Video-assisted Mediastinoscopic Lymphadenectomy Research Articles

Video-assisted mediastinoscopic lymphadenectomy (VAMLA): Mature results for staging non–small cell lung cancer with normal mediastinum

ObjectivesThe aim of this study is to analyze the accuracy of video-assisted mediastinoscopic lymphadenectomy (VAMLA) and the unsuspected (u) N2/3 rates in patients with non–small cell lung cancer (NSCLC) and normal mediastinum by integrated positron emission tomography-computed tomography. MethodsProspective observational single-center study of 603 consecutive VAMLAs from 2010 to 2022. Exclusion criteria: other indications (n = 32), tumors different from NSCLC (n = 91), and clinical (c) N2/3 tumors by positron emission tomography-computed tomography (n = 46). Systematic nodal dissection was the gold standard to validate negative VAMLAs. Those patients with negative VAMLA and missing reference standard test were excluded. uN2/3 rates were analyzed in the global series and in the subgroups of tumors according to their clinical nodal and tumor categories. Pathologic findings were reviewed, and staging values were calculated. ResultsThree hundred eighty-three patients with cN0/1 NSCLC underwent VAMLA. Staging values of VAMLA were: sensitivity, 0.98 (95% CI, 0.92-0.99); negative predictive value, 0.99 (95% CI, 0.98-1); and diagnostic accuracy, 0.99 (95% CI, 0.98-1). The uN2/3 rate for the whole series (N = 383) was 18.8%. The uN2/3 rates according to presurgical nodal and tumor categories determined by positron emission tomography computed tomography were: 3.6% (4 out of 111) in cT1N0; 16.3% (18 out of 110) in cT2N0; 10.25% (4 out of 39) in cT3N0; and 32% (7 out of 22) in cT4N0. Forty-two percent (39 out of 93) in cN1; complication rate was 7%. ConclusionsThis series of NSCLC with normal mediastinum staged by VAMLA demonstrates a high accuracy of this technique and a high rate of uN2/3 disease (specially in cN1 and cT4N0). VAMLA could be considered the reference staging procedure for staging cN0/1 NSCLC.

Mediastinal lymph node removal modulates natural killer cell exhaustion in patients with non-small cell lung cancer.

Non-small cell lung cancer (NSCLC) is the leading cause of cancer-related death globally. In this study, the effect of complete removal of mediastinal lymph nodes by video-assisted mediastinoscopic lymphadenectomy (VAMLA) on natural killer (NK) cell phenotype and functions in patients with NSCLC was evaluated. The study included 21 NSCLC patients (cIA-IVA) undergoing VAMLA staging and 33 healthy controls. Mononuclear cells were isolated from peripheral blood of all participants and mediastinal lymph nodes of the patients. NK cells were analyzed by flow cytometry to define NK subsets, expressions of PD-1, CTLA-4, activating/inhibitory receptors, granzyme A, and CD107a. The plasma levels of soluble PD-1, PDL-1, and CTLA-4 were measured by ELISA. Mediastinal lymph nodes of NSCLC patients had increased ratios of exhausted NK cells, increased expression of PD-1 and IL-10, and impaired cytotoxicity. Mediastinal lymph nodes removal increased CD56dimCD16bright cytotoxic effector phenotype and reduced exhausted NK cells. PD-1+ NK cells were significantly more abundant in patients' blood, and VAMLA significantly reduced their ratio as well. The ratio of IL-10 secreting regulatory NK cells was also reduced after VAMLA. Blood NK cells had increased cytotoxic functions and spontaneous IFN-γ secretion, and these NK cell functions were also recovered by VAMLA. Mediastinal lymph node removal reversed NK cell exhaustion, reduced regulatory NK cells, and improved antitumoral functions of NK cells. Tumor-draining lymph nodes may contribute to tumor evasion from antitumoral immune responses. The role of their removal needs to be further studied both to better understand this mechanism and as a potential immunotherapeutic approach.

Portrayal of video-assisted mediastinoscopic lymphadenectomy’s range subsequent to its simultaneous use with uniportal VAT-lobectomy for left-sided NSCLC: a case-based perspective

BackgroundVideo-assisted mediastinoscopic lymphadenectomy (VAMLA) is the most precise approach combining staging and therapeutic interventions in non-small cell lung cancer (NSCLC). In the case of left-sided NSCLC, the likelihood of mediastinal lymph node metastases depends on the involvement of the left lung regional lymphatic network. As such, it appears obvious – at least for selected patients with mediastinal staging by either PET-CT or EBUS-TBNA ± EUS-FNA and with cN ≤ 2 – to merge VAMLA and left-sided video-assisted thoracoscopic (VAT) lobectomy for a single-stage therapeutical procedure.Case presentationWe present the clinical course of an 83-year-old patient following simultaneous VAMLA and VAT-lobectomy for invasive mucinous adenocarcinoma of the left upper lobe with a provisional cT3cN0cM0 stage. The patient developed a clinically relevant postoperative pneumothorax due to a persistent parenchymal air leak. CT scan revealed a substantial pneumomediastinum and showed the capability of VAMLAs range for mediastinal lymph node dissection in a unique way. Following the prompt insertion of a second chest tube, the situation was stabilized with an unremarkable further in-hospital stay. The patient remains free of tumor recurrence or distant metastases at a one-year follow-up.ConclusionPresenting this aperçu, we encourage reviving the debate on (1) precise mediastinal staging in general and (2) VAMLA’s important role as a diagnostic and therapeutic tool.

