Confirmatory Mediastinoscopy after Negative Endobronchial Ultrasound-guided Transbronchial Needle Aspiration for Mediastinal Staging of Lung Cancer: Systematic Review and Meta-analysis

Sanz-Santos, José; Almagro, Pere; Malik, Komal; Martínez‐Camblor, Pablo; Caro, Conxi; Rami‐Porta, Ramón

doi:10.1513/annalsats.202111-1302oc

Cited by 20 publications

(12 citation statements)

References 41 publications

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“…The higher rate of mediastinal nodal spread among patients receiving more diagnostic tests was also demonstrated by Sanz-Santos, demonstrating a 19.5% higher N2-3 prevalence in studies performing confirmatory mediastinoscopy. 24 Although this meta-analysis showed large heterogeneity, the randomized ASTER trial found a 32) 48 (31) .7900…”

Section: Discussionmentioning

confidence: 88%

“…A meta-analysis by Sanz-Santos showed an increase in negative predictive value from 79% to 92% by confirmatory mediastinoscopy after negative EBUS, with a NNT of 24. 24 The underlying primary research question in our trial therefore was not to assess the inevitable loss in sensitivity by omitting mediastinoscopy, but to determine whether the expected increase in uN2 was within predefined limits. Our premise hereby was that the increase in uN2 will be counterbalanced by a reduction in the drawbacks of confirmatory mediastinoscopy (secondary outcome).…”

Section: Discussionmentioning

confidence: 99%

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Endosonography With or Without Confirmatory Mediastinoscopy for Resectable Lung Cancer: A Randomized Clinical Trial

Bousema

Dijkgraaf

Heijden

et al. 2023

JCO

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PURPOSE Resectable non–small-cell lung cancer (NSCLC) with a high probability of mediastinal nodal involvement requires mediastinal staging by endosonography and, in the absence of nodal metastases, confirmatory mediastinoscopy according to current guidelines. However, randomized data regarding immediate lung tumor resection after systematic endosonography versus additional confirmatory mediastinoscopy before resection are lacking. METHODS Patients with (suspected) resectable NSCLC and an indication for mediastinal staging after negative systematic endosonography were randomly assigned to immediate lung tumor resection or confirmatory mediastinoscopy followed by tumor resection. The primary outcome in this noninferiority trial (noninferiority margin of 8% that previously showed to not compromise survival, Pnoninferior < .0250) was the presence of unforeseen N2 disease after tumor resection with lymph node dissection. Secondary outcomes were 30-day major morbidity and mortality. RESULTS Between July 17, 2017, and October 5, 2020, 360 patients were randomly assigned, 178 to immediate lung tumor resection (seven dropouts) and 182 to confirmatory mediastinoscopy first (seven dropouts before and six after mediastinoscopy). Mediastinoscopy detected metastases in 8.0% (14/175; 95% CI, 4.8 to 13.0) of patients. Unforeseen N2 rate after immediate resection (8.8%) was noninferior compared with mediastinoscopy first (7.7%) in both intention-to-treat (Δ, 1.03%; UL 95% CIΔ, 7.2%; Pnoninferior = .0144) and per-protocol analyses (Δ, 0.83%; UL 95% CIΔ, 7.3%; Pnoninferior = .0157). Major morbidity and 30-day mortality was 12.9% after immediate resection versus 15.4% after mediastinoscopy first ( P = .4940). CONCLUSION On the basis of our chosen noninferiority margin in the rate of unforeseen N2, confirmatory mediastinoscopy after negative systematic endosonography can be omitted in patients with resectable NSCLC and an indication for mediastinal staging.

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Section: Discussionmentioning

confidence: 88%

Section: Discussionmentioning

confidence: 99%

Endosonography With or Without Confirmatory Mediastinoscopy for Resectable Lung Cancer: A Randomized Clinical Trial

Bousema

Dijkgraaf

Heijden

et al. 2023

JCO

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“…The diagnostic spectrum has substantially broadened as years passed – primarily by different anatomic and metabolic imaging techniques and endoscopies. But the VAMLAs role as the most precise diagnostic mediastinal staging instrument is still unrivaled [ 11 , 12 ]. For example, endoscopic fine-needle aspiration techniques have their own unique limitations: (1) neither EBUS-TBNA nor EUS-FNA ensures a systematic mapping of the mediastinal lymph node zones as they are limited to individual lymph node samples of interest, and (2) as tumor cells do not consistently affect lymph node tissue, random sampling of lymph nodes may fail to detect cancer cells [ 13 ].…”

