Transcervical extended mediastinal lymphadenectomy: results of staging in two hundred fifty-six patients with non-small cell lung cancer.

Transcervical extended mediastinal lymphadenectomy (TEMLA) is a new surgical procedure for staging of the mediastinal lymph nodes in patients with non-small cell lung cancer (NSCLC). The operation is performed through the 5- to 8-cm collar incision in the neck and enables complete removal of all mediastinal nodal stations except for the pulmonary ligament nodes (station 9) and the most distal left paratracheal nodes (station 4L). Generally, TEMLA is an open procedure performed partly with mediastinoscopy-assisted and videothoracoscopy-assisted techniques. Operative technique of TEMLA includes elevation of the sternal manubrium with a special retractor and bilateral visualization of the laryngeal recurrent and vagus nerves. From January 1, 2004 to November 15, 2005, TEMLA was performed in 256 patients. Length of operation was 80 to 330 minutes (mean, 161 minutes). Complication of TEMLA occurred in 11.3% of patients with temporary laryngeal nerve palsy in 6 of 256 patients (2.3%) and permanent nerve palsy in 2 of 256 patients (0.8%). The number of dissected nodes during TEMLA was 15 to 85 (mean, 38.9). N2-3 nodes were found in 80 patients (31.3%). During subsequent thoracotomy, omitted N2 nodes were found in 5 of 138 patients, and omitted normal mediastinal nodes were found in 13 of 138 patients (9.4%). Sensitivity of TEMLA in discovery of N2-3 nodes was 94.1%, specificity was 100%, accuracy was 98%, negative predictive value was 97.2%, and positive predictive value was 100%. Preliminary results may suggest some therapeutic impact for patients who underwent TEMLA and subsequent R0 resection, with a 77.2% survival rate after the mean 24-month follow-up period.