Survival of Non-Small Cell Lung Cancer Patients with Unexpected N2 after Complete Resection: Role of Aggressive Invasive Mediastinal Staging should be Considered

Objective: Mediastinal lymph node (N2) metastasis is one of the poor prognostic factors in non-small cell lung cancer patients (NSCLC). However, the accuracy of mediastinal lymph node staging in real practice is uncertain and inadequate. Consequently, the aim of this study was to determine the survival of NSCLC patients with clinically non-suspicious mediastinal lymph node metastases who underwent complete resection but were pathologically confirmed as having N2 metastases (unexpected N2).Materials and Methods: A retrospective review was performed of all pathology-proven N2 metastases NSCLC patients who underwent curative surgical resection from January 2007 to December 2016. A total of 158 patients were initially included in the study. After the exclusions (known N2, small cell carcinomas, neuroendocrine tumor), 125 unexpected N2 patients who underwent complete resection were analyzed. Survival analysis was determined using the Kaplan–Meier method and multivariate analysis was determined using the Cox regression method.Results: The overall 2-year, 3-year, and 5-year survival rates were 40%, 24%, and 20% respectively. Complete resection was achieved in all patients. Invasive mediastinal staging (IMS) was performed in 47 patients (37.6%), by endobronchial ultrasonography (EBUS) in 46 (36.8%) patients (82.6% negative and 17.4% inadequate tissue) while only 1 patient underwent mediastinoscopy. The factors affecting the survival rate upon comparison were the histology type (p=0.019), differentiate characteristics (p=0.004), adjuvant therapy (p=0.011), and presence of distant metastasis by postoperative re-staging (p=0.003). The independent predictive factors for survival werechemo-radiation therapy (odds ratio 0.367, 95% confidence interval 0.176–0.766) and distant metastasis (odds ratio 2.280, 95% confidence interval 1.334–3.897). However, a small size, periphery lesion, T staging, and number of N2 lesions were not significant factors.Conclusion: The survival rate of unexpected N2 patients was low despite complete resection being achieved in these patients. Adjuvant therapy seemed to improve survival for those with unexpected N2 metastasis as it is a systemic disease. However, not all patients received IMS, which was mostly done by EBUS and which had a high false negative, leading to underestimating the staging. Other modalities, such as cervical mediastinoscopy, videoassisted mediastinoscopic lymphadenectomy (VAMLA) or open biopsy should be considered for the adequate evaluation of N2 metastasis, nonetheless further study is still needed.

Comparison of Long-Term Outcomes Between Minimally Invasive Pulmonary Resection With and Without Video-Assisted Mediastinoscopic Lymphadenectomy for Left-Sided Lung Cancer.

This study aimed to assess the long-term outcomes of video-assisted mediastinoscopic lymphadenectomy (VAMLA) combined with video-assisted thoracic surgery (VATS) for left-sided lung cancer pulmonary resection. We retrospectively reviewed 1194 consecutive patients who underwent VATS anatomical resection for left-sided lung cancer between January 2007 and December 2016. Using propensity score-based inverse probability of treatment weighting (IPTW), perioperative outcomes and long-term survival outcomes were compared. Among 1194 patients, 295 (24.7%) underwent additional VAMLA (VATS + VAMLA group) and 899 patients (75.3%) underwent VATS only (VATS group). The proportion of patients with advanced N stage were higher in the VATS + VAMLA group (24.7%) than in the VATS group (18.3%). After IPTW adjustment, all baseline profiles between the two groups became similar. The long-term overall survival (OS) and recurrence-free survival (RFS) rates were similar between the VATS + VAMLA group and the VATS group (5-year OS, 77.8% versus 79.3%, p = 0.957; 5-year RFS, 69.6% versus 70.1%, p = 0.498). However, among patients with borderline pulmonary function (FEV1 ≤ 60% or DLCO ≤ 60%), the VATS + VAMLA group (n = 23) had a better prognosis than the VATS group (n = 36) (5-year OS, 67.4% versus 46.7%, respectively; p = 0.047; 5-year RFS, 74.6% versus 53.5%, respectively; p = 0.027). VAMLA might be a good complement to VATS for left-sided lung cancer, wherein optimal mediastinal lymph node dissection is not feasible under one-lung ventilation, such as when patients have borderline pulmonary function.

