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Eur J Cardiothorac Surg 2001;20:652-653
© 2001 Elsevier Science NL

Letter to the Editor

Mediastinoscopy as a standardised procedure for mediastinal lymph-node staging in non-small cell carcinoma. Do we have to accept the compromise?

Department of Surgical Sciences, Division of General Thoracic Surgery, Catholic University, Rome, Italy

Received 13 April 2001; accepted 12 June 2001.

Corresponding author. Tel.: +39-0335-8366161; fax: +39-06-3051162
e-mail: alfcesario{at}yahoo.com

The recently published letter by Daniels and colleagues [1] compels us to make this comment to the Editor.

We agree that a correct staging procedure is ‘an essential part of the work up of a patient presenting with non-small cell lung cancer (NSCLC)’. When the authors focus their attention on cervical mediastinoscopy they advise the use of this procedure in every patient with a potentially operable NSCLC. What they actually do is ‘to take routine biopsies of all paratracheal, tracheo–bronchial and subcarinal nodes during mediastinoscopy even if not suspect during inspection and palpation’.

As far as we are concerned ‘inspection’ and ‘palpation’ of all the lymph-nodes of station 7, during cervical mediastinoscopy represents quite a difficult operative procedure. Could the authors specify this step?

Our second concern regards the concept that ‘complete’ lymph-node sampling of stations 2, 4 and 7 would represent a significant step forward in the staging procedure. What about stations 5, 6, 8 and 9? Is a biopsy representative of the entire lymph-node? What about micro metastases [2]?

Furthermore the authors state that ‘during mediastinoscopy biopsies of all MLN stations should be taken routinely’. This sentence raises a second surgical problem: could the authors specify how?

Given the data reported by the authors, accuracy, being based on the true positive and true negative rates would have been more adequate and rather interesting (95%).

So, in our opinion, the reported data, even if encouraging, are affected by the biases represented by:

1. The surgical problems in inspecting, palpating and taking biopsies of all the mediastinal lymph-nodes in station 7.
   
2. The limitation represented by the biopsy itself (low probability to biopsy the area containing an eventual micro-metastasis).
   
3. The limitation represented by the fact that only three out of nine mediastinal lymph-node stations are explored.
   

Thus, the conclusion that cervical mediastinoscopy should be performed in every operable case of NSCLC is not satisfyingly supported.

In our opinion few concepts are, in this setting, to be focused:

1. Survival of the pathological N2 (pN2) patients operated upon and completely resected is not much different of that of clinical N2 (cN2) patients globally involved in induction therapy trials (responders plus non-responders) [3]; this difference is smaller if the so-called ‘minimal’ pN2 disease cases are considered [4];.
   
2. Cervical mediastinoscopy cannot technically assess all of the mediastinal lymph-node stations. Using it routinely is a compromise, as it is a compromise evaluating a lymph-node on the basis of the CT scan findings only, but much more aggressive.
   
3. 18FDG-PET scan will probably change this setting, when the problems correlated with the false positive rate will be correctly addressed and the technique will be widely available [5].
   
4. Cyto or histological confirmation of the mediastinal lymph-node involvement (cervical mediastinoscopy, extended mediastinoscopy, anterior mediastinotomy, fine needle aspiration citology, VATS) should be reserved in all those cases where CT scan is suspect and the patient is to be enrolled in an induction therapy protocol.
   
5. The discrepancy (rather unsatisfying accuracy ratio) represented by what a CT scan assesses as negative and what it is actually positive represents one of the rationales in the many induction therapy trials now ongoing in early stage NSCLC.
   

References

1. Daniels J.M.A., Rijina H., Postmus P.E., van Mourik J.C. Mediastinoscopy as standardised procedure for mediastinal lymph-node staging in non-small cell lung carcinoma. Eur J Cardio-thorac Surg 2001;19:377-378.[Free Full Text]
2. Kubuschok B., Passlick B., Izbicki J.R., Thetter O., Pantel K. Disseminated tumor cells in lymph nodes as a determinant for survival in surgically resected non-small-cell lung cancer. J Clin Oncol 1999;17(1):19-24.[Abstract/Free Full Text]
3. Andre F., Grunenwald D., Pignon J.P., Dujon A., Pujol J.L., Brichon P.Y., Brouchet L., Quoix E., Westeel V., Le Chevalier T. Survival of patients with resected N2 non-small-cell lung cancer: evidence for a subclassification and implications. J Clin Oncol 2000;18(16):2981-2989.[Abstract/Free Full Text]
4. Bollen E.C., Theunissen P.H., van Duin C.J., Drenth B.M., van Noord J.A., Blijham G.H. Clinical significance of intranodal and extranodal growth in lymph node metastases of non-small cell lung cancer. Scand J Thorac Cardiovasc Surg 1994;28(3-4):97-102.[Medline]
5. Dunagan D., Chin R., Jr, McCain T., Case L., Harkness B., Oaks T., Haponik E. Staging by positron emission tomography predicts survival in patients with non-small cell lung cancer. Chest 2001;119(2):333-339.[Abstract/Free Full Text]

This article has been cited by other articles:

				S. Margaritora, A. Cesario, V. Porziella, and P. Granone Intrathoracic staging of non small cell lung cancer with mediastinal involvement: still a moonless foggy night? Eur. J. Cardiothorac. Surg., February 1, 2003; 23(2): 256 - 256. [Full Text] [PDF]

				A. Dujon and M. Riquet Reply to Margaritora et al. Eur. J. Cardiothorac. Surg., February 1, 2003; 23(2): 257 - 257. [Full Text] [PDF]

				A. Dujon, F. Le Pimpec Barthes, M. Saab, and M. Riquet Routine mediastinoscopy and lymph node staging: 'much ado about nothing'? Eur. J. Cardiothorac. Surg., September 1, 2002; 22(3): 485 - 485. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Stefano Margaritora Alfredo Cesario Domenico Galetta Pierluigi Granone Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Margaritora, S. Articles by Granone, P. Search for Related Content PubMed PubMed Citation Articles by Margaritora, S. Articles by Granone, P. Related Collections Mediastinum