Surgical mediastinal lymph node sampling for staging of non small cell lung carcinoma

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urgical Mediastinal Lymph Node Samplingor Staging of Non-Small Cell Lung Carcinomaeffrey J. Siracuse, MD,* and Malcolm M. DeCamp, Jr, MD†

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ediastinal lymph node sampling has been used to di-agnose lymphoma and sarcoidosis and to diagnose and

tage non-small-cell lung cancer (NSCLC). The optimal treat-ent of patients with NSCLC is determined by mediastinal

ymph node involvement. Surgical staging is the gold stan-ard for NSCLC patient management.It is mandatory to sample lymph nodes that are greater

han 1 cm on computed tomographic scan1 and fluorodeoxy-lucose-positive lymph nodes on positron emission tomog-aphy.2 Daniels, using an empiric scalene lymph node bi-psy, first described lymph node sampling to assessesectability of lung cancer in 1949.3 The first mediastinalymph node sampling was done in 1954 by Harken using aaryngoscope through a supraclavicular incision. Carlens

odified this in 1959 to a pretracheal incision for insertion ofmediastinoscope.4 Cervical mediastinoscopy was champi-ned in North America in the 1960s by Pearson and col-eagues at the Toronto General Hospital.5

ervical Mediastinoscopyervical mediastinoscopy allows for sampling of ipsilateralnd contralateral lymph nodes at stations 2, 4, and 7 and it isighly sensitive and specific.6 Computed tomography andositron emission tomographic scans have been used to clin-

cally assess for mediastinal lymph node involvement. How-ver, these imaging modalities both share a low positive-redictive value; all suspicious nodes on imaging need to bessessed surgically.2 Other minimally invasive methods ofampling, such as endobronchial ultrasound-guided trans-ronchial fine-needle aspiration, do have specific advantageshen compared with cervical mediastinoscopy but have notet proven to be as efficacious as a routine staging tool.

Cervical mediastinoscopy has very low morbidity andortality and is today considered to be an outpatient proce-ure.7 Morbidity rates of 0.6% to 3.7% and mortality rates of% to 0.3% have been reported.8 Complications include

Department of Surgery, Beth Israel Deaconess Medical Center and HarvardMedical School, Boston, Massachusetts.

Division of Cardiothoracic Surgery, Beth Israel Deaconess Medical Centerand Harvard Medical School, Boston, Massachusetts.

ddress reprint requests to Malcolm M. DeCamp, Jr, MD, Chief, Division ofCardiothoracic Surgery, Beth Israel Deaconess Medical Center, 185 Pil-grim Road, Deaconess 201, Boston, MA 02215. E-mail: mdecamp@

cbidmc.harvard.edu

12 1522-2942/09/$-see front matter © 2009 Elsevier Inc. All rights reserved.doi:10.1053/j.optechstcvs.2009.06.003

leeding, recurrent laryngeal nerve injury, and tracheobron-hial injury. Contraindications are inability to tolerate gen-ral anesthesia, extreme kyphosis, previous mediastinos-opy, and cutaneous tracheostomy. A heavily calcified aortas also a relative contraindication due to concern for athero-mbolism from external manipulation. Bleeding can be con-rolled in most cases by local tamponade with a 4 � 8 gauzeponge or vaginal gauze packing placed through the scopesing the scope to achieve direct compression. This criticalaneuver allows better identification and visualization of the

pecific injury and can prevent catastrophic hemorrhage. Ifacking and direct pressure do not result in hemostasis after0 to 15 minutes, then an open approach to address theource of bleeding will be required. Repacking allows thenesthesia team time to obtain better vascular access, to ob-ain blood products in the room, and to achieve selective lungentilation if needed. Level 4R has been shown to be the mostommon site of bleeding.8

To perform a cervical mediastinoscopy, the patient is po-itioned supine with extension of the neck using a shoulderole to elevate both scapulae. The patient should be preppedor a sternotomy in the rare instance that uncontrollableleeding is encountered. A 3-cm transverse incision is madecm above the suprasternal notch (Fig. 1A and B). The

latysma muscle is divided transversely and the strap mus-les are split in the midline. Army-Navy retractors are used toeflect the strap muscles laterally and to retract the inferioroles of the thyroid gland in a cephalad direction, exposinghe pretracheal fascia (Fig. 2) Scissors are used to gain accesso this space. Digital dissection is used to develop an opera-ive plane along the left and right paratracheal spaces andnteriorly in the subinnominate space (Fig. 3A and B). In theight paratracheal space, one can identify the innominatertery, stations 2R and 4R nodes, as well as the azygous veinFigs. 4 and Fig 5A and B). On the left side, stations 2L and 4Lodes are seen and the left recurrent laryngeal nerve can beisualized, although vigorous dissection to identify it isnnecessary and could be potentially harmful (Figs. 6 andig 7). Cautery should be avoided in this area due to the riskf injury to the left recurrent laryngeal nerve.The subcarinal space contains station 7 lymph nodes (Fig.

