Mediastinal Staging Of Non-small Cell Lung Cancer Research Articles

Prediction Models for Mediastinal Metastasis and Its Detection by Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Potentially Operable Non-Small Cell Lung Cancer: A Prospective Study

Prediction models for mediastinal metastasis and its detection by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) have not been developed using a prospective cohort of potentially operable patients with non-small cell lung cancer (NSCLC). Can mediastinal metastasis and its detection by EBUS-TBNA be predicted with prediction models in NSCLC? For the prospective development cohort, 589 potentially operable patients with NSCLC were evaluated (July 2016-June 2019) from five Korean teaching hospitals. Mediastinal staging was performed using EBUS-TBNA (with or without the transesophageal approach). Surgery was performed for patients without clinical N (cN) 2-3 disease by endoscopic staging. The prediction model for lung cancer staging-mediastinal metastasis (PLUS-M) and a model for mediastinal metastasis detection by EBUS-TBNA (PLUS-E) were developed using multivariable logistic regression analyses. Validation was performed using a retrospective cohort (n= 309) from a different period (June 2019-August 2021). The prevalence of mediastinal metastasis diagnosed by EBUS-TBNA or surgery and the sensitivity of EBUS-TBNA in the development cohort were 35.3%and 87.0%, respectively. In PLUS-M, younger age (< 60 years and 60-70 years compared with≥ 70 years), nonsquamous histology (adenocarcinoma and others), central tumor location, tumor size (> 3-5cm), cN1 or cN2-3 stage by CT, and cN1 or cN2-3 stage by PET-CT were significant risk factors for N2-3 disease. Areas under the receiver operating characteristic curve (AUCs) for PLUS-M and PLUS-E were 0.876 (95%CI, 0.845-0.906) and 0.889 (95%CI, 0.859-0.918), respectively. Model fit was good (PLUS-M: Hosmer-Lemeshow P= .658, Brier score= 0.129; PLUS-E: Hosmer-Lemeshow P= .569, Brier score= 0.118). In the validation cohort, PLUS-M (AUC, 0.859 [95%CI, 0.817-0.902], Hosmer-Lemeshow P= .609, Brier score= 0.144) and PLUS-E (AUC, 0.900 [95%CI, 0.865-0.936], Hosmer-Lemeshow P= .361, Brier score= 0.112) showed good discrimination ability and calibration. PLUS-M and PLUS-E can be used effectively for decision-making for invasive mediastinal staging in NSCLC. ClinicalTrials.gov; No.: NCT02991924; URL: www. gov.

Statistical approach to mediastinal staging in NSCLC with M.E.S.S.i.a. software.

The exclusion of pathological involvement of mediastinal lymph nodes in patients affected by NSCLC plays a central role in assessing their prognosis and operability. Ceron et al. developed a software - called M.E.S.S.i.a (Mediastinal Evaluation with Statistical Support; instan approach) - that allows the calculation of the residual probability of lymph node involvement after a certain number of tests has been done, by integrating every test result with the pre-test prevalence. M.E.S.S.i.a. bridges a gap of current American College of Chest Physicians (ACCP) guidelines, providing probability values of mediastinal metastasis for a correct clinical decision. We conducted a preliminary retrospective study in a series of 108 patients affected by non small cell lung cancer (NSCLC). Pathological staging was compared to the probability of nodal involvement calculated by M.E.S.S.i.a. software. Forty-two out of 108 subjects (39%) had a calculated post-test probability <8%; none of these had proven N2/N3 metastasis at surgical staging (negative predictive value, NPV: 100%). In 12/41 cases M.E.S.S.i.a. was able to avoid invasive procedures. The remaining 66 (61%) patients did not reach the surgical threshold; among these, 11 displayed N2 positivity at pathological staging. Receiving operator curve (ROC) analysis produced an area under curve (AUC) value of 0.773 (p<0.001). These preliminary data show high accuracy of M.E.S.S.i.a. software in excluding N2/N3 lymph node involvement in NSCLC. We have therefore promoted a prospective multicenter study in order to to get a validation of the calculator at different levels of probability of lymph node involvement. The recruitable subjects are potentially operable NSCLC patients; the gold standard for detection of mediastinal disease is the surgical lymph node dissection.

