Comparison of Diagnostic and Therapeutic Efficacy of Endobronchial/Endoesophageal Ultrasound and Transcervical Extended Mediastinal Lymphadenectomy in Non-Small-Cell Lung Cancer. A Randomised Controlled Trial

Non-Small-Cell Lung Cancer (NSCLC) is the most common malicious neoplasm characterized by very bad prognosis: 5-year survival rate is only 15%, and the main factors responsible for unfavorable treatment results are late diagnosis, rapid progression of the tumor and high rate of metastasis. The most important issue before selection of the treatment is to establish presence of the metastasis to nodes on the same side of the body (N2) and to lymph nodes on the other side of the mediastinum or a spread to the supraclavicular nodes (N3).

A presence of metastasis to N2 (stage IIIA) is not an absolute contradiction for the surgical treatment but a discovery of N2 is followed by referral of the patients for neoadjuvant or adjuvant treatment depending if N2 are found before or after surgery. Presence of N3 is a contraindication for surgery and an indication for chemo-radiotherapy.

Preoperative techniques of lymph nodes staging includes CT, PET/CT and endoscopy/ultrasound techniques EBUS-TBNA and EUS-NA. Surgical staging techniques include mediastinoscopy, anterior mediastinotomy, VATS, Video-mediastinoscopic lymphadenectomy (VAMLA) and TEMLA.

Endobronchial Ultrasound guided Transbronchial Needle Aspiration (EBUS-TBNA) and Endoscopic Ultrasound guided Needle Aspiration (EUS-NA) are real-time imagining and biopsy techniques used in lung cancer staging. Transbronchial ultrasound examination allow to access upper and lower right paratracheal nodes (2R, 4R), subcarinal (7), hilar and interlobar (10, 11), transesophageal ultrasound examination allow to visualize upper and lower left paratracheal nodes (2L, 4L), subaortic (5), para-aortic (6), subcarinal (7), paraesophageal (8), pulmonary ligament (9) nodes. Furthermore EUS allow to localize mediastinal structures including heart, big vessels, main bronchi, vertebral column and diaphragm and can be used in for visualization of tumor infiltration of surrounding structures especially aorta, pulmonary artery or left atrium.

Transcervical Extended Mediastinal Lymphadenectomy (TEMLA) is minimally invasive surgical technique enabling extensive bilateral lymphadenectomy. The procedure starts from 5-8 cm collar incision in the neck, sternum is elevated with a hook connected to a Rochard frame, both laryngeal recurrent nerves and vagus nerves are visualized. During TEMLA all mediastinal nodal stations except for the pulmonary ligament nodes (9) are removed.