nodal involvement [71]. In a systematic review from 2013 of 238 patients, the reported median sensitivity of the Chamberlain procedure was 71% and the NPV was 91% [12]. With the invention of video-assisted thoracic surgery (VATS), this has largely replaced the Chamberlain procedure for accessing the aortopulmonary window (station 5) and para-aortic (station 6) lymph nodes. A retrospective cohort study was done in 2007 which included 112 patients with clinically suspected N2 disease in lymph node stations 5 and 6. Thirty-nine patients underwent VATS which concluded in the correct diagnosis in 100% [74].

Video-Assisted Thoracic Surgery

The rst practical use of thoracoscopy was reported in 1910 by Dr. Jacobaeus when he used a thoracoscope to investigate and treat pleural effusions. The rst thoracoscopes were similar to the rst endoscopes. There were several limitations which included a lack of magni cation, only the operator can see the structures clearly, and the function of the assisted instruments were lacking. With the invention of the video-assisted imaging system, surgeons were able to magnify the image but also share the image with other surgeons simultaneously. The minimal requirements to perform a VATS include a rigid telescope, a light source with cable, a camera, and an imaging processor [75].

VATS for mediastinal staging is usually performed when needle techniques fail or are unable to access the lymph nodes in question. One major advantage of VATS over needle techniques is the direct visualization of the lung and mediastinal structures, including lymph node stations. It can provide a complete staging including TNM (Fig. 28.1). The major disadvantage of VATS is increased morbidity and mortality associated with surgery. In a 2013 meta-analysis of 4 studies, the reported median sensitivity was 99% (range 58–100%) and the negative predictive value was 96% (range 88–100%) for staging the mediastinum [12].

Surgical vs Minimally Invasive

Techniques

When evaluating a patient with lung cancer, accurate staging is what dictates treatment and management. Invasive biopsy is still the main modality for diagnosis and staging, which can be done surgically or with minimally invasive techniques. The guidelines recommend that minimally invasive needle techniques are the rst modality of choice to con rm mediastinal involvement in accessible lymph nodes stations. This recommendation is based on the availability of these technologies (EBUS-TBNA, EUS-FNA, etc.) and the appropriate skill of the operator. If minimally invasive techniques are negative and there is still a high clinical suspicion of disease, surgical biopsy is then recommended ( [12], Table 28.2).

Case 3 Concluded

Patient was evaluated by Cardiothoracic Surgery and underwent PFTs which were favorable for surgery. She underwent wedge resection that showed squamous cell carcinoma and subsequently underwent lobectomy with mediastinal lymph node dissection with curative intent.

Case 4

A 64-year-old man, former smoker with a 45-pack year smoking history, presented with a productive cough, dyspnea, and tachycardia. A chest CT showed a 1.4 cm right upper lobe nodule without lymphadenopathy along with centrilobular emphysema. A subsequent PET-CT revealed increased uptake in with an SUV of 3.3 from the right upper lobe nodule with no mediastinal or hilar uptake (Figs. 28.9 and 28.10). Patient had a clinical stage IA tumor. Pulmonary function tests showed moderate obstruction with FEV1 of 60%. Given his high-risk nature; A referral to cardiothoracic surgery was placed. After evaluation, patient underwent a right upper lobectomy in the

operating room for curative intent. Pathology showed aT1bN0M0 squamous cell carcinoma.

When there is a high probability that the lesion in question is lung cancer with a normal clinical examination and no suspicious extrathoracic abnormalities on chest CT, the patient should be considered for curative intent treatment. The next step is to obtain a PET-CT to evaluate for mediastinal uptake and distant metastasis. If the PET shows negative nodal involvement, invasive perioperative evaluation of the mediastinal nodes is not required [12]. Ideally, the patient should be

evaluated by a thoracic surgeon or a multidisciplinary team for consideration of surgical resection.

Summary

When evaluating patients suspected of having lung cancer, the rst step is to acquire a thorough history, complete exam, and radiologic data to guide further treatment. Once imaging is obtained, further diagnostic workup is usually

warranted with tissue sampling to acquire a histological diagnosis and accurate stage. CT scan of the chest is usually the rst imaging test of choice, followed usually by PET-CT if further information is required. PET-CT has proven to be invaluable in aiding physicians by providing information about the tumor, mediastinum, and metastases, both within the chest and beyond. Brain MRI has proven to be superior to CT in identifying metastases to the brain and can be utilized to search for metastatic disease. Once imaging is completed, the next step in diagnosis is usually tissue acquisition by needle techniques and these include EBUS-TBNA, EUS-FNA, TTNA, TBNA, and navigational bronchoscopy with use of RP-EBUS. When patients have stage I or II disease, surgery is usually the best option and patients may undergo surgical staging of the mediastinum. Surgical staging includes standard cervical mediastinoscopy, extended cervical mediastinoscopy, anterior mediastinoscopy (Chamberlain Procedure), and VATS. Regardless of technique, molecular analysis and immunohistochemical staining have become crucial in the treatment for NSCLC and should be evaluated.

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