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Ann Thorac Surg 2000;70:1641-1643
© 2000 The Society of Thoracic Surgeons

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Original articles: general thoracic

Extended cervical mediastinoscopy in the staging of bronchogenic carcinoma

^a Thoracic Surgery and Respiratory Services, Hospital General Universitario de Gran Canaria, Las Palmas de Gran Canaria, Canary Islands, Spain
^b Thoracic Surgery Service, Hospital Puerta de Hierro, Madrid, Spain

Address reprint requests to Dr Freixinet Gilart, Thoracic Surgery Service, Hospital General Universitario de Gran Canaria, Las Palmas de Gran Canaria, Canary Islands, Spain
e-mail: jfreixi{at}correo.hpino.rcanaria.es

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Extended cervical mediastinoscopy (ECM) is a technique in the staging of bronchogenic carcinoma described first by Ginsberg in 1984. To update our experience we have prospectively evaluated our results on 106 patients who underwent the technique from 1985 to 1998.

Methods. The ECM technique is performed once the operability of the patient has been evaluated, according to the computed tomography findings. The intervention is carried out at the same time as a standard cervical mediastinoscopy through the same incision following the same technique as previously published. The ECM is considered positive when metastatic nodes or tumor involvement directly in the paraaortic or subaortic regions is detected and confirmed histologically. Negative cases of ECM and positive cases of standard cervical mediastinoscopy are excluded from this study. A false-negative ECM is defined as the presence of infiltrated adenopathies at the paraortic level detected on postoperative histologic study.

Results. We had performed ECM in 106 patients, and a total of 13 were subsequently excluded for the reasons stated above. Of the remaining cases, 26 were positive, 61 negative and 6 had false-negative results with no false-positive results. Sensitivity was 81.2%, specificity 100%, accuracy 93.3%, positive predictive value 100%, and negative predictive value 91%. There were no complications with the technique.

Conclusions. We conclude that ECM is a useful technique for staging bronchogenic carcinoma that allows samples to be taken from paraortic and subaortic regions with minimally invasive techniques.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Extended cervical mediastinoscopy (ECM) is a well-known technique in the staging of bronchogenic carcinoma in those cases where the presence of adenopathies in the aortopulmonary window is suspected. This technique was first described by Ginsberg and colleagues in 1984 [1] and their articles as well as the work we have done modifying the previously described procedure [2] have confirmed its usefulness. It has been compared to other mediastinal staging techniques in bronchogenic carcinoma such as mediastinotomy or video-assisted thoracoscopic surgery. It has shown the advantage of being able to be carried out simultaneously with standard mediastinoscopy (SCM) and through the same incision. In this article we update our previously published work in this area [2] and relate our experience over the past 14 years.

	Material and methods

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This study comprises 106 cases of ECM performed prospectively for the staging of bronchogenic carcinoma from 1985 to 1998. All of the cases met general operability criteria.

For the staging third-generation computed tomography (CT) was carried out making serial cuts 1 cm thick from the apex of the thorax to the diaphragmatic domes. When adenopathies larger than 1 cm or those suspected of direct tumoral infiltration was observed, ECM was performed.

The extension study consisted of abdominal CT or abdominal ultrasonography, or both along with a brain CT scan in all cases of adenocarcinoma and nondifferentiated large cell carcinoma and also in epidermoid carcinomas with neurologic symptoms. Bone scintigraphy was reserved for those patients with symptoms or with high alkaline phosphatase serum levels .

The ECM technique is carried out at the same time as a standard cervical mediastinoscopy (SCM) through the same incision following the same technique as has been previously published [2]. The technique consists of a dissection through a cervical incision (the same incision as the SCM) of the retrosternal space, between the anterior face of the left innominate vein and the posterior face of the sternum, separating the fascia lying between both structures. That allows entry at the level of the aortic arch at the origin of the innominate artery. Extended cervical mediastinoscopy is contraindicated in malformations or enlargement of supraaortic vessels. The existence of paraaortic nodes in ascertained first by palpation, and then using the mediastinoscope, which is passed into place by sliding it along the left anterolateral face of the aortic arch until it reaches the subaortic space or the aortopulmonary window. Our technique differs from the one described by Ginsberg and associates [1] in that we carried out the intervention by penetrating above the venous innominate trunk and not between it and the aortic arch through the innominate triangle. All areas suspected of harboring neoplasms were biopsied. Those cases in which the examination proved positive were excluded from surgery, and those in which neoplasms were not found were operated on using standard procedures for pulmonary resection, such as a lymphadenectomy, for postoperative staging.