). Lymph node sampling is undertaken under direct visual-zation with cold-cupped biopsy forceps. When there is con-
ern whether the identified “node” could actually be a vessel,
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Lymph node sampling for staging NSCLC 113

Figure 1 (A) Anterior view of the patient positioned in the supine position. The patient should be prepped for a fullsternotomy in case uncontrollable bleeding is encountered. A 3-cm incision is made one finger-breath above the sternal
notch. (B) Lateral view of positioned patient. A roll is place between the scapulae and the neck is in extension.

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114 J.J. Siracuse and M.M. DeCamp, Jr

e aspirate the target with a 21-G spinal needle before intro-ucing the biopsy forceps (Fig. 5C and D).Video-assisted mediastinoscopy has become increasingly

opular. Instead of using a conventional mediastinoscope, ainder-Dahan videomediastinoscope consisting of a twin-laded speculum is used. This scope creates a wider field ofision and allows for bimanual dissection. This combinedith the video-image allows for more surgical options, in-

reased precision, improved documentation, and easier useith trainees. Reported complication rates are similar to con-entional cervical mediastinoscopy.9 One surgical techniquehat video-assisted mediastinoscopy has made possible isideo-assisted mediastinoscopic lymphadenectomy. As op-

Figure 2 The platysma is divided and the strap muscles arexposing the pretracheal fascia. m. � muscle.

osed to lymph node sampling done by conventional cervical d

ediastinoscopy, the pertinent lymph node stations are com-letely dissected and removed. This resection of more lym-hatic tissue decreases the false-negative rate and will mostertainly lead to more accurate pathologic staging. Video-ssisted mediastinoscopy lymphadenectomy also is helpfulor patients needing a video-assisted thoracoscopic surgeryVATS) lobectomy. During VATS lobectomy especially onhe left, subcarinal lymphadenectomy can be very difficultnd therefore doing a complete pre-VATS lymphadenectomys potentially advantageous.10

The aortopulmonary window and the prevascular or para-ortic lymph nodes, stations 5 and 6, are difficult to assessith cervical mediastinoscopy. Ginsberg and colleagues have

The inferior portion of the thyroid is retracted cranially
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escribed using extended cervical mediastinoscopy to assess

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igure 3 (A) Digital dissection is used to expose the left andight paratracheal and subinnominate spaces. (B) Anterioriew showing the mediastinal lymph nodes and their relationo the tracheobronchial tree and major vessels. a. � artery;o � aorta; PA � pulmonary artery; pulm. lig. � pulmonary

igament; SVC � superior vena cava; v. � vein.


Figure 4 Right paratracheal space showing the innominate artery, azygous vein, and station 4R. a. � artery; Az �
azygous vein; SVC � superior vena cava.

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tations 5 and 6.11 However, this is a technically demandingrocedure that has not gained in popularity. Alternatively, annterior mediastinotomy, also known as the Chamberlainrocedure, has been used to access this area. As opposed toervical mediastinoscopy, which accesses the middle medi-stinum, here the anterior mediastinum is accessed. An inci-ion is usually made at the second left intercostal space forptimal access (Fig. 8) It was originally done in an openashion but is now done with a Carlen’s mediastinoscope. Aortion of the medial (cartilaginous) left second rib can beesected in the subperichondrial plane to enhance exposure.

nterior Mediastinoscopye typically do not use a double lumen endotracheal tube for

nterior mediastinotomy, preferring brief periods of apnea ifhe inflated lung obscures our view. We make a 5- to 6-cmncision directly anterior to the second rib in the left peris-ernal position; through this access, a mediastinoscope is in-erted. The pleura is reflected laterally while the internalhoracic vessels are swept medially to gain access to the an-erior mediastinum and the aortopulmonary (station 5) andrevascular or para-aortic (station 6) lymph nodes (Figs. 9nd Fig 10) Although we attempt to avoid entering the pleu-al space, this can happen especially in thin or hyperinflated/

Figure 5 Video-mediastinoscopy images of (A) right par(C) needle-aspiration of the 4R node, and (D) cold-cup

mphysematous patients. In such cases, we evacuate the pas- (

ive pneumothorax with a simple red rubber catheter duringValsalva maneuver before skin closure. An indwelling chestrain is unnecessary.

ATSATS is another highly accurate way of assessing stations 5nd 6 and has become increasingly popular, replacing ante-ior mediastinotomy in some centers. It allows concurrentherapeutic resection of pulmonary malignancy if the medi-stinal nodes are benign. VATS exploration allows for betterisualization of the lymph nodes and their relationships tohe great vessels and phrenic and vagus nerves and allowsnspection of the entire ipsilateral mediastinum and pleuralpace. The operator can biopsy pleural and pericardial le-ions and visualize vascular involvement. VATS avoids inter-ally mammary artery conduits in patients who have had aoronary artery bypass. Especially useful for patients with leftpper lobe tumors, VATS can provide better visualization ofhe relevant N1 and N2 lymph nodes.12 VATS is done usingwo to four ports utilizing 1- to 2-cm incisions (Fig. 11). Theatient is placed in the lateral decubitus position and split-

ung ventilation is required. A lung retractor is used with thether ports being used for the camera and the biopsy forceps

eal dissection, (B) an enlarged station 4R lymph node,psy of the 4R node.

