Eur J Cardiothorac Surg 2003;24:192-195
© 2003 Elsevier Science NL
Video-assisted mediastinoscopic lymphadenectomy (VAMLA) – a method for systematic mediastinal lymphnode dissection
Gunda Leschber*,
Gabriele Holinka,
Albert Linder
Department of Thoracic Surgery, Lungenklinik Hemer, Theo-Funccius-Str. 1, D- 58675 Hemer, Germany
Received 8 November 2002;
received in revised form 19 February 2003;
accepted 19 March 2003.
* Corresponding author. Tel.: +49-2372-9082243; fax: +49-2372-9089243
e-mail: gunda.leschber{at}lungenklinik-hemer.de
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Abstract
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Objective: Video-assisted mediastinal lymphadenectomy (VAMLA) increases quality of mediastinal lymph node staging in bronchial carcinoma. The video-mediastinoscope allows systematic lymphadenectomy by bimanual preparation. Complete bilateral resection of lymph nodes in stations 1, 2, 3, 4 and 7 (Naruke) can safely be done after visualization of limiting structures (trachea, main bronchi, oesophagus, pericardium, pulmonary artery, aorta, upper vena cava and azygos vein). In this initial study, we compared histopathological findings from VAMLA with final lymph node staging from subsequent thoracotomy. Methods: Between January 2001 and December 2001, 25 patients were operated by VAMLA (among 162 mediastinoscopies), two patients for diagnostic purposes and 23 for staging of bronchial carcinoma. Eighteen patients underwent subsequent thoracotomy for tumor resection and systematic lymphadenectomy. Pathological findings were reviewed. Results: In VAMLA, lymph node dissection of station 2R, 2L and 4R was achieved in 96, 28 and 92%, respectively, whereas resection of lymph nodes in station 7 and 4L was performed in 100%. Other locations were dissected in 44%. A mean of 8.6 lymph nodes were removed in each patient. No residual lymph node tissue was found in the subcarinal compartment at open surgery. When comparing histopathological staging from VAMLA with final pathology, there were no false negative results. Seventeen patients who had N0 disease at VAMLA proved to be N0 or N1 at thoracotomy, one patient diagnosed as N2 at mediastinoscopy had N2 disease at final pathology. The only complication observed in VAMLA was a blood loss of >100 ml in 12% of patients without need for transfusion or surgical intervention. Conclusion: Mediastinal lymph node staging is improved by VAMLA. A systematic lymphadenectomy is performed bimanually through the video mediastinoscope. The number of lymph nodes removed is doubled compared to standard mediastinoscopy. There were no false negative results at final pathology. This new technique presents the basis for video-assisted thoracic surgery (VATS) lobectomy because complete resection of the mediastinal lymph nodes can be achieved by VAMLA. Potential complications of VAMLA such as injury of major mediastinal vessels, airways, pneumothorax or recurrent laryngeal nerve injury indicate the need for a full thoracic surgical infrastructure.
Key Words: Video-assisted surgery • Mediastinoscopy • Lymphadenectomy • Staging of lung cancer • Lung neoplasm
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1. Introduction
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Correct staging of bronchial carcinoma is essential for adequate stage-oriented therapy. Understaging as well as overstaging may result in a therapeutic regimen that does not provide the best treatment to the patient. Besides staging for metastatic disease exclusion of mediastinal lymph node involvement is a crucial point [1]. Modern radiological techniques such as computed tomography (CT) or positron emission tomography (PET) are non-invasive methods that are easily available. Initial studies indicated high sensitivity and specificity but with wider clinical use these results were not reliable [2–5]. Mediastinoscopy in contrast is an invasive procedure requiring general anesthesia. So far, it remains the clinical method with the highest sensitivity and specificity for exclusion of mediastinal lymph node involvement [6–8].
Since the introduction of mediastinoscopy into clinical use in 1959 by Carlens [9], little has changed in the way lymph node dissection is done. Most thoracic surgeons perform the procedure routinely by taking samples or dissecting whole lymph nodes from predetermined locations.