Cases in which SCM was positive and ECM was negative were excluded from the study for the purpose of evaluating only neoplastic tissue found at the paraaortic or subaortic level during ECM. A false-negative result on the ECM was defined as a tumor detected during the thoracotomy but not during the ECM. Values of sensitivity, specificity, diagnostic accuracy, positive predictive value, and negative predictive value of the technique were calculated according to the corresponding formulas (Table 1).

	Results

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Table 2 shows the data obtained with respect to the positivity and negativity of the technique. The lymphatic spread diagnosed by ECM and SCM is shown in Table 3. Twenty-six cases stand out as true-positive and 61 as true-negative results. On 13 occasions the adenopathy was limited to the paratracheal space without infiltrating the paraortic or subaortic spaces (cases excluded from the study). In 26 cases there was evidence of infiltration in those spaces (true-positive results). There were no complications resulting from the technique.

The postoperative histologic study demonstrated adenopathy in the subcarinal space in 6 patients (lymphatic nodal group not accessible by ECM; considered true-negative results) and the presence of adenopathies in the aortopulmonary window in 6 patients (false-negative results).

All patients with tumoral affectation in the aortopulmonary window had in the upper left lung carcinomas. None of the neoplasms of the lower lobe were positive on the ECM. Sensitivity of the technique was 81.2%, specificity was 100%, diagnostic accuracy was 95.5%, the positive predictive value was 100%, and the negative predictive value was 91%.

	Comment

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The prognosis of non–small cell bronchogenic carcinoma is directly related to the extent of the local, regional, and distance neoplasia. Findings of neoplasia in the ipsilateral (N2) or contralateral (N3) ganglionar mediastinal area worsens the prognosis and considerably lowers the expectations for cure. In those patients with contralateral lymphatic nodal extension, the life expectancy is not higher than 3% for more than 5 years whereas, in the best of cases, 5-year survival is expected in only 25% of those with ipsilateral neoplasia.

Appraisal of the operability of non–small cell bronchogenic carcinoma from an oncologic point of view demands, therefore, the mediastinal staging, which is performed using CT scanning [4, 5]. When the findings suggest the presence of mediastinal involvement, surgical procedures are indicated and are generally applied when the adenopathies detected on the CT scan are of a size considered to be pathologic, and the involved area is considered accessible to stated techniques [5]. With this method an adequate selection of those cases that can really benefit from surgery is guaranteed. Cases for induction therapy can also be selected and reevaluated for later surgery.

The classic technique for staging in non–small cell bronchogenic carcinoma has been SCM, because it allows inspection and biopsy of bilateral paratracheal, pretracheal, tracheobronchial, and anterior subcarinal adenopathies [7]. Lymphatic nodes of the paraaortic and subaortic regions might be explored by anterior mediastinostomy, or Chamberlain procedure [8]. In this intervention an incision is made in the second intercostal space at the anterior level. Access to the aortopulmonary window is achieved by laterally pushing aside pleura, allowing the technique to be carried out extrapleurally. It should be noted, however, that lymph nodes in the upper mediastinum are often not assessed when surgeons use the Chamberlain procedure alone or videothoracoscopy; a positive result in this region would eliminate the patient from surgical consideration. This procedure has been described as a valid technique, and its use is widespread [9].

