Surgical evaluation of mediastinal lymphadenopathy
- Michael J Liptay, MD, FACS
Michael J Liptay, MD, FACS
- The Mary and John Bent Professor and Chairman
- Department of Cardiovascular and Thoracic Surgery
- Rush University Medical Center
- Edward Hong, MD
Edward Hong, MD
- Core Courtesy Assistant Professor
- Morsani College of Medicine
- Assistant Professor of Surgery
- University of Central Florida, College of Medicine
The evaluation of mediastinal nodes is paramount for staging patients with suspected or proven bronchogenic carcinomas . The National Comprehensive Cancer Network Guidelines for Non-small Cell Lung Cancer recommend that pretreatment evaluation include pathological mediastinal lymph node evaluation for patients clinically assessed to have stage IB (peripheral T2a, N0), stage I (central T1ab-T2a, N0), stage II (T1ab-T2ab, N1; T2b, N0), stage IIIA (except when unresectable) or IIIB disease, or those with separate pulmonary nodule(s) . The operative procedures are the standard approach for evaluating mediastinal adenopathy and for establishing the diagnosis of a primary or secondary mediastinal malignancy (eg, lymphoma, thymoma, breast cancer).
The operative approach for evaluation of mediastinal lymphadenopathy and the complications of the procedures are discussed here. The differential diagnosis, radiographic evaluation, and pathology of mediastinal masses are reviewed separately. (See "Approach to the adult patient with a mediastinal mass" and "Pathology of mediastinal tumors".)
CLASSIFICATION MEDIASTINAL LYMPH NODES
Mediastinal lymph nodes are located in the anterior, middle, and posterior mediastinal compartments (figure 1 and figure 2). Most of the mediastinal nodes are in close approximation to the left innominate vein, the anterior surface of the trachea, circumference of the main bronchi, and inferior and to the left of the aortic arch .
The International Association for the Study of Lung Cancer (IASLC) proposed classifying mediastinal nodes into regional lymph node stations and zones [3-5]. The lymph node stations and zones are shown in the figure (figure 3) .
SELECTION OF BIOPSY PROCEDURE
Selection of the biopsy procedure depends on the stations of adenopathy and a history of prior neck and mediastinal surgical procedures. The procedure options include cervical mediastinoscopy, thoracoscopy, anterior mediastinotomy, endobronchial ultrasound, navigational bronchoscopy, and esophageal ultrasound .
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- CLASSIFICATION MEDIASTINAL LYMPH NODES
- SELECTION OF BIOPSY PROCEDURE
- TECHNICAL APPROACHES
- Gross appearance of nodes
- Anterior mediastinotomy
- COMPLICATIONS OF MEDIASTINOSCOPY
- - Life-threatening hemorrhage
- - Tracheal injury
- - Esophageal injury
- - Pneumothorax
- - Recurrent laryngeal nerve injury
- COMPLICATIONS OF ANTERIOR MEDIASTINOTOMY
- COMPLICATIONS OF THORACOSCOPY
- SUMMARY AND RECOMMENDATIONS