopy as the initial procedure for mediastinal staging of non-small cell lung cancer remains controversial. Herein, we perform a systematic review of randomized controlled trials and observational studies (both procedures performed in same subjects) comparing the two procedures. Nine studies (960 subjects) were identified. The pooled risk-difference of the sensitivity of endosonography versus mediastinoscopy in observational studies and randomized controlled trials was 0.11 (95% confidence interval, -0.07 to 0.29) and 0.11 (95% confidence interval, -0.03 to 0.25), respectively suggesting equivalence of the two procedures. The complication rate was significantly lower with endosonographic procedures. Endoscopic ultrasound-guided fine needle aspiration/endobronchial ultrasound-guided transbronchial needle aspiration was found to have similar yield but lower complication rate compared to mediastinoscopy in the initial mediastinal staging of non-small cell lung cancer.

The role of cervical mediastinoscopy in Nigerian thoracic surgical practice

Introduction

Cervical mediastinoscopy is the gold standard for obtaining histological diagnosis of mediastinal pathology. It has been used for the staging of lung cancer as well as to determine the cause of Isolated Mediastinal Lymphadenopathy. There is very limited evidence in the literature of its use in Nigeria to assess mediastinal pathology. The aim of this study was to describe our institutional experience with cervical mediastinoscopy.

Methods

This study was a retrospective analysis of 40 patients that underwent cervical mediastinoscopy in our institution between March 2007 and February 2013.

Results

The indication for Cervical Mediastinoscopy was Isolated Mediastinal Lymphadenopathy in 24 patients (60%) and lung cancer staging in 16 patient (40%). The mean age of the patients was 52.7 + 15.1 years. There were 21 females (52.5%) and 19 males (47.5%). The most commonly biopsied lymph nodes were level 4 in 35 patients (87.5%) and level 7 in 21 patients (52.5%). Malignant diagnosis was made in 16 (66.7%) patients with Isolated Mediastinal Lymphadenopathy and in 13 (81.3%) patients staged for lung cancer. Hospital stay was less than 24 hours in all patients and there were no complications.

Conclusion

Cervical Mediastinoscopy is available in Nigeria and has been performed in our institution with high diagnostic yield and no complications. Its increased use, along with the development of other mediastinal biopsy techniques is advocated to increase tissue biopsy of mediastinal pathology, especially for lung cancer and isolated mediastinal lymphadenopathy.

Performing robotic lobectomy and segmentectomy: cost, profitability, and outcomes

BACKGROUND

The primary objective of this study was to evaluate our experience using a completely portal (no access incision) robotic pulmonary lobectomy or segmentectomy.

METHODS

This was a retrospective review of a consecutive series of patients.

RESULTS

From February 2010 until October 2013, 862 robotic operations were performed by 1 surgeon. Of these, 394 were for a planned anatomic pulmonary resection, comprising robotic lobectomy in 282, robotic segmentectomy in 71, and conversions to open in 41 (10 for bleeding, 1 patient required transfusion; and no conversions for bleeding in the last 100 patients). Indications were malignancy in 88%. A median of 17 lymph nodes were removed. Median hospital stay was 2 days. Approximate financial data yielded: median hospital charges, $32,000 per patient (total, $12.6 million); collections, 23.7%; direct costs, $13,800 per patient; and $4,750 profit per patient (total, $1.6 million). Major morbidity occurred in 9.6%. The 30-day operative mortality was 0.25%, and 90-day mortality was 0.5%. Patients reported a median pain score of 2/10 at their 3-week postoperative clinic visit.

CONCLUSIONS

Robotic lobectomy for cancer offers outstanding results, with excellent lymph node removal and minimal morbidity, mortality, and pain. Despite its costs, it is profitable for the hospital system. Disadvantages include capital costs, the learning curve for the team, and the lack of lung palpation. Robotic surgery is an important tool in the armamentarium for the thoracic surgeon, but its precise role is still evolving.