MEDIASTinal staging of non-small cell lung cancer by endobronchial and endoscopic ultrasonography with or without additional surgical mediastinoscopy (MEDIASTrial): study protocol of a multicenter randomised controlled trial

BackgroundIn case of suspicious lymph nodes on computed tomography (CT) or fluorodeoxyglucose positron emission tomography (FDG-PET), advanced tumour size or central tumour location in patients with suspected non-small cell lung cancer (NSCLC), Dutch and European guidelines recommend mediastinal staging by endosonography (endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS)) with sampling of mediastinal lymph nodes. If biopsy results from endosonography turn out negative, additional surgical staging of the mediastinum by mediastinoscopy is advised to prevent unnecessary lung resection due to false negative endosonography findings. We hypothesize that omitting mediastinoscopy after negative endosonography in mediastinal staging of NSCLC does not result in an unacceptable percentage of unforeseen N2 disease at surgical resection. In addition, omitting mediastinoscopy comprises no extra waiting time until definite surgery, omits one extra general anaesthesia and hospital admission, and may be associated with lower morbidity and comparable survival. Therefore, this strategy may reduce health care costs and increase quality of life. The aim of this study is to compare the cost-effectiveness and cost-utility of mediastinal staging strategies including and excluding mediastinoscopy.Methods/designThis study is a multicenter parallel randomized non-inferiority trial comparing two diagnostic strategies (with or without mediastinoscopy) for mediastinal staging in 360 patients with suspected resectable NSCLC. Patients are eligible for inclusion when they underwent systematic endosonography to evaluate mediastinal lymph nodes including tissue sampling with negative endosonography results. Patients will not be eligible for inclusion when PET/CT demonstrates ‘bulky N2-N3’ disease or the combination of a highly suspicious as well as irresectable mediastinal lymph node. Primary outcome measure for non-inferiority is the proportion of patients with unforeseen N2 disease at surgery. Secondary outcome measures are hospitalization, morbidity, overall 2-year survival, quality of life, cost-effectiveness and cost-utility. Patients will be followed up 2 years after start of treatment.DiscussionResults of the MEDIASTrial will have immediate impact on national and international guidelines, which are accessible to public, possibly reducing mediastinoscopy as a commonly performed invasive procedure for NSCLC staging and diminishing variation in clinical practice.Trial registrationThe trial is registered at the Netherlands Trial Register on July 6th, 2017 (NTR 6528).

Cost-effectiveness of mediastinal lymph node staging in non–small cell lung cancer

ObjectiveTo assess the cost-effectiveness of various modes of mediastinal staging in non–small cell lung cancer (NSCLC) in a single-payer health care system. MethodsWe performed a decision analysis to compare the health outcomes and costs of 4 mediastinal staging strategies: no invasive staging, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), mediastinoscopy, and EBUS-TBNA followed by mediastinoscopy if EBUS-TBNA is negative. We determined incremental cost effectiveness ratios (ICER) for all strategies and performed comprehensive deterministic sensitivity analyses using a willingness to pay threshold of $80,000/quality adjusted life year (QALY). ResultsUnder the base-case scenario, the no invasive mediastinal staging strategy was least effective (QALY, 5.80) and least expensive ($11,863), followed by mediastinoscopy, EBUS-TBNA, and EBUS-TBNA followed by mediastinoscopy with 5.86, 5.87, and 5.88 QALYs, respectively. The ICER was ∼$26,000/QALY for EBUS-TBNA staging and ∼$1,400,000/QALY for EBUS-TBNA followed by mediastinoscopy. The mediastinoscopy strategy was dominated. Once pN2 exceeds 2.5%, EBUS-TBNA staging is cost-effective (∼$80,000/QALY). Once the pN2 reaches 57%, EBUS-TBNA followed by mediastinoscopy is cost-effective (ICER ∼$79,000/QALY). Once EBUS-TBNA sensitivity exceeds 25%, EBUS-TBNA staging is cost-effective (ICER ∼$79,000/QALY). Once pN2 exceeds 25%, confirmatory mediastinoscopy should be added, in cases of EBUS-TBNA sensitivity ≤ 60%. ConclusionsInvasive mediastinal staging in NSCLC is unlikely to be cost-effective in clinical N0 patients if pN2 <2.5%. In patients with probability of mediastinal metastasis between 2.5% and 57% EBUS-TBNA is cost-effective as the only staging modality. Confirmatory mediastinoscopy should be considered in high-risk patients (pN2 > 57%) in case of negative EBUS-TBNA.

Negative EBUS-TBNA Predicts Very Low Prevalence of Mediastinal Disease in Staging of Non-Small Cell Lung Cancer.

