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 .
- Genereux GP, Howie JL. Normal mediastinal lymph node size and number: CT and anatomic study. AJR Am J Roentgenol 1984; 142:1095.
- NCCN Guidelines Version 5.2015
- Rusch VW, Asamura H, Watanabe H, et al. The IASLC lung cancer staging project: a proposal for a new international lymph node map in the forthcoming seventh edition of the TNM classification for lung cancer. J Thorac Oncol 2009; 4:568.
- Section 7. Thorax. In: Gray's Anatomy: The anatomical basis of clinical practice, Fortieth, Standring S.. (Ed), Churchill, Livingstone, Elsevier, London, UK 2008. p.909.
- Smithuis R. Lung cancer lymph node map - Update. http://www.radiologyassistant.nl/en/4646f1278c26f (Accessed on October 31, 2011).
- Chapter 20. Video-Assisted Mediastinoscopy. In: Atlas of Minimally Invasive Thoracic Surgery, First, McKenna RJ, Mahtabifard A, Swanson SJ, Saunders, Philadelphia, PA 2010. p.203-212.
- Al-Sarraf N, Aziz R, Gately K, et al. Pattern and predictors of occult mediastinal lymph node involvement in non-small cell lung cancer patients with negative mediastinal uptake on positron emission tomography. Eur J Cardiothorac Surg 2008; 33:104.
- Karnak D, Ciledağ A, Ceyhan K, et al. Rapid on-site evaluation and low registration error enhance the success of electromagnetic navigation bronchoscopy. Ann Thorac Med 2013; 8:28.
- Gephardt GN, Rice TW. Utility of frozen-section evaluation of lymph nodes in the staging of bronchogenic carcinoma at mediastinoscopy and thoracotomy. J Thorac Cardiovasc Surg 1990; 100:853.
- Chapter 21. Right-Sided Mediastinal Lymph Node Dissection. In: Atlas of Minimally Invasive Thoracic Surgery, First, McKenna RJ, Mahtabifard A, Swanson SJ, Saunders, Philadelphia, PA 2010. p.213.
- Rau B, Hunerbein M, Below C, Schlag PM: Video-assisted thoracic surgery: Staging and management of thoracic tumors. Surg Endosc 1998;12:133.
- Park BJ, Flores R, Downey RJ, et al. Management of major hemorrhage during mediastinoscopy. J Thorac Cardiovasc Surg 2003; 126:726.
- Roberts JR, Wadsworth J. Recurrent laryngeal nerve monitoring during mediastinoscopy: predictors of injury. Ann Thorac Surg 2007; 83:388.
- Lemaire A, Nikolic I, Petersen T, et al. Nine-year single center experience with cervical mediastinoscopy: complications and false negative rate. Ann Thorac Surg 2006; 82:1185.
- Nechala P, Graham AJ, McFadden SD, et al. Retrospective analysis of the clinical performance of anterior mediastinotomy. Ann Thorac Surg 2006; 82:2004.
- Dernevik L, Larsson S, Pettersson G. Esophageal perforation during mediastinoscopy--the successful management of 2 complicated cases. Thorac Cardiovasc Surg 1985; 33:179.
- Benouaich V, Marcheix B, Carfagna L, et al. Anatomical bases of left recurrent nerve lesions during mediastinoscopy. Surg Radiol Anat 2009; 31:295.
- Angelillo-Mackinlay T. Transcervical repair of distal membranous tracheal laceration. Ann Thorac Surg 1995; 59:531.
- Rubin AD, Sataloff RT. Vocal fold paresis and paralysis. Otolaryngol Clin North Am 2007; 40:1109.
- Slinger, PD, Campos, JH. Anesthesia for thoracic surgery. In: Miller's Anesthesia, Miller, RD (Eds), Churchill Livingstone, 2009. p.1855.
- Vallières E, Pagé A, Verdant A. Ambulatory mediastinoscopy and anterior mediastinotomy. Ann Thorac Surg 1991; 52:1122.
- 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