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Eur J Cardiothorac Surg 2008;33:289-293. doi:10.1016/j.ejcts.2007.10.021
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
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Does video-mediastinoscopy improve the results of conventional mediastinoscopy?

Gunda Leschber*, Dorothea Sperling, Wolfram Klemm, Johannes Merk

Department of Thoracic Surgery, ELK Berlin Chest Hospital, Berlin, Germany

Received 1 June 2007; received in revised form 18 October 2007; accepted 30 October 2007.

* Corresponding author. Address: Department of Thoracic Surgery, ELK Berlin Chest Hospital Lindenberger Weg 27, 13125 Berlin, Germany. Tel.: +49 30 94802102; fax: +49 30 94802180. (Email: gunda.leschber{at}elk-berlin.de).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: Despite new technologies, mediastinoscopy remains the gold standard for mediastinal staging of lung cancer even though the procedure is not standardised. Introduction of video-mediastinoscopy (VM) may help to overcome this problem as it better visualises the anatomy and allows a more uniform dissection than conventional mediastinoscopy (CM). Does the use of VM result in more lymph node tissue, higher accuracy and lower complication rates as compared to CM? Methods: All mediastinoscopies from June 2003 to December 2005 were analysed. In a protocol surgeons documented location of lymph node stations, number of lymph nodes resected or biopsied and technique (VM or CM). Two groups were created for analysis: group 1 (n = 366) consisting of all mediastinoscopies was reviewed for complication rates; group 2 included all patients with lung cancer who had a pN0 status by mediastinoscopy and underwent subsequent thoracotomy (n = 171). This group was studied for the number of lymph nodes resected or biopsied according to the technique (VM or CM), on accuracy and negative predictive value. Results: Of 366 mediastinoscopies, 132 were CM (36.1%) and 234 VM (63.9%). Complications occurred in 17 patients (4.6%): 9 recurrent laryngeal nerve palsies (VM 2.1%, CM 3.0%), 5 mediastinal enlargement on routine chest radiography interpreted as postoperative bleeding (VM 0.9%, CM 2.3%), pneumonia (1), intraoperative laceration of the pleura (1) and main bronchus (1), both corrected during the procedure (all VM 1.3%). No intraoperative haemorrhage or death occurred. VM resected more lymph nodes (mean 8.1, range 3–25) then CM (mean 6.0, range 3–11), for all mediastinoscopies the mean lymph node yield was 7.6 (range 3–25). Comparison of lymphadenectomy via thoracotomy in patients classified pN0 by mediastinoscopy (n = 171) showed an accuracy of 87.9% for VM versus 83.8% for CM (85.8% for all mediastinoscopies) with a negative predictive value of 0.83 for VM and 0.81 for CM (0.82 for all mediastinoscopies). Conclusion: This study demonstrates that in comparison with CM, VM routinely yields more lymph nodes with fewer complications with a tendency towards better accuracy and negative predictive value. For these reasons, we believe that VM should replace CM as the method of choice. Furthermore VM would allow standardisation, thereby having an advantage in comparison to the less invasive newer staging techniques. This way mediastinoscopy could remain the gold standard despite its invasiveness.

Key Words: Video-mediastinoscopy • Mediastinoscopy • Lung cancer • Staging • Mediastinal lymph nodes


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
Staging of the mediastinum in patients with lung cancer is currently undergoing major changes. With the implementation of imaging techniques such as PET-CT scan, or staging procedures with ultrasound-assisted biopsy techniques such as EBUS-TBNA (endobronchial ultrasound guided transbronchial needle aspiration) or EUS-NA (endoscopic ultrasound guided fine-needle aspiration), some clinicians question the value of mediastinoscopy. They argue that these modern methods are less invasive but still have the same diagnostic yield as mediastinoscopy. They neglect the crucial point that studies of one diagnostic procedure generally have a patient population that differs from the population of another invasive test [1,2]. For example, patients managed with EBUS-TBNA or EUS-NA have, in most cases, enlarged mediastinal lymph nodes. Therefore this group shows a high prevalence of N2/3 disease. These patients also generally have lymph nodes easily accessible by the new techniques—otherwise these procedures would not be used. In contrast, patients undergoing mediastinoscopy as a staging procedure often have normal appearing lymph nodes on the CT scan. One has to remember that the most important decision is whether or not patients with cancer will benefit from surgery or should undergo non-surgical therapy. Therefore accurate information about the tumour stage is of utmost importance as indicated in the current ESTS Guideline on lymph node staging [3].

Among surgeons it is generally accepted that mediastinoscopy remains the gold standard in the mediastinal staging of lung cancer. The high diagnostic yield of simultaneous tissue diagnosis and staging in combination with very low morbidity has made this procedure widely accepted in thoracic surgical centres throughout the world [4].

