Paratracheal Stations Research Articles

Role of EBUS in lymphoma presenting as superior vena cava syndrome: bronchoscopic and sonographic findings: a case report

BackgroundThe clinical description of superior vena cava syndrome has been widely studied; however, there is limited information on bronchoscopic findings in clinical practice.Case presentationA 57-year-old man presented with facial and neck swelling and pedal edema of 6 months duration. Computed tomography showed mediastinal lesions in the right paratracheal stations with thrombosis of the right internal jugular vein and superior vena cava (SVC). Without establishing a diagnosis, he was started on oral steroids elsewhere and his symptoms progressed. He did not receive anticoagulation therapy. Bronchoscopy showed edematous supraglottic and glottic regions with hyperemia of the airway mucosa. Endobronchial Ultrasonography revealed a mediastinal mass of heterogeneous echotexture in the lower right paratracheal region, with mediastinal collateral blood vessels. He underwent EBUS-guided aspiration cytology and intranodal forceps biopsy, which confirmed the diagnosis of non-Hodgkin’s.ConclusionIn cases with an unconfirmed diagnosis of lymphoma, it is prudent to refrain from administering glucocorticoids, as these medications can exhibit lympholytic properties and may hinder the diagnostic process. Due to extensive collateral formation in superior vena cava syndrome, utilizing Doppler during endobronchial ultrasound transbronchial needle aspiration (EBUS TBNA) can identify numerous mediastinal collateral vessels, thus minimizing the risk of bleeding.

Exploration of lymph node recurrence patterns and delineation guidelines of radiation field in middle thoracic oesophageal carcinomas after radical surgery: a real-world study.

Oesophageal squamous cell carcinoma is one of the most commonly diagnosed carcinomas in China, and postoperative radiotherapy plays an important role in improving the prognosis of patients. Carcinomas in different locations of the oesophagus could have different patterns of lymph node metastasis after surgery. In this multicentric retrospective study, we enrolled patients with middle thoracic oesophageal squamous cell carcinomas from 3 cancer centres, and none of the patients underwent radiotherapy before or after surgery. We analysed the lymph node recurrence rates in different stations to explore the postoperative lymphatic recurrence pattern. From January 1st, 2014, to December 31st, 2019, 132 patients met the criteria, and were included in this study. The lymphatic recurrence rate was 62.1%. Pathological stage (P = 0.032) and lymphadenectomy method (P = 0.006) were significant predictive factors of lymph node recurrence. The recurrence rates in the supraclavicular, upper and lower paratracheal stations of lymph nodes were 32.6%, 28.8% and 16.7%, respectively, showing a high incidence. The recurrence rate of the subcarinal node station was 9.8%, while 8.3% (upper, middle and lower) thoracic para-oesophageal nodes had recurrences. We recommend including the supraclavicular, upper and lower paratracheal stations of lymph nodes in the postoperative radiation field in middle thoracic oesophageal carcinomas. Subcarinal station is also potentially high-risk, while whether to include thoracic para-oesophageal or abdominal nodes needs careful consideration.

Extended lower paratracheal lymph node resection during esophagectomy for cancer – safety and necessity

BackgroundThe ideal extent of lymphadenectomy (LAD) in esophageal oncological surgery is debated. There is no evidence for improved survival after standardized paratracheal lymph node resection performing oncological esophagectomy. Lymph nodes from the lower paratracheal station are not standardly resected during 2-field Ivor-Lewis esophagectomy for esophageal cancer. The objective of this study was to evaluate the impact of lower paratracheal lymph node (LPL) resection on perioperative outcome during esophagectomy for cancer and analyze its relevance.MethodsRetrospectively, we identified 200 consecutive patients operated in our center for esophageal cancer from January 2017 – December 2019. Patients with and without lower paratracheal LAD were compared regarding demographic data, tumor characteristics, operative details, postoperative complications, tumor recurrence and overall survival.Results103 out of 200 patients received lower paratracheal lymph node resection. On average, five lymph nodes were resected in the paratracheal region and cancer infiltration was found in two patients. Those two patients suffered from neuroendocrine carcinoma and melanoma respectively. Cases with lower paratracheal lymph node yield had significantly less overall complicated procedures (p = 0.026). Regarding overall survival and recurrence rate no significant difference could be detected between both groups (p = 0.168 and 0.371 respectively).ConclusionThe resection of lower paratracheal lymph nodes during esophagectomy remains debatable for distal squamous cell carcinoma or adenocarcinoma of the esophagus. Tumor infiltration was only found in rare cancer entities. Since resection can be performed safely, we recommend LPL resection on demand.

