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Eur J Cardiothorac Surg 2008;34:1081-1084. doi:10.1016/j.ejcts.2008.07.034
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
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Extended cervical mediastinoscopy in the staging of bronchogenic carcinoma of the left lung

Sergi Calla,*, Ramon Rami-Portaa, Mireia Serra-Mitjansa, Roser Saumencha, Carlos Bidegaina, Manuela Iglesiasa, Guadalupe Gonzalez-Pontb, Jose Beldaa

a Thoracic Surgery Service, Hospital Mutua de Terrassa, University of Barcelona, Terrassa, Barcelona, Spain
b Department of Pathology, Hospital Mutua de Terrassa, University of Barcelona, Terrassa, Barcelona, Spain

Received 22 May 2008; received in revised form 22 July 2008; accepted 23 July 2008.

* Corresponding author. Address: Thoracic Surgery Service, Hospital Mutua de Terrassa, Plaza Dr. Robert 5, 08221 Terrassa, Barcelona, Spain. Tel.: +34 937365050; fax: +34 937365059. (Email: 38641scc{at}comb.es).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: To evaluate the technical feasibility and the sensitivity, specificity and accuracy of extended cervical mediastinoscopy (ECM) in the staging of bronchogenic carcinoma (BC) of the left lung. Methods: From 1998 to 2003, 89 patients underwent routine ECM for staging of BC of the left lung. In 2004, positron emission tomography (PET) was included in our staging protocol and ECM was reserved for those with positive mediastinal or hilar PET images, large lymph nodes on computed tomography (CT) scan or central tumours. From 2004 to 2007 we performed selective ECM in 67 patients. ECM was considered positive when metastatic nodes or tumour involvement directly in the subaortic or para-aortic regions was confirmed pathologically. One hundred and forty-three patients with negative ECM underwent subsequent thoracotomy for tumour resection and systematic nodal dissection. Pathological findings were reviewed and staging values were calculated. Results: One hundred and fifty-six patients underwent ECM (89 routine and 67 selective). In 13, ECM was positive and thoracotomy was contraindicated. The rest of the patients were operated. We performed 88 lobectomies, 34 pneumonectomies, 6 wedge resections, 13 exploratory thoracotomies and 2 parasternal mediastinotomies. Lymphadenectomy specimens showed tumour involvement of subaortic lymph nodes in 8 patients. Complication rate was 2%: two cases of mediastinitis, one ventricular fibrillation, and one superficial surgical wound infection. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of routine/selective ECM were: 0.45/0.75, 1/1, 1/1, 0.94/0.95, 0.94/0.95, respectively. Conclusion: ECM is a feasible staging technique that allows ruling out subaortic and para-aortic nodal disease with high negative predictive value, accuracy and sensitivity. Its indication based on the CT and PET findings seems more advisable that its routine use to stage bronchogenic carcinoma of the left lung.

Key Words: Extended cervical mediastinoscopy • Bronchogenic carcinoma • Staging • Invasive staging of bronchogenic carcinoma


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
Surgical exploration of the lymph nodes of the anterior mediastinum and subaortic space in patients with bronchogenic carcinoma (BC) of the left lung has traditionally required the combination of standard cervical mediastinoscopy (SCM) [1,2] and left anterior mediastinotomy [3]. The latter is usually performed if no nodal involvement can be proved at mediastinoscopy. Video-assisted thoracoscopic surgery (VATS) is a useful tool to stage lung cancer [4–6] and allows the exploration of these nodal stations, but there are no specific reports on this indication. Extended cervical mediastinoscopy (ECM), a technique described by Ginsberg et al. in 1987 [7,8], allows assessment of para-aortic and subaortic nodal stations through the same incision of the SCM.

In this paper we describe our experience over the last 10 years, initially with routine ECM regardless of the results of computed tomography (CT), and subsequently with its selective use depending on the results of computed tomography (CT) and positron emission tomography (PET).


