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Letters to the Editor |
Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
Received 7 May 2008; accepted 2 June 2008.
* Corresponding author. Address: Department of Thoracic Surgery, UZ Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium. Tel.: +32 16346822; fax: +32 16346821. (Email: Paul.deleyn{at}uz.kuleuven.ac.be).
Key Words: Remediastinoscopy • Lung cancer • Staging • Induction therapy • Restaging
We read with great interest the review of Van Schil and Dewaele on remediastinoscopy [1]. We agree that cyto-histological proof of persistent N2-disease after induction treatment is recommended.
In Table 3, they report the literature results of remediastinoscopy after induction therapy. It is claimed that good results with remediastinoscopy can be obtained in four out of the five centres that published their experience [1]. They report that the sensitivity of remediastinoscopy in the study of Pitz et al. was 71.4%. The sensitivity is however not reported in that article [2] and it is not clear to us how it was calculated. In 6 of the 15 patients no biopsies or incomplete biopsies were obtained due to fibrosis or adhesions. Of all patients with an adequate repeat mediastinoscopy (n = 9), two had positive nodes. Seven biopsies showed negative results. In two patients this proved to be false negative at thoracotomy. When we calculate the sensitivity (true positive/true positive + false negative) we obtain a sensitivity of 50%. The authors [2] conclude: ‘the results of repeat mediastinoscopy are disappointing and proved to be a not so effective restaging tool because of the high number of incomplete procedures and because it yields false negative results.’
In a prospective study we evaluated the accuracy of PET-CT and remediastinoscopy in restaging after mediastinoscopy proven N2 disease. Remediastinoscopy, although technically feasible, had a very low sensitivity [3]. It is suggested by Van Schil that a possible explanation for the discrepancy could be the use of a videomediastinoscope because that videomediastinoscope is larger and the three-dimensional view is lost.
Videomediastinoscopy has internationally been accepted to result in improved visualisation and accuracy of mediastinal staging. We use the Lerut-videomediastinoscope (Storz®). At the tip, the external diameter of this videomediastinoscope is only 1 mm larger in height and breadth, compared to the regular mediastinoscope. Such small differences cannot be responsible for the differences in sensitivity [3]. This assumption clearly lacks scientific evidence. Moreover, a view through the scope always remains possible providing a three-dimensional view whenever judged necessary.
The aim of mediastinoscopy in staging of potentially resectable NSCLC is to have a full mapping of all mediastinal lymph nodes (LNs). In contrast to all other studies, our study was a prospective study reporting the number of LN levels biopsied during the first mediastinoscopy. In one of the retrospective studies, one third of the patients had more LN levels involved at remediastinoscopy compared to the initial mediastinoscopy suggesting that at initial mediastinoscopy not all LN levels were biopsied [4]. We believe that the lower sensitivity in our study is related to more adhesions and fibrosis, which is most likely the result of a more complete first mediastinoscopy.
So basically, the good results with remediastinoscopy are only obtained in three very experienced centres and are based on retrospective data. Moreover, in a combined series, 3 out of 104 patients developed severe bleeding during remediastinoscopy resulting in one mortality and one thoracotomy with pneumonectomy [5]. One can assume, if this is occurring in high volume expert centres that further diffusion in centres with less experience may result in even more catastrophes.
It seems to us that a thorough mediastinoscopy can only be performed once safely. Therefore, we do not believe that remediastinoscopy is a valuable tool for restaging after induction therapy. In an area of PET or PET-CT, endoscopic fine needle aspiration, we have to rethink staging and restaging algorithms.
References
This article has been cited by other articles:
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  P. E. Van Schil, M. De Waele, and R. Rami-Porta Reply to De Leyn and Lerut. Mediastinoscopy and repeat mediastinoscopy: still useful tools in experienced hands! Eur. J. Cardiothorac. Surg., September 1, 2008; 34(3): 709 - 710. [Full Text] [PDF]
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