856 NODAL METASTASES AFTER NEOADJUVANT CHEMORADIATION AND R0 RESECTION IN ESOPHAGEAL ADENOCARCINOMA: PATTERNS AND PROGNOSIS

Abstract Although the pattern of nodal metastasis and the prognosis of number and location of positive nodes have been well described with esophageal cancer undergoing upfront surgery, little is known about nodal metastasis after neoadjuvant treatment. The aim of this study is to assess the pattern of nodal metastases in esophageal adenocarcinoma treated with neoadjuvant chemoradiation and surgery and evaluate its effect on prognosis. Methods All patients with esophageal adenocarcinoma who had undergone neoadjuvant chemoradiation and an R0 esophagectomy between 2010 and 2018 at our institution were included (n = 577). Pathology reports were reviewed for sites of lymph node metastases. Patients were excluded if nodal stations were not listed separately (n = 40). Age, sex, race, tumor location, TRG, pT stage, number of positive lymph nodes, number of positive nodal stations, and specific nodal stations were analyzed for risk of recurrence using univariable Cox regression, and significant covariates were included in multivariable Cox regression model. Results Of 537 patients, 193(36%) had pathologic nodal metastases. 153 patients(28%) had single-station disease: 135(88%) at the paraesophageal station, 16(10%) at the left gastric, 1 at the subcarinal and 1 at the paratracheal station(0.65% each). 32 patients(6.0%) had two-station and 8(1.5%) had three-station disease. The majority of patients with multiple positive nodal stations had positive nodes in the paraesophageal(90%) and/or left gastric artery stations(60%). On multivariable analysis, the number of positive nodal stations (HR 1.59, CI 1.35–1.84, p < 0.001), subcarinal (HR 2.78, CI 1.54–5.03, p < 0.001), and paraesophageal stations (HR 2.0, CI 1.58–2.54, p < 0.001) were associated with increased risk of recurrence. Conclusion Patients who have undergone neoadjuvant and R0 esophagectomy for adenocarcinoma often have lymph node metastases at time of surgery, most commonly at the paraesophageal station. The number of nodal stations, along with subcarinal and paraesophageal metastases, were associated with increased risk of recurrence.

676 NECESSITY OF EXTENDED LOWER PARATRACHEAL LYMPH NODE RESECTION DURING ESOPHAGECTOMY FOR CANCER

Abstract Objective To evaluate the impact of lower paratracheal lymph node resection on oncological radicality and complication rate during esophagectomy for cancer. Backround The ideal extend of lymphadenectomy (LAD) in esophageal surgery is debated. Until today, there has been no proof for improved survival after standardized paratracheal lymph node resection performing oncological esophagectomy. Methods Lymph nodes from the lower paratracheal station are not standardly resected during 2-field Ivor-Lewis esophagectomy for esophageal cancer. Retrospectively, we identified 200 patients operated in our center for esophageal cancer from January 2017—December 2019. Histopathologically, 143 patients suffered from adenocarcinoma, 53 patients from squamous cell carcinoma, two patients from neuroendocrine carcinoma, and one from melanoma of the esophagus. Patients with and without lower paratracheal LAD were compared to patients regarding demographic data, tumor characteristics, operative details, postoperative complications, tumor recurrence and overall survival. Results 103 of 200 patients received lower paratracheal lymph node resection. On average, six lymph nodes were resected in the paratracheal region with histopathological cancer positivity in two patients. Those two patients suffered from neuroendocrine carcinoma and melanoma, none of the AC or SCC patients were positive. There was no significant difference between both groups regarding age, gender, BMI, or comorbidity. Harvesting of lower paratracheal lymph nodes was associated with less postoperative overall complications (p-value 0,029). Regarding overall survival and recurrence rate no difference could be detected between both groups (p-value 0,168, respectively 0,371). Conclusion The resection of lower paratracheal lymph nodes during esophagectomy seems not mandatory for distal squamous cell carcinoma or adenocarcinoma of the esophagus. It may be necessary in NEC, Melanoma of the esophagus or on demand if suspicious LN are detected in the CT scan. No increase of morbidity was caused by paratracheal dissection.

