Hartert Marc, Tripsky Jan, Huertgen Martin
Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany.
Mediastinum. 2020 Mar 25;4:3. doi: 10.21037/med.2019.09.06. eCollection 2020.
Precise preoperative staging and restaging of mediastinal lymph nodes in patients with potentially resectable non-small cell lung cancer (NSCLC) is of supreme importance. Over the last years, algorithms on preoperative mediastinal staging incorporating imaging, endoscopic and surgical techniques have been widely published, offering more evidence concerning different mediastinal staging techniques. Current guidelines well define when and how to receive tissue confirmation in case of computed tomography (CT)-enlarged or positron emission tomography (PET)-positive mediastinal lymph nodes. Endosonography [(endoscopic bronchial ultrasonography/oesophageal ultrasonography (EBUS/EUS)] with fine needle aspiration still is the first choice (when accessible) since it is minimally invasive and has a high sensitivity to confirm mediastinal nodal disease. If negative, surgical staging with nodal dissection or biopsy is indicated. Video-assisted mediastinoscopic lymphadenectomy (VAMLA) and transcervical extended mediastinal lymphadenectomy (TEMLA) are preferred over conventional mediastinoscopy if a mediastinal R0-resection can be achieved. The mutual use of endoscopic and surgical staging effects highest accuracy. Straight surgical resection of tumors ≤3 cm (located within the external third of the lung) with systematic nodal dissection is justified as soon as there are no enlarged lymph nodes on CT-scan and once there is no nodal uptake on PET-CT. In case of central tumors and enlarged or FDG avid nodes regardless of cytological result, preoperative invasive mediastinal staging is indicated to rule out mediastinal nodal spread. However, accuracy needed in preoperative nodal staging has been under continuous debate ever since and with the advent of immunotherapy is right now intensely revived. During the last two decades VAMLA has been growing up from being a merely staging tool to an expert-recognized therapeutic tool in the context of minimal invasive lung cancer resection.
对于潜在可切除的非小细胞肺癌（NSCLC）患者，纵隔淋巴结的精确术前分期及再分期至关重要。在过去几年中，关于结合影像学、内镜及手术技术的术前纵隔分期算法已广泛发表，为不同纵隔分期技术提供了更多证据。当前指南明确规定了在计算机断层扫描（CT）显示纵隔淋巴结肿大或正电子发射断层扫描（PET）显示阳性时，何时以及如何获取组织确诊。超声内镜检查[（支气管内镜超声检查/食管超声检查（EBUS/EUS）]联合细针穿刺抽吸仍是首选方法（若可行），因为其微创且对确诊纵隔淋巴结疾病具有高敏感性。若结果为阴性，则需进行手术分期，包括淋巴结清扫或活检。如果能够实现纵隔R0切除，视频辅助纵隔镜淋巴结清扫术（VAMLA）和经颈扩大纵隔淋巴结清扫术（TEMLA）优于传统纵隔镜检查。内镜和手术分期的相互结合可实现最高的准确性。一旦CT扫描未发现淋巴结肿大且PET-CT未发现淋巴结摄取，对于直径≤3 cm（位于肺外三分之一）的肿瘤，直接进行手术切除并系统清扫淋巴结是合理的。对于中央型肿瘤以及无论细胞学结果如何出现淋巴结肿大或FDG摄取阳性的情况，需进行术前有创纵隔分期以排除纵隔淋巴结转移。然而，自那时起，术前淋巴结分期所需的准确性一直存在持续争论，随着免疫疗法的出现，这一争论目前又激烈起来。在过去二十年中，VAMLA已从仅仅是一种分期工具发展成为在微创肺癌切除背景下得到专家认可的治疗工具。