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
From 1998 to 2007, ECM was performed in 156 patients for staging of cyto-histologically proven or suspicious BC of the left lung. Between 1998 and 2003, our staging protocol included bronchoscopy, CT of the chest and upper abdomen, and bone scan; CT of the brain was reserved for symptomatic patients or for those with locally advanced tumours. Operability was assessed by medical history and physical examination, complete blood count and blood analysis, EKG, pulmonary function tests, and ventilation–perfusion lung scans in patients with FEV1 of 2000 ml or less and tumours requiring pneumonectomy; or with FEV1 of 1500 ml or less and tumours requiring lobectomy. Surgical exploration of the mediastinum (mediastinoscopy for tumours of the right lung, and mediastinoscopy with extended cervical mediastinoscopy for tumours of the left lung) was performed routinely, that is, regardless of the size of the nodes on CT scan, as the final staging procedure before thoracotomy once distant metastases had been ruled out, the tumour had been deemed resectable and operability had been established. Following this protocol, 89 patients underwent routine ECM.

In 2004, routine PET or PET-CT scan was introduced in the staging protocol and bone scan was not performed routinely any more. There were no changes in the assessment of operability. With this new protocol, surgical exploration of the mediastinum was indicated when there was mediastinal uptake on PET scan, and in the following situations when PET scan did not show any suspicious uptake in the mediastinum: hilar uptake, central tumours, tumours contacting the mediastinum and when there were enlarged lymph nodes (over 1 cm in the short axis) on CT scan. From 2004 to 2007, 67 patients underwent ECM according to this new protocol.

At mediastinoscopy, nodes from the right and left paratracheal and subcarinal stations were biopsied or removed. Nodes that looked suspicious of tumour involvement were sent for frozen section and, if the result was positive, exploration was not carried out any further. However, in patients with tumours of the left lung, if mediastinoscopy was negative, mediastinal exploration was completed with cervical ECM to explore the para-aortic and subaortic nodal stations that cannot be reached with mediastinoscopy.

ECM was performed through the same cervical incision used for mediastinoscopy. Blunt dissection with the index finger is carried out between the innominate artery and the left carotid artery over the aortic arch. This digital dissection opens the fascia between the origins of these vessels, and the finger slips over the aortic arch and below the left innominate vein. This manoeuvre allows the insertion of the mediastinoscope obliquely over the aortic arch to reach the subaortic nodal station. If the mediastinoscope is slightly rotated medially, the para-aortic nodes can be reached. Nodes are either immediately identified or can be dissected from the fatty tissue found in these areas using the standard dissection–coagulation–suction device used in mediastinoscopy [9].

ECM was considered positive when either tumour metastases in the lymph nodes or direct tumour involvement in the subaortic or para-aortic stations was confirmed pathologically. Patients with positive ECM either received definitive chemoradiation or induction chemotherapy or chemoradiotherapy, and further restaging if there was no disease progression. Patients in whom both mediastinoscopy and extended cervical mediastinoscopy were negative underwent thoracotomy for lung resection and systematic nodal dissection. Systematic nodal dissection was considered the gold standard for comparing the results of ECM. Pathologic findings were retrospectively reviewed and staging values (sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy) were calculated using the standard formulas. Confidence intervals were calculated using the CIA (Confidence Interval Analysis. Version 1.0) software package (Martin J. Gardiner & British Medical Journal, 1989).


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
ECM was performed in 156 patients with diagnosis or suspicion of BC of the left lung. There were 145 men and 11 women with a mean age of 65 years (range: 44–83 years). ECM was positive in 13 patients: involvement of the subaortic nodes in 11 patients, involvement of the para-aortic nodes in 1, and direct tumour involvement of the subaortic space in 1. The remaining 145 patients with negative ECM underwent subsequent thoracotomy for tumour resection and systematic nodal dissection. There were 88 lobectomies (in 5 patients with en bloc resection of the thoracic wall), 34 pneumonectomies (in 1 patient with en bloc resection of the thoracic wall), 6 wedge resections, and 13 exploratory thoracotomies (8 tumours were considered unresectable and in 5 patients pneumonectomy was the required operation to achieve complete resection, but was contraindicated because of inadequate lung function)

Pathologic study of lymphadenectomy specimens showed N2 disease in the subaortic nodes in eight patients, and these results were considered false-negative ECM. In three patients there were tumour metastases in the subcarinal nodes, but with no involvement of the subaortic or para-aortic nodal stations. For the purpose of this study, these three cases were considered true-negative results of ECM because the subcarinal space does not fall within the exploration range of ECM. Staging values of the whole series of ECM were: sensitivity 0.62, specificity 1, positive predictive value 1, negative predictive value 0.94, and diagnostic accuracy 0.95. Table 1 shows the staging values in the two periods with different staging protocols: from 1998 to 2003 (routine ECM) and from 2004 to 2007 (selective ECM).


