Clinical value of video-assisted thoracoscopy for preoperative staging of non-small cell lung cancer: A prospective study of 105 patients

doi:10.1016/j.lungcan.2003.06.001

Lung Cancer

Volume 42, Issue 3, December 2003, Pages 297-301

https://doi.org/10.1016/j.lungcan.2003.06.001 Get rights and content

Abstract

This study prospectively evaluated the usefulness of thoracoscopy for staging non-small cell lung cancer in 105 consecutive patients. A comparison was made of TNM stage grouping classification according to clinical disease, thoracoscopic data, and pathological findings. In 40 (38%) patients, thoracoscopy was unreliable for assessing extent of disease due to pleural symphysis. In 13 T1 clinical lesions, thoracoscopy was unreliable in 5, clinical and thoracoscopic staging concurred in 4, but 4 cases changed to T2. In 62 T2 clinical lesions, thoracoscopy was not feasible due to technical difficulties in 21 (34%); however, in the remaining 41 cases, 6 lesions changed to T3 and 1 to T4. In the group of 23 T3 or T doubtful clinical disease, thoracoscopy was conclusive, whereas in 12 T4 clinical lesions, thoracoscopy contributed for tailoring treatment strategies. With regard to N stage, 72 N0 clinical cases, thoracoscopy revealed false negatives in 25%. N1 clinical lesions were not evaluated due to the small number of patients. In 30 N2 clinical lesions, thoracoscopy was incomplete in 11. In another 11 cases, mediastinal node involvement at nodal groups not accessible by mediastinoscopy was confirmed by thoracoscopy. Clinical and thoracoscopic findings were not concurrent in eight cases, therefore in clinical N2 lesions, the diagnostic accuracy of thoracoscopy was 63%. Only one case of unsuspected pleural metastasis was detected. Thoracoscopy-related complications occurred in nine cases. In summary, video-assisted thoracoscopy was useful for staging T3, T4, and T doubtful clinical disease as well as N2 lesions especially for the surgical exploration of lymph nodes at the lower paratracheal level (region 4), aortopulmonary window (region 5), paraaortic (region 6), posterior subcarinal space (region 7), paraesophageal (region 8), and inferior pulmonary ligament (region 9).

Introduction

Exact preoperative staging is a prerequisite for establishing an adequate treatment plan for patients with bronchial carcinoma [1]. Computed tomographic (CT) scan of the chest is a common diagnostic modality for assessing the primary tumor (T stage) and regional lymph nodes (N stage). However, despite intensive use of CT scanning facilities, the true extent of intrathoracic disease is frequently underestimated [2], [3]. Mediastinal lymph node invasion is associated with a poor prognosis even in patients undergoing curative operative therapy [4], [5]. Although primary surgical resection may be justified for a selected group of patients with mediastinal distal paratracheal involvement, most patients are candidates for induction chemotherapy before evaluating operability [6], [7]. Mediastinoscopy is an important diagnostic tool in patients with mediastinal nodal disease, avoiding unnecessary exploratory thoracotomy or incomplete resections in technically unresectable tumors [8]. On the other hand, cervical mediastinoscopy is associated with difficulties in adequately appraising hilar and interlobar nodes, the aortopulmonary window, lower paratracheal lymph nodes, aortic nodes, and inferior mediastinal nodes [9]. Anterior mediastinoscopy or the Chamberlain procedure and extended cervical mediastinoscopy are useful for the evaluations of subaortic and paraaortic nodes, with advantages and limitations for the assessment of other node chains. In addition, accurate evaluation of the T status preoperatively allows correctly selecting patients for the most appropriate surgical approach.

Video-assisted thoracoscopy possess some unique capabilities as a staging procedure for lung cancer operations [10], [11]. It is the only modality that allows complete visualization of the pleural space, with the added potential of permitting inspection of both the parietal and visceral pleural surfaces, the aortic and mediastinal lymph nodes, and the pulmonary hilum. This study prospectively evaluated the usefulness of video-assisted thoracoscopy for staging non-small cell lung cancer, considering T status, N status, and M status independently.

