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Endosonographic staging strategy may not improve NSCLC survival
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Although an endosonographic strategy appeared more sensitive and less invasive for mediastinal nodal staging of non–small cell lung cancer than a surgical strategy, the two staging strategies conferred comparable survival outcomes, according to a post-hoc analysis of the Assessment of Surgical Staging vs. Endosonographic Ultrasound in Lung Cancer trial.
“Accurate mediastinal nodal staging is crucial in the management of NSCLC because it directs therapy and has prognostic value,” Jolanda C. Kuijvenhoven, MD, from the department of respiratory medicine at the Academic Medical Center in Amsterdam, and colleagues wrote.
“If mediastinal staging is improved, more patients should receive optimal treatment and might survive longer.”
The Assessment of Surgical Staging vs. Endosonographic Ultrasound in Lung Cancer trial included patients with potentially resectable NSCLC who were randomly assigned to undergo endosonographic staging (n = 123) — which combined the use of endobronchial and transesophageal ultrasound followed by mediastinoscopy, if negative — or mediastinoscopy surgical staging (n = 118).
Previously published results from the trial showed the endosonographic strategy was more sensitive in diagnosing mediastinal nodal metastases than the surgical strategy (94% vs. 79%).
Kuijvenhoven and colleagues conducted a post-hoc analysis of this trial to determine if improved mediastinal staging with the endosonographic strategy led to longer survival.
Researchers obtained 5-year survival data for 237 patients (77% men; mean age at randomization, 65 years) from the trial.
In total, 35% of patients in both the endosonographic and surgical strategy groups survived 5 years (OR = 0.97; 95% CI, 0.57-1.66).
The surgical strategy was associated with an estimated median survival of 33 months compared with 31 months with the endosonographic strategy (HR = 0.98; 95% CI, 0.73-1.32).
A subgroup analysis showed that among patients with N2/N3 metastases, the 5-year survival rate was 17% with the endosonographic strategy compared with 19% with the surgical strategy (OR = 0.87; 95% CI, 0.34-2.25). Among patients with N0/N1 metastases, rates of 5-year survival were 54% with the endosonographic strategy compared with 48% with the surgical strategy (OR = 1.27; 95% CI, 0.62-2.6).
Since the original publication of data from this study, clinical guidelines on lung cancer management recommended endosonography over mediastinoscopy as the initial step for mediastinal nodal metastases, as this strategy is “more accurate, less invasive and reduces unnecessary thoracotomies,” the researchers wrote.
There are several reasons why there was no survival difference between the two strategies.
“[This trial] was powered to detect a difference in diagnostic sensitivity, not survival, as reflected by the wide confidence intervals,” Kuijvenhoven and colleagues added. “If a survival difference between the strategies exists, it is likely to be small and a larger sample size may be needed to detect it. However, randomized trials to detect a survival difference based on staging strategy are not likely to be conducted as the endosonographic strategy is now advised in clinical guidelines.” – by Kristie L. Kahl
Disclosure: Kuijvenhoven reported no relevant financial disclosures. Please see study for a full list of all researchers’ financial disclosures.
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