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  		Table 1 Staging values of extended cervical mediastinoscopy
 
Complication rate was 2% with two cases of mild mediastinitis, treated with superficial wound drainage and antibiotics; one ventricular fibrillation, treated with intraoperative defibrillation; and one superficial wound infection, treated with wound drainage. There were no deaths attributable to the procedure.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
In the management of patients with lung cancer, correct preoperative staging of the mediastinum is necessary to determine the best therapeutic option and assess prognosis.

Bronchogenic carcinoma of the left lung may metastasize to the subaortic and para-aortic lymph nodes, especially those located in the upper lobe and hilum. Standard cervical mediastinoscopy remains the gold standard for staging the superior mediastinal lymph nodes, but it cannot reach the subaortic and para-aortic nodal stations. Traditionally, surgical staging of bronchogenic carcinoma of the left lung required the combination of standard cervical mediastinoscopy with other surgical techniques, such as left parasternal mediastinotomy (Chamberlain's procedure) or left thoracoscopy, otherwise the subaortic and para-aortic nodal stations would remain unexplored.

ECM allows the assessment of the subaortic and para-aortic nodes through the incision used in SCM. For the purpose of left lung cancer staging, both procedures are performed sequentially; mediastinoscopy first, then extended cervical mediastinoscopy in the same operation. We perform the same technique described by Ginsberg et al. [7] in 1987. After digital dissection to create a passage, the mediastinoscope is advanced over the aortic arch between the innominate artery and the left carotid artery, under the left innominate vein [7]. Other authors have described a modification of this technique in which the dissection is made in the retrosternal space, between the anterior surface of the innominate vein and the posterior surface of the sternum [10,11]. This technical variation does not seem to influence the results (Table 2 ).


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  		Table 2 Staging values of published series of extended cervical mediastinoscopies and our study
 
Table 2 shows the results of ECM published to date and those of the present series. Sensitivity of ECM ranges between 0.62 and 0.83; negative predictive value, between 0.89 and 0.97; and diagnostic accuracy, between 0.91 and 0.98, [7,10,11]. The values of the present series fall within the range of the published results. However, in our experience, sensitivity increased when ECM was indicated selectively according to the results of CT and PET. In our first series with routine ECM, sensitivity was much lower (0.45). The main reason for this low sensitivity is the difficulty to identify and biopsy small positive nodes buried in the fatty tissue that is invariably found in the subaortic space. The other authors indicated ECM only when large nodes were shown on CT and, therefore, the likelihood of finding them with ECM was higher. That is why their sensitivity was much higher than the one we had in the period when ECM was used routinely. In our second series, when ECM as performed selectively, sensitivity increased (0.75) and was within the range of published values.

ECM has a high negative predictive value that compares very favourably with those of blind transbronchial needle aspiration, endobronchial ultrasonography with fine needle aspiration, and oesophageal ultrasonography with fine needle aspiration [12–14]. This is important because ruling out nodal disease is more difficult than confirming it. While a small piece of node or a few cells aspirated from a node may be enough to confirm disease, to confirm its absence needs a more thorough exploration. According to the published results and the results of the present series, ECM seems thorough enough to rule out nodal disease with a negative predictive value of over 0.9 (Table 2).

Complications related to the technique are infrequent and some authors suggest that ECM has less postoperative morbidity than anterior mediastinotomy and VATS [15]. Published series on ECM [7,10,11] define ECM as a useful and safe technique with little morbidity. In the series reported by Ginsberg et al. [7] there was one case of cervical wound infection and another case of an accidental laceration of the innominate artery when a sharp-tipped metal sucker was used inadvertently. Specific reports on ECM complications are few. Urschel reported a cerebrovascular accident following this procedure [16] and Haciibrahimogu described an abscess six months after the operation in a patient with tuberculosis in whom ECM was not indicated to stage lung cancer, but as a diagnostic procedure [15].