Mediastinal lymph node removal ameliorates cytotoxic T-lymphocyte functions in patients with non-small cell lung cancer.

Mediastinal lymph node (MLN) removal by video-assisted mediastinoscopic lymphadenectomy (VAMLA) for preoperative cancer staging was reported to be associated with increased survival. The aim of this study was to evaluate the immunologic effects of complete MLN removal by VAMLA on cytotoxic T lymphocyte (CTL) phenotype and function. Seventeen patients with non-small cell lung cancer (NSCLC) (stage cT1-4N0-3M0-1A) and 20 healthy participants were included in this study. Blood samples were collected before and 4 weeks after the procedure. Lymphocytes were isolated from the removed MLNs. CTL phenotypes and functions were evaluated by flow cytometry. Plasma levels of soluble programmed cell death protein 1 (sPD-1), soluble programmed cell death protein 1 ligand, and soluble CTL antigen 4 (sCTLA-4) were measured with enzyme-linked immunosorbent assay. The ratio of the immunosenescent CTLs (CD3+CD8+CD28-) was increased in peripheral blood and MLNs of the patients with NSCLC compared to controls (p = 0.037), and MLN removal did not change this ratio. PD-1 and CTL antigen 4 expressions were significantly reduced in peripheral blood CTLs after MLN removal by VAMLA (p = 0.01 and p = 0.01, respectively). Granzyme A expression was significantly reduced in the peripheral blood CTLs of the patients compared to controls (p = 0.006) and MLN removal by VAMLA significantly improved Granzyme A expression in CTLs (p = 0.003). Plasma concentrations of sPD-1 and sCTLA-4 remained unchanged after VAMLA. CTLs in the MLNs and peripheral blood of the patients with NSCLC had an immunosenescent phenotype, increased immune checkpoint receptor expression, and impaired cytotoxicity. MLN removal by VAMLA improved these phenotypic and functional characteristics of CTLs. These changes may explain the potential contribution of VAMLA to improved survival.

Controversies in Mediastinal Staging for Nonsmall Cell Lung Cancer

AbstractMediastinal lymph nodal involvement in nonsmall cell lung cancer plays a crucial role in deciding treatment strategy. Survival falls markedly with increasing involvement of mediastinal nodal stations. Hence, accurate staging of the mediastinum with lowest morbidity is of utmost importance. A wide array of invasive and noninvasive modalities that complement each other in assessing the nodes are available at our disposal. Guidelines recommend noninvasive imaging as the initial step in the staging algorithm for all tumors, followed by invasive staging. No single modality has proven to be the ideal method to stage the mediastinum when used alone. In the present decade, minimally invasive endobronchial ultrasound (EBUS) has challenged the position of surgical mediastinoscopy, which has been the gold standard, historically. However, a negative EBUS needs to be confirmed by surgical mediastinoscopy. Video-assisted mediastinoscopic lymphadenectomy has also come to the forefront in last two decades and has shown exceptional results, when performed in experienced centers. This review details the various modalities of mediastinal staging and the controversies surrounding the optimal method of staging, restaging after neoadjuvant therapy, and the most cost-effective strategy.

Surgical mediastinal lymph node staging for non-small-cell lung carcinoma.

BackgroundThe current preferred approach for surgical mediastinal staging of non-small-cell lung carcinoma is video-assisted mediastinoscopy. An alternative technique in which lymph nodes are resected instead of biopsied is video-assisted mediastinoscopic lymphadenectomy (VAMLA) that is suggested to be superior in detecting N2 disease. Yet, evidence is conflicting and furthermore limited by sample size. The objective was to compare mediastinal staging through VAMLA and video-assisted mediastinoscopy.MethodsA single-center cohort study was conducted. All consecutive patients that underwent surgical mediastinal staging of non-small-cell lung carcinoma by VAMLA (2011 to 2018) were compared to historic video-assisted mediastinoscopy controls (2007 to 2011). Patients with negative surgical mediastinal staging underwent subsequent anatomical resection with systematic regional lymphadenectomy. Primary outcome was the sensitivity and negative predictive value for detecting N2 disease.ResultsTwo-hundred-sixty-nine video-assisted mediastinoscopic lymphadenectomies and 118 video-assisted mediastinoscopies were performed. The prevalence of N2 disease was 20% and 26% respectively in the VAMLA and video-assisted mediastinoscopy group, while the rate of unforeseen pN2 resulting from lymph node dissection during anatomical resection was 4% and 11%, respectively. Invasive staging using VAMLA demonstrated superior sensitivity of 0.82 and a negative predictive value of 0.96 when compared to video-assisted mediastinoscopy (0.62 and 0.89, respectively), offering a 64% decrease in risk of unforeseen pN2 following anatomical resection. However, VAMLA is also associated with a 75% risk increase on complications (P=0.36).ConclusionsWe conclude that performing invasive mediastinal lymph node assessment for staging of non-small-cell lung carcinoma, VAMLA should be the preferred technique with superior sensitivity and negative predictive value in detecting N2 disease. Though, VAMLA is also associated with an increased risk of complications.

