Combined endoscopy, surgical staging had best sensitivity for operable NSCLC

Annema JT. JAMA. 2010:304:2245-2252.

The use of a staging approach that combined endosonography and surgical staging for patients with suspected non-small cell lung cancer has the best sensitivity for mediastinal nodal metastases and resulted in fewer patients undergoing unnecessary thoracotomies, according to the results of a randomized multicenter trial.

Currently, endosonography is recommended as a minimally invasive alternative to surgical staging, or mediastinoscopy, in patients with suspected NSCLC. Surgical staging of these patients may result in significantly impaired health following the surgery and a higher risk from death, according to the researchers.

To further compare endosonography with mediastinoscopy, the researchers randomly assigned 241 patients to undergo either mediastinoscopy, or endosonography followed by mediastinoscopy in the cases where no nodal metastases were found using the noninvasive method.

The researchers sought to determine the sensitivity for mediastinal nodal metastases for both procedures.

One-hundred eighteen patients underwent surgical staging and 123 underwent endosonography. Of the patients who underwent endosonography, 65 also underwent surgical staging.

Thirty-five percent of patients who underwent surgical staging were found to have nodal metastases compared with 46% of patients who underwent endosonography and 50% of patients who underwent both procedures.

This resulted in a sensitivity of 79% for surgical staging, 85% for endosonography and 94% for both procedures combined.

Eighteen percent of patients who underwent surgical staging alone had unnecessary thoracotomy compared with 9% in the endosonography group (P=.02).

In an accompanying editorial, Mark D. Iannettoni, MD, of the University of Iowa Hospitals and Clinics, Iowa City, wrote that the level of expertise of the operator during endoscopic procedures is still of critical importance.

“Even though this emerging technology of endoscopic study can result in excellent results for predicting both positive and now improved negative results, highly skilled interventionalists are required to provide these exceptional outcomes,” he wrote. “Until this modality can be reproduced at all centers where thoracic surgery is commonly performed, or until all of these patients are cared for at specialized centers, surgical staging must remain the gold standard for adequate preoperative evaluation.”

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