Trying to increase the sensitivity of mediastinoscopy Hürtgen developed video-mediastinoscopy into a systematic mediastinal lymph node dissection (video-assisted mediastinal lymphadenectomy, VAMLA) [10]. Key improvement was the video-mediastinoscope for bimanual preparation (Wolf Company). This instrument allows a more accurate dissection of lymph node tissue even from adjacent vessels as lymph nodes are more clearly exposed and the limiting structures are much better identified than in standard mediastinoscopy. The mediastinoscope is inserted similar to standard mediastinoscopy. Bimanual dissection of mediastinal tissue planes along the trachea, main bronchi or adjacent structures is achieved by the use of bipolar scissors or suction tube. An endoscopic clamp is used for grasping the lymph node tissue and gentle retraction facilitates dissection. A total mediastinal lymphadenectomy can be performed. On the left side, the recurrent laryngeal nerve is identified and preserved during further dissection. The use of bipolar scissors is especially helpful in this area. Early experience exists for using a nerve stimulation and detection device to reduce the risk of recurrent laryngeal nerve injury.
We started with VAMLA in January 2001 and compared histological findings from mediastinoscopy and the following open systematic lymphadenectomy in cancer patients. Additionally, we counted the numbers of lymph nodes resected.
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2. Methods
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Between January 2001 and December 2001, 25 VAMLA were performed (out of 162 mediastinoscopies done during this time interval). VAMLA was performed by using the video-mediastinoscope with a two bladed speculum of the Wolf Company (Richard Wolf GmbH, Postfach 1164, D-75434 Knittlingen, Germany) (see Fig. 1
). Routine exploration of lymph node stations for staging purposes included 2 (paratracheal) on the right and left, 4 (tracheobronchial) right and left and 7 (subcarinal) according to the Naruke classification [11]. Other enlarged lymph nodes encountered during mediastinoscopy were also dissected. Intraoperatively, surgeons indicated the number and location of lymph nodes removed by VAMLA in a protocol. Eighteen patients subsequently underwent thoracotomy for resection and standard lymphadenectomy for cancer. Pathological findings from VAMLA and thoracotomy were reviewed and stages compared. Protocols from VAMLA were analyzed for the number of lymph nodes resected.
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Fig. 1. Video-mediastinoscope (Wolf Company, Knittlingen, Germany) with the two blades opened for demonstration.
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3. Results
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All 25 mediastinoscopies done as VAMLA were finished as video-assisted procedures. Indication was staging of bronchial carcinoma in 23 patients, two patients had unknown mediastinal disease and were operated for diagnostic reasons although bronchial carcinoma was diagnosed by mediastinoscopy. The mean number of resected lymph nodes as determined by the surgeon was 8.6 (4–14). Lymph nodes of station 2 right and 2 left were identified and removed in 96 and 28%, the lymph nodes in 4 right in 92%. Station 7 and 4 left were resected in all patients (see Table 1). There was a clear difference to the only 44% of lymph nodes of other origin (station 1, 3 or 5). Mean operation time was 74 min (60–100).
In 18 patients, subsequent thoracotomy for resection of bronchial carcinoma was performed. The other patients received neoadjuvant therapy prior to resection or were found to be inoperable for various reasons. At thoracotomy following tumor resection, a systematic lymphadenectomy and exploration concerning residual lymph node tissue were carried out. There were no residual lymph nodes found in the subcarinal area (station 7) (Fig. 2
), but some lymph nodes in the tracheobronchial and paratracheal areas (station 4 and 2) on the right side (Fig. 3
).
When comparing histological findings from lymph node dissection via mediastinoscopy and open surgery of the 17 patients with N0-disease at mediastinoscopy, 13 were found to be N0 and four to be N1 at final pathology. The only patient with mediastinoscopic N2-disease who then underwent immediate surgical resection for hemoptysis proved to be N2. There were no false negative results (see Table 2).
