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Ann Thorac Surg 2001;72:1698-1704
© 2001 The Society of Thoracic Surgeons

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Original article: general thoracic

Combined video-assisted mediastinoscopy and video-assisted thoracoscopy in the management of lung cancer

^a Service de Chirurgie Thoracique, CHU de Nice, Hôpital Pasteur, Nice, France

Accepted for publication June 27, 2001.

* Address reprint requests to Dr Mouroux, Service de Chirurgie Thoracique, Hôpital Pasteur, 30, Avenue de la Voie Romaine - BP 69, 06002 Nice Cedex 1, France
e-mail: chir-thoracique{at}chu-nice.fr

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. This study seeks to assess the safety and usefulness of combined video-assisted mediastinoscopy and video-assisted thoracoscopy in the management of patients with lung cancer.

Methods. Ten consecutive patients with lung neoplasms were evaluated. Indications for this combined approach included inconclusive findings from imaging techniques concerning locoregional extension and resectability; possible involvement of different structures not accessible to a single procedure; and failure to obtain histologic diagnosis by a single technique.

Results. Histologic diagnosis was obtained in 6 patients without preoperative histologic typing. In 3 patients, in contrast with preoperative imaging studies, combined thoracoscopy and mediastinoscopy showed the resectability of the primary tumor and the absence of metastatic mediastinal lymph nodes. These findings were confirmed at thoracotomy. In 3 other patients prevascular lymph nodes metastases were found. They underwent neoadjuvant chemotherapy; at subsequent operation, a complete resection was possible. In the remaining four cases combined exploration proved definitive contraindications for operation (recognition of oat-cell carcinoma, n = 2; T4 status, n = 1; T3N2, n = 1).

Conclusions. Combined video-assisted mediastinoscopy and video-assisted thoracoscopy seems to be a safe and useful tool in the management of selected patients with lung neoplasms. Both the extent of primary tumor and the possible intrathoracic spread may be exhaustively evaluated. In patients with left lung cancer a complete exploration of the aortopulmonary window is possible.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Optimal treatment of lung cancer depends on accurate staging. The assessment of both tumor extent and nodal involvement is of fundamental importance to plan the most adequate locoregional treatment. Although operation remains the therapy of choice for non–small cell lung cancer, increasing evidence has brought into question the usefulness of combining neoadjuvant treatments with operations. Induction chemotherapy seems to provide improved 5-year survival in cases with involvement of homolateral mediastinal nodes (N2) [1–3]. The advantages of neoadjuvant therapies followed by operation in patients with involvement of contralateral mediastinal nodes (N3) has been evaluated less extensively [4]; thus this condition is still regarded as a definitive surgical contraindication in most institutions. However, exact prethoracotomy assessment of the T status would be suitable to avoid exploratory thoracotomy for unresectable T4 tumors.

Clinical staging is based on chest roentgenogram, bronchoscopy, computed tomography (CT) and, in some instances, magnetic resonance imaging. Although generally useful, these methods are sometimes inadequate to provide correct information about locoregional extension and resectability, especially in tumors involving hilar regions [5,6]. Furthermore, they lack diagnostic accuracy in evaluation of mediastinal node metastases [5, 6]. Positron emission tomography (PET) seems a promising technique in this field [7]; however, its use will be probably limited to a few institutions in the next years (In France, currently only 2 centers are equipped with PET).

Cervical mediastinoscopy, anterior mediastinotomy or mediastinoscopy, and video-assisted thoracoscopy (VT) have been widely used for both diagnostic and staging purposes. Each of these techniques has evident merits in addition to limitations and "blind spots" [8]. Therefore, exact prethoracotomy staging of lung cancer remains difficult. This also explains the difficulties in selection of patients for neoadjuvant treatment trials, in which histologic evidence of N2 status is almost always considered mandatory.

