Mediastinal staging by videomediastinoscopy in clinical N1 non-small cell lung cancer: a prospective multicentre study

Abstract

A quarter of patients with clinical N1 (cN1) non-small cell lung cancer (NSCLC) based on positron emission tomography-computed tomography (PET-CT) imaging have occult mediastinal nodal involvement (N2 disease). In a prospective study, endosonography alone had an unsatisfactory sensitivity (38%) in detecting N2 disease. The current prospective multicentre trial investigated the sensitivity of preoperative mediastinal staging by video-assisted mediastinoscopy (VAM) or VAM-lymphadenectomy (VAMLA).Consecutive patients with operable and resectable (suspected) NSCLC and cN1 after PET-CT imaging underwent VAM(LA). The primary study outcome was sensitivity to detect N2 disease. Secondary endpoints were the prevalence of N2 disease, negative predictive value (NPV) and accuracy of VAM(LA).Out of 105 patients with cN1 on imaging, 26% eventually developed N2 disease. Invasive mediastinal staging with VAM(LA) had a sensitivity of 73% to detect N2 disease. The NPV was 92% and accuracy 93%. Median number of assessed lymph node stations during VAM(LA) was 4 (IQR 3-5), and in 96%, at least three stations were assessed.VAM(LA) has a satisfactory sensitivity of 73% to detect mediastinal nodal disease in cN1 lung cancer, and could be the technique of choice for pre-resection mediastinal lymph node assessment in this patient group with a one in four chance of occult-positive mediastinal nodes after negative PET-CT.

Multidisciplinary consensus statement on the clinical management of patients with stage III non-small cell lung cancer

“…Both techniques have a sensitivity close to 90% and a specificity of 100% [17,[22][23][24][25]. However, if the result is negative, not assessable or not sufficiently reliable (NPV: < 90%), staging must be completed with surgical techniques [24,26,27].…”

Lung cancer staging: a concise update

“…Endosonography for mediastinal/hilar nodal staging in early stage non-small cell lung cancer In patients with tumours classified as clinical N0 at PET-CT, recent studies reported a risk of mediastinal nodal involvement of <20% and sensitivity of 0.17-0.41 for EBUS-TBNA to detect mediastinal nodal disease [63][64][65][66]. Two prospective multicentre studies reported a risk of mediastinal nodal involvement of 25% in 205 patients classified as clinical N1 at PET-CT [67,68]. In resectable patients classified as clinical N1 at PET-CT, a sensitivity of 0.38-0.53 has been reported for endosonography to detect mediastinal nodal disease [66,67,69].…”

“…Overall, the routine use of a preoperative EBUS-TBNA for systematic mediastinal nodal sampling in clinical stage I−IIB non-small cell lung cancer has only a moderate sensitivity to detect mediastinal nodal disease and does not greatly increase the negative predictive value of PET-CT [63][64][65][66][67][68]. In the concepts of Bayesian decision analysis, given a pre-test prevalence of 10-25% and sensitivity for EBUS-TBNA of less than 50% to detect mediastinal nodal disease in early stage non-small cell lung cancer, a post-test probability of greater than 10% is expected requiring another invasive staging test, taking into account the testing decision threshold of 10% required by the ESTS guidelines [2].…”

“…Ga-DOTA-peptides, have been used in a research environment but could have an important role in the next few years in the era of personalised therapy for patients with lung cancer [52]. In fact, 68 Ga-DOTA-peptide scan already is part of the standard staging work-up in cases of FDG-negative (a)typical carcinoid. In a study of 53 patients, 18 F-NaF PET showed no false-negatives in the detection of bone metastases, while bone scan and SPECT had six and one false-negatives, respectively [53].…”

Mediastinal staging by videomediastinoscopy in clinical N1 non-small cell lung cancer

“…This article reports the findings of a prospective clinical trial by D ecaluwé et al . [ 11 ]. Investigators attempted to evaluate preoperatively the sensitivity of video-assisted mediastinoscopy (VAM) or VAM–lymphadenectomy (VAM(LA)) in mediastinal staging of operable and resectable suspected NSCLC and clinical N1 disease (cN1).…”