VIDEO-ASSISTED MEDIASTINOSCOPY FOR MEDIASTINAL STAGING OF LUNG CANCER

Transcription

1 VIDEO-ASSISTED MEDIASTINOSCOPY FOR MEDIASTINAL STAGING OF LUNG CANCER Christophoros N. Foroulis Associate Professor of Thoracic Surgery Aristotle University of Thessaloniki 1 st International Course on Interventional Pulmonology: EBUS-TBNA: Exploring the mediastinum Interbalcan Medical Center, Thessaloniki, April 22, 2017

2 Cervical Mediastinoscopy Minimally invasive procedure invented by the Swedish Eric Carlens about 60 years ago (1959) to obtain biopsies by the mediastinal nodes in stations No 2R and 2L (paratracheal nodes), station No 7 (subcarinal nodes and No 4R, 4L nodes (tracheobronchial angle) Carlens E. Mediastinoscopy: a method for inspection and tissue biopsy in the superior mediastinum. Dis Chest 1959; 36: Introduction and widespreading in USA by the Canadian Thoracic Surgeon Griffith Pearson from the Toronto University in 1965 Pearson, F.G., Kergin, F.G.: Mediastinoscopy: a method of biopsy in the superior mediastinum. J. Thorac Cardiovasc Surg 1965; 49: 11

3 Memorial Sloan-Kettering Cancer Center (NY) Late introduction of the technique in 1985 from Larry kaiser who arrived at NY this year coming from the University of Toronto!

4 We can distinguish two variations of the technique: a) Classical cervical mediastinoscopy Biopsies from lymph node stations Νο 1 (Delphian), 2R, 2L,4R, 4L and 7 b) Extended cervical mediastinoscopy (Ginsberg et al, A single staging procedure for bronchogenic carcinoma of the left upper lobe. J Thorac Cardiovasc Surg 1987; 94: ) Biopsies from lymph node stations Νο 3a, 5, 6

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6 Which is the current role of mediastinoscopy in thoracic cancer; Mediastinal staging (parameter N) in lung cancer, esophageal cancer, thyroid cancer, pleural mesothelioma, neck and head carcinomas and before resection of pulmonary metastases from extrathoracic carcinomas Evaluation and diagnosis of the cause of undetermined mediastinal lymphadenopathy (lymphomas, sarcoidosis, tuberculosis, metastatic carcinomas) Histologic diagnosis/confirmation of lung cancer by sampling the invaded mediastinal nodes in selected cases where tissue confirmation of the tumor was not possible through bronchoscopy or CT-guided FNB

7 The main indication of cervical mediastinoscopy is preoperative staging of the parameter N (nodes) of the TNM system in NSCLC by confirming or excluding possible invasion of the ipsilateral (N2) or contralateral (N3) mediastinal nodes» Foroulis C, Papaconstantinou C. Anatomy and diagnostic procedures of the diseases of the chest. In Foroulis C (ed.): Thoracic Surgery. University Studio Press, Thessaloniki 2012, pp:

8 Staging mediastinoscopy Mediastinoscopy performed as a separate staging procedure before thoracotomy (in some instances together with bronchoscopy) Mediastinoscopy performed as staging procedure at the time of thoracotomy V-med frozen section of suspicious nodes positive negative induction treatment curative surgery

9 Evaluate PET/CTpositive mediastinal nodes by mediastinal sampling (except when there is definite distant metastatic disease or a high probability that N2/N3 disease is metastatic [for example, if there is a chain of lymph nodes with high 18F-deoxyglucose uptake]). Consider combined EBUS and EUS for initial staging of the mediastinum as an alternative to surgical staging. Confirm negative results obtained by EBUS-guided TBNA and/or EUS-guided FNA using surgical staging if clinical suspicion of mediastinal malignancy is high. NICE, Clinical Guideline 121, 2011

10 CT scan or PET-CT scan ESTS Clinical Guidelines on Mediastinal Staging (2007) Negative (Ν0) Positive (Ν2 Ν3) Histologic confirmation Mediastinoscopy Negative EBUS or EUS Negative Positive Positive Surgery Chemo-radiotherapy

11 From: Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer. Eur J Cardiothorac Surg 2014; 45:

12 The revised ESTS clinical guidelines (2014) for preoperative mediastinal staging in NSCLC suggest to perform mediastinoscopy, EBUS or EUS in the following cases even in the absence of mediastinal nodes involvement in PET/CT scan: cn1 disease in CT scan ή PET/CT scan Centrally located neoplasm Tumor more than 3cm in diameter and especially in adenocarcinomas with a high SUVmax value De Leyn et al. Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer. Transl Lung Cancer Res 2014; 3(4):