The only complication of mediastinoscopy was bleeding exceeding 100 ml in three patients (12%). This occurred during preparation but was not due to injury of any major vessel and therefore there was no need for further intervention. No injury of the recurrent laryngeal nerve, pleura or other organs was observed. There was no wound infection.
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4. Discussion
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VAMLA as described by Hürtgen [10] and performed in our institution is a new method improving staging for bronchial carcinoma. Use of a video-mediastinoscope enables the surgeon to perform bimanual dissection with resection of more lymphatic tissue under direct vision than with standard mediastinoscopy. In a previous study analyzing mediastinoscopy [12], a mean of 4.1 lymph nodes were resected in each patient. With VAMLA, the number of lymph nodes resected according to the surgeon increased to 8.6, which indicates a more than a twofold increase. Except for the left paratracheal region, where lymph nodes were only removed in 28% (due to the vicinity of the recurrent laryngeal nerve), all other stations were dissected in 92–100%. The probability of false negative mediastinoscopy results is markedly decreased if there is more lymph node tissue available for pathologic examination. Sensitivity of mediastinoscopy ranges from 80 to 87% [7,12,13]. On performing VAMLA, we did not see any false negative results with lymph node staging. Although the current study was done on a small group of patients, the higher diagnostic yield of video-mediastinoscopy compared to standard mediastinoscopy is remarkable.
At time of thoracotomy, we did not find residual lymph nodes in the subcarinal area. This implicates a major advantage for patients scheduled to undergo video-assisted thoracic surgery (VATS) lobectomy. In VATS, while lymphadenectomy can be performed without problems in the right paratracheal area and at the hilum, dissection of lymph nodes remains difficult in the subcarinal region due to anatomic reasons. Even for experienced surgeons, the risk of complications is high. It is, however, mandatory to perform a systematic – or radical – lymphadenectomy in cancer patients regardless of whether the operation is done by VATS or by thoracotomy. VAMLA may solve this problem for VATS-lobectomy. Systematic mediastinal lymphadenectomy is done at the time of mediastinoscopy and completed at VATS-lobectomy. Without offending oncological standards, this form of treatment could be offered to patients with small tumors and N0 or N1 disease (stage I or II).
In patients with more advanced stages, i.e. N2 disease, it has been shown that neoadjuvant therapy leads to better survival [14,15]. This again indicates the importance of exact mediastinal lymph node staging. In contrast, overstaging nodal disease by means of radiological or functional methods (CT or PET) alone could be deleterious. Positive findings must be verified by histological examination. Mediastinoscopy remains the gold standard [16,17].
Teaching this ‘gold standard’ has been a problem in the past and can be solved for both teacher and surgeon-in-training by using the technique of video-mediastinoscopy. With better visualization, it is easier to identify lymph nodes and the limiting structures. The procedure can be standardized. Although we did not observe complications in our patients undergoing VAMLA, there are potential hazards such as injury of major mediastinal vessels, bronchi, pneumothorax or recurrent laryngeal nerve injury. Therefore, VAMLA should only be performed in centers providing the necessary infrastructure.
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Footnotes
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Presented at the 10th Annual Meeting of the European Society of Thoracic Surgeons, Istanbul, Turkey, Ocober 26–28, 2002.
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References
|
|---|
- Muers M.F. Preoperative screening for metastases in lung cancer. Thorax 1994;49:1-2.[Medline]
- Takamochi K., Nagai K., Yoshida J., Suzuki K., Ohde Y., Nishimura M., Takahashi K., Nishiwaki Y. The role of computed tomographic scanning in diagnosing mediastinal node involvement in non-small cell lung cancer. J Thorac Cardiovasc Surg 2000;119:1135-1140.[Abstract/Free Full Text]
- Scott W.J., Schwabe J.L., Gupta N.C., Dewan N.A., Reeb S.D., Sugimoto J.T., Members of the PET-Lung Tumor Study Group. Positron emission tomography of lung tumors and mediastinal lymph nodes using [18 F] Fluorodeoxyglucose. Ann Thorac Surg 1994;58:698-703.[Abstract]
- Pietermann R.M., Van Putten J.W.G., Meuzelaar J.J., Mooyaart E.L., Vaalburg W., Koëter G.H., Fidler V., Pruim J., Groen H.J.M. Preoperative staging of non-small-cell lung cancer with positron-emission tomography. N Eng J Med 2000;343:254-261.[Abstract/Free Full Text]
- Berlangieri S.U., Scott A.M. Metabolic staging of lung cancer. N Eng J Med 2000;343:290-292.[Free Full Text]
- Pearson F.G. Staging of the mediastinum: role of mediastinoscopy and computed tomography. Chest 1993;103:346S-348S.