Section snippets

Patients and methods

Between 1996 and 1998, a total of 17 hospitals constituted the Spanish Video-Assisted Thoracic Surgery Study Group, with the objective of developing a protocol for the study and treatment of lung cancer, in particular, to collect data prospectively from patients with bronchial carcinoma at different stages in order to assess the clinical value of video-assisted thoracoscopy in the study and treatment of the disease. Patients with histologically documented non-small cell lung cancer (previously

Results

A total of 135 protocols from patients with non-small cell lung cancer were reviewed. However, 30 patients were excluded because of lack of histopathologic confirmation of specimens obtained by thoracotomy or biopsy. Therefore, the study population consisted of 105 patients with definite non-small cell lung cancer and who underwent clinical and videothoracoscopic lung cancer staging. Ninety patients (86%) underwent thoracotomy. The tumor was considered unresectable in four patients due to

Discussion

There is an increasing demand for accurate preoperative staging of bronchial carcinoma with respect to determination of tumor stage and nodal status. Video-assisted thoracoscopy provides an opportunity for evaluation and biopsy within the pleural space and at the pulmonary hilum. Most studies have shown that diagnostic accuracy of CT scan for lung cancer staging is lower than 60% [2], [5]. Systemic or selective mediastinoscopy allows visualization of nodes in the pretracheal, paratracheal and

Acknowledgements

This study was supported by Xunta de Galicia, Spanish Foundation of Pneumology and Thoracic Surgery (SEPAR), and Ethicon Endosurgery (Madrid, Spain). We are indebted to Javier Muñiz, MD, and Alfonso Castro, MD, Instituto de Ciencias de la Salud de A Coruña, for their contribution in data collection, and Marta Pulido, MD, for editing the manuscript and editorial assistance.

References (16)

C.F. Mountain
Revisions in the international system for staging lung cancer
Chest
(1997)
J.R. Izbicki et al.
Accuracy of computed tomographic scan and surgical assessment for staging of bronchial carcinoma. A prospective study
J. Thorac. Cardiovasc. Surg.
(1992)
J. Loscertales et al.
An assessment of the resectability of lung cancer by exploratory video thoracoscopy
Arch. Bronconeumol.
(1996)
L. Molins
Videothoracoscopic surgery in the year 2000
Med. Clin.
(2000)
T. De Giacomo et al.
Thoracoscopic staging of IIIB non-small cell lung cancer before neoadjuvant therapy
Ann. Thorac. Surg.
(1997)
J.C. Wain
Video-assisted thoracoscopy and the staging of lung cancer
Ann. Thorac. Surg.
(1993)
R.J. Landreneau et al.
The role of thoracoscopy in lung cancer management
Chest
(1998)
A.P. Yim
Routine video-assisted thoracoscopy prior to thoracotomy
Chest
(1996)

There are more references available in the full text version of this article.

Cited by (33)

