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
