Transcervical Extended Mediastinal Lymphadenectomy
Section snippets
Material and methods
TEMLA was performed on patients with proved NSCLC who were candidates for pulmonary resection, regardless of the state of the mediastinal nodes on CT or PET/CT, after negative result of EBUS/TBNA or EUS. The aim of TEMLA was to maximally and accurately stage and possibly improve late results of treatment of NSCLC. All mediastinal nodal stations (according to the Mountain-Dresler map), except for the pulmonary ligament nodes (station 9), were removed during procedure.15
Surgical technique
The operation starts with a 58-cm collar incision in the neck. The platysma muscle is divided and the anterior jugular veins are exposed, suture ligated, and divided. Visualization and protection of the laryngeal recurrent nerves bilaterally is a priority. The technique of visualization of the laryngeal recurrent nerves is described elsewhere.16 In brief, to reach the nerve below the level of the thyroid gland, divide the deep cervical fascial layers covering the carotid arteries until the
Results
There were 587 patients, 480 men and 107 women ages 41 to 79 (mean age 60.8), studied from January 1, 2004, to January 31, 2009. There were 431 squamous cell carcinomas, 114 adenocarcinomas, 20 large cell carcinomas, and 22 other carcinomas. Time of operation was 80 to 330 minutes (mean 161 minutes). In the last 100 patients, mean time of operation was 112.3 minutes. There were no intraoperative injuries of the vitally important structures, including major vessels, tracheobronchial tree, or the
Comment
The main advantage of TEMLA for staging of NSCLC is the possibility of removing almost all mediastinal lymph nodes with the surrounding fatty tissue. A mean number of 38.9 nodes per procedure was removed (from 15 to 85 nodes/procedure). Such complete removal of the mediastinal nodes increases the reliability of staging. No other invasive staging technique enables such complete assessment of the mediastinal nodes. For comparison, a mean number of 8.7 to 20.7 nodes was removed during VAMLA.10, 11
Summary
Operative technique of a new surgical method, TEMLA, is described in detail. TEMLA enables almost complete en bloc removal of the mediastinal nodes in semiopen fashion. Sensitivity and NPV of TEMLA for staging were 95.6% and 98.4%, respectively, and for restaging, 95.7% and 98.4%, respectively. Other uses of TEMLA include resection of the mediastinal tumors and resection of the metastatic nodes to the mediastinum, esophagectomy with 3-field dissection (combined with laparoscopy or laparotomy),
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Cited by (21)
Invasive and Noninvasive Advances in the Staging of Lung Cancer
2014, Seminars in OncologyCitation Excerpt :The procedure consists of retracting the sternum to allow access, through a slightly larger incision (5–8 cm), to most lymph node stations (1, 2R and 2L, 4R and 4L, 7, 8, 3a, 3p, 5 and 6). While clearly reported sensitivity and specificity are excellent, approximately 96% and 100%, respectively, the reported complication rate is also higher with a morbidity of 6.6% in one study.62–66 This technique also may be of interest for restaging after induction chemo- and radiation therapy for stage III–N2 disease, with only one false negative patient in a study including 63 patients overall.67
New standard in lung cancer staging? a word of warning
2013, Journal of Thoracic and Cardiovascular SurgeryReply to the editor
2013, Journal of Thoracic and Cardiovascular SurgeryThe true false-negative rates of EBUS and EUS
2011, Annals of Thoracic SurgeryTechnical Pitfalls of Transcervical Extended Mediastinal Lymphadenectomy-How to Avoid Them and to Manage Intraoperative Complications
2010, Seminars in Thoracic and Cardiovascular SurgeryTranscervical Extended Mediastinal Lymphadenectomy (TEMLA)
2021, Operative Techniques in Thoracic and Cardiovascular SurgeryCitation Excerpt :Transcervical extended mediastinal lymph node dissection (TEMLA) has emerged as an alternative for extirpation of such lymph nodes. TEMLA was developed by Zielinski and colleagues.1 Designed as an extension of the traditional cervical mediastinoscopy, the procedure includes a longer cervical incision, sternal elevation to create additional space, the use of a videomediastinoscope whenever necessary, as well as a dissection akin to the traditional extended mediastinoscopy.