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Eur J Cardiothorac Surg 2007;32:351-354. doi:10.1016/j.ejcts.2007.04.031
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
St James University Hospital, Leeds, United Kingdom
Received 19 September 2006; received in revised form 10 April 2007; accepted 19 April 2007.
* Corresponding author. Address: 51 Tolkien Way, Hartshill, Stoke on Trent ST4 7SJ, Staffordshire, UK. Tel.: +44 7973674826; fax: +44 1706 646734. (Email: ashvinimenon{at}aol.com).
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Abstract |
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 Top Abstract 1. Introduction2. Material and method3. Results4. DiscussionAppendix AReferences |
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Key Words: Video mediastinoscopy • Pulmonary metastasectomy • Mediastinal lymph nodes
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1. Introduction |
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TopAbstract1. Introduction2. Material and method3. Results4. DiscussionAppendix AReferences |
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Metastasectomy has now been performed for a wide variety of primary tumours, e.g. renal cell carcinoma and colorectal carcinoma, with encouraging results [10]. Mediastinal lymph node involvement has been reported in up to 14% of patients undergoing thoracotomy for metastasectomy. The presence of lymph node metastases has an adverse effect on prognosis and influences the decision for adjuvant therapy [2,3].
The role of VAM in nodal staging of pulmonary metastases has not been fully evaluated. Therefore, we performed this study to assess the value of VAM in the assessment of mediastinal lymph nodes in patients with pulmonary metastasis.
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2. Material and method |
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TopAbstract1. Introduction2. Material and method3. Results4. DiscussionAppendix AReferences |
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There were 44 men and 13 women with a mean age of 59 years. Five patients had sequential pulmonary metastasectomy. Seven patients were re-operated for recurrence of pulmonary metastasis.
Preoperative evaluation included physical examination, cardiopulmonary assessment, chest X-ray and computed tomography (CT) of chest and abdomen. All patients had no radiological evidence of primary disease at the time of pulmonary metastasectomy. Positron emission tomography (PET) scan was not performed at our institution during this time period, as it was not available.
VAM was performed in all patients regardless of radiological evidence of mediastinal lymphadenopathy. All samples were sent for routine histological evaluation.
All patients were followed up at 6 weeks and at 3 monthly intervals. Those with positive lymph nodes were offered adjuvant treatment.
2.1 Procedure
VAM was performed via a 3–4 cm transverse incision in the suprasternal notch and followed by blunt dissection down to the pretracheal space. A Karl–Storz video mediastinoscope was utilised. Blunt dissection was performed and any lymph nodes identified were biopsied and sent for histology labelled with the appropriate station level. The patient was then placed in the thoracotomy position and an open or VATS pulmonary metastasectomy was performed depending on the anatomical location of the lesion. Bilateral lesions were resected via median sternotomy or sequential thoracotomies depending on the surgeon's preference. The mediastinal lymph nodes were assessed for tumour spread to N2 lymph node station according to the International System for Staging of Lung Cancer.
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3. Results |
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TopAbstract1. Introduction2. Material and method3. Results4. DiscussionAppendix AReferences |
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The primary site was predominantly colorectal in 39 patients (Table 1 ). One patient (2.6%) had positive mediastinal lymph node. This patient survived for 30 months following adjuvant chemotherapy. The disease-free interval for colorectal patients (from primary to lung) is 39.7 months.
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The survival without adjuvant therapy in two patients with positive lymph nodes, one from renal cell carcinoma and the other bladder carcinoma, was 8 and 4 months respectively.
The surgical approach was mainly thoracotomy or VATS. Median sternotomy was performed for bilateral metastasectomy (Table 2 ).
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Thirty-four patients (59.6%) are still alive. This is a heterogeneous group of patients with various pathologies, and, therefore, it would not be appropriate to apply any statistical analysis to this group. It is too early to produce an accurate Kaplan–Meier survival curve in this heterogeneous group of patients.
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4. Discussion |
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TopAbstract1. Introduction2. Material and method3. Results4. DiscussionAppendix AReferences |
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However, better survival figures are seen in renal cell carcinoma. Isolated pulmonary metastases from renal cell carcinoma can have up to 50% 5-year survival [5]. In recent years, increasing number of patients are presenting with colorectal carcinoma and lung metastases. Although there are emerging techniques like thoracoscopic photodynamic therapy (PDT) or radio frequency ablation (RFA), surgery remains the treatment of choice in most thoracic units.
The importance and frequency of nodal involvement in pulmonary metastasectomy has been an intriguing subject since 1950s. An autopsy series demonstrated a 33% incidence of mediastinal lymph node involvement in the presence of pulmonary metastases [6]. In recent years, several centres have demonstrated the presence of positive mediastinal lymph nodes via systematic mediastinal lymph node dissection at thoracotomy. The incidence of positive nodes ranged from 14 to 28% of patients [2,3], but no study has been performed to assess the role of mediastinoscopy. Therefore, since 2002, we elected to assess the role of VAM in our institution in pulmonary metastasectomy. At this time, routine PET scanning was not available.
