Juan Carlos Trujillo-Reyes

Survival of Patients With Unsuspected pN2 Non-Small Cell Lung Cancer After an Accurate Preoperative Mediastinal Staging

BACKGROUND The aim of this study is to analyze the survival of patients with non-small cell lung cancer (NSCLC) without clinical suspicion of mediastinal lymph node involvement who underwent complete resection and whose tumors were finally proven to be pathologic N2 (pN2). METHODS This is a retrospective study of a prospective database from January 2004 to December 2010. A total of 621 patients with NSCLC were staged and operated according to the European Society of Thoracic Surgeons guidelines. After exclusions (previous induction treatment, carcinoid tumors, small cell carcinomas), 540 patients were analyzed; 406 (75%) required surgical exploration of the mediastinum and 134 (25%) underwent surgery directly. Survival analysis was performed by the Kaplan-Meier method and the log-rank test was used for comparisons. RESULTS Thirty (5.5%) patients had unsuspected pN2 and complete resection was achieved in 27 (90%). Three- and 5-year survival rates were 87% and 81%, respectively, for patients with a true negative result of the protocol (pN0-1), and 79% and 40%, respectively, for those with a false negative result (unsuspected pN2) (p < 0.0001). CONCLUSIONS The rate of unsuspected pN2 in patients whose tumors were staged according to the European Society of Thoracic Surgeons guidelines was low. The survival of this group of patients was better than expected. Therefore, resection of properly staged unsuspected pN2 NSCLC is reasonable and should not be avoided if complete resection can be achieved.

Video-Assisted Mediastinoscopic Lymphadenectomy for Staging Non-Small Cell Lung Cancer

BACKGROUND The aim of this study was to evaluate the results of video-assisted mediastinoscopic lymphadenectomy (VAMLA) for staging of non-small cell lung cancer (NSCLC). METHODS This was a prospective observational study of all consecutive VAMLAs performed from January 2010 to April 2015 for staging NSCLC. For left lung cancers, extended cervical videomediastinoscopy was added to explore the subaortic and paraaortic nodes. Patients with negative VAMLA results underwent tumor resection and lymphadenectomy of the remaining nodes. Those with N2-3 disease underwent chemoradiation. The rate of unsuspected pathologic (p)N2-3 was analyzed in the global series and in the subgroups of patients according to their nodal status diagnosed by imaging and metabolic techniques. RESULTS One hundred sixty VAMLAs were performed for staging NSCLC (138 tumors were clinical (c)N0-1 based on imaging techniques). The rate of unsuspected N2-3 disease was 18% for the whole series: 40.7% for cN1, 22.2% for cN0 and tumor size greater than or equal to 3 cm, and 6.4% for cN0 and tumor size less than 3 cm. Staging values were sensitivity, 0.96 (95% confidence interval [CI], 0.81-99.3); specificity, 1 (95% CI, 0.97-1); positive predictive value, 1 (95% CI, 0.87-1); negative predictive value, 0.99 (95% CI, 0.95-0.99); and diagnostic accuracy, 0.99 (95% CI, 0.96-0.99). The complication rate was 5.9%. CONCLUSIONS VAMLA is a feasible and highly accurate technique. The high rate of unsuspected mediastinal node disease diagnosed by VAMLA in patients with cN1 or cN0 disease and tumor size larger than 3 cm suggests that preresection lymphadenectomies should be included in the current staging algorithms.

Subxiphoid video-pericardioscopy

Pericardial effusion may be associated with many diseases, but sometimes its aetiology is not easy to elucidate. Subxiphoid video-pericardioscopy is useful for the study of the pericardial cavity. Through a subxiphoid approach, the pericardium is incised and a rigid (usually a video-mediastinoscope) or a flexible endoscope (flexible bronchoscope or flexible choledoscope) is inserted into the pericardial cavity. The inner surface of the parietal pericardium and the epicardium can be explored and biopsies can be taken under visual control. In addition, a subxiphoid pericardial window can be developed, and sclerosing agents instilled for pericardiodesis, if a malignant aetiology is confirmed. In case of pericardial effusion associated with lung cancer, video-pericardioscopy helps to confirm the absence or presence of pericardial tumour implant or infiltration, and to establish the resectability of the tumour. Other than transient arrhythmias during the procedure, video-pericardioscopy has no major complications. When compared with surgical pericardial drainage, video-pericardioscopy has higher sensitivity without specific risks. Rigid endoscopes are the best devices to explore the posterior and lateral pericardial surfaces, the pulmonary veins being the posterior limit of the exploration. Big anterior mediastinal masses and pericardial symphysis may render the exploration impossible.

Utility of the transcervical approach in bilateral synchronous lung cancer

Bilateral pulmonary nodules represent a challenge in distinguishing between synchronous bronchogenic carcinomas and metastatic disease. In the case of potentially curable synchronous lung cancer, it is recommended to treat each lesion with curative intent if there is no evidence of mediastinal involvement or extrathoracic disease. In this situation, surgical staging of the mediastinum is recommended. This case shows the utility of a transcervical approach to perform precise mediastinal staging and lymphadenectomy, and to access the pleural cavity to resect a pulmonary nodule. Moreover, video-assisted mediastinoscopic lymphadenectomy combined with video-assisted lobectomy could be a good option for a radical lymphadenectomy.

Scalene Fat Pad Biopsy

Intrathoracic, abdominal and pelvic inflammations, infections and malignancies may spread along the lymphatic vessels cranially to the lymph nodes of the scalene fat pad. Its biopsy may make other more invasive procedures, such as mediastinoscopy, thoracoscopy, thoracotomy or laparoscopy, unnecessary. For staging of bronchogenic carcinoma, it is mainly indicated when there is involvement of the mediastinal lymph nodes. Stomach cancer and cancer of the cervix tend to metastasize to these nodes. For the latter, scale lymph node biopsy is especially indicated when there is evidence of para-aortic nodal involvement. With the introduction of computed tomography and positron emission tomography in clinical practice, scalene fat pad biopsy has been almost abandoned, but it should be considered among the available diagnostic and staging procedures if involvement of these nodes modifies therapy.

Tension pneumocephalus: a rare complication after resection of a neurogenic tumour by thoracoscopic surgery

A 30-year old man presented with back pain. Computed tomography (CT) (Fig. 1A) revealed a posterior mediastinal mass, which was removed by thoracoscopic excision (Fig. 1B). The diagnosis was schwannoma. Seventy-two hours later, he developed headaches and vomiting. The cranial CT (Fig. 1C) performed revealed pneumocephalus. His symptoms improved in 48 h with bed rest and oxygen. The patient was discharged asymptomatic on the 10th postoperative day.