A standardized technique of systematic mediastinal lymph node dissection by video-assisted thoracoscopic surgery (VATS) leads to a high rate of nodal upstaging in early-stage non-small cell lung cancer



A substantial part of the oncologic surgical procedure in non-small cell lung cancer (NSCLC) is systematic lymph node dissection (sLND). However, controversies still exist regarding the quality of minimally invasive (video-assisted thoracoscopic surgery, VATS) sLND in oncologic resections. The rate of stage migration from clinical to pathological N-status has been discussed as one parameter for the quality of sLND.


Between March 2011 and May 2014, seventy-seven patients (62 male, 15 female) were scheduled for anatomical lung resection and sLND by VATS for clinical stage I (UICC 7th edition) NSCLC. Preoperative staging was performed by [18F]-fluorodesoxyglucose positron emission tomography with computed tomography (FDG-PET/CT). Patient data were retrospectively analyzed with regard to divergence in clinical and pathological N-factor. FDG-PET/CTs of patients with lymph node (LN) upstaging after VATS resections were blindly re-evaluated by an experienced radiologist.


In FDG-PET/CT, preoperative tumor stage was cT1N0M0 in 41 (53.2 %) and cT2aN0M0 in 28 (36.4 %) patients. In six (7.8 %) patients the primary tumor was not suspicious for malignancy, and in two (2.6 %) patients the tumor was not evaluable due to prior wedge resection before FDG-PET/CT. Thirty-one (40.3 %) left-sided and 46 (59.7 %) right-sided pulmonary resections with sLND were performed; 19.57 ± 0.99 LNs were dissected. In 13 (16.9 %) patients a nodal stage migration from preoperative clinical to postoperative pathological N-stage was observed [cN0 to pN1 in 9 (11.7 %) and cN0 to pN2 in 4 (5.2 %) cases]. In correlation to the clinical T-factor, the rate of N-factor upstaging for cT1 was 12.2 % and for cT2a was 28.6 %, respectively. In 50 % of the patients with postoperative nodal staging shift, no changes were observed on re-evaluation of the preoperative FDG-PET/CT.


In this series of clinical stage I NSCLC patients, the rate of nodal stage migration after sLND by VATS is higher than previously reported. Prospective randomized controlled trials are needed to prove the oncologic quality of a sLND by VATS versus standard open approach.

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Martin Reichert, Dagmar Steiner, Stefanie Kerber, Julia Bender, Bernd Pösentrup, Andreas Hecker, and Johannes Bodner have no conflicts of interest or financial ties to disclose.

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Correspondence to Martin Reichert.

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Right-sided subcarinal lymph node dissection (WMV 80896 kb)

Right-sided pre- and paratracheal lymph node dissection (WMV 75591 kb)

Left-sided subcarinal lymph node dissection (WMV 65544 kb)

Left-sided aorto-pulmonary and paraaortic lymph node dissection (WMV 52943 kb)

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Right-sided subcarinal lymph node dissection (WMV 80896 kb)

Video 2

Right-sided pre- and paratracheal lymph node dissection (WMV 75591 kb)

Video 3

Left-sided subcarinal lymph node dissection (WMV 65544 kb)

Video 4

Left-sided aorto-pulmonary and paraaortic lymph node dissection (WMV 52943 kb)

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Reichert, M., Steiner, D., Kerber, S. et al. A standardized technique of systematic mediastinal lymph node dissection by video-assisted thoracoscopic surgery (VATS) leads to a high rate of nodal upstaging in early-stage non-small cell lung cancer. Surg Endosc 30, 1119–1125 (2016) doi:10.1007/s00464-015-4312-9

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  • Video-assisted thoracoscopic surgery
  • VATS
  • Nodal upstaging
  • Non-small cell lung cancer
  • Early-stage NSCLC
  • Systematic lymph node dissection