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. 2021 Aug;10(8):3645-3658.
doi: 10.21037/tlcr-21-364.

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

Pieter W J Lozekoot  1 , Jean H T Daemen  1   2 , Robert R van den Broek  1 , Jos G Maessen  3   4 , Michiel H M Gronenschild  5 , Yvonne L J Vissers  1 , Karel W E Hulsewé  1 , Erik R de Loos  1
Affiliations

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

Pieter W J Lozekoot et al. Transl Lung Cancer Res. 2021 Aug.

Abstract

Background: The 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.

Methods: A 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.

Results: Two-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).

Conclusions: We 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.

Keywords: Non-small cell lung carcinoma (NSCLC); sensitivity; unforeseen pN2 disease; video-assisted mediastinoscopic lymphadenectomy (VAMLA); video-assisted mediastinoscopy.

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/tlcr-21-364). The authors have no conflicts of interest to declare.

Figures

Video 1
Video 1
Video-assisted mediastinoscopic lymphadenectomy: the surgical technique and anatomical landmarks.
Figure 1
Figure 1
STARD flow chart of patients with histologically proven NSCLC who underwent surgical mediastinal staging through VAMLA and, if applicable, subsequent anatomical resection. NSCLC, non-small-cell lung carcinoma; VAMLA, video-assisted mediastinoscopic lymphadenectomy; EBUS, endo-bronchial ultrasonography; EUS, endo-esophageal ultrasonography; FDG, 18F-deoxyglucose; pN2, pathological N2 disease.
Figure 2
Figure 2
STARD flow chart of patients with histologically proven NSCLC who underwent surgical mediastinal staging through VAM and, if applicable, subsequent anatomical resection. NSCLC, non-small-cell lung carcinoma; VAM, video-assisted mediastinoscopy; EBUS, endo-bronchial ultrasonography; EUS, endo-esophageal ultrasonography; FDG, 18F-deoxyglucose; pN2, pathological N2 disease.
See this image and copyright information in PMC

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