In conclusion, ECM is a feasible staging technique that allows determining mediastinal nodal disease or tumour involvement directly of the subaortic and para-aortic spaces, with high sensitivity, negative predictive value and accuracy and without being associated with specific complications. Its indication depending on the CT and PET findings seems more advisable that its routine use to stage bronchogenic carcinoma of the left lung.


   Acknowledgments
 
We thank Salvador Quintana, MD, from the Intensive Care Unit and Statistical Department of Hospital Mutua de Terrassa, for his assistance in the statistical revision of this manuscript.


   Footnotes
 
{star} Presented at the 16th European Conference on General Thoracic Surgery, Bologna, Italy, June 8–11, 2008.


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

  1. Carlens E. Mediastinoscopy: a method of inspection and palpation in the superior mediastinum. Dis Chest 1959;36:343-352.[Medline]
  2. Pearson FG, Nelems JM, Henderson RD, Delarue NC. The role of mediastinoscopy in the selection of treatment for bronchial carcinoma with involvement of superior mediastinal nodes. J Thorac Cardiovasc Surg 1972;64:382-390.[Medline]
  3. McNeill TM, Chamberlain JM. Diagnostic anterior mediastinotomy. Ann Thorac Surg 1966;2:532-539.[Medline]
  4. Naruke T, Asamura H, Kondo H, Tsuchiya R. Thoracoscopy for staging of lung cancer. Ann Thorac Surg 1993;56:661-663.[Abstract]
  5. Wain JC. Video-assisted thoracoscopy and the staging of lung cancer. Ann Thorac Surg 1993;56:776-778.[Abstract]
  6. Roviaro GC, Varoli F, Rebuffat C, Vergani C, Maciocco M, Scalambra SM, Sonnino D, Gozi G. Videothoracoscopic staging and treatment of lung cancer. Ann Thorac Surg 1995;59:971-974.[Abstract/Free Full Text]
  7. Ginsberg RJ, Rice TW, Goldberg M, Waters PF, Schmocker BJ. Extended cervical mediastinoscopy. A single staging procedure for bronchogenic carcinoma of the left upper lobe. J Thorac Cardiovasc Surg 1987;94:673.[Abstract]
  8. Ginsberg RJ. Extended cervical mediastinoscopy. Chest Surg Clin N Am 1996;6(1):21-30.[Medline]
  9. Rami-Porta R, Mateu-Navarro M. Videomediastinoscopy. J Bronchol 2002;9:132-144.
  10. López L, Varela A, Freixinet J, Quevedo S, Lopez Pujol J, Rodriguez de Castro F, Salvatierra A. Extended cervical mediastinoscopy: prospective study of fifty cases. Ann Thorac Surg 1994;57:555-558.[Abstract]
  11. Freixinet Gilart J, Gámez García P, Rodriguez de Castro P, Rodriguez Suarez P, Santana Rodriguez N, Varela de Ugarte A. Extended cervical mediastinoscopy in the staging of bronchogenic carcinoma. Ann Thorac Surg 2000;70:1641-1643.[Abstract/Free Full Text]
  12. Toloza EM, Harpole L, McCrory DC. Noninvasive staging of non-small cell lung cancer: a review of the current evidence. Chest 2003;123:137S-146S.[CrossRef][Medline]
  13. Holty JEC, Kuschner WG, Gould MK. Accuracy of transbronchial needle aspiration for mediastinal staging of non-small cell lung cancer: a meta-analysis. Thorax 2005;60:949-955.[Abstract/Free Full Text]
  14. Annema JT, Verteegh MI, Veselic M, Voigt P, Rabe KF. Endoscopic ultrasound fine-needle aspiration in the diagnosis and staging of lung cancer and its impact on surgical staging. J Clin Oncol 2005;23:8357-8361.[Abstract/Free Full Text]
  15. Haciibrahimoglu G, Cevik A, Bedirhan MA, Kutlu CA. Late complication of extended cervical mediastinoscopy. Can J Surg 2004;47:223-224.[Medline]
  16. Urschel JD, Vretenar DF, Dickout WJ, Nakai SS. Cerebrovascular accident complicating extended cervical mediastinoscopy. Ann Thorac Surg 1994;57:740-741.[Abstract]



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