1. LUNG CANCER STAGINGTHE INVASIVE TECHNIQUESProf. Abdulsalam Y TahaSchool of Medicine/ University of Sulaimani/Iraqhttps://sulaimaniu.academia.edu/AbdulsalamTaha

2. Abbreviations EUS: endoscopic ultrasound. EBUS: endobronchial ultrasound. EUS-FNA: endoscopic ultrasound guidedfine needle aspiration. EUS-TBNA: endobronchial ultrasoundwith transbronchial needle aspiration. NTBNA: navigational TBNA. MED: Mediastinoscopy. VATS: video-assisted thoracoscopic10/14s/1u4 rgery. Prof. Abdulsalam Y Taha 2 3. Staging Lung Cancer - bronchoscopy10/14/14 Prof. Abdulsalam Y Taha 3 4. Bronchial system10/14/14 Prof. Abdulsalam Y Taha 4 5. Endobronchial ultrasound10/14/14 Prof. Abdulsalam Y Taha 5 6. (J Bronchol 2006;13:8491)6Endobronchial Ultrasound:clinical applications guidance ofmediastinallymph nodebiopsiesHerth FJ et al. Ultrasound-guided transbronchial needle aspiration: an experience in 242 patients.10/14/14 Prof. Abdulsalam Y TahaChest 2003;123:604 7. 7. 7Endobronchial Ultrasound:principles piezoelectriccrystal standardfrequency forEBUS is 20 MHz (radial) 7.5 MHz(convex)6.9 mm10/14/14 Prof. Abdulsalam Y Taha 8. 8The Processor10/14/14 Prof. Abdulsalam Y Taha 9. 9EBUS-TBNA10/14/14 Prof. Abdulsalam Y Taha 10. 10Angle ofexaminationand angle ofinsertion willbe important10/14/14 Prof. Abdulsalam Y Taha 11. 11Use of Doppler demonstratesblood flow10/14/14 Prof. Abdulsalam Y Taha 12. 12Needleinsertion10/14/14 Prof. Abdulsalam Y Taha 13. 13EBUS-TBNA All mediastinallymph nodesaccessibleexcept: Subaortic (5 and 6) Paraesophageal (8 and 9)Gen Thorac Cardiovasc Surg (2008) 56: 268-276 10/14/14 Prof. Abdulsalam Y Taha 14. 10/14/14 Prof. Abdulsalam Y Taha 14 15. 15NavigationalTBNA10/14/14 Prof. Abdulsalam Y Taha 16. 16Navigational TBNAReturn oninvestment ??10/14/14 Prof. Abdulsalam Y Taha 17. Four-compartment 10/14/14 Prof. Abdulsalamm Yo Tdaheal of the mediastinum 17 18. 10/14/14 Prof. Abdulsalam Y Taha 18 19. Nodal zones Peripheral 12-14 Hilar 10 & 11 Upper 1-4 Aorto-pulmonarywindow 5 & 6 Subcarinal 7 Lower 8 & 910/14/14 Prof. Abdulsalam Y Taha 19 20. Mediastinal staging modalities10/14/14 Prof. Abdulsalam Y Taha 20 21. Mediastinal staging modalities10/14/14 Prof. Abdulsalam Y Taha 21 22. 10/14/14 Prof. Abdulsalam Y Taha 22 23. 23Comparisons: Differentmodalities10/14/14 Prof. Abdulsalam Y Taha 24. 24Although cervical mediastinoscopy is used in thediagnosis of lymphoma, sarcoidosis and mediastinaltumors, it is mainly used as an invasive stagingmethod in patients with non-small cell lung cancer(NSCLC). Surgical exploration of the mediastinum wasfirst developed by Harken et al. Through asupraclavicular incision, a Jackson laryngoscope wasinserted into the mediastinum and lymph nodebiopsies were taken. They reasoned that the presenceof involved mediastinal lymph nodes in patients withlung cancer would preclude successfull resection ofthe cancer. More than fifty years later, their reasoningstill proves to be very valid. Cervical mediastinoscopythrough a pretracheal suprasternal incision wasdeveloped by Carlens in Sweden and subsequentlypopularized by Pearson in North-America. Theprognostic importance of the level and extent of nodalinvolvement has led to the development of aninternationally used lymph node map10/14/14 Prof. Abdulsalam Y Taha 25. Indications Lymph nodes or masses in the middlemediastinum of unknown origin(sarcoidosis, lymphoma, ). Mediastinal staging in patients withNSCLC.10/14/14 Prof. Abdulsalam Y Taha 25 26. There remains controversy regarding the selected use ofmediastinoscopy in patients with NSCLC. Before PET scan becameavailable, many centers used to perform cervical mediastinoscopyin every patient since it has been proved that small nodes on CTscan can harbor metastatic disease of clinical importance [2].There is consensus that the positive predictive value of both CT aswell as PET scan is low and that positive mediastinal findings on CTor PET scan need to be proven histologically. Other less invasivetechniques such as transbronchial