Recurrent laryngeal nerve monitoring during totally robot-assisted Ivor Lewis esophagectomy

PurposeThe robot-assisted approach for Ivor Lewis esophagectomy offers an enlarged, three-dimensional overview of the intraoperative situs. The vagal nerve (VN) can easily be detected, preserved, and intentionally resected below the separation point of the recurrent laryngeal nerve (RLN). However, postoperative vocal cord paresis can result from vagal or RLN injury during radical lymph node dissection, presenting a challenge to the operating surgeon.MethodsFrom May to August 2019, 10 cases of robot-assisted minimally invasive esophagectomy (RAMIE) with extended 2-field lymphadenectomy, performed at the University Medical Center Mainz, were included in a prospective cohort study. Bilateral intermittent intraoperative nerve monitoring (IONM) of the RLN and VN was performed, including pre- and postoperative laryngoscopy assessment.ResultsReliable mean signals of the right VN (2.57 mV/4.50 ms) and the RLN (left 1.24 mV/3.71 ms, right 0.85 mV/3.56 ms) were obtained. IONM facilitated the identification of the exact height of separation of the right RLN from the VN. There were no cases of permanent postoperative vocal paresis. Median lymph node count from the paratracheal stations was 5 lymph nodes.ConclusionIONM was feasible during RAMIE. The intraoperative identification of the RLN location contributed to the accuracy of lymph node dissection of the paratracheal lymph node stations. RLN damage and subsequent postoperative vocal cord paresis can potentially be prevented by IONM.

EBUS-TBNA versus EUS-B-FNA for the evaluation of undiagnosed mediastinal lymphadenopathy: The TEAM randomized controlled trial.

Endobronchial Ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a standard of care modality for the evaluation of mediastinal lymphadenopathy. Transesophageal Bronchoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-B-FNA), wherein one introduces the EBUS bronchoscope through the esophageal route, is also a safe and efficacious diagnostic modality for sampling the mediastinal lymph nodes. The objective of this study was to compare the diagnostic yield and patient comfort with these two available approaches. We randomized subjects with predominant subcarinal or lower left paratracheal mediastinal lymph node enlargement to either EBUS-TBNA or EUS-B-FNA (50 to each group). Co-Primary objectives were the comparison of adequate and diagnostic aspirates between groups. Key secondary objectives were a comparison of Operator rated cough and Operator rated procedural comfort on Visual Analog scale (VAS), procedure duration and complications between the groups. Baseline characteristics were comparable between the groups. The proportion of adequate (EBUS-TBNA 46/50; 92% and EUS-B-FNA 48/50;96%, P=0.4) and diagnostic aspirates (EBUS-TBNA 38/50; 76% and EUS-B-FNA 36/50;74%, P=0.4) were similar between the two groups. Operator rated cough was significantly less, and Operator rated patient comfort significantly higher with the EUS-B-FNA approach. Procedure duration was significantly shorter with EUS-B-FNA [18.1(14.4) minutes versus 16.4 (49.6) minutes, P<0.001]. Minor complications occurred in one patient in the EBUS-TBNA group and none in the EUS-B-FNA group. During the endosonographic evaluation for undiagnosed mediastinal lymphadenopathy located at predominantly the subcarinal or lower left paratracheal stations, EUS-B-FNA as compared with EBUS-TBNA provides greater patient comfort with a similar diagnostic yield.