Confirmation of mediastinal disease (N2/3) in non-small cell lung cancer (NSCLC) generally precludes curative surgical management. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become a routine first test in mediastinal staging of NSCLC; however, it remains unclear whether a negative EBUS-TBNA should be followed by mediastinoscopy before proceeding to surgery. Understanding the prevalence of metastases in lymph nodes with benign findings on EBUS-TBNA will inform decision making following negative EBUS-TBNA. We examined a retrospective cohort of patients who underwent EBUS-TBNA before resection with mediastinal lymph node sampling for NSCLC between December 2009 and June 2014 in 3 hospitals in Melbourne, Australia. All patients had integrated positron emission tomography/computed tomography (PET/CT) before EBUS-TBNA. Eighty-two matched mediastinal lymph node stations were sampled in 57 patients by both EBUS-TBNA and surgical resection, 47 nodes in patients staged cN0/1 by PET/CT and 35 nodes in patients staged cN2/3. All patients had a negative EBUS-TBNA. Four malignant nodes were identified surgically (4.9% of lymph nodes). The mean size of malignant deposits was 5.5 mm. Per-node negative predictive value was 78/82=0.95. All malignant nodes were located in patients with moderate-high risk disease (cN2/3), giving a disease prevalence in cN2/3 patients of 11%, and 0% in cN0/1. In patients staged cN2, per-node NVP was 0.89. The prevalence of mediastinal nodal disease following negative EBUS-TBNA is very low, at 4.9%. The per-node NVP of EBUS-TBNA is 0.95, decreasing to 0.89 in moderate-high risk patients. We suggest that a negative EBUS-TBNA of mediastinal nodes does not need to be confirmed by mediastinoscopy of those nodal stations, regardless of PET/CT findings.

Endoscopic ultrasound-guided fine needle aspiration and endobronchial ultrasound-guided transbronchial needle aspiration: Are two better than one in mediastinal staging of non–small cell lung cancer?

The role of combined endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) with a single bronchoscope is poorly understood. The purpose of the present study was to elucidate the roles of EBUS-TBNA and EUS-FNA with a single bronchoscope in the preoperative hilar and mediastinal staging of non-small cell lung cancer (NSCLC). A total of 150 patients with potentially resectable known or suspected NSCLC were enrolled in our prospective study. EBUS-TBNA was performed, followed by EUS-FNA, with an EBUS bronchoscope for N2 and N3 nodes≥5 mm in the shortest diameter on ultrasound images, in a single session. EBUS-TBNA was performed for 257 lymph nodes and EUS-FNA for 176 lymph nodes. Of the 150 patients, 146 had a final diagnosis of NSCLC. Of these 146 patients, 33 (23%) had N2 and/or N3 nodal metastases. The sensitivity of EBUS-TBNA, EUS-FNA, and the combined approach per patient was 52%, 45%, and 73%, respectively (EBUS-TBNA vs the combined approach, P=.016, McNemar's test). The corresponding negative predictive value was 88%, 86%, and 93%. Two patients (1%) developed severe cough from EBUS-TBNA. The combined endoscopic approach with EBUS-TBNA and EUS-FNA is a safe and accurate method for preoperative hilar and mediastinal staging of NSCLC, with better results than with each technique by itself.

Mediastinoscopy in the era of endobronchial ultrasound: when should it be performed?

Accurate mediastinal lymph node staging is critical for patients with non-small cell lung cancer (NSCLC). Although cervical mediastinoscopy has been regarded as the method of choice for mediastinal staging in NSCLC, emergence of minimally invasive sonography, for example endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound fine needle aspiration (EUS-FNA), has led to questions about the routine use of mediastinoscopy. EBUS-TBNA has access to all the mediastinal lymph nodes accessible by mediastinoscopy but also extends to the N1 nodes. EUS-FNA enables access to paraesophageal (station 8) and pulmonary ligament (station 9) lymph nodes, which are not accessible by either mediastinoscopy or EBUS-TBNA. On the basis of current evidence, sonographic staging is the recommended choice for patients with high pretest probability of lymph node metastatic involvement; all negative results should, however, be verified by mediastinoscopy, especially in centers with low expertise. For patients with low pretest probability, mediastinoscopy may be omitted.