Executive summary of the SEPAR recommendations for the diagnosis and treatment of non-small cell lung cancer
2016, Archivos de Bronconeumologia
La Sociedad Española de Neumología y Cirugía Torácica (SEPAR), a través de las áreas de Cirugía Torácica y de Oncología Torácica, ha promovido la realización de un manual de recomendaciones para el diagnóstico y el tratamiento del cáncer de pulmón de células no pequeñas. Las elevadas incidencia y mortalidad de esta patología hacen necesaria una constante actualización de las mejores evidencias científicas para su consulta por parte de los profesionales de la salud.
Para su confección se ha contado con un amplio grupo de profesionales de distintas especialidades que han elaborado una revisión integral, que se ha concretado en 4 apartados principales. En el primero se ha estudiado la prevención y el cribado de la enfermedad, incluyendo los factores de riesgo, el papel de la deshabituación tabáquica y el diagnóstico precoz mediante programas de cribado. En un segundo apartado se ha analizado la presentación clínica, los estudios de imagen y el riesgo quirúrgico, incluyendo el cardiológico y la evaluación funcional respiratoria. Un tercero trata sobre los estudios de confirmación cito-histológica y de estadificación, con un análisis de las clasificaciones TNM e histológica, métodos no invasivos y mínimamente invasivos, así como las técnicas quirúrgicas para el diagnóstico y estadificación. En un cuarto y último capítulo se han abordado aspectos del tratamiento, como el papel de las técnicas quirúrgicas, la quimioterapia, la radioterapia, el abordaje multidisciplinar por estadios y otros tratamientos dirigidos frente a dianas específicas, terminando con recomendaciones acerca del seguimiento del cáncer de pulmón y los tratamientos paliativos quirúrgicos y endoscópicos en estadios avanzados.
The Thoracic Surgery and Thoracic Oncology groups of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) have backed the publication of a handbook on recommendations for the diagnosis and treatment of non-small cell lung cancer. Due to the high incidence and mortality of this disease, the best scientific evidence must be constantly updated and made available for consultation by healthcare professionals.
To draw up these recommendations, we called on a wide-ranging group of experts from the different specialties, who have prepared a comprehensive review, divided into 4 main sections. The first addresses disease prevention and screening, including risk factors, the role of smoking cessation, and screening programs for early diagnosis. The second section analyzes clinical presentation, imaging studies, and surgical risk, including cardiological risk and the evaluation of respiratory function. The third section addresses cytohistological confirmation and staging studies, and scrutinizes the TNM and histological classifications, non-invasive and minimally invasive sampling methods, and surgical techniques for diagnosis and staging. The fourth and final section looks at different therapeutic aspects, such as the role of surgery, chemotherapy, radiation therapy, a multidisciplinary approach according to disease stage, and other specifically targeted treatments, concluding with recommendations on the follow-up of lung cancer patients and surgical and endoscopic palliative interventions in advanced stages.
Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American college of chest physicians evidence-based clinical practice guidelines
2013, Chest
Citation Excerpt :
It is reported that it is feasible to get adequate specimens via TBNA in approximately 80% to 90% of cases.273–276 For this iteration of the guideline, 2,408 patients were included in an updated systematic review (Fig 13).176,273–298 The overall median sensitivity was 78%, with values ranging from 14% to 100%.
Correctly staging lung cancer is important because the treatment options and prognosis differ significantly by stage. Several noninvasive imaging studies and invasive tests are available. Understanding the accuracy, advantages, and disadvantages of the available methods for staging non-small cell lung cancer is critical to decision-making.
Test accuracies for the available staging studies were updated from the second iteration of the American College of Chest Physicians Lung Cancer Guidelines. Systematic searches of the MEDLINE database were performed up to June 2012 with the inclusion of selected meta-analyses, practice guidelines, and reviews. Study designs and results are summarized in evidence tables.
The sensitivity and specificity of CT scanning for identifying mediastinal lymph node metastasis were approximately 55% and 81%, respectively, confirming that CT scanning has limited ability either to rule in or exclude mediastinal metastasis. For PET scanning, estimates of sensitivity and specificity for identifying mediastinal metastasis were approximately 77% and 86%, respectively. These findings demonstrate that PET scanning is more accurate than CT scanning, but tissue biopsy is still required to confirm PET scan findings. The needle techniques endobronchial ultrasound-needle aspiration, endoscopic ultrasound-needle aspiration, and combined endobronchial ultrasound/endoscopic ultrasound-needle aspiration have sensitivities of approximately 89%, 89%, and 91%, respectively. In direct comparison with surgical staging, needle techniques have emerged as the best first diagnostic tools to obtain tissue. Based on randomized controlled trials, PET or PET-CT scanning is recommended for staging and to detect unsuspected metastatic disease and avoid noncurative resections.
Since the last iteration of the staging guidelines, PET scanning has assumed a more prominent role both in its use prior to surgery and when evaluating for metastatic disease. Minimally invasive needle techniques to stage the mediastinum have become increasingly accepted and are the tests of first choice to confirm mediastinal disease in accessible lymph node stations. If negative, these needle techniques should be followed by surgical biopsy. All abnormal scans should be confirmed by tissue biopsy (by whatever method is available) to ensure accurate staging. Evidence suggests that more complete staging improves patient outcomes.
Endothoracic Sonography Improves the Estimation of Operability in Locally Advanced Lung Cancer
2010, Annals of Thoracic Surgery
Citation Excerpt :
The cancer in 36.8% of these patients was overstaged and misclassified as inoperable. VAT has been used for operative staging of lung cancer [10, 11], and is of great value in clinical N2 stages, especially when lymph nodes are located in areas inaccessible through mediastinoscopy [8, 12, 13]. In the case of ipsilateral pleural effusion in patients with lung cancer, thoracoscopy should be used to stage those patients before proceeding to thoracotomy [14].
Patients with T4 non-small cell lung cancers with limited involvement of mediastinal structures can undergo resection, with acceptable long-term survival. Computed tomography has not proven to be reliable in determining the operability of locally advanced lung carcinoma. This study evaluated the ability of video-assisted thoracoscopy alone and with endothoracic sonography to determine operability.
Computed tomography showed a close contact of the tumor with mediastinal structures (T4) in 155 patients. Staging was expanded with video-assisted thoracoscopy, followed by thoracoscopic ultrasound. Lateral thoracotomy with hilar and mediastinal dissection was considered the gold standard in determining operability.