Ultrasound guided fine-needle aspiration biopsy of metastases in nonpalpable supraclavicular lymph nodes in lung cancer patients

&#x0D; &#x0D; &#x0D; Background and objectives: To assess frequency and signifi- cance of enlarged nonpalpable supraclavicular lymph nodes with routine ultrasound (US) evaluation and US-guided fine- needle aspiration biopsy (FNAB) for the diagnosis and staging of patients with lung cancer.&#x0D; Materials and methods: 106 consecutive patients with lung cancer and nonpalpable supraclavicular lymph nodes were evaluated with cervical US for the presence of pathological lymph nodes. FNAB was performed in patients with nodes with short-axis &gt; 5 mm, rounded shape and missing echogenic hilum.&#x0D; Results: 27 (25.5%) patients had enlarged supraclavicular lymph nodes on US. Fourteen patients (13.2%) had cytologically proven lymph node involvement. Supraclavicular lymph node metastasis was more frequent in patients with medi- astinal invasion (p = 0.0001) and patients with enlarged lymph nodes on upper paratracheal stations on thorax CT (p = 0.0001). No relation was found between supraclavicular lymph node involvement and T stage (p = 0.27), distant metastasis (p = 0.50) or histological type (p = 0.80). Three patients were upstaged from IIIA to IIIB status. US-guided FNAB was the only diagnostic method in 2 patients.&#x0D; Conclusion: US-guided FNAB is a simple and safe procedure which can document N3 stage of disease in lung cancer patients. Thereby more invasive and expensive diagnostic procedures can be avoided in selected lung cancer patients.&#x0D; &#x0D; &#x0D;

ANALYSIS OF THE FIRST 100 CASES OF ENDOBRONCHIAL ULTRASOUND-GUIDED TRANSBRONCHIAL NEEDLE ASPIRATION AT A TERTIARY CARE HOSPITAL IN SAUDI ARABIA

SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) has been recommended in obtaining a cytological and histological diagnosis for patients with mediastinal and hilar lymphadenopathy for suspected lung cancer, sarcoidosis, and tuberculosis. The purpose of this study is to describe EBUS-TBNA results for the first one hundred patients at KFMC in Riyadh, Saudi Arabia. ‏ METHODS: EBUS-TBNA data for the first 105 patients who were referred to pulmonary service in KFMC with mediastinal and hilar lymphadenopathy. The data were collected retrospectively from June 2015 until February 2019. All patients had chest tomography before the procedure. Only five patients were excluded either due to an inaccessible intrathoracic lesion, malfunctioning scope or lack of rapid on-site evaluation. RESULTS: A total of 190 lymph nodes samples were obtained from 100 patients. The mean duration for the procedure was (52.4 ± 23.9) minutes. The mean biopsied lymph node diameter was (19.0 ± 10.3) millimeters. Sub-carinal lymph node station was the most common site of puncture (36.3%) followed by lower paratracheal stations with (33.2%), and interlobular stations with (14.7%). The mean age of the patients was (54.6 ± 14.7) years, with a predominance of males (66%). Only one complication of minor bleeding occurred during the procedure that did not require any further intervention. Majority of patients had the procedure done with conscious sedation (62%). A total of 89 patients (89%) had an adequate sample for cytology, and histopathological evaluation and three patients (3%) required further bronchoscopic intervention due to inadequate sample. We referred the remaining eight patients (8%) for further surgical or radiological intervention. A total of 49 patients (49%) were diagnosed malignancy with histopathology. Adenocarcinoma was the most common malignancy (20%) followed by squamous cell carcinoma (10%), and small lung cancer (8%). Sarcoidosis was found in 6 patients (6%), and two patients (2%) were diagnosed with tuberculosis. CONCLUSIONS: EBUS-TBNA is a useful modality in facilitating a rapid diagnosis with high diagnostic yield for hilar and mediastinal lymphadenopathy in KFMC. We were able to use it more under conscious sedation with no significant complications and low demand for further surgical intervention. CLINICAL IMPLICATIONS: Based on our results, EBUS-TBNA can be used safely as a first diagnostic procedure for hilar and mediastinal lymphadenopathy at our center. DISCLOSURES: No relevant relationships by Khalid Alokla, source=Web Response No relevant relationships by Norah Khalid Shafi, source=Web Response

Utility and safety of endobronchial ultrasound-guided transbronchial needle aspiration in patients with mediastinal and hilar lymphadenopathy: Western region experience.

