Unforeseen N2 Disease after Negative Endosonography Findings with or without Confirmatory Mediastinoscopy in Resectable Non–Small Cell Lung Cancer: A Systematic Review and Meta-Analysis

Bousema, Jelle E.; Dorp, Martijn van; Noyez, V.J.; Dijkgraaf, Marcel G. W.; Annema, Jouke T.; Broek, Frank J.C. van den

doi:10.1016/j.jtho.2019.02.032

Cited by 32 publications

(21 citation statements)

References 60 publications

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“… 31 A meta-analysis including studies until September 2019 showed comparable unforeseen N2 rates after invasive mediastinal nodal staging by endosonography with or without mediastinoscopy. 10 When evaluating complications as well as accuracy in our treatment trade-off method, we found a clear dichotomy in our study results, with approximately 40% always choosing mediastinoscopy and 40% always choosing to omit mediastinoscopy. Whether the occurrence of complications or a futile resection has contributed to their choices remains unclear, but we cannot ignore the fact that 70% of patients answered the TTM conform their randomization allocation suggesting that cognitive dissonance reduction could have influenced patients’ choices.…”

Section: Discussionmentioning

confidence: 66%

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Patients’ Preferences Regarding Invasive Mediastinal Nodal Staging of Resectable Lung Cancer

Bousema

Hoeijmakers

Dijkgraaf³

et al. 2021

PPA

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Background Variability in practice and ongoing debate on optimal invasive mediastinal staging of patients with resectable non-small cell lung cancer (NSCLC) are widely described in the literature. Patients’ preferences on this topic have, however, been underexposed so far. Methods An internet-based questionnaire was distributed among MEDIASTrial participants (NTR6528, randomization of patients to mediastinoscopy or not in the case of negative endosonography). Literature, expert opinion and patient interviews resulted in five attributes: the risk of a futile lung resection (oncologically futile in case of unforeseen N2 disease), the length of the staging period, resection of the primary tumor, complications of staging procedures and the mediastinoscopy scar. The relative importance (RI) of each attribute was assessed by using adaptive conjoint analysis and hierarchical Bayes estimation. A treatment trade-off was used to examine the acceptable proportion of avoided futile lung resections to cover the burden of confirmatory mediastinoscopy. Results Ninety-seven patients completed the questionnaire (57%). The length of the staging period was significantly the most important attribute (RI 26.24; 95% CI: 25.05–27.43), followed by the risk of a futile surgical lung resection (RI 23.44; 95% CI: 22.28–24.60) and resection of the primary tumor (RI 22.21; 95% CI: 21.09–23.33). Avoidance of 7% (IQR 1– >14%) futile lung resections would cover the burden of confirmatory mediastinoscopy, with a dichotomy among patients always (39%) or never (38%) willing to undergo confirmatory mediastinoscopy after N2 and N3-negative endosonography. Conclusion Although a strong dichotomy among patients always or never willing to undergo confirmatory mediastinoscopy was found, the length of the staging period was the most important attribute in invasive mediastinal staging according to patients with resectable NSCLC. Trial Registration Not applicable.

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Section: Discussionmentioning

confidence: 66%

“… 6–10 A recent meta-analysis including studies until 2019 revealed comparable unforeseen N2 rates after invasive mediastinal nodal staging by endosonography with or without mediastinoscopy, underlining the suggested limited additional diagnostic value of confirmatory mediastinoscopy. 10 …”

Section: Introductionmentioning

confidence: 99%

Patients’ Preferences Regarding Invasive Mediastinal Nodal Staging of Resectable Lung Cancer

Bousema

Hoeijmakers

Dijkgraaf³

et al. 2021

PPA

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“…According to these reports, mediastinal staging should start with endosonography-guided puncture followed by subsequent surgical procedures only in the case of negative results. A metanalysis which included 42 studies and a total of 3,248 patients, the rate of unforeseen N2s after negative endosonography was similar in patients who underwent surgical resection with or without prior surgical mediastinal staging (30). Thus, there is sufficient evidence to recommend surgical resection alone for early stage tumours.…”