In our study, the incidence of mediastinal lymph node metastases was 10%. This correlates with similar results from previous studies where systematic mediastinal lymph node dissection at operation was practised [2].
VAM is widely used by surgeons and trainees. It has high sensitivity and specificity, making it a reliable method for identifying diseased mediastinal lymph nodes. In our study, we had no morbidity or mortality. However, Ercan and colleagues have shown complications in 10% of their 70 patients who underwent complete mediastinal lymph node dissection at thoracotomy [3].
Several studies have suggested the use of mediastinoscopy in identifying metastatic lymph nodes in pulmonary metastasis [5]. Some centres have performed mediastinoscopy only in patients with CT evidence of mediastinal lymph node involvement [7]. However, the sensitivity of CT scan to correctly predict lymph node involvement is only 73% [8,9]. Loehe and colleagues have shown that the frequency of misdiagnosed mediastinal lymph node metastases in patients with pulmonary metastases is 17%, similar to non-small cell bronchial carcinomas [2]. PET scanning in the UK has now become a recommended preoperative investigation for patients with non-small cell bronchial carcinoma [9]. The role of PET scan in pulmonary metastasectomy remains unclear and requires further investigation. The current benefit of PET is restricted in identifying active primary site and extrathoracic metastases or positive mediastinal lymph nodes. This is where the role of VAM is essential in providing histological diagnosis. A suggestive flowchart for the management of pulmonary metastasectomy is recommended (Fig. 1 ).
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Appendix A |
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TopAbstract1. Introduction2. Material and method3. Results4. DiscussionAppendix AReferences |
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Dr S. Mattioli (Bologna, Italy): Just a comment. I wonder if for soft tissue metastases VATS is truly a good indication, because those who have been doing this kind of surgery know that soft tissue tumors give the lung very little metastases, not even appreciable with a CAT scan, and palpation is a crucial maneuver in these tumors. Everybody knows about the Memorial randomized trial which was closed by Pat McCormack because of this reason. So this is my concern.
Dr P. Van Schil (Antwerp, Belgium): I think there is a bit of confusion. This paper mainly discusses mediastinal staging which was performed by video-mediastinoscopy and not by a VATS approach. In that respect, could you comment on which nodes were positive? Were they all on the ipsilateral side? Were there some contralateral positive nodes?
Dr Menon: They were ipsilateral nodes and they were R4 and subcarinal nodes that were positive.
Dr Van Schil: Did you also look at survival in those patients? Your conclusion is that those patients should not be operated upon, but is that a valid conclusion from the study you performed?
Dr Menon: As I say, we still should proceed to operate on these patients. That's why I said that if these nodes come back as positive, they should undergo metastasectomy as well as chemoradiation, because it has been shown in previous studies that metastasectomy improves survival in positive or negative nodes, but these patients should be subjected to chemoradiation as well.
Dr Van Schil: And regarding those patients who did not have a mediastinoscopy before the operation, were there any cases of N2 or N3 involvement that you detected during thoracotomy?
Dr Menon: No, we didn’t actually look at that.
Dr B. Witte (Koblenz, Germany): In the patients who were node-negative at videomediastinoscopy, you obviously did proceed to an open operation. Did you reassess the mediastinum by lymphadenectomy and did you find any overlooked positive nodes in them? To put it short, what was the false-negative rate of video-mediastinoscopy?
Dr Menon: No, we did the video-mediastinoscopy before we proceeded to the pulmonary metastasectomy, and we didn’t assess the other nodes at that time, so we didn’t do a mediastinal lymph node sampling during the time of thoracotomy.
Dr Witte: Oh, so it's not about accuracy data. I see.
Dr M. Zielinski (Zakopane, Poland): I have some concerns about your algorithm. I think that we should treat these patients in a very individual way. For example, if there is a single metastasis in the lung, in one lung, and during mediastinoscopy you find only one metastasis in one node, why not proceed to thoracotomy? Maybe you should perform metastasectomy, exploration of the lung, and lymphadenectomy and it might be a better solution than to refer the patient to chemoradiation in that case. So I think I would advise you to be more flexible in your qualifications.
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Footnotes |
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References |
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TopAbstract1. Introduction2. Material and method3. Results4. DiscussionAppendix AReferences |
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This article has been cited by other articles:
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  M. H. Chamberlain, K. Fareed, A. Nakas, A. E. Martin-Ucar, and D. A. Waller Video-assisted cervical thoracoscopy: a novel approach for diagnosis, staging and pleurodesis of malignant pleural mesothelioma. Eur. J. Cardiothorac. Surg., July 1, 2008; 34(1): 200 - 203. [Abstract] [Full Text] [PDF]
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T. Treasure Editorial comment: Surgical resection of pulmonary metastases Eur. J. Cardiothorac. Surg., August 1, 2007; 32(2): 354 - 355. [Full Text] [PDF]
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