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Letters to the Editor |
a Department of Thoracic and Vascular Surgery, University of Antwerp, Antwerp, Belgium
b Department of Thoracic Surgery, Hospital Mútua de Terrassa, Terrassa, Barcelona, Spain
Received 2 June 2008; accepted 2 June 2008.
* Corresponding author. Address: Department of Thoracic and Vascular Surgery, University Hospital of Antwerp, Wilrijkstraat 10, B-2650 Edegem, Antwerp, Belgium. Tel.: +32 3 8214360; fax: +32 3 8214396. (Email: paul.van.schil{at}uza.be).
Key Words: Lung cancer • Staging • Restaging • Mediastinoscopy • Repeat mediastinoscopy
With the advent of functional imaging modalities and minimally invasive endoscopic techniques, staging and restaging of locally advanced lung cancer remains a controversial topic as can be appreciated by the comments of De Leyn and Lerut [1]. The specific role of each modality has not been decided and the pendulum is still swinging from one side to the other, also depending on the experience a centre has with a specific technique.
Regarding the accuracy of remediastinoscopy (reMS) De Leyn and Lerut have suggested several times that we are not performing a complete first mediastinoscopy (MS) and in this way encounter less mediastinal fibrosis when performing reMS. In 1997 we published a prospective study of 100 consecutive mediastinoscopies with a sensitivity of 89% and an accuracy of 97%, providing scientific evidence that we correctly biopsy the different lymph node stations during initial MS. Regarding the specific table the authors refer to, it should be indicated that not all initial MS were performed at our centre and we only mentioned information on specific lymph node stations that was clearly available. In fact, the insertion of this table was suggested by the reviewers to demonstrate that with a carefully performed reMS, it is feasible to biopsy involved lymph nodes at different levels. It is difficult to accept the argument of the authors that all centres reporting similar results with reMS, which are also teaching hospitals, would not be able to thoroughly perform a first MS.
Regarding the study of Pitz et al., De Leyn and Lerut correctly indicate that calculating sensitivity on such a small number of patients is not valid. In the table they refer to we mentioned the negative predictive value (5 true negative/2 false negative + 5 true negative results = 71.4%) but the caption related to this was not inserted due to an error on our side. However, the authors do not mention that in this study only stage IIIB lung cancers were included, which represent the locally most advanced cancers. So, the results of this small series cannot be generalised. Very strict criteria were applied by Pitz et al. to define a complete reMS. Moreover, precisely in this centre in the Netherlands with a large experience of reMS for new and recurrent lung cancer and even performing rereMS or third mediastinoscopies, I was taught how to correctly perform a reMS!
Regarding the mediastinoscope itself, the authors state that there is not a large difference between the videomediastinoscope and classical mediastinoscope. At the tip the difference is 1.2 mm in height and 1.3 mm in width, which represents a larger difference when surface area is calculated. The authors do not mention that the videomediastinoscope is substantially longer (+60.8 mm) making it more difficult to rotate, angulate and advance once inserted in the mediastinum, especially in patients with rigidity of the cervical spine or a short neck. In the centre with the largest experience in reMS a classical mediastinoscope is also found to be more useful when performing reMS [2]. As the Lerut-videomediastinoscope® (Storz Company, Tuttlingen, Germany) was designed at the University of Leuven, there might be a potential conflict of interest when discussing the use of this device.
Combining published series of reMS performed after induction therapy, there was 1 fatal case out of 314 reported procedures. This accounts for a mortality of 0.3% which is not different from the figure reported for a first MS [3]. As stated in the conference discussion this fatal case was not a good indication for a reMS [4].
Looking at everyday practice, even first MS are not always correctly performed. In a recent study from the Netherlands only 40% of first MS were performed according to gold standards. Also first MS may give rise to serious complications. In the overall experience of De Leyn and Lerut major complications such as severe bleeding requiring immediate intervention, oesophageal and bronchial injury were encountered [3]. In the latter review or other manuscripts from their institution the authors do not provide detailed figures on the number of reMS they performed and the complications that occurred, although they stated in a previous letter that they have ‘substantial experience in mediastinoscopy and remediastinoscopy’ [3,5]. However, from their publications it is not clear how large their experience was before starting their prospective study, results of which may reflect their learning curve with this technique.
Although the authors state that ‘we have to rethink staging and restaging algorithms’, it is not clear which precise strategy they propose. In 2005 they wrote ‘Thoracic surgeons will be faced more and more frequently with the need to repeat the mediastinoscopy’ [3] and in the 2007 ESTS guidelines of which both are authors ‘At the present time, neither CT, PET or PET-CT are accurate enough to make final further therapeutic decisions based on their results. An invasive technique providing cyto-histological information is recommended’. Since its introduction 50 years ago, MS and even more reMS has been the subject of constant criticism by radiologists, nuclear physicians and now even thoracic surgeons. However, due to their ability to provide pathologic and prognostic evidence, these invasive techniques are still valid and, in experienced hands, remain useful tools in staging and restaging patients with locally advanced lung cancer.
References
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