Reliable and valid assessment of competence in endoscopic ultrasonography and fine-needle aspiration for mediastinal staging of non-small cell lung cancer

Fine-needle aspiration (FNA) guided by endoscopic ultrasonography (EUS) is important in mediastinal staging of non-small cell lung cancer (NSCLC). Training standards and implementation strategies of this technique are currently under discussion. The aim of this study was to explore the reliability and validity of a newly developed EUS Assessment Tool (EUSAT) designed to measure competence in EUS - FNA for mediastinal staging of NSCLC. A total of 30 patients with proven or suspected NSCLC underwent EUS - FNA for mediastinal staging by three trainees and three experienced physicians. Their performances were assessed prospectively by three experts in EUS under direct observation and again 2 months later in a blinded fashion using digital video-recordings. Based on the assessments, intra-rater reliability, inter-rater reliability, and construct validity were explored. The intra-rater reliability was good (Cronbach's α = 0.80), but comparison of results based on direct observations and blinded video-recordings indicated a significant bias favoring consultants (P = 0.022). Inter-rater reliability was very good (Cronbach's α = 0.93). However, one rater assessing five procedures or two raters each assessing four procedures were necessary to secure a generalizability coefficient of 0.80. The assessment tool demonstrated construct validity by discriminating between trainees and experienced physicians (P = 0.034). Competency in mediastinal staging of NSCLC using EUS and EUS - FNA can be assessed in a reliable and valid way using the EUSAT assessment tool. Measuring and defining competency and training requirements could improve EUS quality and benefit patient care.

Staging Non–Small Cell Lung Cancer

In Brief During the staging process of non–small cell lung cancer (NSCLC), accurate mediastinal lymph node staging is a critical factor which affects patient outcome. Cervical mediastinoscopy has been considered the “Gold Standard” for mediastinal staging in NSCLC. Recently, there is an increasing interest in minimally invasive endoscopic mediastinal staging techniques. In particular, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) uses ultrasound technology built into a flexible bronchoscope for real-time ultrasound-guided sampling of mediastinal lymph nodes. EBUS-TBNA has access to all of the mediastinal lymph nodes accessible by mediastinoscopy as well as N1 nodes. Based on the current evidence, EBUS-TBNA represents a minimally invasive procedure as an alternative to mediastinoscopy for mediastinal staging of NSCLC with discrete N2 or N3 lymph node enlargement, provided negative results are confirmed by surgical staging. Until we have the final results of the controlled comparative study of EBUS-TBNA versus mediastinoscopy, it is uncertain whether EBUS-TBNA will completely replace mediastinoscopy. It will also be important to incorporate new minimally invasive endoscopic techniques in the algorithm of lung cancer staging. EBUS-TBNA may be considered for initial staging of NSCLC in patients with suspicious mediastinal lymph nodes on noninvasive staging, provided negative results are confirmed by surgical staging. This will allow mediastinoscopy to be reserved for restaging after induction treatment. EBUS-TBNA also has potential for providing molecular diagnosis. Endobronchial ultrasound-guided transbronchial needle aspiration is a new minimally invasive modality for mediastinal staging of lung cancer. This article reviews the recent development and results of endobronchial ultrasound-guided transbronchial needle aspiration for lymph node staging and compares it to the “gold standard” mediastinoscopy.

Incidence of occult mediastinal node involvement in cN0 non-small-cell lung cancer patients after negative uptake of positron emission tomography/computer tomography scan

This study sought to assess the real incidence of pN2 among patients with non-small-cell lung cancer (NSCLC) (cN0) with negative mediastinal uptake of 2-deoxy-2-(18F)-fluoro-o-glucose (FDG). During 30 consecutive months (January 2007-May 2009), all patients with NSCLC scheduled for surgery in our unit had a preoperative FDG-positron emission tomography (PET)/computed tomography (CT) in our institution, after a dedicated chest CT (n=259). Only patients with both FDG-PET/CT and negative dedicated chest CT scan (N1 and N2 nodes <1cm) were prospectively included (n=125). Patients with cN1/cN2/cN3 and patients who had undergone preoperative chemo-radiotherapy were excluded. No invasive surgical staging was carried out in this group and curative resection plus systematic mediastinal dissection was performed except in the event of unexpected oncological contraindication. All variables were collected prospectively and, when pathological information was obtained, all the cases were carefully reviewed. Mediastinal assessment by FDG-PET/CT, negative predictive value (NPV) was 85.6%, confidence interval (CI): [77-91]; false negatives (FNs) for mediastinal lymph nodes involvement was 14.4% (18 cases). The pN2 stations most frequently involved were: 4R (six cases), seven (six cases) and five (five cases). Multiple-level pN2 occurred in six (4.8%) cases. Occult (pN2) lymph nodes were more frequent in women (p<0.01), adenocarcinoma (p<0.05) and pN1 (p<0.05). Pathological N2 prevalence for pN1 was 34 (27.7%). Considering pathological staging as the gold standard, the agreement was 70% and 47.5% for stage IA and IB (Kappa's index: 0.72 and 0.76) and, in all patients, 47% (Kappa's index: 0.27). In general, down-staging is more frequent than up-staging. Mediastinal staging of NSCLC by FDG-PET/CT showed a considerable incidence of FNs. NPV is lower than previously reported and the preoperative mediastinal staging by 18FDG-PET/CT may jeopardise the accurate treatment for early stage NSCLC patients.