Still, there is debate about adequate lymph node sampling in mediastinoscopy. The European guideline recommends systemically exploring and always performing a biopsy of station 4 R and L as well as station 7. In addition station 2 bilaterally should be sampled or biopsied if present [3]. The American guideline states that five nodal stations (stations 2 R + L, 4 R + L and 7) should be routinely examined and at least one node sampled from each location unless none is present [4]. This indicates that there are many differences in the way mediastinoscopy is performed by individual surgeons, probably due to different teaching methods of the procedure. Personal experience with complications further leads to modification of what should be a standard approach. Teaching mediastinoscopy has been difficult in the past with the conventional technique, but this has changed with invention of the video-mediastinoscope.

Video-mediastinoscopy (VM) enables the surgeon to operate bimanually, grasping the lymph node tissue and using gentle traction while dissecting the surrounding structures, as in open surgery. Exposure of the anatomical landmarks such as the pulmonary artery, the vena azygos and vena cava, the recurrent laryngeal nerve on the left side as well as the oesophagus dorsal and caudal to the subcarinal lymph nodes is further facilitated by visualisation on the video screen. Lymph nodes are easily identified and resected without compromising adjacent tissues [5,6].

To our knowledge no study has compared conventional mediastinoscopy (CM) with VM to date. The aim of this study was to investigate whether VM results in the resection of more lymph node tissue, lower complication rates and higher accuracy with lower false negative values compared to CM.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
2.1 Patient population
All consecutive mediastinoscopies performed between June 2003 and December 2005 at our institution were analysed retrospectively (n = 377). According to local guidelines, all patients with proven non-small cell lung cancer (NSCLC), who were candidates for surgical resection, underwent staging mediastinoscopy regardless of the size of the mediastinal lymph nodes on the CT scan. Patients with radiological enlarged mediastinal lymph nodes or mediastinal masses without a diagnosis of lung cancer were subjected to diagnostic mediastinoscopy if other procedures failed to reveal the diagnosis.

As in most centres in Germany, mediastinoscopy was performed without immediate frozen section of lymph node tissue or an immediate thoracotomy. Specimens were sent for pathology and only when the results were available thoracotomy was scheduled.

2.2 Technique of mediastinoscopy
The mediastinoscope was inserted and advanced down to the bifurcation where dissection begun. Exploration of the pre- and paratracheal spaces by a combination of blunt and sharp dissection prepared for resection of lymph nodes. The upper (station 2) [7] and lower (station 4) paratracheal lymph nodes bilaterally and the subcarinal lymph nodes (station 7) were routinely explored, as well as any enlarged lymph nodes demonstrated on the CT scan. Wherever possible complete lymph nodes were resected, otherwise only biopsies were taken.

For VM the Linder-Dahan video-mediastinoscope with spreadable blades was utilised (Richard Wolf Company, Knittlingen, Germany). Visualisation of mediastinal structures including the pulmonary artery, the oesophagus and the recurrent laryngeal nerve was achieved by careful dissection of the anatomical landmarks.

As our institution is a teaching hospital, some of the procedures were performed by surgeons-in-training under supervision of three board-certified thoracic surgeons.

2.3 Thoracotomy and lymphadenectomy
In proven lung cancer, an anterolateral thoracotomy for anatomical tumour resection and systematic hilar and mediastinal lymph node dissection was performed within 2 weeks of mediastinoscopy. On the right side lymph nodes station 2, 4, 7, 8, 9, 10 and 11 were resected; for a left thoracotomy the stations 5, 6, 7, 8, 9, 10 and 11 were removed. En bloc resection was performed whenever possible and specimens sent for histopathological examination by an experienced pathologist. Examination of frozen sections of lymph nodes was done only for special indications.

2.4 Type of mediastinoscopy
Assignment of procedures to CM or VM was not randomised, but depended on the availability of the video-mediastinoscope (one video-mediastinoscope for two operating rooms). If the video-mediastinoscope was available, it was preferentially used for teaching purposes. As a result, more CM procedures were performed by the board-certified surgeons than by the ones in training.

2.5 Data collection and statistics
Operative data of the mediastinoscopy were documented prospectively in a standard protocol at the end of the procedure based on the lymph node classification described by Naruke et al. [7]. Documentation included whether biopsy or complete resection of the lymph node was performed and the total number of lymph nodes biopsied or removed in each station. It is important to point out that the surgeon counted the number of lymph nodes (resected or biopsied) and not the pathologist. Further information included the type (CM or VM) and indication of the mediastinoscopy (diagnostic or staging procedure), intraoperative complications, such as bleeding (>100 ml) or laceration of mediastinal organs.

These data were later correlated retrospectively with results from histopathology and information about the postoperative course extracted from the discharge letter. If patients with proven NSCLC underwent thoracotomy with systematic lymphadenectomy, all histopathological data concerning this were collected and compared to the findings of mediastinoscopy.

