Systematic mediastinal nodal dissection and video-assisted thoracic surgery

Abstract

A recent study by Amer et al. [1] investigated the role of systematic mediastinal nodal dissection performed during videoassisted major pulmonary resection as a staging approach for non-small-cell lung cancer versus preoperative staging by computed tomography (CT) and positron emission tomography (PET). Precise staging is essential to provide accurate knowledge of disease progression in patients with non-small-cell lung cancer; in effect, the valuable editorial comment on the mentioned trial remarked that the authors ‘ignored the data that support the use of mediastinoscopy prior to VATS lobectomy, even in clinical stage I disease’ [2]. In reality, the American College of Chest Physicians clinical practice guidelines are open to the possibility that invasive staging is probably not needed in patients with peripheral tumours with no nodal involvement on CT and PET scans [3]. The coeval European Society of Thoracic Surgeons guidelines indicated that invasive staging can be omitted for patients with stage I lung cancer and negative mediastinal PET imaging on the condition that the tumour is peripheral [4]. From a formal point of view, the colleagues from Southampton could not be blamed for their preoperative protocol. Moreover, standard cervical mediastinoscopy usually only biopsies the paratracheal and subcarinal stations [4]; but, in order to reach every mediastinal station, transcervical extended mediastinal lymphadenectomy (TEMLA) [5] should be carried out. In addition, when positive lynphnodes are found, TEMLA should be redone for restaging after chemotherapy even if such a procedure seems excessive in a patient with a peripheral pulmonary nodule of a few millimetres plus negative mediastinal imaging. As an alternative, the endoscopic ultrasonography transbronchial needle aspiration (EBUS-TBNA) provides accurate mediastinal staging; such a technique is accepted by the American College of Chest Physicians and European Society of Thoracic Surgeons guidelines for clinical N2–3 lung cancer, but EBUS-TBNA has been proposed in the staging of CTand PET-negative mediastinum [6] our 6-year-long experience in EBUS-TBNA suggests that the biopsy of a few millimetre lymph-node is a hard duty especially in paratracheal stations. In conclusion, we consider that the Amer et al. preoperative behaviour is shareable and in good equilibrium between idealism and pragmatism [1]. Amer et al. underline the effectiveness of video-assisted thoracic surgery in the systematic mediastinal nodal dissection [1]. A number of studies had validated the video-assisted mediastinal dissection, but more explanatory is the simple photograph included in the article: during video-assisted thoracic surgery, the vision on mediastinal structures is so close and clear that surgeons can work in the best conditions. We conclude ‘nullus est liber tam malus, ut non aliqua parte prosit’ (There is no book so bad that it is not profitable in some part, Pliny); the article from Southampton highlights an up-to-date clinical practice based on good common sense and, moreover, restates the feasibility of a complete mediastinal dissection during video-assisted thoracic surgery.