Section: E B U S -T B N a A N D E U S -F N A A R E E N D O S C O P Y Techniques That Have Shown A High Diagnostic Value Formentioning

confidence: 91%

Mediastinal staging for non-small cell lung cancer

Leiro-Fernández¹,

Fernández-Villar²

2021

Transl Lung Cancer Res

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The staging of mediastinal lymph nodes for lung cancer is crucial for planning treatments or reinterventions. In potentially curable patients the aim of mediastinal staging is to exclude the presence of malignancy in mediastinal lymph nodes with a high level of accuracy while also considering clinical factors and the balance of the benefits and risks of tissue sampling techniques. Mediastinal staging is based on computed tomography (CT) and positron emission tomography (PET) and can be sufficient when no mediastinal abnormalities are present and the probability of unforeseen N2 disease is low. In the case of bulky lymph nodes with a high probability of malignancy in PET-CT, tissue confirmation is not normally required. If mediastinal sampling is needed it can be achieved by endosonographic techniques, including endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) or a combination of the two. Positive results do not need further confirmation. In the case of negative results, surgical techniques still play a role in the selected cases discussed by multidisciplinary lung cancer committees. New mediastinal surgical techniques including video-assisted cervical mediastinoscopy (VACM), video-assisted mediastinoscopic lymphadenectomy (VAMLA), and transcervical extended mediastinal lymphadenectomy (TEMLA) have been shown to be useful in selected patients. Final pathological staging is based on lymph node removal during surgery and can be achieved by taking one of two approaches: lymph node sampling or systematic lymph node sampling.The accuracy of PET-CT and mediastinal endosonography is lower for mediastinal restaging than it is for surgical techniques; their false positive and false negative (FN) rate is high and so, they require histological confirmation. Here we explain and revise the results from the most recent studies and current international guidelines.

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“…One recent meta-analysis has showed that the overall likelihood of occult mediastinal metastasis after a negative EBUS is below 10%. 58 However, instead of this post-test probability, which otherwise can be low even after a suboptimal EBUS procedure in patients with low prevalence of N2 disease, the question to be answered is about clinical benefit of performing confirmatory mediastinoscopy. One multicentre randomized control trial (ASTER I) 59 showed that mediastinoscopy diagnosed mediastinal involvement in 9% of patients with negative combined EBUS/EUS; however, the prevalence of N2 in this population was high (>40%).…”

Section: Current Controversies Confirmatory Mediastinoscopy After a Nmentioning

confidence: 99%

“…The performance of confirmatory mediastinoscopy after negative EBUS is an issue open to debate. One recent meta‐analysis has showed that the overall likelihood of occult mediastinal metastasis after a negative EBUS is below 10% 58 . However, instead of this post‐test probability, which otherwise can be low even after a suboptimal EBUS procedure in patients with low prevalence of N2 disease, the question to be answered is about clinical benefit of performing confirmatory mediastinoscopy.…”

Section: Current Controversies and Future Perspectivesmentioning

confidence: 99%

Preoperative staging of the mediastinum is an essential and multidisciplinary task

Sanz-Santos

Call

2020

Respirology

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Mediastinal staging is a crucial step in the management of patients with NSCLC. With the recent development of novel techniques, mediastinal staging has evolved from an activity of interest mainly for thoracic surgeons to a joint effort carried out by many specialists. In this regard, the debate of cases in MDT sessions is crucial for optimal management of patients. Current evidencebased clinical guidelines for preoperative NSCLC staging recommend that mediastinal staging should be performed with increasing invasiveness. Image-based techniques are the first approach, although they have limited accuracy and findings must be confirmed by pathology in almost all cases. In this setting, the advent of radiomics is promising. Invasive staging depends on procedural factors rather than diagnostic performance. The choice between endoscopy-based or surgical procedures should depend on the local expertise of each centre. As the extension of mediastinal disease in terms of number of involved lymph nodes and nodal stations affects prognosis and the choice of treatment, systematic samplings are preferred over random targeted samplings. Following this approach, a diagnosis of single mediastinal nodal involvement can be unreliable if all reachable mediastinal nodal stations have not been assessed. The performance of confirmatory mediastinoscopy after a negative endoscopy-based procedure is controversial but currently recommended. Current indications of invasive staging in patients with radiologically normal mediastinum have to be re-evaluated, especially for central tumour location.

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Unforeseen N2 Disease after Negative Endosonography Findings with or without Confirmatory Mediastinoscopy in Resectable Non–Small Cell Lung Cancer: A Systematic Review and Meta-Analysis

Cited by 32 publications

References 60 publications

Patients’ Preferences Regarding Invasive Mediastinal Nodal Staging of Resectable Lung Cancer

Patients’ Preferences Regarding Invasive Mediastinal Nodal Staging of Resectable Lung Cancer

Mediastinal staging for non-small cell lung cancer

Preoperative staging of the mediastinum is an essential and multidisciplinary task

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