MEDIASTINAL STAGING surgical pro

MEDIASTINAL STAGING surgical pro Paul E. Van Schil, MD, PhD Department of Thoracic and Vascular Surgery University of Antwerp, Belgium Mediastinal staging Invasive techniques lymph node mapping cervical mediastinoscopy anterior mediastinoscopy extended mediastinoscopy thoracoscopy (VATS) alternative, less invasive techniques conclusion

Mediastinal staging Invasive techniques lymph node mapping cervical mediastinoscopy anterior mediastinoscopy extended mediastinoscopy thoracoscopy (VATS) alternative, less invasive techniques conclusion N factor: zones Rusch V. J Thorac Oncol 2009; 4:568-77

TNM 7th edition Mediastinal staging Invasive techniques lymph node mapping cervical mediastinoscopy anterior mediastinoscopy extended mediastinoscopy thoracoscopy (VATS) alternative, less invasive techniques conclusion

Cervical mediastinoscopy Cervical mediastinoscopy 25 30 % abnormal lymph nodes exploratory thoracotomy : 50 15 % bilateral exploration (N3 disease) mediastinal invasion primary tumor staging NSCLC: not indicated when both CT and PET are negative: LN < 1 cm and no FDG uptake unless central tumor or FDG uptake in primary tumor

Cervical mediastinoscopy hot spots low cervical, supraclavicular + sternal notch nodes(1) upper paratracheal (2 R-L) lower paratracheal (4R-L) ant. subcarinal (7A) blind spots aortopulmonary (5,6) post. subcarinal (7P) esophageal (8) inf. pulmonary ligament (9) scalene lymph nodes [N3] Cervical mediastinoscopy REVIEW 20 000 CASES mortality < 0.5 % morbidity 2.5 % hemorrhage L recurrent nerve paralysis pneumothorax rare : tear tracheobronchial wall perforation of esophagus stroke, chylous leak, air embolus experience! Kirschner P. Chest Surg Clin North Am 1996; 6 : 1-20

Cervical mediastinoscopy video-assisted advantages: magnification ergonomic position of operator teaching possibility disadvantages : 2 - dimensional view cost

Cervical mediastinoscopy video-assisted 240 consecutive cases CT enlarged LN (short axis > 1 cm) 2 complications : pneumothorax, injury innominate artery 47 pts thoracotomy 3 FN (N2 found at operation) p staging = MS staging 44 pts (93.6 %) NSCLC sensitivity 97.3 % specificity 100 % accuracy 98.6 % safe and effective in nodal asessment of mediastinum Venissac N. Ann Thorac Surg 2003; 76: 208-12 Mediastinal staging Invasive techniques lymph node mapping cervical mediastinoscopy anterior mediastinoscopy extended mediastinoscopy thoracoscopy (VATS) alternative, less invasive techniques conclusion

Anterior mediastinoscopy McNeill TM, Chamberlain JM. Ann Thorac Surg 1966; 2: 532 Anterior mediastinoscopy disadvantages limited exposure cosmetic appearance morbidity (pain, infection) alternatives extended cervical mediastinoscopy VATS

Mediastinal staging Invasive techniques lymph node mapping cervical mediastinoscopy anterior mediastinoscopy extended mediastinoscopy thoracoscopy (VATS) alternative, less invasive techniques conclusion Extended mediastinoscopy Aortopulmonary window indications LN 5,6 invasion aortopulmonary window technique from cervical incision prevascular substernal plane innominate triangle Ginsberg R. J Thorac Cardiovasc Surg 1987; 94: 673-78

Extended mediastinoscopy Extended mediastinoscopy

Extended mediastinoscopy Aortopulmonary window results 100 tumors LUL : 20 % anterior or superior mediastinal involvement complications (> 500 cases) wound infection laceration innominate artery transient R hemiplegia Ginsberg R. Chest Surg Clin North Am 1996; 6: 21-30 Extended mediastinoscopy Scalene lymph node biopsy from cervical incision rotating mediastinoscope to supraclavicular fossa 39 pts N2 at mediastinoscopy indication 6 (15 %) occult supraclavicular disease N2 before considering combined modality approach Lee J, Ginsberg R. Ann Thorac Surg 1996; 62: 338-41

