Call Sergi, Obiols Carme, Rami-Porta Ramon
Department of Thoracic Surgery, Hospital Universitari Mutua Terrassa, University of Barcelona, Terrassa, Spain.
Department of Morphological Sciences, School of Medicine, Autonomous University of Barcelona, Bellaterra, Spain.
J Thorac Dis. 2018 Aug;10(Suppl 22):S2601-S2610. doi: 10.21037/jtd.2018.03.183.
Preoperative mediastinal staging is crucial in the management of patients with non-small cell lung cancer (NSCLC), especially to define prognosis and the most proper treatment. To obtain the highest certainty level before lung resection, the current American and European guidelines for preoperative mediastinal nodal staging for NSCLC recommend getting tissue confirmation of regional nodal spread in all cases except in patients with small (≤3 cm) peripheral carcinomas with no evidence of nodal involvement on computed tomography (CT) and positron emission tomography (PET). We have a wide variety of surgical methods for mediastinal staging that are well integrated in the current preoperative algorithms. Their main indication is the validation of negative results obtained by minimally invasive endoscopic techniques. However, recent studies have reported the superiority of mediastinoscopy over endosonography methods in terms of accuracy for those tumours classified as clinical (c) N0-1 by CT and PET or with intermediate risk of N2 disease (cN1 and central tumours). Apart from the exploration of the mediastinum, other surgical procedures [parasternal mediastinotomy, extended cervical mediastinoscopy (ECM) and video-assisted thoracoscopic surgery (VATS)] allow the completion of the staging process with the assessment of the primary tumour and metastasis, exploring the lung, pleural cavity, and pericardium when it is required. Transcervical lymphadenectomies represent the evolution of mediastinoscopy and they are already considered the most reliable method for mediastinal staging, mainly in the subgroup of patients in whom endosonography methods have a low sensitivity: tumours with normal mediastinum by CT and PET. In addition to their indication for staging, these procedures have also demonstrated to be feasible as preresectional lymphadenectomy in VATS lobectomy, improving the radicality of the number of lymph nodes and lymph node stations explored, mostly for left-sided tumours for which a complete mediastinal nodal dissection is not always possible by VATS approach.
术前纵隔分期对于非小细胞肺癌（NSCLC）患者的治疗至关重要，尤其是在确定预后和最恰当的治疗方案方面。为了在肺切除术前获得最高的确定性水平，当前美国和欧洲关于NSCLC术前纵隔淋巴结分期的指南建议，除了那些直径≤3 cm、外周型、计算机断层扫描（CT）和正电子发射断层扫描（PET）均无淋巴结受累证据的小癌患者外，所有病例均需获得区域淋巴结转移的组织学证实。我们有多种用于纵隔分期的手术方法，这些方法已很好地整合到当前的术前算法中。其主要适应证是验证通过微创内镜技术获得的阴性结果。然而，最近的研究报告称，对于CT和PET分类为临床（c）N0-1或N2疾病中度风险（cN1和中央型肿瘤）的肿瘤，纵隔镜检查在准确性方面优于超声内镜检查方法。除了纵隔探查外，其他手术操作[胸骨旁纵隔切开术、扩大颈部纵隔镜检查（ECM）和电视辅助胸腔镜手术（VATS）]可通过评估原发肿瘤和转移灶来完成分期过程，必要时可探查肺、胸腔和心包。经颈淋巴结清扫术是纵隔镜检查的发展，目前已被认为是纵隔分期最可靠的方法，主要用于超声内镜检查方法敏感性较低的患者亚组：CT和PET显示纵隔正常的肿瘤。除了用于分期外，这些操作还已证明在VATS肺叶切除术中作为术前淋巴结清扫是可行的，可提高探查的淋巴结数量和淋巴结站的根治性，主要适用于左侧肿瘤，对于这些肿瘤，通过VATS方法并不总是能够进行完整的纵隔淋巴结清扫。