In the present study we aimed at evaluating the clinical usefulness of combined video-assisted mediastinoscopy (VM) and VT in the management of patients with lung neoplasms, with the idea that the combination of the two techniques would overcome their respective limitations, while preserving their individual merits.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Patients
Ten consecutive patients (8 men, mean age 65.0 years, range 60 to 72 years, Table 1) were evaluated by combined VM and VT between July 1998 and June 1999. During the same time period, 206 patients with lung cancer were admitted to our service: in 44 of them only a medical treatment was judged suitable; 107 underwent immediate thoracotomy (106 lung resections, 1 explorative thoracotomy), and the remaining 55 received diagnostic or staging surgical procedures (39 VM, 6 VT, 10 combined VM and VT), in 17 instances followed by lung resection.

Preoperative evaluation included chest roentgenogram, fiberoptic bronchoscopy, and thoracic and upper abdominal CT scan by a third-generation apparatus making serial cuts 8 mm thick. Brain CT and bone scintigraphy were performed only in patients with clinically suspected cerebral or bone metastases. Nodal metastases were suspected in the presence of enlarged (short axis longer than 1 cm) nodes at CT scan.

Locations of the primary tumor were the left upper lobe in 6 cases, the right upper lobe in 3 cases, and the left lower lobe in 1 case. Histology was known preoperatively in 4 patients (squamous cell carcinoma in all cases).

Informed consent was obtained by all the patients and the study was conducted according to principles stated in the Declaration of Helsinki.

Techniques
Video-assisted mediastinoscopy and VT can be performed successively or simultaneously. General anesthesia with double-lumen intubation was necessary. In the case of successive approach, VM was generally performed first with the patient in the dorsal decubitus position and a roll under the shoulders to provide extension of the cervical area. When VM was completed, the patient was turned in full lateral position as for a standard posterolateral thoracotomy. In the case of simultaneous approach, the patient was positioned in dorsal decubitus, with a longitudinal roll in the paraspinal region of the involved side, the head and the neck in slight extension, and the face turned to the side opposite the lesion. In the case of simultaneous approach, two surgical teams and two complete sets of video equipment were necessary (Fig 1). Patients were prepared for the simultaneous approach when we suspected mediastinal invasion by a hilar tumor.

View larger version (28K): [in this window] [in a new window]   Fig 1. Schematic view of simultaneous combined video-assisted mediastinoscopy and video-assisted thoracoscopy. (1 = endoscope; 2 = operating instrument; 3 = operating instrument; 4 = cervical incision for mediastinoscope; M = monitor; N = nurse; S = surgeon.)

Surgical technique up to the introduction of the scope was essentially the same as that used for standard mediastinoscopy. After the paratracheal fascia opening and finger blunt dissection along the trachea, the video-mediastinoscope was inserted; its inferior valve was blocked in the open position. Further dissection was performed under direct visual control. The video-mediastinoscope was handled by the assistant, thus allowing the surgeon to operate with both hands. Generally, a metal blunt-tipped coagulation-suction device and an endoscopic swab (Peanut, Auto Suture, Elancourt, France) or grasp was used simultaneously for dissection of anatomical structures. Trachea, superior vena cava, azygos vein, right main pulmonary artery, and left recurrent nerve were easily identified. Progression behind the right main pulmonary artery allowed exploration of the two main bronchi and subcarinal area. Lymph nodes of levels 2, 4, and 7 were accessible for dissection and biopsy. The possibility of operating with two instruments in his or her hands (possibly one to grasp and tract, the other to dissect or coagulate) allowed the surgeon to completely enucleate lymph nodes in several instances. If a neoplastic infiltration of the outer surfaces of trachea or main bronchi was suspected, a biopsy of these structures was carried out. Needle (18-gauge) puncture was performed before biopsy if doubts existed concerning the possible vascular nature of a structure. Biopsies of enlarged lymph nodes were carried out; systematic biopsies of all the accessible sites were also performed. Specimens were sent to the laboratory for frozen sections. Minor hemorrhage occurring during the operative maneuvers was controlled by coagulation or compression with a gauze. In some instances clips were used to control minor bleeding or lymphatic leakage. The mediastinal bed was not drained routinely; if judged necessary, a 9-Ch (3 mm) drainage attached to a suction device was used.

