Surgical Mediastinal Lymph Node Staging for Non-Small-Cell Lung Carcinoma

Pieter W. J. Lozekoot; Jean H. T. Daemen; Robert R. van den Broek; Jos G. Maessen; Michiel H. M. Gronenschild; Yvonne L. J. Vissers; Karel W. E. Hulsewé; Erik R. de Loos


Transl Lung Cancer Res. 2021;10(8):3645-3658. 

In This Article

Abstract and Introduction


Background: The current preferred approach for surgical mediastinal staging of non-small-cell lung carcinoma is video-assisted mediastinoscopy. An alternative technique in which lymph nodes are resected instead of biopsied is video-assisted mediastinoscopic lymphadenectomy (VAMLA) that is suggested to be superior in detecting N2 disease. Yet, evidence is conflicting and furthermore limited by sample size. The objective was to compare mediastinal staging through VAMLA and video-assisted mediastinoscopy.

Methods: A single-center cohort study was conducted. All consecutive patients that underwent surgical mediastinal staging of non-small-cell lung carcinoma by VAMLA (2011 to 2018) were compared to historic video-assisted mediastinoscopy controls (2007 to 2011). Patients with negative surgical mediastinal staging underwent subsequent anatomical resection with systematic regional lymphadenectomy. Primary outcome was the sensitivity and negative predictive value for detecting N2 disease.

Results: Two-hundred-sixty-nine video-assisted mediastinoscopic lymphadenectomies and 118 video-assisted mediastinoscopies were performed. The prevalence of N2 disease was 20% and 26% respectively in the VAMLA and video-assisted mediastinoscopy group, while the rate of unforeseen pN2 resulting from lymph node dissection during anatomical resection was 4% and 11%, respectively. Invasive staging using VAMLA demonstrated superior sensitivity of 0.82 and a negative predictive value of 0.96 when compared to video-assisted mediastinoscopy (0.62 and 0.89, respectively), offering a 64% decrease in risk of unforeseen pN2 following anatomical resection. However, VAMLA is also associated with a 75% risk increase on complications (P=0.36).

Conclusions: We conclude that performing invasive mediastinal lymph node assessment for staging of non-small-cell lung carcinoma, VAMLA should be the preferred technique with superior sensitivity and negative predictive value in detecting N2 disease. Though, VAMLA is also associated with an increased risk of complications.


According to current American and European guidelines,[1,2] mediastinal lymph node assessment plays a pivotal role in staging of non-small cell lung carcinoma (NSCLC). Patients suspected of NSCLC routinely undergo an 18F-deoxyglucose positron emission tomography-computed tomography (FDG-PET-CT) scan. When imaging shows suspicious (i.e., enlarged or FDG-avid) ipsilateral or contralateral hilar or mediastinal lymph nodes, in absence of distant organ metastasis, mediastinal staging by endosonography [endo-bronchial (EBUS) and/or endo-esophageal ultrasonography (EUS)] is indicated as first best test.[1,2] Though, if N2 disease is suspected on imaging and mediastinal lymph node sampling via E(B)US is negative, surgical mediastinal staging is advised by both the European and American guidelines.[1,2] The standard approach for this diagnostic step is video-assisted mediastinoscopy (VAM), as advised by the European guidelines.[1] In contrast, American guidelines do not advise on the preferred technique for surgical staging.[2] The sensitivity of VAM ranges from 0.75 to 0.95 and NPV from 0.59 to 0.96.[3–7] An alternative technique for surgical mediastinal staging is video-assisted mediastinoscopic lymphadenectomy (VAMLA). In VAMLA, the mediastinal lymph node stations are resected compared to simple biopsy during VAM. Recent studies suggest a superior sensitivity and NPV up to 1.0. However, these series are limited by small sample sizes thereby impairing evidential value.[8–10] In addition, the few studies comparing VAM and VAMLA show conflicting evidence regarding sensitivity and NPV.[11,12]

The aim of this study is to compare mediastinal staging through VAMLA and VAM, focusing on their sensitivity and NPV in detecting N2 disease among patients suspected for NSCLC. We present the largest VAMLA cohort to date, evaluating its performance for the mediastinal evaluation of NSCLC compared to VAM. This report was written in compliance with the STARD[13] reporting checklist (available at