fine needle aspiration andesophageal and tracheal endoscopic ultrasound needle aspirationhave become available in specialized centers with high sensitivityin clinically obviously involved mediastinal nodes. The sensitivityand negative predictive value (NPV) of these techniques are,however, significantly lower when compared to mediastinoscopyand mediastinoscopy remains the gold standard. Cervicalmediastinoscopy has a high accuracy. Its specificity is 100%, thesensitivity is dependent upon the surgeons experience butsensitivity rates of 90% are usually reported [2]. Therefore,cervical mediastinoscopy remains the gold standard to which allother techniques are to be compared.2610/14/14 Prof. Abdulsalam Y Taha 27. 27However, because PET scan has a high NPVup to 93% in primary mediastinal staging inpatients with NSCLC [3] cervicalmediastinoscopy can nowadays be omitted insome circumstances (peripheral tumor, N0on PET and CT scan).10/14/14 Prof. Abdulsalam Y Taha 28. 28Absolute contraindications for cervicalmediastinoscopy are very rare.Contraindication for generalanesthesiaExtreme kyphosisCutaneous tracheostomy (afterlaryngectomy)Superior vena cava syndrome,previous sternotomy and enlargedgoiter do not precludemediastinoscopy as well as previousradiotherapy and mediastinoscopy.Due to fibrosis and adhesions theintervention can be much morechallenging and is more timeconsuming.10/14/14 Prof. Abdulsalam Y Taha 29. 29Accessible lymph node stationsby cervical mediastinoscopy(Schematics 2, 3, 4, 5, 6, 7)By cervical mediastinoscopy thefollowing nodal stations (according tothe MountainDresler modification(1997) from Naruke/ATS-LCSG Map)can be searched for and biopsied: theleft and right upper paratrachealnodes (station 2L and 2R), left andright lower paratracheal nodes(station 4L and 4R) and thesubcarinal nodes (station 7).10/14/14 Prof. Abdulsalam Y Taha 30. The endotracheal tube is positioned at the left corner of the mouth, with the anesthesiaequipment at the patients left side.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 30 2005 European Association for Cardio-thoracic Surgery 31. Station 1 nodes are not routinely accessed by cervical mediastinoscopy.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 31 2005 European Association for Cardio-thoracic Surgery 32. A horizontal line drawn tangential at the upper margin of the aortic arch delineates the lowerborder of station 2 nodes.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 32 2005 European Association for Cardio-thoracic Surgery 33. Station 3 nodes are also not accessible by conventional cervical mediastinoscopy.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 33 2005 European Association for Cardio-thoracic Surgery 34. The posterior subcarinal nodes (station 7p), the para-esophageal nodes (station 8), theinferior pulmonary ligament nodes (station 9) are not accessible by conventional media-stinoscopy.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 34 2005 European Association for Cardio-thoracic Surgery 35. The subaortic nodes (station 5) and para-aortic nodes (station 6) cannot be biopsied througha standard cervical mediastinoscopy.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 35 2005 European Association for Cardio-thoracic Surgery 36. A bolster is placed under the patients shoulders and the neck is extended.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 36 2005 European Association for Cardio-thoracic Surgery 37. Operation room setup for conventional mediastinoscopy.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 37 2005 European Association for Cardio-thoracic Surgery 38. For mediastinoscopy, only few instruments are needed.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 38 2005 European Association for Cardio-thoracic Surgery 39. Conventional mediastinoscope.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 39 2005 European Association for Cardio-thoracic Surgery 40. A 3 cm transverse cervical incision is made one-finger breadth above the suprasternal notch.