Video-assisted thoracoscopy
A 10-mm thoracoport is inserted with the blunt-dissection technique in the seventh intercostal space in the middle axillary line. The 0° degree endoscope was then introduced to explore the pleural cavity (search for eventual carcinosis) and to plan the position of the other ports. The other ports were generally placed on the fourth or fifth intercostal space in the anterior and posterior axillary lines, respectively. Five- to 12-mm thoracoports were used to introduce operating instruments. Possible pleural adhesions were coagulated and cut. Pleural biopsies were taken near suspected lesions. Further biopsy depended on the preoperative studies. Wedge resections of concurrent lung nodules were possible by using standard endoscopic instruments.

The possible extension of the primary tumors to mediastinal structures could be evaluated easily. Lung could be retracted by endoscopic retractors; if necessary, mediastinal pleura or pericardium, or both, could be opened. Whenever safe, biopsies with frozen sections were taken to confirm the neoplastic involvement of a structure or organ. Biopsies of lymph nodes nonaccessible at cervical mediastinoscopy (those located in the anterior or the inferior mediastinum) could also be obtained. Care was necessary when dissecting nodes in the aortopulmonary window to avoid injury to vascular or nervous structures. Hemostasis and lymphostasis required accuracy and were achieved with the use of electrocoagulation or endoscopic clips. Generally a single drain was sufficient to adequately drain the thoracic cavity, especially if no injury to lung parenchyma had been provoked.

At combined VM and VT exploration, simultaneous instrumental palpation and transhillumination of hilar and mediastinal structures was possible. On the left side, simultaneous dissection through VM and VT allowed an exhaustive exploration of the aortopulmonary window: when there was no bulky tumor, all the anatomical structures were recognized and dissection advanced up to the jointing of mediastinoscopic and thoracoscopic instruments. All the encountered lymph nodes (including the Botallo’s ligament nodes) could be sampled.

If combined VM and VT demonstrated the resectability of the tumor, lung resection was performed immediately through a thoracotomy; otherwise the combined exploration was generally performed with an overnight stay.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Mean operative times were 85 and 106 minutes for simultaneous (n = 5) and successive procedures (n = 5), respectively. No intraoperative complication was recorded. Drainage of mediastinal bed was used in two cases; in both patients the drain was removed on the first postoperative day. Mean chest drainage time was 2 days (range 1 to 3 days); mean hospital stay was 3 days (range 2 to 5 days). No late complication (port site implantation) was observed.

In 3 patients, in contrast with preoperative imaging studies, mediastinal exploration by combined VT and VM showed the immediate resectability of the primary tumor and no mediastinal lymph node metastasis. In particular, in 1 patient the presence of superior vena cava invasion and intrapulmonary metastatic spread was ruled out by VT with wedge resection of a suspected nodule. In the other 2 patients, involvement of proximal pulmonary artery and tracheobronchial angle was ruled out. These 3 patients underwent immediate lung resection with mediastinal nodal dissection (case numbers 1 to 3, Table 1, Fig 2). The resection was complete in all the instances. Pathologic examination of operative specimens confirmed that the patients had been correctly staged by combined VM and VT.

View larger version (95K): [in this window] [in a new window]   Fig 2. Thoracic computed tomography scan of patient number 3 demonstrating a close contact of the tumor with mediastinum and enlarged lymph nodes. Combined exploration showed the immediate primary tumor resectability and the absence of nodal metastases. These findings were confirmed at thoracotomy.

