Abstract
NSCLC staging: mediastinoscopy can be omitted in selected cases following a nodal negative EBUS/EUS examination http://ow.ly/TKKkf
From the authors:
We read with interest the comments of Li and colleagues on the need for a routine mediastinoscopy following a nodal negative endosonographic mediastinal evaluation. This topic is frequently a subject of discussion in multidisciplinary lung cancer teams and therefore deserves full attention.
Accurate mediastinal nodal staging is required to provide patients with the optimal treatment. Roughly speaking, about half the patients that are referred for an endosonographic mediastinal evaluation have metastatic nodal involvement. Both endobronchial ultrasound (EBUS) and endoscopic oesophageal ultrasound (EUS) are excellent techniques in confirming metastases, but have limitations in excluding them. Routine performance of mediastinoscopy in all patients that are staged negative by EBUS/EUS confirms endosonography findings in the vast majority of cases. In both the study by Verhagen et al. [1] and the ASTER study [2], mediastinoscopy did not provide any benefit in eight out of nine patients. The drawbacks for these patients are obvious: a delay in the diagnostic workup and start of treatment, performance of unnecessary surgery and anaesthesia, and use of scarce healthcare recourses.
For the optimal use of subsequent surgical staging, the key question is to identify predictors for false negative EBUS/EUS outcomes. They could be related to specific imaging findings (nodal size, 2-fluoro-2-deoxy-d-glucose positron emission tomography uptake or specific sonographic characteristics) and tumour histology. Another approach is to assess the thoroughness of the endosonographic evaluation: performance of EBUS alone versus the EBUS–EUS combination, systematic nodal evaluation of the mediastinum versus the “hit and run” approach, the number of nodal stations sampled and adequacy of nodal tissue obtained. Currently, more data are urgently needed to shed light on this issue in order to create a predictive model for false negative EBUS/EUS findings [4].
The European Society of Gastrointestinal Endoscopy/European Respiratory Society/European Society of Thoracic Surgeons guideline on combined EBUS–EUS lung cancer staging [3] provides room for the local tumour board to proceed directly to thoracoscopy (video-assisted thoracic surgery) or thoracotomy following a tumour negative endosonography, and omit a confirmatory mediastinoscopy. This is only allowed after careful consideration and in combination with meticulous monitoring and evaluation of endosonography outcomes. On this point we fully agree with Li and colleagues.
It should be clear that in the opinion of the guideline authors, endosonographic needle-based techniques are complementary to surgical staging and are not completely substituting it. However, mediastinoscopy should preferably be performed only in those patients with a high risk of false negative EBUS/EUS results as routine performance results in too many unnecessary surgical staging procedures. Identification of predictors of false negative EBUS/EUS outcomes is therefore important, and this is exactly the research topic on which both pulmonologists and surgeons should focus.
Footnotes
Conflict of interest: Disclosures can be found alongside the online version of this article at erj.ersjournals.com
- Received September 3, 2015.
- Accepted September 26, 2015.
- Copyright ©ERS 2015