The most recent introduction of video-assisted thoracoscopy permits exploration of mediastinal areas that are not accessible through these other methods. Good results have been described with this method [10], although its use has not been as extended as SCM in the staging of bronchogenic carcinoma. Paratracheal spaces and aortopulmonary window can be approached with videothoracoscopy, as can other regions, such as the subcarinal and the lower pulmonary ligament. The method does, however, have the serious inconvenience of not being able to access the paratracheal chain of the contralateral side it explores. To its advantage is its capacity to explore the pleural cavity in search of the possibility of pleural or pulmonary metastasis, as well as its ability to appraise the resectability of the tumor. The difficulty in adequately appraising the pulmonary hilum without either palpating or dissecting it adequately has put these advantages in doubt.

Extended cervical mediastinoscopy, initially described by Ginsberg and associates [1] and modified by us [2], has demonstrated its effectiveness in the staging in the subaortic and paraortic node chains that in other forms are studied by anterior mediastinotomy or video-assisted thoracoscopy. The advantages of ECM are that the exploration can be carried out through the same incision as SCM. Risks and potential complications such as opening of the pleura, infection of the wound, and postsurgical pain are also avoided. The results are optimal because of the absence of complications directly related to the technique, and it allows for an excellent sensibility, specificity, and diagnostic accuracy. For those three measures, our results were 81.2%, 100%, and 93.3%, respectively, which leads us to consider ECM to be a useful technique that allows us to avoid other more invasive explorations, such as anterior mediastinotomy and video-assisted thoracoscopy. Mediastinotomy requires an anterior thoracic incision, and video-assisted thoracoscopy requires intubation with an endobronchial double-lumen tube to produce pulmonary collapse and three thoracic incisions. However, with ECM, paraortic and subaortic mediastinal staging can be carried out without the necessity of more incisions.

For this reason we believe that, with the proper training of the surgical team, ECM is the technique of choice when adenopathies in the paraaortic and subaortic spaces are discovered on CT scanning. This exploration can be combined, through the same incision, with SCM. [3] [6] [11]

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Ginsberg R.J., Rice T.W., Goldberg M., Walters P.F., Schomocker B.J. Extended cervical mediastinoscopy. A single procedure for bronchogenic carcinoma of the left upper lobe. J Thorac Cardiovasc Surg 1984;94:673-678.[Abstract]
2. López L., Varela A., Freixinet J., et al. Extended cervical mediastinoscopy. Ann Thorac Surg 1994;57:555-558.[Abstract]
3. Mountain C.F. Revisions in the International System for Staging lung cancer. Chest 1997;111:1710-1717.[Abstract/Free Full Text]
4. Canadian Lung Oncology Group. Investigation for mediastinal disease in patients with apparently operable lung cancer. Ann Thorac Surg 1995:1382-1389.
5. American Thoracic Society/European Respiratory Society. Pretreatment evaluation of non-small-cell lung cancer. Am J Crit Care Med 1997;156:320-332.[Free Full Text]
6. Grupo de trabajo de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR). Normativa actualizada (1998) sobre diagnóstico y estadificación del carcinoma broncogénico. Arch Bronconeumol 1998;34:437-452.[Medline]
7. Pearson F.G., DeLarue N.C., Ilves R., Todd T.R.J., Cooper J.D. Significance of positive superior mediastinal lymph nodes identified at mediastinoscopy in patients with resectable cancer of the lung. J Thorac Cardiovasc Surg 1982;83:1-11.[Medline]
8. McNeil T.M., Chamberlain J.M. Diagnostic anterior mediastinoscopy. Ann Thorac Surg 1966;2:532-539.[Medline]
9. Best L.A., Munichor M., Ben-Shakhar M., Lemer J., Lichting C., Peleg H. The contribution of anterior mediastinotomy in the diagnosis and evaluation of diseases of the mediastinum and lung. Ann Thorac Surg 1987;43:78-81.[Abstract]
10. Roviaro G.C., Varolli F., Rebuffat C., et al. Videothoracoscopic staging and treatment of lung cancer. Ann Thorac Surg 1995;59:971-974.[Abstract/Free Full Text]
11. Kaiser L., Friedberg S. The role of surgery in the multimodality management of non–small cell lung cancer. Semin Thorac Cardiovasc Surg 1997;9:60-79.[Medline]

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