13 Comparison of EBUS and cervical mediastinoscopy in NSCLC staging: Which is the available evidence;

14 University of Alabama, (R. Cefolio) Conclusions: Both EBUS and EUS are useful initial tests to biopsy suspicious N2 mediastinal lymph nodes; however, as EBUS and EUS have high false negative rates, especially at stations 4R and 7, mediastinoscopy is still required for patients with suspicious nodal disease in these stations. Ann Thorac Surg 2010;90: Mayo Clinic Conclusions: Endobronchial ultrasound with transbronchial needle aspiration can effectively sample mediastinal lymph node stations in patients with lung cancer. However, in this early experience, 28% of patients with high clinical suspicion of nodal disease had N2 mediastinal nodal metastases confirmed by mediastinoscopy despite negative EBUS-TBNA. Ann Thorac Surg 2010;90:1753 8

15 University of Seoul, South Korea Conclusions: EBUS-TBNA was superior to mediastinoscopy in terms of its diagnostic performance for mediastinal staging of cn1 3 NSCLC. Because EBUS-TBNA is both less invasive and affords superior diagnostic sensitivity, it should be the first-line procedure performed in patients with NSCLC. J Thorac Oncol. 2015;10: University of Toronto (K. Yasufuku) Conclusions: EBUS-TBNA and mediastinoscopy achieve similar results for the mediastinal staging of lung cancer. As performed in this study, EBUS- TBNA can replace mediastinoscopy in patients with potentially resectable non small cell lung cancer. J Thorac Cardiovasc Surg 2011;142: System, equipment and research support funding from Olympus Medical Systems

16 Block MI,and Tarrazzi FA. Invasive Mediastinal Staging: Endobronchial Ultrasound, Endoscopic Ultrasound and Mediastinoscopy. Semin Thoracic Surg 2013; 25: Conclusions: EUS-FNA and EBUS-TBNA should no longer be considered promising new technologies. The evidence and experience have established them as appropriate choices for invasive mediastinal staging. When conducted in a systematic fashion and executed with skill, these alternatives to mediastinoscopy offer several advantages and equivalent or superior sensitivity. Although mediastinoscopy will always play an important role in the management of patients with lung cancer, it is likely that endosonography will become the dominant procedure for invasive mediastinal staging. Thoracic surgeons must become adept at these procedures because only they can ensure that all the options will be available for future patients. Patients with lung cancer are best served by clinicians experienced with all three methods for invasive mediastinal staging.

17 CERVICAL MEDIASTINOSCOPY 1. Conventional or Video-Assisted (V-med) 2. Training easier with the Video-Assisted technique 3. Relative and absolute contraindications 4. Low mortality < 0.5% and morbidity < 2% 5. The role of the technique in mediastinal restaging after induction treatment is limited because of the inaccuracy and the high risk of injury to the mediastinal vessels 6. EBUS-TBNA and EUS-FNA will eliminate the application of the technique in mediastinal NSCLC staging, however, V-med still remains an important diagnostic technique in recent clinical guidelines 7.Mediastinoscopy can be applied as day-case surgery

18 CONTRAINDICATIONS OF MEDIASTINOSCOPY Α) ABSOLUTE 1) Permanent tracheostomy (i.e. after total laryngectomy) 2) Severe kyphosis or limited neck flexibility 3) Coagulopathies or contraindication for general anesthesia 4) Small patient size (i.e. in children) Β) RELATIVE 1) Superior vena cava syndrome 2) Previous mediastinal irradiation 3) Previous mediastinoscopy (repeat mediastinoscopy) Temporary tracheostomy and previous median sternotomy are not contraindications for cervical mediastinoscopy

19 Schematic presentation of the technique (from Glenn s Thoracic and Cardiovascular Surgery)

20 The mediastinal area to be explored by mediastinoscopy is a minefield!

21 Crucial: avoid hyperextension of the head and neck

22 Important step of the technique: recognition of the pretracheal fascia

23 Finger exploration through the avascular pretracheal plane down to the mediastinum until the precarinal area

24 Insertion of the Video-mediastinoscope

25 The innominate artery

26 Innominate artery Trachea

27 Left recurrent nerve Esophagus Crucial: Special care during the application of cautery in the left paratracheal space to avoid damage to the recurrent nerve

28 Right pulmonary artery Subcarinal nodes (Νο 7)

29 The right main bronchus Lymph nodes of station 10R The superior trunk of the right pulmonary artery is pushed-up by the scope

30 Remnants of biopsied lymph nodes in station Νο 4R The azygos vein

31 EQUIPMENT FOR MEDIASTINOSCOPY Insulated suction tube for dissection and hemostasis Biopsy forceps with suction channel Biopsy forceps