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 40 2005 European Association for Cardio-thoracic Surgery 41. Illustration of the anatomy of this region.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 41 2005 European Association for Cardio-thoracic Surgery 42. Sharp dissection exposes the pretracheal muscles which are separated vertically in themidline to expose the anterior surface of the trachea.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 42 2005 European Association for Cardio-thoracic Surgery 43. Incision of the pretracheal fascia.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 43 2005 European Association for Cardio-thoracic Surgery 44. The surgeon's middle finger is advanced along the pretracheal plane and blunt dissection iscarried out along the anterior surface of the trachea down to the carina.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 44 2005 European Association for Cardio-thoracic Surgery 45. The mediastinum is carefully palpated for the presence of nodal disease.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 45 2005 European Association for Cardio-thoracic Surgery 46. The finger is withdrawn and the mediastinoscope is advanced.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 46 2005 European Association for Cardio-thoracic Surgery 47. The plane in front of the mediastinoscope is developed with the use of blunt dissection,using a metal sucker through the channel of the mediastinoscope.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 47 2005 European Association for Cardio-thoracic Surgery 48. 48Prior to biopsying the lymph node, the node should bemobilized as much as possible to ensure that it is alymph node and not a vessel. This mobilization isperformed by the use of the suction device. For theupper paratracheal lymph nodes this can be safelyperformed with the finger. In case of doubt, a longaspiration needle can be placed in the lymph node andsuction is applied to the attached syringe, to ensurethat the structure to be biopsied is not a vessel. Anexperienced surgeon will find this seldom necessarywhen the nodes were adequately mobilized and theanatomical structures are clearly identified. The lymphnode is grasped with a biopsy forceps. In case ofresistance, one should be cautious not to pull toostrongly because the diseased lymph node may beattached to an adjacent vascular structure such as theazygos vein, the first branch of the right PA or theinnominate artery. This may lead to a vascular tearwith major bleeding10/14/14 Prof. Abdulsalam Y Taha 49. To avoid and to handle major complications, it is important to visualize the anatomicallandmarks such as the azygos vein, the right and left main bronchus and the first branch ofthe right pulmonary artery before biopsies are taken.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 49 2005 European Association for Cardio-thoracic Surgery 50. The left recurrent nerve lies approximately 1 cm lateral to the trachea and can usually bevisualized in the mid tracheal plane.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 50 2005 European Association for Cardio-thoracic Surgery 51. Sequentially, the paratracheal tissues are entered to expose the lymph nodes at the variousstations.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 51 2005 European Association for Cardio-thoracic Surgery 52. 52One starts to biopsy the obviousenlarged nodes and those nodes thatfelt firm by palpation. However, smalllymph nodes may also containmetastatic deposits.Routine sampling of all accessiblemediastinal nodal stations is advised.The standard is that biopsies of thesubcarinal nodal station, twoipsilateral nodal stations and onecontralateral nodal station arebiopsied or removed (Photos 5 and6 ). The author uses adhesive labelson which the stations according tothe MountainDressler map areprinted. This increases the accuracyin labelling10/14/14 Prof. Abdulsalam Y Taha 53. The biopsies are stored in separate vials, labelled with these adhesive labels and sent forpathology.