AIMS:The aim of the study was to evaluate the clinical utility and safety of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in patients with mediastinal and hilar lymphadenopathy and to explicitly describe the utility of this procedure in patient's outcome.METHODS:A retrospective review and analysis was conducted on 52 patients with mediastinal or hilar lymphadenopathy who underwent EBUS-TBNA from June 2012 to June 2016. All the patients were evaluated by computed tomography (CT) chest with contrast before EBUS examination. Enlarged mediastinal or hilar lymph node was defined as >1 cm short axis on the enhanced CT.RESULTS:Among the 52 patients studied, 57.7% were presented with mediastinal or hilar lymphadenopathy for diagnosis and 42.3% presented with suspected mediastinal malignancy. Paratracheal stations were the most common site for puncture in 33 lymph nodes (43%). The best diagnostic yield was obtained from subcarinal stations and the lowest yield from the hilar stations. Surgical biopsies confirmed lymphoma in six patients, tuberculosis (TB) in three, sarcoidosis in two and one had metastatic adenocarcinoma of unknown primary. The sensitivity, specificity, positive predictive value, and negative predictive value of EBUS-TBNA for diagnosis of mediastinal and hilar lymph node abnormalities were 78.6%, 100%, 100%, and 80%, respectively. The diagnostic yield of EBUS-TBNA in malignant and benign conditions was 79.0%.CONCLUSIONS:EBUS-TBNA is a safe and efficacious procedure which can be performed using conscious sedation with high yields. It can be used for the staging of malignancies as well as for the diagnosis of inflammatory and infectious conditions such as sarcoidosis and TB.

Station 4R and 2R. Exposure of the right paratracheal stations by excising the mediastinal pleura above the azygos vein just lateral to the superior vena cava

Station 4R and 2R. Exposure of the right paratracheal stations by excising the mediastinal pleura above the azygos vein just lateral to the superior vena cava

Station 4L. After excision of station 5 the area below the aortic arch is entered and left paratracheal station can be accessed

Station 4L. After excision of station 5 the area below the aortic arch is entered and left paratracheal station can be accessed

Three-dimensional virtual bronchoscopy using a tablet computer to guide real-time transbronchial needle aspiration.

We proposed a new virtual bronchoscopy tool to improve the accuracy of traditional transbronchial needle aspiration for mediastinal staging. Chest-computed tomographic images (1 mm thickness) were reconstructed with Osirix software to produce a virtual bronchoscopic simulation. The target adenopathy was identified by measuring its distance from the carina on multiplanar reconstruction images. The static images were uploaded in iMovie Software, which produced a virtual bronchoscopic movie from the images; the movie was then transferred to a tablet computer to provide real-time guidance during a biopsy. To test the validity of our tool, we divided all consecutive patients undergoing transbronchial needle aspiration retrospectively in two groups based on whether the biopsy was guided by virtual bronchoscopy (virtual bronchoscopy group) or not (traditional group). The intergroup diagnostic yields were statistically compared. Our analysis included 53 patients in the traditional and 53 in the virtual bronchoscopy group. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy for the traditional group were 66.6%, 100%, 100%, 10.53% and 67.92%, respectively, and for the virtual bronchoscopy group were 84.31%, 100%, 100%, 20% and 84.91%, respectively. The sensitivity ( P = 0.011) and diagnostic accuracy ( P = 0.011) of sampling the paratracheal station were better for the virtual bronchoscopy group than for the traditional group; no significant differences were found for the subcarinal lymph node. Our tool is simple, economic and available in all centres. It guided in real time the needle insertion, thereby improving the accuracy of traditional transbronchial needle aspiration, especially when target lesions are located in a difficult site like the paratracheal station.