Mediastinal staging for non-small cell lung cancer

The staging of mediastinal lymph nodes for lung cancer is crucial for planning treatments or reinterventions. In potentially curable patients the aim of mediastinal staging is to exclude the presence of malignancy in mediastinal lymph nodes with a high level of accuracy while also considering clinical factors and the balance of the benefits and risks of tissue sampling techniques. Mediastinal staging is based on computed tomography (CT) and positron emission tomography (PET) and can be sufficient when no mediastinal abnormalities are present and the probability of unforeseen N2 disease is low. In the case of bulky lymph nodes with a high probability of malignancy in PET-CT, tissue confirmation is not normally required. If mediastinal sampling is needed it can be achieved by endosonographic techniques, including endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) or a combination of the two. Positive results do not need further confirmation. In the case of negative results, surgical techniques still play a role in the selected cases discussed by multidisciplinary lung cancer committees. New mediastinal surgical techniques including video-assisted cervical mediastinoscopy (VACM), video-assisted mediastinoscopic lymphadenectomy (VAMLA), and transcervical extended mediastinal lymphadenectomy (TEMLA) have been shown to be useful in selected patients. Final pathological staging is based on lymph node removal during surgery and can be achieved by taking one of two approaches: lymph node sampling or systematic lymph node sampling. The accuracy of PET-CT and mediastinal endosonography is lower for mediastinal restaging than it is for surgical techniques; their false positive and false negative (FN) rate is high and so, they require histological confirmation. Here we explain and revise the results from the most recent studies and current international guidelines.

The learning curve of video-assisted mediastinoscopic lymphadenectomy for staging of non-small-cell lung carcinoma.

The objective of this study was to define the learning process of video-assisted mediastinoscopic lymphadenectomy (VAMLA) by the assessment of consecutive procedural metrics. We conducted a single-centre retrospective observational study of all consecutive VAMLAs performed between 2011 and 2018 for the staging of non-small-cell lung carcinoma. Learning curves were assessed using non-risk adjusted cumulative observed minus expected (CUSUM) failure charts of complications. Boundary lines were defined by the acceptable and unacceptable complication rates of 4.5% and 15.0%. The Kruskal-Wallis test with post hoc analysis was used to assess trends in operation time and blood loss. Two-hundred-thirty-six unique VAMLAs by 4 surgeons performing their first procedures were evaluated. CUSUM charts of surgeons A and B showed a typical learning curve with an initial incline, followed by a turning point towards lower complications rates after 16-17 cases, whereas surgeons C and D showed an average performance. The median time between consecutive VAMLAs was shorter for surgeons A and B (13.0 vs 28.5-38.0 days for surgeons C and D). Overcoming the learning curve, complication rates of surgeons A and B decreased from 19% to 3% and from 18% to 5%, respectively. Operation time and blood loss showed a significant improvement after, respectively, 81-100 and 61-80 procedures compared to the first 20 procedures. VAMLA is a safe procedure to adopt and perform with acceptable complication rates from the first operation onward, regardless of the caseload. To overcome its learning curve, 16-17 cases are required, preferably at least 1 per 2 weeks.

Video-Assisted Thoracoscopic Lung Resection Following Video-AssistedMediastinoscopic Lymphadenectomy in the Cure of Non-Small Cell LungCancer