In 2 other patients (case numbers 7 and 8) a diagnosis of oat-cell carcinoma was established on the basis of biopsy samples taken at VT. In patient 7, biopsy of a level 6 node showed tumoral infiltration, whereas in patient 8 a hilar tumor was sampled and histologic diagnosis obtained. Biopsy samples of paratracheal and subcarinal stations taken at VM were negative, despite enlarged dimensions of lymph nodes. In both cases results from preoperative fiberoptic bronchoscopy with biopsy and CT guided fine-needle aspiration biopsy had been negative. These 2 patients underwent subsequent chemotherapy.

In another patient (number 9), preoperative imaging studies had shown the presence of a right hilar tumor with paratracheal adenomegalies and pleural effusion. Repeated thoracocenteses had been nondiagnostic. Video-assisted mediastinoscopy showed the absence of retrovascular nodal metastasis, but a pleural carcinosis was found at thoracoscopy. He underwent systemic chemotherapy.

In the last patient (number 10), thoracic CT scan had shown a pleural effusion, paratracheal mediastinal adenopathies, and possible involvement of chest wall. Preoperative thoracocentesis had not retrieved malignant cells. Frozen sections of biopsy samples of paratracheal nodes taken at VM showed malignant cells. At VT pleura was normal, but the presence of chest wall involvement was confirmed. Definitive pathologic results were consistent with a diagnosis of lung leiomyosarcoma. The patient was judged not operable and chemotherapy was started.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Both mediastinoscopy and VT have been widely used in the staging of lung cancer. Standard cervical mediastinoscopy allows access and biopsy of paratracheal and subcarinal lymph nodes (Naruke stations 2, 4 and 7) [11]. Information regarding the extension of the primary tumor into mediastinal structures is also available with standard cervical mediastinoscopy, which is a safe procedure with low morbidity and mortality [11]. Complications include major bleeding requiring emergency sternotomy, chylous leak, injury to esophagus, and recurrent nerve and tracheobronchial tree [11]. Cervical mediastinoscopy is generally performed in the presence of enlarged (short axis longer than 1 cm) paratracheal or subcarinal nodes at CT scan [11]. However, due to lack of diagnostic accuracy of CT scan for nodal metastatic involvement [6], in some institutions mediastinoscopy is performed systematically in all patients with potentially resectable lung cancer [12]. The impossibility to explore and biopsy inferior (pulmonary ligament, paraesophageal) and anterior (precaval, aortopulmonary window) mediastinal nodes represents the main limitation of standard cervical mediastinoscopy [11]. An "extended" cervical mediastinoscopy has been proposed to obtain access to left anterior mediastinal nodes [13, 14]. However, probably due to technical difficulties, this method has not gained wide approval and its practice is limited to a few institutions.

Anterior mediastinoscopy or mediastinotomy are also used to approach and sample prevascular mediastinal nodes, especially in patients with left upper lobe cancer [15, 16]. Both present the advantage of technical simplicity, but their field of examination is limited. Furthermore, it has been pointed out that in the setting of staging left upper lobe tumors, biopsy through the anterior mediastinotomy is hazardous and assessment of mediastinum is limited to a digital examination of the aortic arch and subaortic fossa [17] .

Video-assisted thoracoscopy has been used for both diagnostic and staging purposes [18–20]. Indications for VT include suspicion of pleural dissemination or intrapulmonary metastases [18]. Video-assisted thoracoscopy has also been proposed to confirm the presence of other T4 tumors (involving the aorta, atrium, esophagus, superior vena cava, spine) before enrolling patients in protocols of neoadjuvant treatments [21]. In the left hemithorax, prevascular (Naruke levels 5 and 6), inferior mediastinal (levels 8 and 9), subcarinal (level 7), and hilar nodes (level 10) are accessible to VT; in the right hemithorax, examination of all stations is possible [22]. Thus VT permits exploration and biopsy of stations inaccessible by cervical mediastinoscopy. Though in the right side VT would allow exploration of levels generally examined by cervical mediastinoscopy, this last remains the "gold standard" for evaluation of retrovascular superior mediastinum, because of its proven characteristics of accuracy and safety [22]. For this reason in this series we performed a VM in some patients with enlarged nodes although an ipsilateral VT was carried out.

