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Endosonographic Staging for N1 DiseaseEndosonographic Staging for N1 Disease FREE TO VIEW

Jouke T. Annema, MD, PhD
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From the Department of Respiratory Medicine, Academic Medical Center Amsterdam.

CORRESPONDENCE TO: Jouke T. Annema, MD, PhD, Department of Respiratory Medicine, Academic Medical Center Amsterdam, Meibergdreef 9, PO Box 22660, 1100 DD Amsterdam, The Netherlands; e-mail: j.t.annema@amc.nl


FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(3):e122. doi:10.1378/chest.14-2577
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To the Editor:

I congratulate Dooms et al1 on their important study recently published in CHEST (January 2015) that investigated the role of endosonography for mediastinal nodal staging in patients with operable and resectable lung cancer and suspicion of N1 involvement based on CT and PET imaging. To my surprise, the sensitivity of endosonography to detect N2 disease was only 38%, with a negative predictive value of 81%. First, the data show that the sensitivity of endosonography in subcentimeter fluorodeoxyglucose-PET nonavid nodes is inferior in comparison with the sensitivity of enlarged and/or fluorodeoxyglucose-PET avid nodes (94%).2 Second, of key interest are the 14 patients whose conditions were staged as false-negative. In only one of these patients, endobronchial ultrasound (EBUS) was followed by endoscopic ultrasound (EUS) or EUS performed with the EBUS scope (EUS-B). Importantly, in eight of the 14 patients, the missed metastases (located in stations 4L, 7, and 8) were located well within reach of EUS-B, and in two more patients, nodes in station 5 could have been well visualized and possibly sampled. In this scenario, as stated by the authors, a sensitivity of > 70% theoretically could have been reached.

For adequate EBUS-guided sampling of small nodes (in this study only 6.9 mm), thin and flexible 25G needles can be helpful. Furthermore, besides the actual endosonographic nodal detection, subcentimeter nodal sampling of stations 4L (paratracheal left) and 7 (subcarinal) often is far easier to perform by a transesophageal (EUS-B) approach compared with a transbronchial (EBUS) approach.3 This specifically applies to a setting using conscious sedation (94% in this study) where cough regularly compromises adequate nodal aspiration.

In the Assessment of Surgical Staging vs Endoscopic Ultrasound in Lung Cancer: a Randomized Clinical Trial (ASTER Study), the landmark trial comparing endosonography with surgical staging,4 combined EBUS + EUS staging (sensitivity of 85%) was performed instead of staging by EBUS only. In a meta-analysis, combined EBUS + EUS-B staging proved to be superior over staging by EBUS alone.5 I do not agree with the conclusion of Dooms et al1 that endosonography is an unsatisfactory test to detect mediastinal nodal metastases in cN1 lung cancer; in my opinion, EBUS alone is. My interpretation of the study findings is that in cN1 disease, especially in patients with an adenocarcinoma, EBUS should be followed routinely by EUS-B. This scenario should be investigated, as should the added value of a confirmatory mediastinoscopy in that specific setting.

References

Dooms C, Tournoy KG, Schuurbiers O, et al. Endosonography for mediastinal nodal staging of clinical N1 non-small cell lung cancer: a prospective multicenter study. Chest. 2015;147(1):209-215. [CrossRef] [PubMed]
 
Gu P, Zhao YZ, Jiang LY, Zhang W, Xin Y, Han BH. Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis. Eur J Cancer. 2009;45(8):1389-1396. [CrossRef] [PubMed]
 
Annema JT. When will we finally adopt endoscopic ultrasound? Chest. 2014;146(3):e117. [CrossRef] [PubMed]
 
Annema JT, van Meerbeeck JP, Rintoul RC, et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA. 2010;304(20):2245-2252. [CrossRef] [PubMed]
 
Zhang R, Ying K, Shi L, Zhang L, Zhou L. Combined endobronchial and endoscopic ultrasound-guided fine needle aspiration for mediastinal lymph node staging of lung cancer: a meta-analysis. Eur J Cancer. 2013;49(8):1860-1867. [CrossRef] [PubMed]
 

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References

Dooms C, Tournoy KG, Schuurbiers O, et al. Endosonography for mediastinal nodal staging of clinical N1 non-small cell lung cancer: a prospective multicenter study. Chest. 2015;147(1):209-215. [CrossRef] [PubMed]
 
Gu P, Zhao YZ, Jiang LY, Zhang W, Xin Y, Han BH. Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis. Eur J Cancer. 2009;45(8):1389-1396. [CrossRef] [PubMed]
 
Annema JT. When will we finally adopt endoscopic ultrasound? Chest. 2014;146(3):e117. [CrossRef] [PubMed]
 
Annema JT, van Meerbeeck JP, Rintoul RC, et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA. 2010;304(20):2245-2252. [CrossRef] [PubMed]
 
Zhang R, Ying K, Shi L, Zhang L, Zhou L. Combined endobronchial and endoscopic ultrasound-guided fine needle aspiration for mediastinal lymph node staging of lung cancer: a meta-analysis. Eur J Cancer. 2013;49(8):1860-1867. [CrossRef] [PubMed]
 
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