Mediastinal staging of NSCLC with endoscopic and endobronchial ultrasound

Mediastinal staging of non-small-cell lung cancer (NSCLC) is of paramount importance. It distinguishes operable from inoperable disease, guides prognosis and allows accurate comparison of outcomes in clinical trials. Noninvasive imaging modalities for mediastinal staging include CT, PET and integrated PET-CT. Mediastinoscopy is considered the current gold standard; however, each of these techniques has limitations in sensitivity or specificity. These inadequacies mean that 10% of operations performed with curative intent in patients with NSCLC are futile, owing to inaccurate locoregional lymph-node staging. Endoscopic and endobronchial ultrasound-guided mediastinal lymph-node aspiration are important and promising innovative techniques with reported sensitivities and specificities higher than standard investigations. The role of these techniques in mediastinal lymph-node staging is evolving rapidly and early data suggest that they may diminish the need for invasive surgical staging of the mediastinum. Furthermore, these are outpatient procedures that do not require general anesthesia and may be combined safely in the same sitting, for optimal accuracy of mediastinal staging. We propose a new algorithm for the diagnosis and staging of NSCLC, based on the current evidence, which incorporates endoscopic and endobronchial ultrasound as a first investigation after CT in patients with intrathoracic disease.

Accuracy of Helical Computed Tomography and [18F] Fluorodeoxyglucose Positron Emission Tomography for Identifying Lymph Node Mediastinal Metastases in Potentially Resectable Non–Small-Cell Lung Cancer

Computed tomography (CT) and [18F] Fluorodeoxyglucose positron emission tomography (FDG-PET) are considered suitable methods for the noninvasive staging of the mediastinum. Our study was intended to estimate the efficacy of contrast-enhanced helical CT (hCT) and FDG-PET, alone and combined, in the diagnosis of lymph node mediastinal metastases. This study was a prospective and blind comparison of the efficacy of hCT and FDG-PET with two alternative reference standards, mediastinoscopy, and mediastinoscopy plus thoracotomy plus a 6-month follow-up to diagnose lymph node mediastinal metastases in 132 consecutive patients with potentially resectable non-small-cell lung cancer (NSCLC). The metastatic disease was assessed histopathologically. Further clinical information was obtained postoperatively after a median follow-up of 42 months. The prevalence of cN2,3 is 0.28. For hCT the sensitivity and specificity are 0.86 (95% CI, 0.70 to 0.93) and 0.67 (95% CI, 0.56 to 0.75), for PET 0.94 (95% CI, 0.81 to 0.98) and 0.59 (95% CI, 0.49 to 0.68), and for hCT and PET combined in-parallel 0.97 (95% CI, 0.84 to 0.99) and 0.44 (95% CI, 0.34 to 0.53), which translate into a negative predicted probability of 0.98 (95% CI, 0.88 to 1.00). The crude diagnostic odds ratio of PET in the total sample studied is 13.1, in the subgroup hCT+ 11.04 (3.0 to 40 0.1), and in the hCT- 3.5 (0.5 to 21.5). Similar results were obtained for hCT stratified by PET. hCT and PET perform similarly in the mediastinal staging of NSCLC, both tests are conditionally dependent and provide complementary information, and their diagnostic value mainly resides on the negative results.

Mediastinoscopy: An Endangered Species?