In this preliminary study we found that combined VM and VT was a safe method requiring a short hospital stay. Operative time was relatively short and will probably decrease in the future as the learning curve reaches a plateau. In our hospital the Service of Pathology is located in a separate building, thus justifying the relatively long time for obtaining results from frozen sections, with a subsequent increase in operative time. We did not observe mortality or major morbidity related to combined VM and VT. No port site seeding was observed at follow-up; it is noteworthy that this kind of late complication occurs rarely after VT for lung cancer [23].

Both T and N status could be adequately evaluated by combined VM and VT. Based on preoperative imaging studies, a doubt concerning a possible involvement of mediastinal structures (superior vena cava, aorta, proximal pulmonary artery, tracheobronchial angle) by the primary tumors existed in 5 patients; it was confirmed in 1 patient, but ruled out in the remaining 4 patients by the combined exploration. The reliability of this evaluation was confirmed in the 3 patients who underwent immediate lung resection and mediastinal nodal dissection. These 3 patients had been considered N2 at clinical staging, but were classed N less than 2 at combined mediastinal exploration. This finding was confirmed at pathologic examination of resected specimens.

Three other patients underwent neoadjuvant chemotherapy for the concurrent N2 status (prevascular nodes). They underwent subsequent thoracotomy and a complete resection was possible. In the remaining 4 patients, the exploration by combined VM and VT allowed us to obtain a histologic diagnosis and a correct staging, thus helping to guide subsequent medical treatment. Thus, in all the examined patients the combined exploration was useful for clinical decision making.

In our experience mediastinoscopy has been carried out using the video-assisted technique. Video-assisted mediastinoscopy has been used for operating procedures, such as the Abruzzini operation [24]. We have recently reported that VM is useful in the staging of lung cancer [25]; although in that preliminary study no formal comparison was made between VM and standard mediastinoscopy, we remarked that VM offers better visualization and allows the surgeon to operate with both hands, thus facilitating dissection, biopsy, and hemostasis. However, VM is slightly more expensive (+20%) than standard mediastinoscopy.

As stated in the Material and Methods section, VM and VT can be performed subsequently or simultaneously. The simultaneous approach offers the advantages of avoiding changes in the patient’s positioning with an obvious shortening of operative times, at the price of moderately increased difficulties in surgical techniques. The particular patient positioning is favorable for exploration of the anterior mediastinum; anterior retraction of the lung allows a complete exploration of posterior mediastinum as well. Furthermore, simultaneous instrumental palpation as well as transhillumination of hilar and mediastinal structures is possible with combined VM and VT. On the left side, simultaneous dissection through VM and VT allows an exhaustive exploration of the aortopulmonary window.

Endoscopic ultrasound probes are available for use during both mediastinoscopy and VT; their use for the staging of lung cancer in selected cases has been proposed [26, 27]. In our institutions we are currently developing a methodology for mediastinal ultrasound exploration through combined VM and VT.

This series evaluated the role of combined VM and VT in diagnosis and staging of lung cancer. Only one other case report discussed the use of combined VT and standard mediastinoscopy in the staging of a patient with left upper lobe carcinoma [28]. However, the combination of standard cervical mediastinoscopy with anterior mediastinotomy has been evaluated extensively [17, 29, 30]. In patients with left upper lobe tumors this technique is used both to examine the paratracheal nodes and to rule out direct tumor invasion or fixed nodes around the aorta or main pulmonary artery [17, 29]. Schreinemakers and colleagues [30] found that periaortic node metastases were present in 22.6% of patients with a normal cervical mediastinoscopy and a very high resectability was achieved in those subjects with negative parasternal and cervical examinations. Jiao and coworkers [17] emphasized the value of bidigital examination through the anterior and the cervical incisions. However, in patients treated by subsequent lung resection with routine mediastinal node dissection, they found a high incidence (37.9%) of N2 disease unrecognized at mediastinal exploration through combined mediastinoscopy and mediastinotomy [17], thus suggesting that such kind of combined mediastinal exploration is not optimal. Exploration through combined VM and VT offers probably better visualization, thus permitting us to hypothesize that an increased sensitivity may be achieved. Prospective studies are obviously mandatory to compare these two types of combined approaches for mediastinal exploration.