- Ebner H., Marra A., Butturini E., De Santis F. Clinical value of cervical mediastinoscopy in the staging of bronchial carcinoma. Ann Ital Chir 1999;70:873-879.[Medline]
- Hammoud Z.T., Anderson R.C., Meyers B.F., Guthrie T.J., Roper C.L., Cooper J.D., Patterson G.A. The current of mediastinoscopy in the evaluation of thoracic disease. J Thorac Cardiovasc Surg 1999;118:894-899.[Abstract/Free Full Text]
- Carlens E. Mediastinoscopy: a method for inspection and tissue biopsy in the superior mediastinum. Dis Chest 1959;36:343-352.[Medline]
- Hürtgen M., Friedel G., Kyriss, Toomes H., Linder A., Fritz P. Radical video-assisted mediastinoscopic lymphadenectomy (VAMLA) – technique and first results. Eur J Cardiothorac Surg 2002;21:348-351.[Abstract/Free Full Text]
- Naruke T., Goya T., Tsuchiya R., Suemasu K. Prognosis and survival in resected lung carcinoma based on the new international staging system. J Thorac Cardiovasc Surg 1988;96:440-447.[Abstract]
- Leschber G., Holinka G., Freitag L., Linder A. Die Mediastinoskopie beim Staging des Bronchialkarzinoms-eine kritische Bewertung. Pneum 2000;54:489-493.[CrossRef]
- Funatsu T., Matsubara Y., Ikeda S., Hatakenaka R., Hanawa T., Ishida H. Preoperative mediastinscopic assessment of N factors and the need for mediastinal lymphnode dissection in T1 lung cancer. J Thorac Cardiovasc Surg 1994;108:321-328.[Abstract/Free Full Text]
- Eberhardt W., Wilke H., Stamatis G., Stuschke M., Harstrick A., Menker H., Krause B., Müller M.R., Stahl M., Flasshove M., Budach V., Greschuchna D., Konietzko N., Sack H., Seeber S. Preoperative chemotherapy followed by concurrent chemoradiation therapy based on hyperfractionated accelerated radiotherapy and definitive surgery in locally advanced non-small-cell lung cancer: mature results of a phase II trial. J Clin Oncol 1998;16:622-634.[Abstract]
- Thomas M., Rübe C., Semik M., von Eiff M., Freitag L., Macha H.N., Wagner W., Klinke F., Scheld H.H., Willich N., Berdel W.E., Junker K. Impact of preoperative bimodality induction including twice daily radiation on tumor regression and survival in stage III non-small-cell lung cancer. J Clin Oncol 1999;17:1185-1188.[Abstract/Free Full Text]
- De Leyn P., Vansteenkiste J., Cuypers P., Deneffe G., Van Raemdonck D., Coosemans W., Verschakelen J., Lerut T. Role of cervical mediastinscopy in staging of non-small cell lung cancer without enlarged mediastinal lymph nodes on CT scan. Eur J Cardiothorac Surg 1997;12:706-712.[Abstract]
- Luke W.P., Pearson F.G., Todd T.R.J., Patterson G.A., Cooper J.D. Prospective evalution of mediastinoscopy for assessment of carcinoma of the lung. J Thorac Cardiovasc Surg 1986;91:53-56.[Abstract]
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Top
Abstract
1. Introduction