Section: Discussionmentioning

confidence: 99%

Portrayal of video-assisted mediastinoscopic lymphadenectomy’s range subsequent to its simultaneous use with uniportal VAT-lobectomy for left-sided NSCLC: a case-based perspective

Hartert

Huertgen

2023

J Cardiothorac Surg

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Background Video-assisted mediastinoscopic lymphadenectomy (VAMLA) is the most precise approach combining staging and therapeutic interventions in non-small cell lung cancer (NSCLC). In the case of left-sided NSCLC, the likelihood of mediastinal lymph node metastases depends on the involvement of the left lung regional lymphatic network. As such, it appears obvious – at least for selected patients with mediastinal staging by either PET-CT or EBUS-TBNA ± EUS-FNA and with cN ≤ 2 – to merge VAMLA and left-sided video-assisted thoracoscopic (VAT) lobectomy for a single-stage therapeutical procedure. Case presentation We present the clinical course of an 83-year-old patient following simultaneous VAMLA and VAT-lobectomy for invasive mucinous adenocarcinoma of the left upper lobe with a provisional cT3cN0cM0 stage. The patient developed a clinically relevant postoperative pneumothorax due to a persistent parenchymal air leak. CT scan revealed a substantial pneumomediastinum and showed the capability of VAMLAs range for mediastinal lymph node dissection in a unique way. Following the prompt insertion of a second chest tube, the situation was stabilized with an unremarkable further in-hospital stay. The patient remains free of tumor recurrence or distant metastases at a one-year follow-up. Conclusion Presenting this aperçu, we encourage reviving the debate on (1) precise mediastinal staging in general and (2) VAMLA’s important role as a diagnostic and therapeutic tool.

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“…Furthermore, the complication rate associated with confirmatory mediastinoscopy was 6%, which includes grade 3 or 4 complications in 1.9% of patients and procedure-related death in 0.5% of patients. In addition, Sanz-Santos et al 24 found that the negative predictive value of EBUS-TBNA was 79%, which increased to 97% with the addition of confirmatory mediastinoscopy. However, the number of patients needed to treat in this analysis was substantial, at 23.8.…”

Section: Clinical Challenges In Evaluation and Managementmentioning

confidence: 99%

Mediastinal Staging in Non–Small-Cell Lung Cancer: Saying Goodbye to Mediastinoscopy

Dunne

Fick

Jones

2023

JCO

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The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. Accurate staging of the mediastinal lymph nodes in resectable non–small-cell lung cancer (NSCLC) is critically important to determine the overall stage of the tumor and guide subsequent management. The staging process typically begins with positron emission tomography (PET) or computed tomography imaging; however, imaging alone is inadequate, and tissue acquisition is required for confirmation of nodal disease. Mediastinoscopy was long considered the gold standard for staging of mediastinal lymph nodes, but, recently, endobronchial ultrasound–guided (EBUS) fine-needle aspiration (FNA) has become the standard of care. EBUS-FNA, in combination with supplementary technologies, such as intranodal forceps biopsy and esophageal ultrasonography, has a high sensitivity and specificity for the diagnosis of nodal metastases. EBUS-FNA is also capable of assessing N1 disease and obtaining adequate tissue for tumor genomic analysis to help guide treatment. In the case of negative findings on EBUS, a confirmatory video mediastinoscopy is still recommended by the European Society of Thoracic Surgeons guidelines. However, whether confirmatory mediastinoscopy is necessary is a matter of debate, and it is not commonly performed in North America. To address this question, Bousema and colleagues performed a randomized noninferiority trial to determine rates of unforeseen nodal metastases after EBUS alone versus EBUS with confirmatory mediastinoscopy in patients with resectable NSCLC. The authors concluded that EBUS alone is noninferior to EBUS with confirmatory mediastinoscopy. These findings affirm our current practice to forgo confirmatory mediastinoscopy after negative findings on EBUS.

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Confirmatory Mediastinoscopy after Negative Endobronchial Ultrasound-guided Transbronchial Needle Aspiration for Mediastinal Staging of Lung Cancer: Systematic Review and Meta-analysis

Cited by 20 publications

References 41 publications

Endosonography With or Without Confirmatory Mediastinoscopy for Resectable Lung Cancer: A Randomized Clinical Trial

Endosonography With or Without Confirmatory Mediastinoscopy for Resectable Lung Cancer: A Randomized Clinical Trial

Portrayal of video-assisted mediastinoscopic lymphadenectomy’s range subsequent to its simultaneous use with uniportal VAT-lobectomy for left-sided NSCLC: a case-based perspective

Mediastinal Staging in Non–Small-Cell Lung Cancer: Saying Goodbye to Mediastinoscopy

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