Extended thoracic lymph node dissection in robotic-assisted minimal invasive esophagectomy (RAMIE) for patients with superior mediastinal lymph node metastasis
Sylvia van der HorstMichiel F.G. de MaatPieter C. van der SluisJelle P. RuurdaRichard van Hillegersberg
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Background: Robot-assisted surgery may have a role in improving oncological outcomes in esophagectomy.Especially in the anatomical areas in the chest that are more difficult to reach in open surgery (including the superior mediastinum).The dexterity of the robotic instruments aid in performing a more extensive nodal dissection and the precision and detailed vision of the robotic system potentially improves staging, oncological outcomes and reduces complications (i.e., recurrent nerve palsy).In this article, we describe our experience and clinical outcomes in patients treated by robot assisted minimal invasive esophagectomy (RAMIE) in cN+ esophageal cancer patients with positive nodes localized in the superior mediastinum.Methods: From May 2007-2018, all patients who had involved nodes by either fluor-18-deoxyglucose positron-emission-tomography-computed tomography (FDG-PET-CT) or endoscopic ultrasound (EUS) + fine needle aspiration (FNA) localized in the superior mediastinum (above level Th4/sternal angle) were identified.Patient characteristics, perioperative data, postoperative clinical outcomes/complications and overall survival were prospectively recorded and retrospectively evaluated.Results: Forty patients (48% adenocarcinoma) met our inclusion criteria.All patients underwent a three-stage procedure with cervical anastomosis and 90% of the patients underwent neoadjuvant chemoradiotherapy.Mortality occurred in three patients (7.5%), of which two were caused by severe acute respiratory distress syndrome (ARDS).The most frequent complications were pneumonia (25%), chylothorax (20%), anastomotic leakage (17.5%) and vocal cord paralysis (17.5%) which was grade 1 in 72% of the patients.Radicality rate (R0 resection) was 98% and the average lymph node yield was 24 (range, 9-57).Median overall and disease-free survival was 26 and 17 months, respectively.Conclusions: RAMIE for esophageal cancer patients with node positive disease in the superior mediastinum is associated with increased mortality/morbidity.Oncological outcome showed excellent lymph node yield, R0 rate and survival was equal compared to patients with lower mediastinal node positive disease.Keywords:
Mediastinal lymph node
Esophagectomy
Ramie
Mediastinal lymph node
Cardiothoracic surgery
Vascular surgery
Primary tumor
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Computed tomography was used to evaluate the mediastinum preoperatively in 60 patients with non-small cell lung cancer; 49 of these patients had thorough surgical-pathologic determination of mediastinal node status. Mediastinal lymph nodes were located by CT using the node-mapping scheme suggested by the American Thoracic Society and were considered abnormal when larger than 100 mm2 in cross-sectional area. The sensitivity of CT was 95% in detecting malignant mediastinal adenopathy; however, specificity was only 64%. Receiver operating characteristic (ROC) curve analysis showed that the optimal size criterion for diagnosing malignant mediastinal adenopathy is 1.0-1.5 cm when the short axis of a node is measured. CT staging of the mediastinum in patients with non-small cell lung cancer is clinically useful; negative mediastinal CT makes mediastinoscopy unnecessary, whereas positive CT should lead to biopsy of the enlarged node.
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To study the metastatic frequency, distribution and feature of mediastinal nodes in lung cancer and to establish criteria for nodal dissection.Clinical data of 386 patients who underwent resection of lung cancers in the past 9 years were analyzed retrospectively. Based on the distribution map of mediastinal lymph nodes developed by Naruke, ipsilateral hilar and mediastinal nodes were resected.147 cases (38.1%) had mediastinal nodal involvement (N2). A total of 289 groups of nodes were dissected. The rate of N2 disease among squamous-cell, adeno-, small-cell and large-cell carcinomas was 30.1%, 44.1%, 48.0% and 50.0%, respectively. In 71 cases with N2 disease in the upper lobes, 146 groups of N2 nodes were resected, including 124 groups in the upper mediastinum (84.9%) and 22 groups in the lower mediastinum (15.1%). In 76 cases with N2 nodes in the lower and middle lobes, 143 groups of N2 nodes were dissected, including 76 groups in the upper mediastinum (53.1%) and 67 groups in the lower mediastinum (46.9%). Saltatory metastases occurred in 79 patients, accounting for 53.7% of N2 nodes and in 16 cases that occurred in the mediastinum (10.9%).The feature of mediastinal lymph node metastases in lung cancer may be saltatory and multiple. Cure can be achieved only after extensive dissection of the upper and lower mediastinal nodes.
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A correlative study of CT,sur-gical and pathologic findings in 55cases of lung cancer is presented.Thesensitivity,specificity and accuracyin detection of mediastinal-hilar ly-mphatic metastases were 67.85%,96.29% and 81.81% respectively;ofinvasion of mediastinum were 75.00%,87.50% and 80.00% respectively;andof invasion of thoracic wall were28.57%,92.31% and 70.00% respectively.It is concluded that CT is reliab-le for detection of mediastinal lymphnode metastases,but lessreliable forhilar lymph node metastases and unre-liable for differentiation between be-nign and malignant lymphadenopathywhich has a diameter below 1.0 cm.Itis often difficult to determine whetheror not the tumor has directly infiltra-ted the mediastinal structures andthe thoracic wall.
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A small ramie decorticator which possesses the double-roller structure and anti-pull mode was studied in this paper.Based on the orthogonal experiment and performance analysis,the main technical parameters of the first generation decorticator were obtained:a diameter of roller is 260 mm,a rotation 15° Initial performance test results of prototype showed that the output rate of dry fiber to total fresh stem was5%,ramie impurity rate was ≤1.5%,pectin content in raw fiber of ramie was 30%,ramie single fiberstrength was 51～54cN.The ramie fiber produced by the decorticator met the nation standard of Ramie.
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肺門縦隔リンパ節にのみ腺癌病巣を認め, 病理組織学的検討にてTO肺癌と診断された2手術例を経験した.症例1: 73歳, 男性.胸部X線, CT検査で最大径4cm大の右肺門縦隔リンパ節腫大が指摘され, CTガイド下生検にて腺癌と診断された.症例2: 53歳, 男性.胸部X線, CT検査で最大径5cm大の右縦隔リンパ節腫大を指摘され, 胸腔鏡下縦隔生検にて腺癌と診断された.肺および他臓器の検索では, 2例ともに異常所見は認められず, 原発不明の肺門縦隔リンパ節腺癌の診断のもとに手術を行った.手術は胸骨正中切開にてアプローチし, 腫瘍を含めた両側縦隔リンパ節郭清術と右上葉切除術を行った.腫瘍細胞は2例ともに免疫組織化学的に抗surfactant apoprotein抗体に免疫活性陽性所見を示したことから, 原発性肺癌のリンパ節転移と判明し, 原発巣が確認できなかったことからTO肺癌と最終診断した.症例1は術後64ヵ月, 症例2は術後36ヵ月現在, 肺原発巣や再発転移巣の出現なく, 経過良好である.
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