Coexistence of Sarcoidosis and Sjögren's Syndrome: A Case-Report

SESSION TITLE: Diffuse Lung Disease Global Case Reports SESSION TYPE: Global Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: Sarcoidosis and Sjögren's syndrome (SS) are both multisystemic diseases of unknown etiology. Sarcoidosis is a multisystemic granulomatous disease of unknown etiology. Although, lungs and the tracheobronchial tree are the most common involvement sites in sarcoidosis it can rarely effect the salivary and lacrimal glands. On the other hand, SS mainly affects the exocrine glands, but it may also have systemic manifestations. Occasionally some features of sarcoidosis may mimic SS when parotid and/or lacrimal gland involvement is present. Although they are different clinical entities there are several reports suggestive of sarcoidosis and coexisting Sjögren's syndrome in the literature (1, 2). CASE PRESENTATION: A 58 years-old Caucasian female presented with dry cough, exertional dyspnea, progressive dry mouth and dry eyes. Physical examination was unremarkable except dryness of oral mucosa and bilateral basal crackles. Laboratory examinations revealed an increased erythrocyte sedimentation rate, C-reactive protein. Routine hematological laboratory and blood chemistry values were normal. Chest radiograph showed bilateral hilar lymphadenopathy and lower zone reticular infiltrates. Chest computed tomography revealed multiple mediastinal and bilateral hilar lymphadenopathies in addition to bilateral pulmonary nodules with peribronchovascular involvement. A mild restrictive ventilatoty defect and mild reduction in carbon monoxide diffusion capacity was observed on pulmonary function tests. She underwent bronchoscopy. A transbronchial fine needle aspiration biopsy from the right lower paratracheal station revealed non-caseating granulomatous inflammation. Serum angiotensin converting enzyme level was elevated. Antinuclear antibody and antibodies against SS-A / Ro were positive. Bilateral Shirmer's tear test yielded positive. Histopathological examination of minor salivary glands showed periductal lymphocytic infiltration. The patient was diagnosed with coexisting SS and sarcoidosis. Treatment with prednisolon and hidroxychloroquine were started. During a 2 year follow-up clinical symptoms and laboratory findings normalized. Radiographic findings regressed. Corticosteroids were tapered and stopped. Until now, the patient has been treated with hidroxychloroquine with no major symptoms and findings. DISCUSSION: Our patient was considered as sarcoidosis on the basis of compatible clinical, radiological findings and histopathological verification of noncaseating granulomas in mediastinal lymph node biopsy. Elevated serum angiotensin converting enzyme also supported sarcoidosis diagnosis. On the other hand, diagnosis of SS was based on dry eye and dry mouth sympthoms, positive bilateral Schirmer's test, the presence of characteristic autoantibody (anti-Ro/SS-A) in addition to evident lymphocytic sialoadenitis in salivary gland biopsy (3). Sarcoidosis and SS share similar immunologic and histopathological features. Making a differential diagnosis between these two diseases may be difficult in cases that present with common clinical features. On the other hand, it was shown that the frequency of sarcoidosis is higher in patients with SS than in the general population (2). Immunologic profile with a high ANA, RF and anti-Ro/SS-A was shown to have an important role in differentiating between sarcoidosis mimicry or coexistence with SS in addition to biopsy. CONCLUSIONS: We emphasize that both sarcoidosis and SS may coexist as illustrated in our case. Analysis of autoantibodies may be very helpful in making differential diagnosis or deciding their coexistence. Currently, the acceptance of sarcoidosis as an exclusion criteria for SS diagnosis may lead to under-diagnosis of SS in these cases. A revision for exclusion criteria of SS diagnosis might be necessary with this respect. Reference #1: Mansour MJ, et. al. Coexistence of Sjogren's syndrome and sarcoidosis: a report of five cases. J Oral Pathol Med 2007:36:337-341. Reference #2: Ramos-Casals M, et. al. Sarcoidosis or Sjogren Syndrome? Clues to defining mimicry or coexistence in 59 cases. Medicine 2004: 83: 85-95. Reference #3: Vitali C, et. al. Classification criteria for Sjogren's syndrome: a revised version of the European criteria proposed by the American-European Consensus Group. Ann Rheum Dis 2002;61:554-558. DISCLOSURE: The following authors have nothing to disclose: Asli Gorek Dilektasli, Ezgi Demirdogen Cetinoglu, Eda Durmus, Esra Uzaslan, Ercument Ege, Mehmet Karadag No Product/Research Disclosure Information

Systematic mediastinal nodal dissection and video-assisted thoracic surgery

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.

