LEFT UPPER LOBE TUMORS AND AORTOPULMONARY WINDOW NODES

Left higher lobe tumors and aortopulmonary window nodes
cancers within the left higher lobe ( lul ) have a predilection for
involvement of the nodes within the apw ( station five ). these nodes
are classified as mediastinal nodes and represent the foremost important
cluster of n2 nodes that aren't accessible by standard
cervical mediastinoscopy. it's been instructed that nodes in
this region shouldn't be viewed as mediastinal nodes and
that resection of patients ought to be performed regardless of
apw node involvement, creating assessment of those nodes
superfluous. 50 this was based mostly on a selected subgroup of 23
utterly resected patients who had apw node involvement
because the merely website of n2 disease. though, analysis of all of the
knowledge during this regard shows that survival of patients with only
apw node involvement isn't substantially totally different than that
of patients with involvement of merely one n2 node station
in an exceedinglynother location. 22, 51 so, the issue is additional a matter
of whether or not patients with involvement of one mediastinal
node station ought to bear surgical resection and not
whether or not apw nodes ought to be classified as n2 nodes.
the classic means of invasively assessing this space may be a
chamberlain procedure ( additionally called an anterior mediastinotomy ),
that involves an incision within the second or third
intercostal area barely to the left of the sternum. traditionally,
an overnight hospital keep was necessary, however in several establishments,
this can be now not found to be necessary, particularly as
surgeons have used visualization between the ribs additional frequently
as opposed to removal of a priceal cartilage. the reliability
of this procedure has not been extensively documented,
despite its common use. the sensitivity of a chamberlain
procedure in an exceedinglyddition to a regular cervical mediastinoscopy
in patients with lul tumors may be approximately 87%, and also the
fn rate may be approximately 10%. five these patients are primarily
from radiographic cluster b, with in all probability many from group
c. 2 further studies concerning this procedure don't have anyt
very addressed the reliability of the procedure for staging of
nsclc. in one study, no actual biopsies were performed in
most patients, and also the procedure was used to assess resectability
( resectable patients included those with bulky apw nodal
involvement during this series ). 52 the opposite study used anterior
mediastinotomy primarily for diagnosis ( not staging ), and
included pulmonary biopsies and analysis of patients with
mediastinal masses. 53 indeed, merely many patients included in
this study had lung cancer.
extended cervical mediastinoscopy offers an alternative
means of invasive assessment of apw nodes, however is employed in only
many establishments. five with this procedure, a mediastinoscope is
inserted through the suprasternal notch and directed lateral to
the aortic arch. 54 in 100 consecutive patients with lul cancers,
customary mediastinoscopy and extended mediastinoscopy
were found to own a sensitivity of 69% and an fn rate of
11% for detection of n2, n3 disease ( prevalence, 29% ). 54
similar results ( sensitivity, 81% ; fn rate, 9% ) were reported
in an exceedinglynother series of 93 such patients, all of whom had enlarged
apw nodes. fifty five these patients are primarily from radiographic
cluster b, with in all probability many from cluster c. in an exceedinglypproximately
550 patients undergoing extended cervical mediastinoscopy,
2 major complications ( one stroke and one aortic injury )
are reported. 54–58
thoracoscopy has been used to assess apw lymph
nodes. five, 35 the merely study specifically addressing this techniques
found complete accuracy in 39 patients. 35 though, the
study is limited as a result of it concerned merely 3 patients without
station five or six node involvement. eus-na additionally provides an
various methodology of sampling apw nodes ( see previous discussion ).
merely one study has specifically addressed eus-na
for stations five and six, however the knowledge reported don't enable calculation
of sensitivity, specificity, and fn or fp rates. though, a
high fn rate is instructed. 35
in conclusion, it seems that the sensitivity of either a
chamberlain or vats assessment of the apw is high, whereas
the results for extended cervical mediastinoscopy, and perhaps
additionally eus-na, are somewhat lower. the fn rate appears
to be low for all procedures with the exception of eus-na.
though, these conclusions are somewhat speculative because
the number of knowledge offered is limited.