Video-Assisted Mediastinoscopic Lymphadenectomy for Staging Non-Small Cell Lung Cancer

Abstract

VAMLA is a feasible and highly accurate technique. The high rate of unsuspected mediastinal node disease diagnosed by VAMLA in patients with cN1 or cN0 disease and tumor size larger than 3 cm suggests that preresection lymphadenectomies should be included in the current staging algorithms.

Pros: should a patient with stage IA non-small cell lung cancer undergo invasive mediastinal staging?

“…The role of transcervical lymphadenectomies in early stage lung cancer has been described, showing better staging values than standard mediastinoscopy and endoscopic ultrasound fine needle aspiration techniques (14)(15)(16)(17)(18). Therefore, in case of central tumours, the accuracy of these techniques adds value to rule out mediastinal disease, enhancing, therefore, clinical staging.…”

“…Therefore, in case of central tumours, the accuracy of these techniques adds value to rule out mediastinal disease, enhancing, therefore, clinical staging. Other challenging situations like bilateral synchronous lung cancer (16,19) and elderly patients or patients with poor performance status (16) can benefit from VAMLA/TEMLA in order to avoid unnecessary lung resections and its complications. Finally, these pre-resectional lymphadenectomies can be indicated in cIA tumours located in the left lung or in combination with VATS lobectomy to achieve a radical lymphadenectomy, even better than by open surgery (16,17).…”

“…In the last years, these techniques, especially VAMLA, have been adopted by other departments besides the institutions where the technique was originally developed, and new indications have been described. In a recent report on 160 VAMLAs for staging NSCLC, a high rate of unsuspected mediastinal involvement was observed in patients with cN1 tumours (40.7%) and in cN0 and tumour size >3 cm (22.2%) (16). The differentiation between central primary tumour and cN1 involvement is not easy to assess by imaging techniques.…”

“…These are the described indications for VAMLA which also includes cIA NSCLC: central tumours, left sided tumours, bilateral synchronous lung cancer, preresectional lymphadenectomy in video-assisted thoracoscopic lobectomy (17) and in elderly patients and patients with poor performance status (16). In all these situations, VAMLA provides an accurate preoperative mediastinal staging and lymphadenectomy.…”

Rebuttal from Dr. Obiols and Dr. Call

“…The recent publication on VAMLA by Call et al (7) shows that among 26 patients with mediastinal involvement diagnosed by VAMLA, 10 had left sided tumours and 40% of them had involvement of left inferior paratracheal nodes, information that would have been missed if VAMLA had not been performed.…”