Aim: The aim of this study was to evaluate the technical feasibility and limitations of video-assisted mediastinoscopic lymphadenectomy (VAMLA) followed by video-assisted thoracoscopic surgery (VATS) lobectomy and video-assisted thoracoscopic surgery (VATS) lobectomy alone in treating patients with non-small cell lung cancer. VATS lobectomy alone or following VAMLA is feasible and can be done with an acceptable safety profile under the hands of specialized, highly trained and cooperating team working in a high volume center treating patients with lung cancer. VAMLA followed by VATS lobectomy allowed the excision of more lymph nodes compared to the VATS approach alone, suggesting that VAMLA is a good adjuvant to VATS lobectomy for complete radical mediastinal lymphadenectomy for the surgical cure of non-small cell lung cancer patients. Over the last decade we witnessed significant change of practice in many thoracic units within the hands of a new generation of young minimally invasive thoracic Surgeons. The goal of our research was to evaluate the technical feasibility and limitations of video-assisted mediastinoscopic lymphadenectomy (VAMLA) followed by video-assisted thoracoscopic surgery (VATS) lobectomy and video-assisted thoracoscopic surgery (VATS) lobectomy alone in treating patients with non-small cell lung cancer. A prospective study from September 2015 to September 2016 involving 22 non-small cell lung cancer patients admitted to the Department of Thoracic Surgery of the Referral Oncologic Center of Basilicata (IRCCS-CROB), Italy, was done. Six patients underwent a combination of subsequent VAMLA and VATS lobectomy (Group A), whereas sixteen patients underwent lobectomy and mediastinal lymphadenectomy using thoracoscopy only (Group B). Comparison between the two studied groups was done regarding the baseline characteristics, operative profiles and complications. Males were more than females (17 patients vs. 5 patients) respectively. The most common tumour was T1 (18 patients). And, the most common encountered tumour was adenocarcinoma (17 Patients). Our results highlighted that the lobectomy operative time was shorter in (Group A), (117 minutes) compared to (Group B), (157.5 minutes). The total number of mediastinal lymph nodes excised in (Group A), (18 lymph nodes) was more than (Group B), (12.5 lymph nodes). VATS lobectomy alone or following VAMLA is feasible and can be done safely under the hands of specialized, highly trained and cooperating team working in a high volume center treating lung cancer patients.

Video-assisted mediastinoscopic lymphadenectomy (VAMLA) for staging & treatment of non-small cell lung cancer (NSCLC).

Precise preoperative staging and restaging of mediastinal lymph nodes in patients with potentially resectable non-small cell lung cancer (NSCLC) is of supreme importance. Over the last years, algorithms on preoperative mediastinal staging incorporating imaging, endoscopic and surgical techniques have been widely published, offering more evidence concerning different mediastinal staging techniques. Current guidelines well define when and how to receive tissue confirmation in case of computed tomography (CT)-enlarged or positron emission tomography (PET)-positive mediastinal lymph nodes. Endosonography [(endoscopic bronchial ultrasonography/oesophageal ultrasonography (EBUS/EUS)] with fine needle aspiration still is the first choice (when accessible) since it is minimally invasive and has a high sensitivity to confirm mediastinal nodal disease. If negative, surgical staging with nodal dissection or biopsy is indicated. Video-assisted mediastinoscopic lymphadenectomy (VAMLA) and transcervical extended mediastinal lymphadenectomy (TEMLA) are preferred over conventional mediastinoscopy if a mediastinal R0-resection can be achieved. The mutual use of endoscopic and surgical staging effects highest accuracy. Straight surgical resection of tumors ≤3 cm (located within the external third of the lung) with systematic nodal dissection is justified as soon as there are no enlarged lymph nodes on CT-scan and once there is no nodal uptake on PET-CT. In case of central tumors and enlarged or FDG avid nodes regardless of cytological result, preoperative invasive mediastinal staging is indicated to rule out mediastinal nodal spread. However, accuracy needed in preoperative nodal staging has been under continuous debate ever since and with the advent of immunotherapy is right now intensely revived. During the last two decades VAMLA has been growing up from being a merely staging tool to an expert-recognized therapeutic tool in the context of minimal invasive lung cancer resection.

Invasive mediastinal staging by endosonography or video-assisted mediastinoscopy in PET-CT clinical N1 non-small cell lung cancer.

Patients with clinical N1 (cN1) non-small cell lung cancer (NSCLC) based on PET-CT imaging are often found to have occult mediastinal nodal involvement (N2-disease) at invasive staging or resection although the PET-CT was negative on the mediastinum. Two multicenter prospective studies in patients with PET-negative mediastinum but suspected cN1-disease were performed to measure sensitivity of two invasive mediastinal staging strategies to detect mediastinal nodal disease, one with endosonography and one with video-assisted mediastinoscopy (VAM) or video-assisted mediastinoscopic lymphadenectomy (VAMLA). Consecutive patients with operable and resectable cN1 (suspected) NSCLC underwent endosonography, if negative followed by mediastinoscopy in the first study (n=100). In the second study with identical inclusion criteria, patients (n=105) underwent a VAM or VAMLA [VAM(LA)]. All patients underwent FDG-PET and CT scan prior to invasive mediastinal staging. The primary study outcome was sensitivity to detect N2-disease. Secondary endpoints were the prevalence of N2-disease, negative predictive value (NPV) and accuracy of the invasive staging procedure. In both studies, 25% of patients with cN1 disease on imaging had eventually pathology-proven N2-disease. Endosonography alone reached a sensitivity (38%) to detect mediastinal nodal disease. Invasive mediastinal staging with VAM(LA) had a sensitivity of 73% to detect N2-disease. The NPV was 92% and accuracy 93%. At endosonography, a mean of 2.1 mediastinal nodal stations were biopsied vs. 3.9 at VAM(LA). VAM(LA) has a satisfactory sensitivity of 73% to detect mediastinal nodal disease in cN1 lung cancer and could be the technique of choice for pre-resection mediastinal lymph node assessment in this patient group with a one in four chance of occult positive mediastinal nodes after negative PET-CT.