We had two points of interest in our study and therefore created two groups for further investigation: for determination of complication rates all eligible patients were reviewed (group 1, n = 366). The second group was created from the 210 patients undergoing staging mediastinoscopy for lung cancer who had a pN0 status proven by mediastinoscopy and underwent subsequent thoracotomy with systematic lymphadenectomy (n = 171, group 2). This group was analysed to study the effects of CM or VM on the number of lymph nodes resected or biopsied, on accuracy and negative predictive value.

Specific attention was paid to the subcarinal lymph nodes (station 7), because this is the only lymph node station that can be reached by left- or right-sided thoracotomy, and by CM or VM. For this reason, the subcarinal lymph nodes were the most appropriate nodes to compare the amount of nodes resected during mediastinoscopy with results obtained by thoracotomy.

For data collection and basic statistical analysis Microsoft Excel XP was used. The values used (negative predictive value, accuracy) to compare the mediastinoscopic procedures were calculated as described by others [4,8].


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
Of 377 consecutive mediastinoscopies performed during the time interval from June 2003 to December 2005, 11 cases (2.9%) were excluded from the study for incomplete data, resulting in a total of 366 patients eligible for further investigation. One hundred and thirty-two were done with by CM (36.1%) and 234 by VM (63.9%). There were 252 men (68.9%) and 114 women (31.1%) with a mean age of 62.1 years (range 20–84 years).

Of the 366 mediastinoscopies, 210 procedures were staging mediastinoscopy in patients with proven lung cancer. One hundred and fifty-six patients underwent diagnostic mediastinoscopy for suspicion of lung cancer (95), mediastinal lymph node enlargement detected on the CT scan without presumed lung cancer (22), confirmation of sarcoidosis (19) or lymphoma (5), assessment of lymph node metastasis of extrathoracic tumours (13), one for tuberculosis and one for thymoma.

3.1 Complication analysis (group 1)
In the 366 procedures analysed, complications were noted in 17 cases (4.6%). The incidence and correlation to the two mediastinoscopic techniques are shown in Table 1 . Recurrent laryngeal nerve palsy that persisted for at least 2 days was the complication most often noticed: 2.5% in all mediastinoscopies (9/366), 3.0% in patients undergoing conventional mediastinoscopy (4/132) and 2.1% in video-mediastinoscopy (5/234). No intraoperative haemorrhage or bleeding from major vessels occurred, but bleeding defined as mediastinal enlargement on routine postoperative chest radiography was seen in five patients (1.4%). One patient required mediastinoscopic re-exploration by VM where diffuse oozing was found; the others recovered without further measures. The other complications all followed VM and included one case of pneumonia, one intraoperative laceration of the pleura and one of the main bronchus, both immediately corrected during the procedure without the need for thoracotomy. There were no perioperative deaths.


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  		Table 1 Complication rates in correlation to the method of mediastinoscopy
 
3.2 Number of lymph nodes resected or biopsied in mediastinoscopy (group 2)
For the patients undergoing mediastinoscopy and thoracotomy for lung cancer (n = 171) mediastinoscopy was analysed for the number of lymph nodes either resected (excisional biopsy) or biopsied according to the technique used (CM or VM). The mean lymph node yield was 7.6 (range 3–25) for all mediastinoscopies. The mean total number of lymph nodes resected by VM was 8.1 (range 3–25). CM yielded a mean 6 lymph nodes (range 3–11). In 87% of all mediastinoscopies, data for subcarinal lymph node exploration were available. Subanalysis of lymph node station 7 showed the same trend: VM resected 2.4 lymph nodes (range 0–7) and CM resected 1.5 (range 0–3), resulting in 2.2 lymph nodes (range 0–7) in all mediastinoscopies. These results are shown in Table 2 .


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  		Table 2 Number of lymph nodes resected or biopsied (total number and number of subcarinal lymph nodes in every procedure) according to the method of mediastinoscopy, average and range
 
3.3 Pathological staging
Studies on the pathological lymph node stages (pN) were done in 171 patients (group 2). In this group, VM was used in 69.6% and CM in 30.4%. All these patients had proven lung cancer and were pN0 at staging mediastinoscopy. They underwent thoracotomy with systematic lymph node dissection within 2 weeks following mediastinoscopy. Tumour localisation of the lung cancer patients was the right side in 54.7%, left side in 44.9% and mediastinum in 0.3%. The histologically confirmed lymph node stages by thoracotomy were correlated with the lymph node stages obtained by mediastinoscopy. Of the 52 patients staged as pN0 by CM, 30 (57.7%) had pN0, 12 (23.1%) had pN1 and 10 (19.2%) were found to have pN2 disease by thoracotomy. Of 119 patients staged as pN0 by VM, 72 (60.5%) patients had pN0, 27 (22.7%) had pN1 and 20 patients (16.8%) had pN2 in thoracotomy. For all mediastinoscopies with pN0 the results for thoracotomy were: pN0, 102 (59.6%); pN1, 39 (22.8%); pN2, 30 (17.6%). The results are summarised in Table 3 .


