Cervical mediastinoscopy and video-assisted mediastinoscopic lymphadenectomy for the staging of non-small cell lung cancer

Abstract

The staging of mediastinal lymph nodes is essential for planning the most adequate treatment for patients with non-small cell lung cancer (NSCLC). For this reason, the current American and European guidelines recommend obtaining tissue confirmation of any mediastinal abnormality seen on chest computed tomography (CT) and positron emission tomography (PET). This can be done by endoscopic techniques, such as endobronchial ultrasonographic fine-needle aspiration (EBUS-FNA), esophageal ultrasonographic FNA (EUS-FNA), or a combination of the two (CUS). Traditionally, surgical methods have been reserved to validate the negative results of minimally invasive endoscopic techniques. However, based on the latest evidence, cervical mediastinoscopy and video-assisted mediastinoscopic lymphadenectomy (VAMLA) have demonstrated their superiority over minimally invasive methods in terms of performance for those tumors with normal mediastinum [clinical (c) N0-1 by CT and PET]. Therefore, cervical mediastinoscopy and VAMLA should be considered in the staging algorithms of this particular subset of NSCLC, and in the other well-established indications.

Mediastinal staging for non-small cell lung cancer

“…The presence of lymph nodes whose size exceed 10 mm on the short axis should be considered a predictor of malignancy. However, results from studies focused in the accuracy of lymph node size for malignancy prediction have demonstrated that size alone is insufficient to confirm or discard metastatic infiltration of lymph nodes because of the low sensitivity (55%) reported for this technique (1)(2)(3)(4)(5)(6)(7)(8)(9)15). Additionally, the clinical relevance of nodal enlargement is limited because metastases have been found in about 20% of lymph nodes with dimensions under 1 cm on the short axis (6).…”

“…The correct evaluation of mediastinal and hilar lymph nodes (Ns) is critical for choosing the best option for the management and treatment of patients with non-small cell lung cancer (NSCLC) who are potential candidates for curative therapeutic strategies, including surgery, radiotherapy, chemotherapy, and multimodal treatments (1)(2)(3)(4)(5)(6)(7). For preoperative mediastinal staging the current guidelines state that it is important to confirm the absence of neoplastic mediastinal involvement with the highest level of certainty possible before performing surgical resection (1,3).…”

“…Thus, mediastinal examination should begin by using endoscopic techniques which are less invasive than surgical techniques (1)(2)(3)(4)(5)(6)(7)(8). The most diagnostically accurate endoscopic techniques currently available are endobronchial or oesophageal ultrasound-guided techniques.…”

“…The most diagnostically accurate endoscopic techniques currently available are endobronchial or oesophageal ultrasound-guided techniques. Therefore, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasoundguided fine needle aspiration (EUS-FNA), or their combination known as mediastinal endosonography (1)(2)(3)(4)(5)(6)(7)(8), have overtaken endoscopic blind puncture techniques in terms of diagnostic accuracy. However, to make the results of mediastinal endosonography reliable, this technique should adhere to international standards (9).…”

“…There are factors that can produce false negatives (FNs) in EBUS-TBNA such as the extensiveness of satisfactory node sampling or the presence of nodes which cannot be reached, especially tumours located on the left side of the body (10). Other factors that, when combined, increase the risk of mediastinal malignancy include the tumour characteristics [histological type, consolidation/tumour ratio, tumour size, and maximum standard uptake value (SUV)], clinical parameters [serum carcinoembryonic antigen (CEA) level and patient age], and methylation biomarkers (7,11).…”