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Adding an invasive procedure will not necessarily change treatment or outcome of NSCLC patients with preoperative clinical N1 disease

Herbert Decaluwé, Christophe Dooms, Paul De Leyn, Pascal Thomas, Ramon Rami-Porta
European Respiratory Journal 2018 51: 1800410; DOI: 10.1183/13993003.00410-2018
Herbert Decaluwé
1Dept of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
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Christophe Dooms
2Dept of Pneumology, University Hospitals Leuven, Leuven, Belgium
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Paul De Leyn
1Dept of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
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Pascal Thomas
3Dept of Thoracic Surgery, Lung Transplantation and Diseases of the Esophagus, North University Hospital, Marseille, France
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Ramon Rami-Porta
4Dept of Thoracic Surgery, Hospital Universitari Mutua Terrassa, Terrassa, Spain
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Abstract

In patients with clinical N1 NSCLC, videomediastinoscopy outperforms endosonography as a mediastinal staging tool http://ow.ly/ShP330iWzN2

From the authors:

We would like to thank A. Addeo and G. Banna for their correspondence with comments on our article entitled “Mediastinal staging by videomediastinoscopy in clinical N1 non-small cell lung cancer: a prospective multicentre study” [1]. In this prospective multicentre study, we found a 25% rate of unforeseen N2 disease after staging and resection, confirming the result of a previous prospective study, similar in size and design, investigating the performance of endosonography in the mediastinal staging of clinical N1 (cN1) patients [2]. However, the sensitivity and negative predictive value of videomediastinoscopy versus endosonography was 0.73 (95% CI 0.54–0.86) versus 0.38 (95% CI 0.18–0.57) and 0.92 (95% CI 0.83–0.97) versus 0.81 (95% CI 0.71–0.91), respectively. We acknowledge the lower accrual than initially projected, which resulted in wider width of confidence interval than aimed for. Nonetheless, with these results we argue that videomediastinoscopy could be the preferred technique of invasive mediastinal staging in patients with cN1 disease, outperforming endosonography in this patient group.

Whether invasive staging should be performed at all in patients with cN1 disease is a different point of discussion that was not part of this study. Correct staging prior to the start of therapy is not only responsible for an apparent better survival due to stage migration, but also leads to diverse surgical and non-surgical treatment strategies in individual patients, and is of paramount importance for comparative purposes. Furthermore, invasive staging in patients with cN1 is indeed recommended by the current guidelines of the European Society of Thoracic Surgeons and the European Society for Medical Oncology [3, 4].

We acknowledge that one third of the videomediastinoscopy procedures were video-assisted mediastinoscopic lymphadenectomies (VAMLA), although not all authors use a bi-manual instrumentation as suggested in the correspondence by A. Addeo and G. Banna. We want to stress to the readers that videomediastinoscopy and VAMLA are performed through the same small incision with similar instruments. While VAMLA goes beyond a pure diagnostic procedure and might be a first step in a complete lymphadenectomy, VAMLA should not be confused with transcervical extended mediastinal lymphadenectomy (TEMLA), which is performed through a cervical incision of 5–8 cm and includes elevation of the sternal manubrium and complete mediastinal lymphadenectomy except for stations 9 and most distal 4L [5]. In our study, the VAMLA results showed no false negatives and no complications [1]. The numbers were too small to compare standard videomediastinoscopy with VAMLA, but in our opinion a pre-resection VAMLA can help to perform a complete mediastinal lymphadenectomy in these cN1 patients with clearly significant clinical risk of mediastinal nodal disease.

Footnotes

  • Conflict of interest: H. Decaluwé reports personal fees from Covidien Medtronic for training lectures, outside the submitted work.

  • Conflict of interest: P. Thomas reports personal fees from Ethicon and Covidien Medtronic for hands-on sessions, from Boehringer for a lecture at an educational meeting, and from Acility for acting as chair and for a lecture at an educational meeting, all outside the submitted work.

  • Received February 27, 2018.
  • Accepted February 27, 2018.
  • Copyright ©ERS 2018

References

  1. ↵
    1. Decaluwé H,
    2. Dooms C,
    3. D'Journo XB, et al.
    Mediastinal staging by videomediastinoscopy in clinical N1 non-small cell lung cancer: a prospective multicentre study. Eur Respir J 2017; 50: 1701493.
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Dooms C,
    2. Tournoy KG,
    3. Schuurbiers O, et al.
    Endosonography for mediastinal nodal staging of clinical N1 non-small cell lung cancer: a prospective multicenter study. Chest 2014; 147: 209–215.
    OpenUrl
  3. ↵
    1. De Leyn P,
    2. Dooms C,
    3. Kuzdzal J, et al.
    Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer. Eur J Cardiothorac Surg 2014; 45: 787–798.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Postmus PE,
    2. Kerr KM,
    3. Oudkerk M, et al.
    Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2017; 28: Suppl. 4, iv1–iv21.
    OpenUrl
  5. ↵
    1. Zielinski M
    . Transcervical extended mediastinal lymphadenectomy: results of staging in two hundred fifty-six patients with non-small cell lung cancer. J Thor Oncol 2007; 2: 370–372.
    OpenUrl
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Adding an invasive procedure will not necessarily change treatment or outcome of NSCLC patients with preoperative clinical N1 disease
Herbert Decaluwé, Christophe Dooms, Paul De Leyn, Pascal Thomas, Ramon Rami-Porta
European Respiratory Journal Apr 2018, 51 (4) 1800410; DOI: 10.1183/13993003.00410-2018

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Adding an invasive procedure will not necessarily change treatment or outcome of NSCLC patients with preoperative clinical N1 disease
Herbert Decaluwé, Christophe Dooms, Paul De Leyn, Pascal Thomas, Ramon Rami-Porta
European Respiratory Journal Apr 2018, 51 (4) 1800410; DOI: 10.1183/13993003.00410-2018
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