Thoracoscopic ultrasound, compared with thoracoscopy alone and computed tomography, had the highest sensitivity (94.1% vs 75.2% vs 43.6%, p < 0.001) and specificity (98.1% vs 57.4% vs 37.0%, p < 0.001) for determining operability. Computed tomography, thoracoscopy, and thoracoscopic ultrasound were falsely negative in 57 (36.8%), 25 (16.1%), and 6 (3.9%) patients and falsely positive in 34 (21.9%), 23 (14.8%), and 1 (0.6%). False-negative results for operability by thoracoscopic ultrasound were found only in tumors involving the left atrium (3.9%).
Estimation of operability in locally advanced lung cancer can be improved with video-assisted thoracoscopy and ultrasound. More than one-third of patients classified as inoperable by computed tomography were able to undergo complete resection.
Usefulness of Video-assisted Thoracoscopy for Correctly Staging Tumors as T3 Because of Chest Wall Invasion
2009, Archivos de Bronconeumologia
La videotoracoscopia exploradora (VTE) es una técnica que permite valorar la resecabilidad del carcinoma de pulmón. El objetivo de este trabajo ha sido comprobar su utilidad para diferenciar los verdaderos tumores T3 por invasión parietal de aquellos que se estadificaron de forma incorrecta por las pruebas de imagen.
Desde marzo de 1993 hasta diciembre de 2007 se estudió a 1.277 pacientes, de los que 150 (137 varones y 13 mujeres; rango de edad: 28–81 años) presentaron tumores estadificados como cT3 por invasión parietal en las pruebas de imagen.
Tras la realización de la VTE, los tumores pT3 por invasión parietal confirmados intraoperatoriamente y mediante estudio anatomopatológico fueron 44. De ellos, 36 se habían clasificado correctamente como cT3 por tomografía computarizada o resonancia magnética. Se observó además que 6 casos habían sido infravalorados como cT2, y otros 2 supravalorados como cT4. La sensibilidad, especificidad y valor predictivo tanto positivo como negativo obtenidos en nuestra serie han sido del 100%.
En nuestra opinión, la VTE es una técnica claramente superior a la tomografía computarizada y/o resonancia magnética para detectar infiltración de pared, por lo que, además de estadificar correctamente la situación tumoral T3 por invasión parietal, permite decidir la vía de abordaje adecuada para cada caso.
Exploratory video-assisted thoracoscopy (EVT) can be used to assess the resectability of lung carcinomas. The aim of this study was to investigate the usefulness of this technique for distinguishing between tumors that invade the chest wall and should be staged as T3 and tumors that have been incorrectly staged as T3 on the basis of imaging studies.
From March 1993 through December 2007, we studied 1277 patients, of whom 150 (137 men and 13 women; age range, 28–81 years) presented tumors classified as cT3 because of chest wall invasion on the basis of imaging studies.
After exploratory EVT, 44 pT3 tumors with chest wall invasion were confirmed intraoperatively and by histopathology. Of these, 36 had been correctly classified as cT3 by computed tomography or magnetic resonance imaging. However, tumors had been understaged as cT2 in 6patients and overstaged as cT4 in 2 patients. The sensitivity, specificity, and positive and negative predictive values obtained were 100%.
We believe that exploratory EVT is clearly better than computed tomography and/or magnetic resonance imaging for detecting chest wall invasion. In addition to correctly staging a tumor as T3 because of chest wall invasion, the technique can also help decide the best surgical approach in each case.
Minimally Invasive Staging of N2 Disease: Endobronchial Ultrasound/Transesophageal Endoscopic Ultrasound, Mediastinoscopy, and Thoracoscopy
2008, Thoracic Surgery Clinics
Citation Excerpt :
No mortality has been reported from thoracoscopic mediastinal staging. In eight studies reporting on 669 patients, 12 complications were reported (average 2%; range 0–9%) [34–41]. Many centers can perform a thoracoscopic mediastinal staging and discharge the patient home the same day or the next morning.
Multiple methods of minimally invasive evaluation of the N2 lymph nodes have been developed in hope of providing information similar to that obtained by a lymph node dissection, but with less morbidity. This article details four minimally invasive procedures: endobronchial ultrasound and needle biopsy, endoscopic transesophageal ultrasound and needle biopsy, cervical mediastinoscopy and biopsy, and thoracoscopy and biopsy. It discusses the lymph nodes that can be evaluated by these procedures, the limitations of the procedures, additional information the procedures can yield beyond lymph node staging, the procedures' reliability in determining whether cancer is present in the N2 lymph nodes, and, most importantly, the potential cost to the patient in answering that question.
Invasive mediastinal staging of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition)
2007, Chest
Citation Excerpt :
Even if the studies are restricted to patients with enlarged nodes, the sensitivity still ranges from 50 to 100%. The low sensitivity comes primarily from a study by Sebastian-Quetglas et al49 This study is the only prospective, multiinstitutional study, and may perhaps be more generally applicable than the results from single institutions with a focused interest and extensive experience. It should be noted that VATS staging was feasible in only 75% of patients in this series.
The treatment of non-small cell lung cancer (NSCLC) is determined by accurate definition of the stage. If there are no distant metastases, the status of the mediastinal lymph nodes is critical. Although imaging studies can provide some guidance, in many situations invasive staging is necessary. Many different complementary techniques are available.
The current guidelines and medical literature that are applicable to this issue were identified by computerized search and were evaluated using standardized methods. Recommendations were framed using the approach described by the Health and Science Policy Committee of the American College of Chest Physicians.
Performance characteristics of invasive staging interventions are defined. However, a direct comparison of these results is not warranted because the patients selected for these procedures have been different. It is crucial to define patient groups, and to define the need for an invasive test and selection of the best test based on this.
In patients with extensive mediastinal infiltration, invasive staging is not needed. In patients with discrete node enlargement, staging by CT or positron emission tomography (PET) scanning is not sufficiently accurate. The sensitivity of various techniques is similar in this setting, although the false-negative (FN) rate of needle techniques is higher than that for mediastinoscopy. In patients with a stage II or a central tumor, invasive staging of the mediastinal nodes is necessary. Mediastinoscopy is generally preferable because of the higher FN rates of needle techniques in the setting of normal-sized lymph nodes. Patients with a peripheral clinical stage I NSCLC do not usually need invasive confirmation of mediastinal nodes unless a PET scan finding is positive in the nodes. The staging of patients with left upper lobe tumors should include an assessment of the aortopulmonary window lymph nodes.