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 53 2005 European Association for Cardio-thoracic Surgery 54. When biopsies are taken from the different nodal stations the biopsy forceps is cleaned eachtime to prevent contamination and false positive results.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 54 2005 European Association for Cardio-thoracic Surgery 55. Mediastinoscopy.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 55 2005 European Association for Cardio-thoracic Surgery 56. 56In the subcarinal area, bronchialarteries are frequently encounteredand bleeding frequently occurs fromthe subcarinal lymph node biopsysites. This bleeding, although usuallymodest, obscures clear vision andfurther dissection and sampling. Incase a bronchial artery is visualized,a vascular clip can be placed. Pushingthe scope deeper into the subcarinalspace the bleeding will stop whichallows to take more representativebiopsies before the bleeding sites areelectrocoagulated.Sufficient tissue has to be removed.In case of doubt, frozen section canbe performed to confirm thatsufficient tissue will be available.When there is no histologicaldiagnosis part of the lymph node issent for culture.10/14/14 Prof. Abdulsalam Y Taha 57. 57Small bleedings from biopsy sites can beelectrocoagulated. Bleeding is best handled withresorbable hemostatic resorbable gauze placed throughthe mediastinoscope.When a major bleeding occurs, packing is the first thing todo. By packing for at least 10 minutes, most of the evendramatic bleedings will stop. A long strip of wide gauzepacking should always be available in the operating roomfor such instances. In case of uncontrollable hemorrhage(for instance injury of aorta or innominate artery), themediastinum is packed or the bleeding site is compressedwith the surgeon's finger, or the mediastinoscope, and thedecision is made whether thoracotomy or sternotomy willbe performed. Decision is based on the location of thebleeding and the location of the tumor if resection isindicated. Right thoracotomy might be indicated when thebleeding is from the first branch of the right pulmonaryartery or from the azygos vein. In all other casessternotomy offers the best chances to control thebleeding.10/14/14 Prof. Abdulsalam Y Taha 58. 58ClosureThe strapmuscles are approximatedwith one suture. Drainage of themediastinal bed is usually notrequired. A subcutaneous interruptedsuture will obliterate the dead space.The skin is closed according to thesurgeons preferences.10/14/14 Prof. Abdulsalam Y Taha 59. 59Cervical mediastinoscopy is a low-risk procedure but thepotential for catastrophic complications is apparent.Unless additional or more extensive procedures aredone under the same general anesthesia, and thepatient's condition permits, the procedure can beperformed on an outpatient basis [4]. In experiencedhands, cervical mediastinoscopy has no mortality andminimal morbidity. In a recent review of over 20000cases complications did not surpass 2.5% and mortalitywas under 0.5% [5]. Only 0.1 to 0.5% of complicationsare considered major. The most important majorcomplication is severe hemorrhage. On the right side,the azygos vein and the anterior branch of the rightpulmonary artery are at risk of injury. The azygos veincan be mistaken for an anthracotic lymph node. Othermajor complications are injury of the esophagus,damage to the recurrent laryngeal nerve (usually theleft) and tracheobronchial tree injuries.10/14/14 Prof. Abdulsalam Y Taha 60. 60In a twenty-year period, weperformed well over 4000 cervicalmediastinoscopies. There was nohospital mortality. Major bleedingrequiring immediate interventionoccurred in four patients, injury tothe esophagus was seen in onepatient in whom the mediastinumwas drained through themediastinoscopy incision and thisfistula dried up after a few days ofconservative treatment [6]. In onecase a tear of the left main bronchuswas made by the biopsy forceps. Thiswas sutured by the endoscopicsuturing technique using thevideomediastinoscope and healedwithout any problems.10/14/14 Prof. Abdulsalam Y Taha 61. 