Combined Use of TBNA and EBUS-TBNA in the Preoperative Staging of Lung Cancer Patients

The identification of the optimal mediastinal staging strategy in lung cancer patients remains an important objective to improve their selection for appropriate treatment. The aim of this study was to analyze our experience with traditional transbronchial needle aspiration (TBNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) as minimally invasive alternative procedures to mediastinoscopy in the preoperative staging of lung cancer patients with positive mediastinal positron emission tomography. Forty-four patients staged N2 or N3 after positron emission tomography were included in the study. Traditional TBNA was used in 15 patients to puncture "easy" targets such as the subcarinal lymph nodes. EBUS-TBNA was used in 29 patients to puncture "difficult" targets such as the paratracheal stations. A malignant adenopathy was identified in 39 patients (89%) who avoided a mediastinoscopy and were referred for neoadjuvant chemotherapy or chemoradiotherapy according to their mediastinal status (N2 or N3), as determined on the positron emission tomography image. In the remaining 5 patients (11%), samples were nondiagnostic. These patients underwent mediastinoscopy and subsequent neoadjuvant chemotherapy (3 cases) or surgery (2 cases) according to the presence of an N2 or an N0 disease. The combined use of traditional and EBUS-TBNA avoided a mediastinoscopy in approximately 90% of lung cancer patients referred for surgery with positive mediastinal positron emission tomography, sparing the associated costs and risks of surgical procedures. Traditional and EBUS-TBNA should be considered as complementary methods in the preoperative staging of lung cancer.

Ultrasound guided fine-needle aspiration biopsy of metastases in nonpalpable supraclavicular lymph nodes in lung cancer patients

Background and objectivesTo assess frequency and significance of enlarged nonpalpable supraclavicular lymph nodes with routine ultrasound (US) evaluation and US-guided fineneedle aspiration biopsy (FNAB) for the diagnosis and staging of patients with lung cancer.Materials and methods106 consecutive patients with lung cancer and nonpalpable supraclavicular lymph nodes were evaluated with cervical US for the presence of pathological lymph nodes. FNAB was performed in patients with nodes with short-axis > 5 mm, rounded shape and missing echogenic hilum.Results27 (25.5%) patients had enlarged supraclavicular lymph nodes on US. Fourteen patients (13.2%) had cytologically proven lymph node involvement. Supraclavicular lymph node metastasis was more frequent in patients with mediastinal invasion (p = 0.0001) and patients with enlarged lymph nodes on upper paratracheal stations on thorax CT (p = 0.0001). No relation was found between supraclavicular lymph node involvement and T stage (p = 0.27), distant metastasis (p = 0.50) or histological type (p = 0.80). Three patients were upstaged from IIIA to IIIB status. US-guided FNAB was the only diagnostic method in 2 patients.ConclusionUS-guided FNAB is a simple and safe procedure which can document N3 stage of disease in lung cancer patients. Thereby more invasive and expensive diagnostic procedures can be avoided in selected lung cancer patients.

Advances in lung cancer diagnosis and staging: endobronchial ultrasound

Endobronchial ultrasound (EBUS) is an accurate and relatively less invasive procedure for the diagnosis of lung lesions and mediastinal lymph node staging for lung cancer. We aimed to evaluate the clinical utility and safety of this new EBUS service established in our hospital. Consecutive patients who underwent EBUS-transbronchial lung biopsy (EBUS-TBLB) for biopsy of peripheral pulmonary lesions or for transbronchial needle aspiration (TBNA) of mediastinal lymph node enlargement were included in this audit. Demographic and clinical data were obtained prospectively. Diagnostic yield from the results of EBUS was compared to other clinical information obtained. Thirty-eight patients underwent EBUS over a 10-month period. The yield from EBUS-TBLB was 62%. The average size of the lung lesions biopsied was 3.5 cm and 62% were located in the upper lobes. Malignancy was diagnosed in 14 cases and a benign aetiology in four. The yield from EBUS-TBNA was 88% and the average size of the lymph nodes was 2.3 cm. The lymph nodes were all located in the subcarinal station except for two that were in the lower paratracheal station. Malignancy was diagnosed in 10 cases on TBNA and 4 cases had benign pathology. There was one complication seen (small pneumothorax). EBUS is safe and an effective method for both, diagnosis of peripheral pulmonary lesions and staging for lung cancer.