View all citing articles on Scopus

¹: Members: J.J. Rivas (general co-ordinator) and M. Deu, Hospital Miguel Servet, Zaragoza, A. Benı́tez, Hospital Carlos Haya, Málaga; A. Blanco, Hospital Virgen del Rocı́o, Sevilla; E. Canalı́s, Hospital Clı́nic, Barcelona; M. Carbajo, Hospital Universitario Marqués de Valdecilla, Santander; J. Freixinet, Hospital Dr. Negrı́n, Las Palmas de Gran Canaria; G. Gómez, Hospital de Sant Pau, Barcelona; F. Heras, Hospital Universitario de Valladolid, Valladolid; M. Jiménez, Hospital Universitario de Salamanca, Salamanca; E. Martı́n, Hospital Virgen de la Candelaria, Santa Cruz de Tenerife; M. Mateu, Hospital Mútua de Terrassa, Terrassa, Barcelona; L. Molins, Hospital del Sagrat Cor, Barcelona; J. Pac, Hospital de Cruces, Barakaldo, Bizkaia; Yat-Wah Pun, Hospital de la Princesa, Madrid; F. Sebastián-Quetglás, Hospital Universitari Josep Trueta, Girona; M. de la Torre, Hospital Juan Canalejo, A Coruña; and A. Torres, Hospital San Carlos, Madrid, Spain.

View full text

Clinical value of video-assisted thoracoscopy for preoperative staging of non-small cell lung cancer: A prospective study of 105 patients

Abstract

Introduction

Section snippets

Patients and methods

Results

Discussion

Acknowledgements

Chest

J. Thorac. Cardiovasc. Surg.

Arch. Bronconeumol.

Med. Clin.

Ann. Thorac. Surg.

Ann. Thorac. Surg.

Chest

Chest