Video-assisted mediastinoscopic lymphadenectomy (VAMLA): A video vignette

Mediastinal staging in potentially resectable non-small cell lung cancer is of paramount importance since it impacts the survival of the patient. With increasing nodal stage, survival was noted to precipitously decline. Nodal status also determined the use of neoadjuvant/adjuvant therapy and other treatment modalities. Various methods of obtaining lymphatic tissue from the mediastinum for staging purposes have been described in the literature, although mediastinoscopic lymph node evaluation remains the gold standard. Endoscopic methods of mediastinal staging, like the endobronchial ultrasound guided and esophageal ultrasound guided fine-needle aspiration techniques, although minimally invasive, provide the highest levels of accuracy when used in conjunction with surgical mediastinal staging. Video-assisted mediastinoscopic lymphadenectomy (VAMLA) provides clear advantages, as far as ergonomics and training are concerned, over conventional mediastinoscopy. Access to stations 2R, 2L, 4R, 4L, and 7 is feasible with VAMLA. In this video vignette, we present the step-by-step technique of a standard VAMLA, with an overview of relevant anatomical relationships, for the effective and safe clearance of lymph node stations for the purposes of staging and defining appropriate therapy.

Controversies in Mediastinal Staging for Nonsmall Cell Lung Cancer

Mediastinal lymph nodal involvement in nonsmall cell lung cancer plays a crucial role in deciding treatment strategy. Survival falls markedly with increasing involvement of mediastinal nodal stations. Hence, accurate staging of the mediastinum with lowest morbidity is of utmost importance. A wide array of invasive and noninvasive modalities that complement each other in assessing the nodes are available at our disposal. Guidelines recommend noninvasive imaging as the initial step in the staging algorithm for all tumors, followed by invasive staging. No single modality has proven to be the ideal method to stage the mediastinum when used alone. In the present decade, minimally invasive endobronchial ultrasound (EBUS) has challenged the position of surgical mediastinoscopy, which has been the gold standard, historically. However, a negative EBUS needs to be confirmed by surgical mediastinoscopy. Video-assisted mediastinoscopic lymphadenectomy has also come to the forefront in last two decades and has shown exceptional results, when performed in experienced centers. This review details the various modalities of mediastinal staging and the controversies surrounding the optimal method of staging, restaging after neoadjuvant therapy, and the most cost-effective strategy.

Validation of National Comprehensive Cancer Network Guidelines (NCCN) at a single institution.

e20556 Background: Invasive mediastinal staging is necessary to identify locally advanced non-small cell lung cancer (NSCLC). We sought to validate NCCN guidelines for invasive mediastinal staging. Methods: We retrospectively reviewed all patients who had curative lung resection for pathologically confirmed NSCLC from October 2018 to December 2019. We excluded patients who had induction therapy without undergoing invasive mediastinal staging first. We evaluated methods of mediastinal staging, staging results, and final pathology. Indications for staging were one or more of the following; mediastinal lymph nodes > 1.0cm in short axis, Standardized Uptake Value of > 3.0 on Positron Emission Tomography, > 50% of tumor on medial side of mid-clavicular line (central vs peripheral), or peripheral lesion > 3.0cm in diameter. Staging methods were mediastinoscopy, endobronchial ultrasound (EBUS), and video-assisted thoracoscopic surgery (VATS) ipsilateral mediastinal staging before resection of main tumor. Results: In total, 457 lung resections were performed. Staging was done in 144/275 indicated cases (52.4%). Mediastinoscopy was completed in 49 patients, with 20.4% (n = 10) N2-positive. The false negative rate of mediastinoscopy was 4.1% (n = 2 at station 7). EBUS was performed in 64 patients and 21.9% (n = 14) were N2 positive. The false negative rate for EBUS was 3.1% (n = 2 at station 7). Two mediastinoscopy and 9 EBUS patients had 0 N2 stations sampled. None of the patients were ultimately N2 positive. Staging of three mediastinal stations (4L, 4R, and 7) was done in 26/49 mediastinoscopies and 15/64 EBUS. Of 20 patients who had VATS ipsilateral mediastinal staging, none were N2 positive and there were 0 false negatives. This left 131 patients who did not received indicated staging. The most common indication in this group was central location, 83.2% (n = 109). Four of these unstaged patients were N2 positive at resection (3.1%). The sole indication for these 4 patients was a centrally located tumor. Clinical tumor sizes were 1.2 cm, 1.3 cm, 1.5 cm, and 1.9 cm. Overall, the N2-positive rate of the staged group was 24/144 (16.7%) vs 4/131 (3.1%) N2 positive in the unstaged group, p < 0.001. Conclusions: The current NCCN staging guidelines accurately reflect the risk of N2 disease for NSCLC. The indication of central location for tumors may benefit from being reevaluated in a larger cohort, particularly given efficacy of adjuvant therapy.