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Eur J Cardiothorac Surg 2002;22:486
© 2002 Elsevier Science NL

Letter to the Editor

Reply to Dujon et al.

VU University Medical Centre, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands

Received 10 May 2002; accepted 14 May 2002.

* Corresponding author. Department of Surgery, VU University Medical Centre, Spaarne 112, 2011 CM, Haarlem, The Netherlands. Tel.: +31-23-5321306
e-mail: hans_daniels{at}hotmail.com

We thank Dujon and colleagues for discussing our recommendations regarding the routine use of cervical mediastinoscopy and congratulate them with the impressive results of their own series.

However, we would like to make a few comments. Firstly, in Dujon's patients, N2 disease was present in 26.6%. It is stated that only 4.7% could have been detected by mediastinoscopy because only right paratracheal (2R) and tracheobronchial (4L+R) lymph nodes can be reached. In our experience also the left paratracheal (2L) lymph nodes and more importantly, the subcarinal nodes station 7, can be sampled. The most dorsal nodes of this station are difficult to reach. In our group, the sensitivity of mediastinoscopy for station 7 was 100% (6/6) for the anterior nodes and 0% (0/3) for the posterior lymph nodes (overall sensitivity 66%). If we apply this result to the group of Dujon et al. we find that in 7.3% (instead of 4.7%) of patients with clinical N0 disease N2 disease could have been detected by mediastinoscopy. Futhermore, even the posterior nodes of station 7 have become more accessible for inspection by video assisted mediastinoscopy. A recent article by Hürtgen et al. [1] showed that with video assisted mediastinoscopic lymphadenectomy (VAMLA) no false negative results were encountered in 46 patients. This method significantly increases the number of lymph nodes that can be reached in pre-operative mediastinal staging. Further improvement can be accomplished with endoscopic ultrasonography guided fine needle aspiration biopsy (EUS-FNAB), which enables us to sample mediastinal lymph nodes that are otherwise inaccessible.

Secondly, Dujon et al. question the role of mediastinoscopy in discriminating operability and resectability. We agree that resection of N2 disease is often technically possible and the 5-year survival rate in their resected patients is quite good. Unfortunately, results in other series are not as favourable. Funatsu et al. [2] reported a relative curative resection in only 13% of these patients and it seems that many of these patients harbour disease that is ‘beyond the knife’. It is presumed that the prognosis of these patients can be improved by pre-operative neoadjuvant treatment [3]. We therefore keep our statement that in N2 positive patients neoadjuvant chemotherapy is justified prior to surgical resection. A detection rate of 7.3% (and presumably higher with the new investigational tools) is high enough to justify mediastinoscopy in all patients except those with cT1N0 squamous cell carcinoma.

However, since addition of positron emission tomography (PET) scan to standard workup has improved selection of surgically curable patients in our region, it has replaced mediastinoscopy in most of our patients, greatly reducing the number of ‘futile thoracotomies’ [4].

Acknowledgments

We kindly thank Dr M.A. Paul for his constructive comments.

References

1. Hürtgen M., Friedel G., Toomes H., Fritz P. Radical video-assisted mediastinoscopic lymphadenectomy (VAMLA) – technique and first results. Eur J Cardiothorac Surg 2002;21:348-351.[Abstract/Free Full Text]
2. Funatsu T., Matsubara Y., Hatakenaka R., Kosaba S., Yasuda Y., Ikeda S. The role of mediastinoscopic biopsy in preoperative assessment of lung cancer. J Thorac Cardiovasc Surg 1992;104:1688-1695.[Abstract]
3. Hoffman P.C., Mauer A.M., Vokes E.E. Lung cancer. Lancet 2000;355:479-485.[Medline]
4. van Tinteren H., Hoekstra O.S., Smit E.F., van den Bergh J.H.A.M., Schreurs A.J.M., Stallaert R.A.L.M., van Velthoven P.C.M., Comans E.F.I., Diepenhorst F.W., Verboom P., van Mourik J.C., Postmus P.E., Boers M., Teule G.J.J., The PLUS study group. Effectiveness of positron emission tomography in the preoperative assessment of patients with suspected non-small cell lung cancer: the PLUS multicentre randomised trial. Lancet 2002;359:1388-1392.[Medline]

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 Lung - cancer Mediastinum