Endobronchial ultrasonography with aspiration biopsy of the mediastinal lymph nodes and video-assisted mediastinoscopic lymphadenectomy in detecting "occult" N2-N3 metastasis in patients with non-small cell lung cancer

The condition of the mediastinal lymph nodes is an important factor in the selection of patients with non-small cell lung cancer for surgical treatment. Of particular concern are patients with not enlarged mediastinal lymph nodes according to CT-scan. The frequency of their “occult” pN2-N3 lesions can reach 22–41%. The aim of the study was to assay the possibilities of endobronchial ultrasono­graphy with transbronchial needle aspiration (EBUS/TBNA) of mediastinal lymph nodes and video-­assisted mediastinal lymphadenectomy (VAMLA) in detecting “occult” N2-N3 metastasis in patients with NSCLC. Materials and methods: 51 patients with proved NSCLC were included in this study. Inclusion criteria were: central tumor localization, peripheral cT2 tumors of more, cN1 stage, absence of mediastinal lymphadenopathy according to CT-scan. All patients performed EBUS/TBNA. Upon confirmation of the N2-N3 stage according to the data of a planned morphological study, the patient was referred to neoadjuvant therapy. With negative results, radical lung resection was performed. With inadequate results of an aspiration biopsy, VAMLA was performed with a frozen section study of one selective lymph node from stations 4R, 4L, 7. If their metastatic lesion was excluded in the same anesthesia, anatomical lung resection with systematic lymphodissection was performed. Results. The overall level of pN2-N3 lesion was 18.6% (9/51). Metastases to the mediastinal lymph nodes statistically prevailed in the group of patients with cN1 stage — 40% of cases (6/15). The fact of metastatic lesion of the lymph nodes did not depend on the adequacy of the aspiration biopsy. A metastatic lesion of the lymph nodes removed during VAMLA was revealed after the fact according to the results of a planned histological examination. The sensitivity of VAMLA was 71%, and PNV — 91%. Sensitivity and PNV of EBUS/TAB were 11% and 84%, respectively. Conclusion. cN1-stage is a factor of extremely high risk of "occult" metastasis. To exclude a regional lesion of not enlarged mediastinal lymph nodes, EBUS/TBNA is not enough. A necessary condition for the use of VAMLA in the framework of N-staging of patients with a high risk of “occult” metastasis is its use as an independent operation, with a mandatory planned study of all removed lymph nodes.

Video-Assisted Mediastinoscopic Lymphadenectomy (VAMLA): Recipe and Cooking Secrets (a Tutorial)

Being a central part in the book of thoracic oncology, correct diagnosis and precise staging of lung cancer is of fundamental interest. As the lung-cancer chapter turned out being more kind of a recipe book of therapeutic possibilities, the list of diagnostic ingredients is not negligible: the various spices consists of different anatomic and metabolic imaging techniques as well as of endoscopies and minimally invasive surgical procedures. Indeed, these staging techniques should be performed well seasoned, that is, sequentially and with an increasing degree of invasiveness. But when it comes to the determination of algorithms on preoperative mediastinal staging, video-assisted mediastinoscopic lymphadenectomy represents indispensably the gold standard when highest accuracy in cytological result is needed. We hereby describe in detail our current operative technique of the video-assisted mediastinoscopic lymphadenectomy procedure, which clarifies its growing up from being just a solely diagnostic and dissection tool to an expert-recognized combined staging and advanced therapeutic tool in the context of minimal invasive lung cancer resection.

