In patients with lung cancer is combined endobronchial ultrasound and endoscopic ultrasound superior to conventional mediastinoscopy in staging the mediastinum?

Abstract

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was ‘In patients with lung cancer, is combined endobronchial ultrasound and endoscopic ultrasound (EBUS + EUS) superior to cervical mediastinoscopy (CM) in staging the mediastinum?’ Altogether more than 110 papers were found, of which one meta-analysis, two RCTs, and two cohort studies represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Studies directly comparing EBUS + EUS and CM are limited in number and quality, with the majority of studies focusing on comparing endosonographic techniques or a single technique with surgical staging. Moreover, in four out of five studies, surgical staging of the mediastinum was undertaken following a negative EBUS + EUS result, limiting the utility of comparing endosonography alone. Regardless of this, the initial EBUS + EUS approach followed by surgical staging if negative resulted in greater sensitivity and detection of N2/3 metastases as well as greater sampling in the majority of studies, resulting in higher likelihood of upstaging and treatment alterations for patients. There was also improved quality of life demonstrated in the EBUS + EUS group with significant reductions in futile thoracotomies and less complications when compared with exclusive CM staging. We conclude that a combined approach of combined endosonography in the first instance, followed by CM staging of the mediastinum results in greater sensitivity of nodal disease and subsequent greater accuracy in upstaging and determining treatment plans with a concurrent reduction in complication rates and futile procedures.