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Eur J Cardiothorac Surg 2001;20:654
© 2001 Elsevier Science NL

Letter to the Editor

Reply to Margaritora et al.

Vrije Universiteit Medical Centre, Amsterdam, The Netherlands

Received 11 June 2001; accepted 12 June 2001.

Corresponding author. van Hanxleden Houwertstraat 69 1, 1063 HS Amsterdam, The Netherlands
e-mail: hans_daniels{at}hotmail.com

Hereby we would like address the concerns of Margaritora and colleagues regarding our recently published letter [1]. The first concern of the authors is about inspection, palpation and taking biopsies of all mediastinal lymph nodes (MLNs) of station 7. We share this concern. Only the lymph nodes of stations 2, 3 and 4 can be palpated before inserting the mediastinoscope. Inspection of station 7 is achieved by preparing and clearing out the whole carinal area until the esophagus is visualized. However, the lymph nodes posterior to the trachea cannot be reached for inspection and taking biopsies. This was the cause of all three false negative mediastinoscopies in our study. Trans-esophageal sono-graphy and fine needle aspiration are good alternatives to reach the posterior nodes of station 7.

The second concern of the authors is that lymph nodes of stations 5, 6, 8 and 9 are not evaluated by mediastinoscopy. Several other techniques (e.g. parasteral mediastinotomy, trans-esophageal sonography and fine needle aspiration) are available to evaluate patients in which these lymph nodes are enlarged on CT scan. However these patients were not included in our study since we aimed to assess only the role of cervical mediastinoscopy. Furthermore it is known that most mediastinal metastases occur in the superior MLNs. Pearson and associates found that patients with metastases in these nodes identified by mediastinoscopy have low complete resectability rate and a 5-year survival of only 9% [2]. Whether a biopsy is representative of an entire lymph node is uncertain. Therefore we try to remove the lymph nodes in total and if not possible we take at least four biopsies per station. Unforeseen N2 disease might still be found during thoracotomy, however De Leyn and colleagues showed that resectability rate of unforeseen N2 disease was higher in patients with a negative cervical mediastinoscopy than in patients without enlarged MLNs on CT scan that did not undergo a mediastinoscopy [3]. In another study De Leyn and associates found a resectability rate of 95% for unforeseen N2 disease after negative mediastinoscopy [4].

For several reasons Margaritora and associates conclude that cervical mediastinoscopy should not be used routinely for MLN staging. The most important reasons for us to disagree with this conclusion are the large interobserver variability and low sensitivity of CT scan [5] and the ability of mediastinoscopy to significantly reduce the number of exploratory thoracotomies [4]. It is true that ¹⁸F-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) might eliminate the need for standard mediastinoscopy in the future. However the role of FDG-PET must be further determined in randomized trials that compare FDG-PET with conventional staging, in which mediastinoscopy is accurately performed. Moreover, it is unlikely that FDG-PET will become widely available in the near future and therefore many patients will still depend on accurate conventional staging.

References

1. Daniels J.M.A., Rijna H., Postmus P.E., van Mourik J.C. Mediastinoscopy as a 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. Pearson F.G., Delarue N.C., Ilves R., Todd T.R.J., Cooper J.D. Significance of positive superior mediastinal nodes identified at mediastinoscopy in patients with resectable cancer of the lung. Thorac Cardiovasc Surg 1982;83:1-11.
3. De Leyn P., Schoonooghe P., Deneffe G., Van Raemsdonck D., Coosemans W., Vansteenkiste J., Lerut T. Surgery for non-small cell lung cancer with unexpected metastases to ipsilateral mediastinal or subcarinal nodes (N2 disease). Eur J Cardio-thorac Surg 1996;10:649-655.[Abstract]
4. De Leyn P., Vansteenkiste J., Cuypers P., Deneffe O., van Raemsdonck D., Coosemans W., Verschakelen J., Lerut T. Role of cervical mediastinoscopy in staging of non-small cell lung cancer without enlarged mediastinal lymph nodes on CT scan. Eur J Cardio-thorac Surg 1997;12(5):706-712.[Abstract]
5. Bollen E.C.M., Goei R., Van’t Hof-Grootenboer B.E., Versteege C.W., Engelshove H.A., Lamers R.J. Interobserver variability and accuracy of computed tomographic assessment of nodal status in lung cancer. Ann Thorac Surg 1994;58:158-162.[Abstract]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Daniels, J. M.A Articles by van Mourik, J. C. Search for Related Content PubMed Articles by Daniels, J. M.A Articles by van Mourik, J. C. Related Collections Mediastinum