Accurate staging is a critical part of the management of newly diagnosed non–small-cell lung cancer (NSCLC), and of the decision to offer patients induction therapy. During the last decade, the introduction into clinical practice of positron emission tomography (PET) and of endoscopic ultrasound biopsy techniques has again raised the question of when mediastinoscopy, long the gold standard for determining the presence and extent of mediastinal nodal metastases, should be performed. In this edition of the Journal of Clinical Oncology, two articles address this issue. PozoRodriguez et al report a prospective study in 132 patients comparing the efficacy of helical computed tomography (CT) and PET in the mediastinal staging of NSCLC. They find that CT and PET have similar accuracies and, when combined, yield a negative predictive probability of .98. Conversely, they note that positive results of either test need to be confirmed pathologically. In the second article, Annema et al evaluated endoscopic ultrasound-guided fine-needle aspiration (EUS FNA) in the diagnosis and staging of lung cancer in 242 consecutive patients for whom mediastinoscopy or exploratory thoracotomy were planned. EUS FNA prevented 70% of scheduled surgical procedures, and the accuracy of this procedure in mediastinal staging was found to be 93%. How does the practicing clinician incorporate this information into daily practice? First, it is important to note that these are not the first studies to highlight the utility of PET and EUS in the staging of NSCLC. A literature search yields a plethora of studies of variable quality on both modalities, especially PET. Table 6 in the article by PozoRodriguez et al summarizes some of the most relevant articles published on CT and PET in NSCLC since 1980. However, the authors correctly point out that their trial was more stringently designed than many previous studies, and benefited from the readings of CT and PET being blinded and independent both of each other and of the reference tests. A long follow-up period allowed clinical confirmation of the study findings. Multiple articles already attest to the safety and accuracy of EUS FNA in detecting mediastinal lymph node metastases and mediastinal tumor invasion in NSCLC. However, Annema et al have performed the largest prospective study to date, even though approximately 15% of their patients had EUS FNA performed for reasons other than the initial staging of NSCLC. Therefore, both of these studies are noteworthy by virtue of their size and careful design. Second, these studies reflect the evolving algorithm of staging of NSCLC that is already reducing the use of mediastinoscopy. In many countries, including the United States, PET (and more recently PET-CT) has become a widely accepted study for the initial extent of disease evaluation of NSCLC. Beyond its utility in mediastinal staging, PET provides important prognostic information and detects distant metastatic disease, obviating the need for additional bone scanning or imaging of the liver and adrenal glands. EUS FNA is not as widely practiced, partly because it is not yet a procedure commonly performed by thoracic surgeons or pulmonary medicine physicians, and partly because it does not provide access anatomically to the right and left paratracheal nodes, which are key to the staging of most NSCLC. However, it is well recognized as an important adjunct in evaluating the periaortic, subcarinal, and periesophageal lymph nodes. Endobronchial ultrasound (EBUS) FNA is just now being introduced into clinical practice outside of Japan and should prove highly effective in diagnosing paratracheal and perhaps even hilar nodal metastases. Thus, the staging algorithm of the not-toodistant future could include a contrast CT of the chest and upper abdomen, a PET-CT, brain imaging (as clinically indicated), and an EBUS FNA with or without an EUS FNA. Mediastinoscopy might only be performed in situations where other staging studies are equivocal or when additional tissue is needed for histologic or molecular evaluation. Initial staging with a combination of EUS, EBUS, and PET may also allow mediastinoscopy to be used more freely for restaging after induction therapy in situations where this is important for decisions about subsequent treatment. The accuracy of EUS and EBUS FNA for restaging will need to be examined in the future. JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 23 NUMBER 33 NOVEMBER 2

Transcervical extended mediastinal lymphadenectomy?the new operative technique and early results in lung cancer staging

Mediastinal staging is one of the most important problems in thoracic surgery. Although the pathological examination is a generally accepted standard, none of the currently used techniques enables complete removal of all lymph node stations of the mediastinum. The aim of the study is to present a new technique of transcervical extended mediastinal lymphadenctomy (TEMLA) and to analyze its value in lung cancer staging. In the prospective study of consecutive group of non-small cell lung cancer (NSCLC) patients, operated on between January and August 2004, we evaluated the usefulness of this original technique of bilateral mediastinal lymphadenectomy, assessing its accuracy and safety. The operations were performed through the transcervical approach, were videomediastinoscopy-assisted, with sternum elevation. Lymph node stations 1, 2R, 2L, 3a, 4R, 4L, 5, 6, 7 and 8 were removed. In patients without mediastinal metastases thoracotomy with pulmonary resection was performed and mediastinum searched for any missed lymph nodes. There were 83 patients operated on with the TEMLA technique. The mean number of nodes removed was 43 (range: 26-85). The sensitivity, specificity and accuracy of the presented method in detecting mediastinal node metastases were: 90, 100, and 96%, respectively, whereas the positive and negative predictive values were: 100 and 95%, respectively. The TEMLA technique is a safe and highly accurate method of mediastinal staging in NSCLC.