We think that when (a) imaging techniques provide inconclusive information about resectability, (b) a doubt exists concerning a possible involvement of different structures not accessible by a single procedure, or (c) a single procedure fails to provide an histologic diagnosis, combined VM and VT represents a potent tool for diagnostic and staging purposes.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Rosell R., Gomez-Codina J., Camps C., et al. A randomized trial comparing preoperative chemotherapy plus surgery with surgery alone in patients with non-small cell lung cancer. N Engl J Med 1994;330:153-158.[Abstract/Free Full Text]
2. Roth J.A., Fossella F., Komaki R., et al. A randomized trial comparing perioperative chemotherapy and surgery with surgery alone in resectable stage IIIA NSCLC. J Natl Cancer Inst 1994;86:673-680.[Abstract/Free Full Text]
3. Einhorn L.H. Neoadjuvant and adjuvant trials in non-small cell lung cancer. Ann Thorac Surg 1998;65:208-211.[Abstract/Free Full Text]
4. Rusch V.W., Albain K.S., Crowley J.J., et al. Neoadjuvant therapy: a novel and effective treatment for stage IIIB non-small cell lung cancer. Ann Thorac Surg 1994;58:290-295.[Abstract]
5. Gdeedo A., Van Schil P., Corthouts B., Van Mieghem F., Van Meerbeeck J., Van Mark E. Comparison of imaging TNM (iTNM) and pathological TNM (pTNM) in staging of bronchogenic carcinoma. Eur J Cardiothorac Surg 1997;12:224-227.[Abstract]
6. Bonomo L., Ciccotosto C., Guidotti A., Storto M.L. Lung cancer staging: the role of computed tomography and magnetic resonance imaging. Eur J Radiol 1996;23:35-45.[Medline]
7. Coleman R.E. PET in lung cancer. J Nucl Med 1999;40:814-820.[Abstract/Free Full Text]
8. Rendina E.A., Venuta F., De Giacomo T., et al. Comparative merits of thoracoscopy, mediastinoscopy, and mediastinotomy for mediastinal biopsy. Ann Thorac Surg 1994;57:992-995.[Abstract]
9. Deslauriers J., Gregoire J. Clinical and radiological staging of non small cell lung cancer. Chest 2000;117(Suppl):96S-103S.[Abstract/Free Full Text]
10. Glazer H.S., Kaiser L.R., Anderson D.J., et al. Indeterminate mediastinal invasion in bronchogenic carcinoma: CT evaluation. Radiology 1989;173:37-42.[Abstract/Free Full Text]
11. Kirschner P.A. Cervical mediastinoscopy. Chest Surg Clin North Am 1996;6:1-20.[Medline]
12. Gdeedo A., Van Schil P., Corthouts B., Van Mieghem F., Van Meerbeeck J., Van Mark E. Prospective evaluation of computed tomography and mediastinoscopy in mediastinal lymph node staging. Eur Respir J 1997;10:1547-1551.[Abstract]
13. Ginsberg R.J., Rice T.W., Goldberg M., Waters P.F., Schomocker B.J. Extended mediastinoscopy. A single staging procedure for bronchogenic carcinoma of the left upper lobe. J Thorac Cardiovasc Surg 1987;94:673-678.[Abstract]
14. Lopez L., Varela A., Freixinet J., et al. Extended cervical mediastinoscopy: prospective study of fifty cases. Ann Thorac Surg 1994;57:555-558.[Abstract]
15. Barendregt W.B., Deleu H.W., Joosten H.J., Berg W., Janssen J.P. The value of parasternal mediastinoscopy in staging bronchial carcinoma. Eur J Cardiothorac Surg 1995;9:655-658.[Abstract]