MS06.05 Transcervical Lymphadenectomies

Introduction: The aim of his study is to analyze the issue of transcervical lympadenectomies for Non-Small-Cell Lung Cancer performed by the techniques of Video-Assisted Mediastinoscopic Lymphadenectomy (VAMLA) and Transcervical Extended Mediastinal Lymphadenectomy (TEMLA). Methods The Pubmed search was performed and there were 27 articles found on VAMLA and 33 articles on TEMLA. After further analysis there were 13 original article on VAMLA and 18 original articles on TEMLA. In the current paper all proven and possible advantages of transcervical lymphadenectomies represented by VAMLA and TEMLA are described. Results The proven advantages of VAMLA and TEMLA: 1. Superior diagnostic value in discovery of the metastatic mediastinal nodes for staging and restaging of NSCLC. 2. bilateral mediastinal lymphadenectomy, more extensive than the techniques of lymphadenectomy used during standard thoracotomy or Video-Assisted Thoracic Surgery (VATS) approaches. Possible advantages include: 1. Improved selection of patients for pulmonary resection for NSCLC 2. Combination of VAMLA/TEMLA with VATS pulmonary resection, 3. Combination of VAMLA/TEMLA with esophegeal resection, 4. Combination of TEMLA and Stereotactic Radiotherapy (SBRT) for advanced NSCLC 5. The use of TEMLA for preoperative staging of mesothelioma, 6. Combination of TEMLA and pulmonary lobectomy through a sole transcevical approach 7. Resection of various metastatic tumors, including thyroid cancer and metastatic mediastinal nodes. 8. Possible impact of VAMLA/TEMLA on improvement of survival for NSCLC patients, which is the most important issue. In case of VAMLA superior survival of patients operated on with the use pulmonary resection with VAMLA in comparison to the pulmonary resection with addition of standard mediastinoscopy. In case of TEMLA no reports on survival has been published, yet Disadvantages of VAMLA/TEMLA include 1. Possible complications, especially the left recurrent nerve palsy 2. Possible delay or elimination of some patients from pulmonary resection due to postoperative complication in case of negative result of VAMLA/TEMLA 3. Scar in the neck (cosmetic) 4. Demanding surgical technique Conclusions 1. Bilateral transcervical lymphadenectomies representd by VAMLA and TEMLA are more extensive than the techniques of lymphadenectomy used during standard thoracotomy or Video-Assisted Thoracic Surgery (VATS) approaches and superior to the other techniques of staging and restaging of NSCLC in regard to the diagnostic value. 2. There are several other possible advantages of TEMLA/VAMLA for the treatment of NSCLC, esophageal cancer, mediastinal tumors and malignant mesothelioma. 3. Possible impact of VAMLA/TEMLA on survival of NSCLC has not been proven, yet. References Hurtgen M, Friedel G, Toomes H et al: Radical video-assisted mediastinoscopic lymphadenectomy (VAMLA) – technique and first results. Eur J Cardiothorac Surg 2002;21:348-51 Zielinski M, Szlubowski A, Kołodziej M, Orzechowski S, Laczynska E, Pankowski J, Jakubiak M, Obrochta A. Comparison of endobronchial ultrasound and/or endoesophageal ultrasound with transcervical extended mediastinal lymphadenectomy for staging and restaging of non-small-cell lung cancer. J Thorac Oncol. 2013 May;8(5):630-6. Zielinski M, Hauer J, Hauer L, Pankowski J, Nabialek T, Szlubowski A. Staging algorithm for diffuse malignant pleural mesothelioma. Interact Cardiovasc Thorac Surg. 2010;10:185-9 Zieliński M, Pankowski J, Hauer L et al: The right upper lobe pulmonary resection performed through the transcervical approach. Eur J Cardiothorac Surg. 2007;32:766-769 Singh AK, Hennon M, Ma SJ, Demmy TL, Picone A, Dexter EU, Nwogu C, Attwood K, Tan W, Hermann GM, Fung-Kee-Fung S, Malhotra HK, Yendamuri S, Gomez-Suescun JA. A pilot study of stereotactic body radiation therapy (SBRT) after surgery for stage III non-small cell lung cancer. BMC Cancer. 2018 Nov 29;18(1):1183. https://doi.org/10.1186/s12885-018-5039-5. Turna A, Demirkaya A, Ozkul S, Oz B, Gurses A, Kaynak K. Video-assisted mediastinoscopic lymphadenectomy is associated with better survival than mediastinoscopy in patients with resected non-small cell lung cancer. J Thorac Cardiovasc Surg. 2013 Oct;146(4):774-80. https://doi.org/10.1016/j.jtcvs.2013.04.036. Epub 2013 Jun 15. Li X, Wang W, Zhou Y, Yang D, Wu J, Zhang B, Wu Z, Tang J. Efficacy comparison of transcervical video-assisted mediastinoscopic lymphadenectomy combined with left transthoracic esophagectomy versus right transthoracic esophagectomy for esophageal cancer treatment. World J Surg Oncol. 2018 Feb 9;16(1):25. https://doi.org/10.1186/s12957-017-1268-3. Call S, Obiols C, Rami-Porta R, Trujilo-Reyes JC, Iglesias M, Saumench R, Gonzalez-Pont G, Serra-Mitjans M, Belda-Sanchís J. Video-Assisted Mediastinoscopic Lymphadenectomy for Staging Non-Small Cell Lung Cancer. Ann Thorac Surg. 2016 Apr;101(4):1326-33. https://doi.org/10.1016/j.athoracsur.2015.10.073. Epub 2016 Jan 21. .Kim HJ, Kim YH, Choi SH, Kim HR, Kim DK, Park SI. Video-assisted mediastinoscopic lymphadenectomy combined with minimally invasive pulmonary resection for left-sided lung cancer: feasibility and clinical impacts on surgical outcomes†. Eur J Cardiothorac Surg. 2016 Jan;49(1):308-13. https://doi.org/10.1093/ejcts/ezv077. Epub 2015 Mar 11 Zielinski M. Transcervical Resection of the Mediastinal Tumors. In Zielinski M, Rami-Porta R (eds). Transcervical Approach in Thoracic Surgery. Springer 2014, pages 141-148.

