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

Abstract

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.

Old habits die hard

“…5 By means of combined ultrasonography, with both endoscopic ultrasonography and endobronchial ultrasonography, lymph nodes that are not accessible to mediastinoscopy, such as the inferior subcarinal, inferior pulmonary ligament, and paraesophageal stations, can be successfully sampled. 6 Fernandez and colleagues 1 try to address less invasive staging by commenting that endosonography is unlikely to have a role in early lung cancer, and I agree. One wonders, however, whether the 2 patients who underwent pneumonectomy with station 7 nodal involvement could have been spared resection if they had undergone staging with combined ultrasonography.…”