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Eur J Cardiothorac Surg 2002;22:485
© 2002 Elsevier Science NL

Letter to the Editor

Routine mediastinoscopy and lymph node staging: ‘much ado about nothing’?

^a Centre Medicochirurgical du Cèdre, 950 rue de la haie Boisguillaume, 76235 Boisguillaume, France
^b Service de Chirurgie Thoracique Hôpital Européen Georges Pompidou, 20-40 rue Leblanc 75015 Paris, France

Received 2 April 2002; accepted 14 May 2002.

* Corresponding author. Tel.: +33-1-56-09-34-51; fax: +33-1-56-09-33-80
e-mail: marc.riquet{at}hop.egp.ap-hop-paris.fr

Daniel et al. [1] recently recommended mediastinoscopy for all patients with possibly operable non-small cell lung cancer, regardless of the outcome of the computed tomographic (CT) scan, except for patients with T1 squamous cell carcinoma. Biopsies of all mediastinal lymph node stations being taken routinely even if not suspect during inspection and palpation. The rationale was to limit the total number of exploratory thoracotomies from 17 to 7%. Margaritora et al. [2] discussed three main biases emerging from their statements: surgical problems in inspecting and taking biopsies of all lymphnodes in station 7; limitation represented by the biopsy itself notably in cases of micrometastasis and limitation due to the fact that only three out of nine mediastinal lymphnode stations were explored.

We suggest another point of view on routine mediastinoscopy. From April 1984 to December 1999, we operated 2048 patients (not explored by routine mediastinoscopy) who underwent complete pulmonary resection for NSCLC: N0=1080 (52.7%), N1=424 (20.7%) and N2=544 (26.6%). In the N2 group, 166 were discovered at histology (30.5%) which represent 11% of 1670 clinical mediastinal N0 (1080+424+166: 45 in 2 R and 4 R stations, 66 in seven station, 34 in 4 L and 31 in five stations) and 4.7% when considering only accessible 2 R, 4 R and 4 L nodes. Over the same period the number of exploratory thoracotomies was 87 of which only 26 were due to N2 disease which represent 4% (87 out of 2135 patients), but 1.2% when considering only exploratory thoracotomies due to this unresectable N2 subset (n=26).

Since we operated all N2 appearing resectable according to CT scan, we do not understand the role mediastinoscopy can play in discriminating operability and resectability (even if the point of view reported by Daniel et al. is also the one reported by De Leyn et al. [3]). Furthermore, global 5-year survival rates in our N2 subgroup was 26.7%, increasing to 32.9% when considering only single N2 station involvement.

We believe mediastinoscopy is useful:

to assess diagnosis of lung cancer not amenable to biopsy but presenting with suspected N2 disease;

to rule out N3 disease; and

to insure the diagnosis of N2 or N0 disease (in case of suspected macroscopic N2) before neoadjuvant chemo and/or radiation therapy in order to insure efficacy of treatment. However, we think mediastinoscopy cannot be accepted as a routine procedure: more than 95% will prove useless, which does not justify the risks inherent to mediastinoscopy (although low) and its cost effectiveness.

Discussing routine mediastinoscopy for staging or to rule out inoperability when not justified on CT scan appears a debate of an ancien millenium, and is probably ‘much ado about nothing’?

References

1. Daniels J.M.A., Rijna H., Postmus P.E., Van Mourik J.C. Mediastonoscopy as a standardised procedure for mediastinal lymph node staging in non-small cell lung carcinoma. Eur J Cardiothorac Surg 2001;19:377-378.[Free Full Text]
2. Margaritora S., Cesario A., Galetta D., Granone P. Mediastinoscopy as a standardised procedure for mediastinal lymph node staging in non-small cell carcinoma?. Eur J Cardiothorac Surg 2001;20:652-653.[Free Full Text]
3. De Leyn P., Vansteenkiste J., Cuypers P., Deneffe G., 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 Cardiothoracic Surg 1997;12:706-712.[Abstract]

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]

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): Michel Saab Marc Riquet Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Dujon, A. Articles by Riquet, M. Search for Related Content PubMed PubMed Citation Articles by Dujon, A. Articles by Riquet, M. Related Collections Lung - cancer