Mediastinoscopy. EBUS versus Mediastinoscopy?

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1 Mediastinoscopy M.A. Paul, MD, PhD Dept of Surgery VU University Medical Center Amsterdam Perspectives in Lung Cancer, Amsterdam 9 10 March EBUS versus Mediastinoscopy? I had prepared for a Pro Con debate! but... a recent editorial in Journal of Thoracic Oncology changed that... (F Detterbeck, JTO Febr 2012) The real problem lies elsewhere! 2 1

2 Invasive staging techniques: Simple comparison is inadequate. - The techniques are used in different patient cohorts e.g. GGO or PET pos mediastinum? - The other techniques are not always used by experts with focussed interest Remember: Tool Technique 3 Mediastinoscopy Drainage pattern Technical Aspects Results: in primary staging in re-staging g Decision making Conclusions 4 2

3 There is no surgery without anatomy Study of drainage pattern in 1815 NSCLC patients Naruke T, Tumors RUL (n=648) Lymphnode metastases: N 1 XII: 15.6 % XI: 9.6 % X: 6.5 % N 2 VII: 4.5 % IV: 80% 8.0 III: 12.3 % Naruke T,

4 Tumors RML (N=79) Lymphnode metastases: N 1 XII: 19.0 % XI: 11.4 % X: 8.9 % N 2 VII: 16.5 % IV: 7.6 % III: 16.5 % I: 10.1 % Tumors RLL (N=380) Lymph node metastases: N 1 XII: 8.7 % XI: 16.3 % X: 12.4 % N 2 VII: 13.7 % IV: 4.2 % III: 6.3 % I: 5.3 % 4

5 Tumors LUL (N=489) Lymphnode metastases: N 1 XII: 20.4 % XI: 11.5 % X: 10.0 % N 2 VII: 3.3 % VI: 67% 6.7 V: 12.3 % IV: 4.9 % Tumors LLL (N=219) Lymphnode metastases: N 1 XII: 19.2 % XI: 18.3 % X: 13.7 % N 2 VII: 11.9 % IV: 4.1 % 5

6 Ventral and dorsal view Cervical mediastinoscopy 6

7 Paratracheal and pre-vascular nodes 7

8 Level 5 and 6 nodes -Anterior mediastinotomy -Extended mediastinoscopy 8

9 Gold standard in performing mediastinoscopy: Two ipsilateral LN levels, one contralateral LN level and subcarinal LN level Videomediastinoscopy Benefits: e - Enhanced visualisation - Improved accuracy - Better teaching - International standardisation of technique 9

10 Videomediastinoscopy PA Videomediastinoscopy 10

11 Cervical mediastinoscopy Low morbidity Almost no contraindications Out-patient procedure Ipsilateral and contralateral nodes Full mapping of mediastinal LN s NPV > 90% (10% unforeseen N2 disease) 50% of FN s: levels not accessible by medastinoscopy Complications of mediastinoscopy : 5000 cervical mediastinoscopies* 9 major bleeding requiring thoracotomy-sternotomy 1 esophageal perforation 1 injury of left main bronchus * University of Leuven 11

12 Accuracy of mediastinoscopy in primary staging of the mediastinum Re-staging the mediastinum remediastinoscopy PA PA LEVEL 7 12

13 Re-mediastinoscopy Combination of blunt and sharp dissection 25 Restaging the mediastinum: Re-mediastinoscopy Navarro et al, Ann Thorac Surg 70 : 391-5, N = 24 (update 2003, n=42) - Technical feasible to reach prechemo involved lymph nodes - Mediastinoscopy positive : 12 (50%) - Sensitivity : 70%, accuracy : 80% Van Schil et al., Lung Cancer 2002, 37 : N = 27 (update 2003, n=32) - Sensitivity : 73%, accuracy : 85% Pitz et al., Ann Thorac Surg 2002;74: N = 15 - No biopsies or incomplete : 6 (40%) - 2 false negative remediastinoscopies 13

14 Re-mediastinoscopy: Inaccurate re-evaluation 4R New developments: Mediastinal lymphnode dissections: - TEMLA (Dr Zielinski, Zakopane, Poland) Transcervical Extended Mediastinal LymphAdenectomy - VAMLA (Dr Huertgen, Koblenz, Germany) Video-assisted Mediastinoscopic LymphAdenectomy 28 14

15 Summary: Mediastinoscopy can reach scalenic, paratracheal and anterior subcarinal lymphnodes Extended Mediastinoscopy for station 6 nodes Re-mediastinoscopy possible, but difficult Large biopsy for advanced pathological testing 29 Know where to go and make a choice! Based on: - Patients comorbidity - Imaging - Location primary tumor - Available Expertise - Tissue needed 15

16 Know where to go: We know where to go... 16

17 PET-CT 33 Know your field 34 17

18 Know your tools... Cervical mediastinoscopy TBNA EBUS-FNA EUS-FNA My opinion: Use EUS - EBUS for diagnosis no general anaethesia needed no scarring at mediastinal LN dissection Use mediastinoscopy if EUS EBUS are negative Use mediastinoscopy upfront if you need much tissue If induction + resection is considered, keep mediastinoscopy for re-staging 36 18

19 Quality control in invasive staging: the real problem! - Only 27% of NSCLC patients get invasive mediastinal staging. Little Only 40% had LN biopsy at mediastinoscopy Holland Discrepancy at auditing MLND surgeons auditor no sampling 48% 42% random sampling 8% 50% systematic sampling 9% mediast. LN dissection 45% 0% overall concordance: 11% Osarogiagbon The real problem: Doctors often take shortcuts and skip invasive staging Shortcuts give long delays Pippin in Lord of the Rings Techniques are not performed well enough! A fool with a tool is still a fool 38 19

20 All roads lead to Rome; which is one reason why many people never get there C.K. Chesterton The benefit of better staging exceeds by severalfold the benefit seen from so called breakthrough advances in treatment F. Detterbeck, JTO

21 Conclusions: Mediastinoscopy is an adequate tool for mediastinal staging The three tools for mediastinal staging (MS, EUS, EBUS) are often complementary. The choice depends on various patient and institute related factors. There is probably no place for a one methods fits all approach in mediastinal staging 41 But mediastinoscopy is here to stay! Thank you! 42 21