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INTRODUCTION

The surgeon performing procedures for the resection of lung cancer has two goals in mind. The first goal is complete extirpation of the cancer itself; the second is complete mediastinal staging. The latter determines the extent and type of further therapy, that is, chemotherapy with or without radiation therapy. In addition, even if the patient is not a candidate for adjuvant therapy, lymph node staging determines prognosis.

Increasingly neoadjuvant therapy is used for non–small-cell lung cancer (NSCLC) involving mediastinal lymph nodes.1 This strategy is motivated by the assumption that neoadjuvant therapy leads to more reliable delivery and tolerance of multimodal therapy and the belief that such a strategy may lead to increased R0 resections.2,3 In addition, the response to therapy serves as a biologic test of the efficacy of chemotherapy for the patient’s specific tumor, thus leading to better patient selection and avoidance of surgical risk. Preresectional staging, therefore, can be used to hone therapeutic strategy. The gold standard for preresectional staging has been cervical mediastinoscopy. Advances in preresectional mediastinoscopy have evolved in two divergent directions. A less invasive method for this is endobronchial ultrasound with fine needle aspiration (EBUS). A slightly more invasive direction is transcervical extended mediastinal lymphadenectomy (TEMLA). The relative performance of all these methods of staging has been summarized by Dhillon et al.4 This chapter focuses on the latter procedure.

GENERAL PRINCIPLES AND CLINICAL CHARACTERISTICS THAT SUPPORT THIS APPROACH

The rationale for TEMLA is the fact that any sampling method has a measurable false-negative rate. This has been amply demonstrated for both EBUS and mediastinoscopy.5 Therefore, the only sure way of accurately staging the mediastinum short of the surgical resection is to approach the lymphadenectomy transcervically. As the space for operative work through the neck is limited, additional maneuvers are needed to increase the working space. This can be attained by retracting the sternum away from the spine using the patient’s own body weight for counter-retraction. Once additional space is thus attained, dissection can be performed using multiple instruments including hemostatic devices. This facilitates a true dissection instead of just extensive sampling.

In a comparison of TEMLA with less invasive sampling methods, Zielinski et al. found that when TEMLA is used for primary staging of patients with NSCLC, sensitivity for the discovery of N2–3 disease was 96.2%, specificity was 100%, negative predictive value (NPV) was 99.6%, and positive predictive value (PPV) was 100%. The mean number of nodes removed was 32.8 (8–77), as opposed to sampling of 1 to 5 stations with EBUS, endoesophageal ultrasound (EUS) sampling, or a combined EBUS and EUS approach. When TEMLA was used for restaging following neoadjuvant therapy, sensitivity for the discovery of N2–3 disease was 96.6%, specificity was 100%, NPV was 98.5%, and PPV was 100%.6

PATIENT SELECTION

As lymphadenectomy in early-stage disease has shown ...

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