Mediastinal staging Invasive techniques lymph node mapping cervical mediastinoscopy anterior mediastinoscopy extended mediastinoscopy thoracoscopy (VATS) alternative, less invasive techniques conclusion VATS : Staging video-assisted technique adjunct to cervical mediastinoscopy replaces ant. or extended MS accessible lymph nodes : aortopulmonary (5,6) inferior mediastinal (7 post., 8, 9) hilar (10)

VATS : Staging indications for thoracoscopy lymph node staging pleural dissemination pleural effusion intrapulmonary metastasis before start of neoadjuvant therapy VATS Staging N2 disease 53-year-old 1994 breast cancer conservative resection + adjuvant chemoradiotherapy 1999 cervix cancer vaginal hysterectomy Sjögren s disease (ocular manifestations) follow-up chest CT: nodule L lung hilar and mediastinal LN

VATS : Staging

Mediastinal staging Invasive techniques lymph node mapping cervical mediastinoscopy anterior mediastinoscopy extended mediastinoscopy thoracoscopy (VATS) alternative, less invasive techniques conclusion Alternative (less) invasive tests 1ary staging sensitivity PPV FN transbronchial needle aspiration (TBNA) 76 % 100 % 29 % endoscopic ultrasound (EUS-NA) 88 % 98 % 23 % transthoracic needle aspiration (TTNA) 91 % 100 % 22 % selected population, high prevalence confirmation mediastinal involvement but FN rate alternative techniques to obtain proof N2,N3,T4 induction therapy mediastinoscopy Urschel J. Lung Cancer 2003; vol 41 suppl 3: S105 Detterbeck FC. Chest 2003; 123 (suppl 1): S167-S175

Accuracy PET - CT scanning anno 2009 200 patients operated lung cancer PET-CT followed by staging mediastinoscopy and resection, if appropriate PET-CT correct staging 99 pts 49.5 % under-staged 59 29.5 % over-staged 42 21 % superior mediastinal nodes not correctly staged in 19 % Carnochan FM, Walker WS. Eur J Cardiothorac Surg 2009; 35:781 True FN rate EUS and EBUS anno 2010 352 patients with lung cancer over 1.5 years FN rate EBUS 29.4 % EUS 14.3 % mediastinoscopy 5.8 % EBUS and EUS useful initial tests EBUS FN rate 4R, 7: mediastinoscopy EUS FN rate 5, 6: VATS Cerfolio RJ. Society of Thoracic Surgeons (STS) congress, 26/01/10

Invasive staging guidelines Recommendations 1 strong 2 weak evidence A high B moderate C (very) low Detterbeck FC. Chest 2007; 132:202-220 Invasive staging guidelines extensive mediastinal infiltration of tumor (no distant mets) CT assessment sufficient recommend. 2C enlarged, discrete mediastinal nodes by CT (no distant mets): invasive staging (regardless of PET findings) recommend. 1B confirmation N2,3: TBNA, TTNA, EUS-NA EBUS-NA (experience!) recommend. 1B needle technique - mediastinoscopy recommend. 1C Detterbeck FC. Chest 2007; 132:202-220

Invasive staging guidelines normal mediastinum on chest CT in case of central tumor or N1 and no distant mets invasive staging (regardless of PET findings) mediastinoscopy suggested (alternative EUS- or EBUS-NA) recommend. 1C recommend. 2C peripheral stage I with + mediastinal nodes PET (no distant mets): mediastinoscopy suggested (alternative EUS- or EBUS-NA) recommend. 1C peripheral stage I with - mediastinal nodes PET (no distant mets): invasive confirmation not needed recommend. 1C Detterbeck FC. Chest 2007; 132:202-220 Invasive staging guidelines LUL cancer, invasive mediastinal staging indicated invasive staging of aortopulmonary nodes 5,6 suggested (other mediastinal lymph node stations not involved) methods: anterior mediastinoscopy extended cervical mediastinoscopy thoracoscopy VATS EUS-NA EBUS-NA recommend. 2C Detterbeck FC. Chest 2007; 132:202-220

Mediastinal staging Invasive techniques lymph node mapping cervical mediastinoscopy anterior mediastinoscopy extended mediastinoscopy thoracoscopy (VATS) alternative, less invasive techniques conclusion different methods Mediastinal staging surgical pro cervical - anterior mediastinoscopy extended cervical mediastinoscopy thoracoscopy VATS no randomized studies available large samples: molecular genetic analysis complete evaluation, high accuracy safe techniques, morbidity Try it and you will like it!