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  		Table 3 Correlation of lymph node stages between mediastinoscopy and systematic lymph node dissection by thoracotomy
 
Limitations of mediastinoscopy were the lymph nodes number 5 and 6 on the left side that were not accessible to our mediastinoscopy technique. In fact when looking at the subset of patients staged N0 by mediastinoscopy but turned out to be pN2 at thoracotomy, almost half of them had a tumour in the left upper lobe.

Based on these findings the negative predictive value for mediastinoscopy is 0.82 (CM 0.81; VM 0.83). In the present study accuracy calculated is 85.8% for all mediastinoscopies with noticeable difference in accuracy of 83.8% for CM and 87.9% for VM.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
New strategies of the process to diagnose, stage, treat (with neoadjuvant therapy), restage and operate lung cancer patients emerge [1,2,9] and comparison of mediastinal staging procedures is necessary under practical and economic aspects [10–13]. As Detterbeck et al. pointed out, ‘Comparison of tests for mediastinal staging is difficult because the question being addressed is not always the same for patients undergoing one procedure versus another’ [4]. When discussing the optimal approach in an individual patient it has to be kept in mind that studies with EUB-NA, EBUS-TBNA and PET in general are performed on patients with enlarged mediastinal lymph nodes, whereas mediastinoscopy is undertaken to rule out mediastinal involvement even with normal-sized lymph nodes.

The chance for mediastinoscopy to remain the gold standard in staging of lung cancer patients despite its invasiveness in our opinion is only given when it becomes standardised.

As VM improves visualisation thus facilitating safe dissection, biopsy and haemostasis [5,14,15] it could set the standard of the surgical staging of the mediastinum.

Exact mediastinal staging is required for patients entering trials on multimodality therapy where it is important not to overlook minimal N2 disease [16]. PET-scan, EUS-NA or EBUS-TBNA show limitations as does conventional mediastinoscopy, still common in many thoracic surgery units. For example, 4% of patients were excluded from a study on lung cancer patients because conventional mediastinoscopy failed to yield adequate tissue for evaluation (less then three lymph nodes stations removed) [17]. Our study showed an advantage in the number of lymph nodes obtained by the videoscopic technique compared to the conventional one.

The statement of the American guidelines that lymph nodes stations 7 posteriorly and 8 cannot be removed [4] was true only for the time before the video-mediastinoscope was invented [18]. The videoscopic approach has enabled thoracic surgeons to even do therapeutic procedures such as removal of mediastinal masses. Hürtgen et al. in 2001 were the first to describe a further development: the technique of video-assisted mediastinal lymphadenectomy (VAMLA) with an en-bloc resection of mediastinal lymph nodes tissue [19,20]. In a recent publication on 144 VAMLA they showed excellent results with a sensitivity of 93.75% [6].

In the present study, there was the tendency towards better accuracy and negative predictive value for video-mediastinoscopy. When comparing histological staging obtained by mediastinoscopy and lymphadenectomy by thoracotomy we found an accuracy of 87.9% for VM compared to 83.8% for CM. Venissac et al. calculated an accuracy of 98.0%, but their indication for VM was limited to enlarged mediastinal lymph nodes; so of the 240 patients undergoing the procedure subsequent thoracotomy was carried out only on 47 patients [5]. In contrast, our policy is to stage all proven lung cancers by mediastinoscopy regardless of the size of mediastinal lymph nodes. So of the total of our 210 staging mediastinoscopies, 171 patients underwent subsequent thoracotomy, which may account for the difference in accuracy compared to the data in the literature.

One of the benefits of the videoscopic approach in our study was a lower rate of palsy of the recurrent laryngeal nerve for VM (2.1%) than for CM (3.0%) even though more lymph nodes were resected. We did not experience any major intraoperative bleeding or complication that forced us to do a thoracotomy or sternotomy. Witte et al. in their experience with 226 consecutive VM procedures saw a decrease in the rate of complications when comparing the first 113 cases to the following 113 [6].

After 50 years of mediastinoscopy the videoscopic technique for the first time offers the chance to standardise this surgical procedure. That would be beneficial for this invasive method and could set a new gold standard in comparison to less invasive techniques.

Standardisation of all methods for staging of the mediastinum seems to be necessary in order to conduct evidence-based studies that elucidate the role of the different staging modalities for lung cancer.


   Footnotes
 
\#9734; Presented at the 15th European Conference on General Thoracic Surgery, Leuven, Belgium, June 3–6, 2007.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 

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