16. Goldstraw P., Mannam G.C., Kaplan D.K., Michail P. Surgical management of non-small-cell lung cancer with ipsilateral mediastinal node metastasis (N2 disease). J Thorac Cardiovasc Surg 1994;107:19-27.[Abstract/Free Full Text]
17. Jiao X., Magistrelli P., Goldstraw P. The value of cervical mediastinoscopy combined with anterior mediastinotomy in the preoperative evaluation of bronchogenic carcinoma of the left upper lobe. Eur J Cardiothorac Surg 1997;11:450-454.[Abstract]
18. Naruke T., Asamura H., Kondo H., Tsuchiya R., Suemasu K. Thoracoscopy for staging of lung cancer. Ann Thorac Surg 1993;56:661-663.[Abstract]
19. Mentzer S., Swanson S.J., DeCamp M.M., Bueno R., Sugarbaker D.J. Mediastinoscopy, thoracoscopy, and video-assisted thoracic surgery in the diagnosis and staging of lung cancer. Chest 1997;112(Suppl):239S-241S.[Medline]
20. Roviaro G., Varoli F., Rebuffat C., et al. Videothoracoscopic staging and treatment of lung cancer. Ann Thorac Surg 1995;59:971-974.[Abstract/Free Full Text]
21. De Giacomo T., Rendina E.A., Venuta F., Della Rocca G., Ricci C. Thoracoscopic staging of IIIB non-small cell lung cancer before neoadjuvant therapy. Ann Thorac Surg 1997;64:1409-1411.[Abstract/Free Full Text]
22. Landrenau R.J., Hazelrigg S., Mack M.J., et al. Thoracoscopic mediastinal node sampling: useful for mediastinal lymph node stations inaccessible by cervical mediastinoscopy. J Thorac Cardiovasc Surg 1993;106:554-558.[Abstract]
23. Johnstone P.A., Rohde D.C., Swartz S.E., Fetter J.E., Wexner S.D. Port site recurrence after laparoscopic and thoracoscopic procedures in malignancy. J Clin Oncol 1996;14:1950-1956.[Abstract/Free Full Text]
24. Azorin J.F., Francisci M.P., Tremblay B., Larmignat P., Carvaillo D. Closure of a postpneumonectomy main bronchus fistula using video-assisted mediastinal surgery. Chest 1996;109:1097-1098.[Abstract/Free Full Text]
25. Venissac N., Alifano M., Karimdjee B.S., Guillot F., Rabary O., Mouroux J. Video-mediastinoscopy in management of patients with lung cancer: a preliminary study. Surg Laparosc Endosc Percutan Tech 2000;10:71-75.[Medline]
26. Menconi G.F., Ambrogi M.C., Melfi F.M., et al. Endothoracic sonography with color Doppler availability during video assisted thoracic surgery (videothoracoscopic operative staging with ultrasound color Doppler) for lung cancer staging. Surg Endosc 1998;12:816-819.[Medline]
27. Nakano N., Nakahara K., Yasumitsu T., Kotake Y., Ikezoe J., Kawashima Y. Mediastinal ultrasonography for the assessment of mediastinal lymph node metastases in lung cancer patients. Surg Today 1994;24:106-111.[Medline]
28. Nazkanishi R., Mitsudomi T., Osaki T. Combined thoracoscopy and mediastinoscopy for the evaluation of mediastinal lymph node metastasis in left upper lobe lung cancer. J Cardiovasc Surg 1994;35:347-349.[Medline]
29. Goldstraw P. Mediastinal exploration by mediastinoscopy and mediastinotomy. Br J Dis Chest 1988;82:111-120.[Medline]
30. Schreinemakers H.J., Joosten H.J.M., Mravunac M., Lacquet L.K. Parasternal mediastinoscopy. Assessment of operability in left upper lobe cancer: a prospective analysis. J Thorac Cadiovasc Surg 1988;95:298-302.[Abstract]

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