Is Lobe-Specific Lymph Node Dissection Appropriate in Lung Cancer Patients Undergoing Routine Mediastinoscopy?

The extent and the necessity of lymph node dissection has yet to be defined after resectional surgery for lung cancer. We aimed to analyze the lobe-specific extent of lymph node positivity in patients who underwent preoperative mediastinoscopy as a routine strategy. A total of 280 patients with non-small cell lung cancer with negative mediastinoscopy were operated on in our center between January 1997 and June 2003. Hilar and mediastinal lymphadenectomy was performed in every patient. The most commonly involved lymph nodes were found to be paratracheal station lymph nodes (n = 83; 96.5 %) for right upper lobe tumors, subcarinal station lymph nodes (n = 52; 88.1 %) for right lower lobe carcinomas, aorticopulmonary lymph nodes (n = 62; 92.5 %) for left upper lobe and subcarinal station lymph nodes (n = 49; 96.0 %) for left lower lobe tumors. In the patients with right upper lobe, right lower lobe and left lower lobe tumors, the presence of a tumor at these stations was found to be an indicator for poor prognosis ( P = 0.033, P = 0.0038 and P = 0.0016, respectively). Patients with multiple station N2 disease did not survive beyond 3 years. In patients who underwent routine mediastinoscopy, lobe-specific lymph node dissection could be recommended. Patients with multilevel N2 involvement did not seem to benefit from resectional surgery.

Clinical Utility of Transbronchial Needle Aspiration of Mediastinal Lymph Nodes in the Diagnosis of Sarcoidosis in Stages I and II

To analyze the individual and combined diagnostic yield and clinical utility of transbronchial needle aspiration and transbronchial biopsy in the histologic diagnosis of sarcoidosis in stages I and II. We performed a prospective study enrolling all the patients admitted to our hospital between July 2001 and June 2006 with mediastinal lymph nodes of a diameter of over 10 mm and clinical and radiological indication of sarcoidosis. The patients underwent the following tests in the order specified: a transbronchial needle aspiration of 1 or more lymph nodes using a 19-gauge histology needle until 2 satisfactory specimens were obtained, a bronchoalveolar lavage, and 4 to 6 transbronchial biopsies. A total of 32 patients were enrolled during the study period. Of these, 26 were finally diagnosed with sarcoidosis. The mean (SD) age of the patients was 38.9 (10.6) years and there were 13 women (50%). The mean (SD) lymph node diameter was 23.5 (6.5) mm. The most common lymph node aspiration sites were the subcarinal station (9 patients, 34.6%) and a combination of the subcarinal and paratracheal stations (7 patients, 26.9%). Computed tomography scans of the chest revealed parenchymal involvement in 12 (46.2%) patients. Fifteen (57.7%) patients were diagnosed by transbronchial biopsy and 16 (61.5%) by transbronchial needle aspiration. These techniques were used in isolation in 7 (26.9%) and 8 (30.8%) patients, respectively (P>.05). Diagnosis was achieved with the combined results of transbronchial biopsy and needle aspiration in 23 (88.4%) patients. Overall, the diagnostic yield of the combined techniques was significantly higher than that of either one in isolation (P=.01 vs transbronchial biopsy and P=.02 vs needle aspiration). In patients with parenchymal involvement, yield was better for the combined techniques only in comparison with transbronchial biopsy (P=.01). Only 4 (15%) patients developed complications and 20 (76.9%) tolerated the procedures well. Diagnostic yield was significantly higher when transbronchial biopsy and transbronchial needle aspiration were used in combination than when used alone, particularly in patients without parenchymal involvement. There were few complications and tolerance was good.