32 Carlens mediastinoscope with adapted telescope Spreadable Linder-Dahan V-med (Wolf) V-med Lerut (Storz)

33 Conventional mediastinoscopy one-man show Unsuitable for teaching purposes

34 Video-Assisted Mediastinoscopy (VAM) is ideal for teaching the procedure

35 DIFFERENCES BETWEEN THE CONVENTIONAL AND VIDEO-ASSISTED TECHNIQUES 1. Better visualization of the mediastinal structures because of the magnification 2. Easier sampling from subcarinal nodes (Νο 7) 3. Training 4. Spreadable video-mediastinoscopes give the opportunity of more extensive techniques such as VAMLA and TEMLA (part of the procedure) 5. Higher rate of minor complications due to more aggressive dissection promoted by the better visualization, especially left laryngeal nerves palsies (in my experience) 6. Mortality, morbidity, number of biopsied lymph nodes and lymph node stations, reliability and negative prognostic value seem to be equal between the two techniques

36 Sayar A, et al. Acta Chirurgica Belgica 2016; 116: Conclusions: Videomediastinoscopy, 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.

37 META-ANALYSIS VAM (956 patients) CM (5,156 patients) Mortality (%) 0 0 P-value Morbidity (%) NS No of biopsied lymph nodes No of lymph node stations sampled NS NS Accuracy (%) NS Negative predictive value (%) NS Zakkar M, Tan C, Hunt I. Is video mediastinoscopy a safer and more effective procedure than conventional mediastinoscopy?, Interact CardioVasc Thorac Surg 2012; 14: 81-4

38 SHORT VIDEO

39 COMPLICATIONS OF MEDIASTINOSCOPY 1. Bleeding (usually from bronchial arteries) 2. Pneumothorax 3. Recurrent nerve palsy 4. Arrhythmias 5. Injury to the tracheobronchial tree 6. Cerebrovascular accident (compression of the innominate artery) 7. Chyle leak 8. Perforation of the esophagus 9. Suppuration of the incision 10. Tumor implants in the incision

40 Personal experience in AHEPA Hospital (3/2006-3/2017) 252 mediastinoscopies (Video-Assisted: Conventional: 133) Mediastinoscopy in specific situations 4 in combination with anterior mediastinotomy 9 in patients with temporary tracheotomy (transition to orotracheal intubation just before the procedure) 21 in patients with previous median sternotomy 5 in patients with superior cava cava syndrome

41 Complications of the 252 mediastinoscopies Pneumothorax requiring chest tube drainage: 2 (0.79%) Tension pneumothorax: 1 (0.39%) Recurrent nerve palsy: 4 (1.58%) - 3 of them with V-med Bleeding: 3 (1,19%) control with compression and cautery in all discontinuation of the procedure in 1 Collection of fluid or suppuration of the wound: 5 (1.98%) Total: 15:252 = 5.95%

42 Can mediastinoscopy be offered as day-case surgery; Only in selected cases: patients without serious concomitant disease uncomplicated procedure easy weaning from anesthesia resident in a short distance from the hospital Chest radiography should be performed in any case before discharge Day Case and Short Stay Surgery, Guideline published by the British Association of Day Surgery and the Association of Anaesthetists of Great Britain & Ireland (2011)

43 EXTENDED CERVICAL MEDIASTINOSCOPY 1. Biopsy of lymph node stations No 5 and 6 through the same incison in the neck 2. Not widely adopted 3. Simpler techniques are available to sample lymph node stations No 5, 6 (Anterior mediastinotomy, combination of cervical mediastinoscopy and anterior mediastinotomy)

44 The technique of access to the lymph nodes station No 5 (aortopulmonary window or subaortic) and 6 (para-aortic) through extended cervical mediastinoscopy

45 VIDEO ASSISTED MEDIASTINOSCOPIC LYMPHADENECTOMY (VAMLA) 1. Operative field equal to that of mediastinoscopy 2. Radical lymph node dissection in lymph node stations N0 2R, 2L, 4R, 4L and 7 3. Spreadable mediastinoscope and specific equipment are required 4. High sensitivity 5. The technique is not widely adopted and therefore the complications rate cannot be estimated 6. It is recommended as definitive lymph node dissection in cases followed by thoracoscopic lobectomy at a second time

46 VAMLA dissection is guided by anatomical landmarks, very similar to open lymphadenectomy 2007 by Oxford University Press Witte B, and Hürtgen M MMCTS 2007;2007:mmcts

47 The Linder-Dahan mediastinoscope (Wolf) is a crossbred of a conventional mediastinoscope and spreadable laryngoscope by Oxford University Press Witte B, and Hürtgen M MMCTS 2007;2007:mmcts

48 The video mediastinoscope set up in the operation theatre, supported by a holder (black arrows) by Oxford University Press Witte B, and Hürtgen M MMCTS 2007;2007:mmcts

49 Which is the future of cervical mediastinoscopy; - Memory; Historical procedure; - Complementary to EBUS or EUS technique; - Reappraisal of the indications;

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51 .. but too old for rock n roll??? Chrysalis 1976

52 Don t forget! Mediastinoscopy, EBUS, EUS Operator dependent techniques