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Fig. 12).


Figure 6 Lateral view of the trachea showing the left recurrent laryngeal nerve in the groove between the trachea and
esophagus. n. � nerve.


Figure 7 Left paratracheal space showing stations 2L and 4L and the recurrent laryngeal nerve. The subcarinal space
containing station 7 and its proximity to the right pulmonary artery is also shown. n. � nerve.


Figure 8 Incision is made over the left second rib.


Figure 9 Operator view looking posteriorly with the lung retracted laterally. The patient’s head is beyond the bottom ofthe image and feet beyond the top. The aortopulmonary window is in the field. Stations 5 and 6 are shown. The internal
thoracic vessels are medial. PA � pulmonary artery.
Figure 10 Lateral view showing PA, aorta, stations 5 and 6, phrenic, vagus, and recurrent laryngeal nerves. n. � nerve;
PA � pulmonary artery.


Figure 11 Port sites and patient position for VATS. Two 5-mm ports are placed—one in the third intercostal space at thelateral edge of the pectoralis major muscle and one in the fifth intercostal space at the tip of the scapula. A 10-mm port
for the camera is placed in the fifth intercostal space in the anterior axillary line.

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onclusionservical mediastinoscopy is the gold standard for samplingediastinal lymph nodes at stations 2, 4, and 7. It is a safe,

ccurate, and an ambulatory procedure. Although lymphode biopsy via endoesophageal or endobronchial ultra-ound is emerging as alternative methods for evaluating wor-isome adenopathy, these techniques have not proven to beuperior to cervical mediastinoscopy, especially for the rou-ine staging of lung cancer. Anterior mediastinotomy remainsuseful technique to assess stations 5 and 6 in the outpatient

etting. VATS requires more sophisticated anesthetic man-gement and usually requires hospital admission. VATS hasained in popularity as it provides enhanced viewing of ad-acent structures and more comprehensive sampling of theortopulmonary window and the para-aortic or prevascularymph nodes as well as the opportunity to proceed to thera-eutic resection if mediastinal staging is histologically be-ign.

eferences1. Passlick B: Initial surgical staging of lung cancer. Lung Cancer 42:S21-

S25, 2003 (suppl 1)2. Gonzalez-Stawinski GV, Lemaire A, Merchant F, et al: A compara-

Figure 12 A lung retractor is placed to aid visualization.n. � nerve.

tive analysis of positron emission tomography and mediastinoscopy

in staging non-small cell lung cancer. J Thorac Cardiovasc Surg 126:1900-1905, 2003

3. Daniels AC: A method of biopsy useful in diagnosing certain intratho-racic disease. Dis Chest 16:360-367, 1949

4. Carlens E: Mediastinoscopy: A method for inspection and tissue biopsyin the superior mediastinum. Chest 36:343-352, 1959

5. Pearson FG: Mediastinoscopy: A method of biopsy in the superiormediastinum. J Thorac Cardiovasc Surg 49:11-21, 1965

6. Porte H, Roumilhac D, Eraldi L, et al: The role of mediastinoscopy inthe diagnosis of mediastinal lymphadenopathy. Eur J CardiothoracSurg 13:196-199, 1998

7. Cybulsky IJ, Bennett WF: Mediastinoscopy as a routine outpatient pro-cedure. Ann Thorac Surg 58:176-178, 1994

8. Park BJ, Flores R, Downey RJ, et al: Management of major hemor-rhage during mediastinoscopy. J Thorac Cardiovasc Surg 126:726-731, 2003

9. Witte Bruta, Wolf M, Huertgen M, et al: Video-assisted mediastino-scopic surgery: Clinical feasibility and accuracy of mediastinal lymphnode staging. Ann Thorac Surg 82:1821-1827, 2006

0. Leschber G, Holinka G, Linder A: Video-assisted mediastinoscopiclymphadenectomy (VAMLA)—A method for systematic mediastinallymph node dissection. Eur J Cardiothorac Surg 24:192-195, 2003

1. Ginsberg RJ, Rice TW, Goldberg M, et al: Extended cervical mediasti-noscopy. A single staging procedure for bronchogenic carcinoma of theleft upper lobe. J Thorac Cardiovasc Surg 94:673-678, 1987

2. Cerfolio RJ, Bryant AS, Eloubeidi MA: Accessing the aortopulmonarywindow (#5) and the paraaortic (#6) lymph nodes in patients with

a and biopsy forceps are placed in the two other ports.
Camer
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Surgical mediastinal lymph node sampling for staging of non small cell lung carcinoma

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