MA08.09 Results of Trimodality Therapy for Patients with cN2 Lung Cancer Diagnosed by Video-Assisted Mediastinoscopic Lymphadenectomy (VAMLA)

MA08.09 Results of Trimodality Therapy for Patients with cN2 Lung Cancer Diagnosed by Video-Assisted Mediastinoscopic Lymphadenectomy (VAMLA)

Cervical mediastinoscopy and video-assisted mediastinoscopic lymphadenectomy for the staging of non-small cell lung cancer.

The staging of mediastinal lymph nodes is essential for planning the most adequate treatment for patients with non-small cell lung cancer (NSCLC). For this reason, the current American and European guidelines recommend obtaining tissue confirmation of any mediastinal abnormality seen on chest computed tomography (CT) and positron emission tomography (PET). This can be done by endoscopic techniques, such as endobronchial ultrasonographic fine-needle aspiration (EBUS-FNA), esophageal ultrasonographic FNA (EUS-FNA), or a combination of the two (CUS). Traditionally, surgical methods have been reserved to validate the negative results of minimally invasive endoscopic techniques. However, based on the latest evidence, cervical mediastinoscopy and video-assisted mediastinoscopic lymphadenectomy (VAMLA) have demonstrated their superiority over minimally invasive methods in terms of performance for those tumors with normal mediastinum [clinical (c) N0-1 by CT and PET]. Therefore, cervical mediastinoscopy and VAMLA should be considered in the staging algorithms of this particular subset of NSCLC, and in the other well-established indications.

Video-assisted mediastinoscopic lymphadenectomy combined with transcervical thoracoscopy.

Surgical techniques remain the gold standard to diagnose and staging lung and pleural tumours. Non-invasive techniques have become more accurate but actually they are not enough to plan and evaluating prognosis of lung and pleural tumours. In some cases, we need to explore the pleural cavity and the mediastinal lymph node status to confirm or rule out tumour dissemination. The combination of video-assisted mediastinoscopic lymphadenectomy (VAMLA) and thoracoscopy through a single transcervical incision allows the surgeon to widen the range of the exploration and to improve the staging for lung and pleural cancers. VAMLA allows to perform a complete lymphadenectomy of the subcarinal space, the right and pretracheal areas. We consider sampling more safety on the left side to avoid left recurrent nerve injuries. Once this mediastinal tissue is removed, the right mediastinal pleura can be identified and incised. Once mediastinal pleura is opened, a 5 mm 30º thoracoscope is inserted through the video- mediastinoscope into the pleural cavity. It allows to obtain samples of parietal or visceral pleural, pleural fluid or lung nodules if present. In case of left-sided thoracoscopy the access to the left pleural cavity is anterior to the aortic arch as for extended cervical mediastinoscopy. The combination of VAMLA and thoracoscopy is useful to explore the mediastinum and the pleural space from a single incision and in the same surgical setting through the transcervical approach.

Diagnosis and staging of locally advanced non-small cell lung cancer

T4 non-small cell lung cancer (NSCLC) might include a wide range of clinical scenarios. In very selected cases a surgical treatment might be indicated, after careful staging and thorough functional evaluation. Performance status, cardiac and pulmonary function should be evaluated in detail, in a tailored fashion according to the planned surgical operation. Besides the anatomical lung unit (lobectomy or pneumonectomy), resection may involve several vital structures, including great vessels and some portion of the atria. Given the particular nature of T4, surgery is often a part of a multimodal approach. In case of induction therapies, pulmonary function should be re-assessed, to rule out any deterioration that could eventually jeopardize survival. Computed tomography (CT) scan and positron emission tomography (PET)-CT should be always performed to stage the disease, but in case of chest wall, airways or other mediastinal organs involvement, more detailed exams, such us Magnetic Resonance, echocardiography or CT angiography (CTA) and magnetic resonance angiography (MRA) should be carried out. Additionally, a careful investigation for possible mediastinal nodal involvement should be routinely performed, given the detrimental effect of nodal diffusion on survival in this subset of patients. Nowadays endobronchial ultrasound (EBUS), endoscopic (esophageal) ultrasound are reliable and semi-invasive tools that can be used as first step prior to more invasive surgical diagnostic procedures such as video assisted mediastinoscopy or even video-assisted mediastinoscopic lymph-adenectomy (VAMLA) and transcervical extended mediastinal lymphadenectomy (TEMLA). Bronchoscopy and EBUS can be safely used for yield diagnostic tissue in case of central tumors, while in case of peripheral masses, transthoracic biopsy is more sensitive.