61Extended cervicalmediastinoscopyLeft upper lobe tumors maymetastasize to the subaortic lymphnodes (station 5) and paraaorticnodes (station 6). These nodescannot be biopsied through routinecervical mediastinoscopy. Ginsbergand associates described a techniqueto explore these stations through thecervical incision. This technique is analternative for the anterior-secondinterspace mediastinotomy which ismore commonly used for explorationof these nodal stations. Theadvantage of the extendedmediastinoscopy is the saving of anadditional incision10/14/14 Prof. Abdulsalam Y Taha 62. 62If the standard cervicalmediastinoscopy is negative, a planeis developed anterior to the aorticarch, down to the subaortic space. Todo so, blunt dissection is performedwith the finger anterior to theinnominate artery, between theinnominate artery and the innominatevein. The mediastinoscope isintroduced through the cervicalincision above the aortic arch. Thescope is advanced over the top of theaortic arch down to theaortopulmonary window.10/14/14 Prof. Abdulsalam Y Taha 63. If the standard cervical mediastinoscopy is negative, a plane is developed anterior to theaortic arch, down to the subaortic space.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 63 2005 European Association for Cardio-thoracic Surgery 64. Biopsies of lymph nodes in the aortopulmonary window are taken.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 64 2005 European Association for Cardio-thoracic Surgery 65. 65In experienced hands the procedurehas a high accuracy and minimalmorbidity. It is important to statethat this procedure is far less easyand therefore is less routinelyperformed compared with theconventional mediastinoscopy.10/14/14 Prof. Abdulsalam Y Taha 66. 66Repeat mediastinoscopyPrecise restaging of the mediastinum after inductiontherapy for patients with involved mediastinal nodes(N2 or N3) disease is of utmost importance sinceconfirmation of downstaging of mediastinal nodes isa very important prognostic factor in these patients.Although long-term survival has been reported inpatients with persistent N2 disease undergoingresection after induction therapy, most of thesepatients will not benefit from surgery sinceresectability and long-term survival is low. AlthoughPET scan has a high accuracy in primary staging ofthe mediastinum, its accuracy is much less inrestaging of the mediastinum after inductiontherapy. So, thoracic surgeons will be faced moreand more frequently with the need to repeat themediastinoscopy. Several authors have shown thatrepeat mediastinoscopy is feasible with an accuracyof 85% and a sensitivity of 73%10/14/14 Prof. Abdulsalam Y Taha 67. 67Technique of repeatmediastinoscopyPositioning of the patient is notdifferent from mediastinoscopy butthe whole sternum is disinfected incase a sternotomy or hemiclamshellwould be necessary. The primaryincision is reopened. Usually theisthmus or even the thyroid may beadherent to the trachea. Sharpdissection is performed to find theanterior surface of the trachea. Thebrachiocephalic trunk is adherent tothe anterior surface of the tracheadue to fibrosis10/14/14 Prof. Abdulsalam Y Taha 68. Repeat mediastinoscopy.Repeatmediastinoscopy.Blunt dissectionis started on theleft side of thetrachea. Thisregion wasusually notextensivelydissected at thepreviousmediastinoscopyand thuscontaining lessfibrosis.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 68 2005 European Association for Cardio-thoracic Surgery 69. A left paratracheal tunnel is created (medial border is trachea, the surface is part of theesophagus) and the scope is inserted.Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.00015810/14/14 Prof. Abdulsalam Y Taha 69 2005 European Association for Cardio-thoracic Surgery 70. Dissection is continued on the left side until the lefttracheobronchial angle is visualized. From this tunnel, bluntdissection to the right side is performed from below in a retrogradefashion. The anterior surface of the trachea is freed from theadherent major vascular structures. Initially this is perfomed with adissection pledget. Once additional space is gained this can becontinued by finger dissection. One has to do this carefully to avoidinjury to the brachiocephalic artery. The pretracheal space nowbeing liberated, the scope can be changed in its normal position.Dense fibrosis and adhesions render the thorough exploration of allnodal stations very difficult or even impossible. To reach thesubcarinal region, the pulmonary artery has to be pushed away.Adhesions can be divided with the endoscopic shears. When thereis a lot of precarinal fibrosis, we advise to dissect as far as possibleon the left main bronchus. From there the subcarinal space can bedissected and biopsied.7010/14/14 Prof. Abdulsalam Y Taha 71. 10/14/14 Prof. Abdulsalam Y Taha 71 72. Staging Lung Cancer - Mediastinoscopy10/14/14 Prof. Abdulsalam Y Taha 72 73. 10/14/14 Prof. Abdulsalam Y Taha 73 74. 10/14/14 Prof. Abdulsalam Y Taha 74 75. 10/14/14 Prof. Abdulsalam Y Taha 75 76. 10/14/14 Prof. Abdulsalam Y Taha 76 77. 10/14/14 Prof. Abdulsalam Y Taha 77 78. 10/14/14 Prof. Abdulsalam Y Taha 78 79. 10/14/14 Prof. Abdulsalam Y Taha 79 80. Rigid video-mediastinoscopy80Case History:* An elderly man with enlargedparatracheal, subcarinal and aorto-pulmonaryLNs.* Rigid video-mediastinoscopy was doneunder GA.* Needle aspiration of right paratrachealLN revealed a caseous materialconsistent with TB.* Multiple biopsies were taken.10/14/14 Prof. Abdulsalam Y Taha 81. 81Enlarged AP windowLymph nodesEnlarged para-trachealLymph nodes.10/14/14 Prof. Abdulsalam Y Taha 82. 82Enlarged sub-carinalLymph nodes.10/14/14 Prof. Abdulsalam Y Taha 83. 10/14/14 Prof. Abdulsalam Y Taha 83 84. 10/14/14 Prof. Abdulsalam Y Taha 84 85. Video assisted mediastinoscopy10/14/14 Prof. Abdulsalam Y Taha 85 86. Staging Lung Cancer - Mediastinotomy10/14/14 Prof. Abdulsalam Y Taha 86 87. Staging Lung Cancer - Mediastinotomy10/14/14 Prof. Abdulsalam Y Taha 87 88. CaseA man of 30 presented with shortness of breath,chest pain and dry cough for few months.Neck veins were distended. No lymphadenopathy.10/14/14 Prof. Abdulsalam Y Taha 88 89. Chest radiograph: greatly widened mediastinumwith a smooth lobulated outline.10/14/14 Prof. Abdulsalam Y Taha 89 90. Lateral chest film: anterior mediastinal mass.Fiberoptic bronchoscopy revealed a mucosalredness.Percutaneous transthoracic FNAC wasinconclusive.10/14/14 Prof. Abdulsalam Y Taha 90 91. CT scan of mediastinum: anterior mediastinalmass mainly to 10/14/14 Prof. Abdulsala mth Y eTa hraight side. 91 92. Diagnostic AnteriorMediastinotomyLarge cell Lymphoma10/14/14 Prof. Abdulsalam Y Taha 92 93. 10/14/14 Prof. Abdulsalam Y Taha 93 94. 10/14/14 Prof. Abdulsalam Y Taha 94 95. Video Assisted Thoracic Surgery10/14/14 Prof. Abdulsalam Y Taha 95 96. Staging Lung Cancer - Thoracoscopy10/14/14 Prof. Abdulsalam Y Taha 96 97. VATS nodal biopsy10/14/14 Prof. Abdulsalam Y Taha 97 98. Thoracotomy10/14/14 Prof. Abdulsalam Y Taha 98 99. Thoracotomy - Posterolateral10/14/14 Prof. Abdulsalam Y Taha 99 100. Thoracotomy - Anterolateral10/14/14 Prof. Abdulsalam Y Taha 100 101. 101EXAMPLES OF LUNG CANCERSTAGING10/14/14 Prof. Abdulsalam Y Taha 102. UICC Stage of Lung Cancer10/14/14 Prof. Abdulsalam Y Taha 102 103. UICC Stage of Lung Cancer10/14/14 Prof. Abdulsalam Y Taha 103 104. UICC Stage of Lung Cancer10/14/14 Prof. Abdulsalam Y Taha 104 105. UICC Stage of Lung Cancer10/14/14 Prof. Abdulsalam Y Taha 105 106. UICC Stage of Lung Cancer10/14/14 Prof. Abdulsalam Y Taha 106 107. UICC Stage of Lung Cancer10/14/14 Prof. Abdulsalam Y Taha 107 108. UICC Stage of Lung CancerIV: Any T,Any N,M1Synchronous tumours indifferent lobes are M110/14/14 Prof. Abdulsalam Y Taha 108 109. Small Cell Lung Cancer10/14/14 Prof. Abdulsalam Y Taha 109