Letter to the Editor

Comment on “Pre- and intra-operative mediastinal staging in non-small-cell lung cancer”

Letter to the editor

DOI: https://doi.org/10.4414/smw.2011.13289
Publication Date: 21.11.2011
Swiss Med Wkly. 2011;141:w13289

Christophe von Garnier, Thomas Geiser

Respiratory Medicine, Bern University Hospital, Bern, Switzerland


In response to the review published by Lardinois in the Journal [1], we would like to attract both the author’s and readers’ attention to a recent well-conducted European randomised controlled multicentre trial for staging in patients with suspected non-small cell lung cancer (NSCLC) [2]. In this trial, Annema et al. randomised patients with resectable NSCLC and indication for mediastinal staging based on PET-CT to either direct surgical staging, or endosonography (combined endobronchial and oesophageal ultrasound-guided needle aspiration (EBUS-TBNA and EUS-FNA)) followed by surgical staging, when no lymph node metastases were detected. This trial convincingly demonstrated that an approach combining sequential endosonographic and surgical staging significantly improved sensitivity (surgical 79% versus endosonographic 85% versus endosonographic plus surgical 94%) and reduced unnecessary thoracotomies, without causing additional complications. Importantly, endosonographic staging was associated with a six-fold lower complication rate (1% versus 6% for mediastinoscopy). Moreover, an increasing body of literature showed that for experienced operators EBUS and EUS reaches almost all mediastinal lymph node stations with a reported overall sensitivity of 93% [3]. Endosonographic staging is performed as an outpatient procedure with sedation (obviating the need for general anaesthesia), reduces the need for surgical staging in up to two-thirds of patients, and is cost-effective [4–7]. Fine needle aspiration tissue samples obtained under endosonography can be prepared as cell blocks that are suitable for molecular analysis [8].

Based on accumulating evidence, we suggest that it is judicious in experienced centres to adopt a staging strategy for NSCLC with sequential endosonography and complementary surgical staging as required, in order to enhance sensitivity for the detection of lymph node metastasis and avoid unnecessary surgical procedures.


Correspondence: Christophe von Garnier, MD, Respiratory Medicine, Bern University Hospital, CH-3010 Bern. christophe.vongarnier@insel.ch

Reply to this Letter to the Editor: http://www.smw.ch/content/smw-2011-13288/


  1 Lardinois D. Pre- and intra-operative mediastinal staging in non-small-cell lung cancer. Swiss Med Wkly. 2011;141:w13168 http://www.smw.ch/content/smw-2011-13168/ .

  2 Annema JT, van Meerbeeck JP, Rintoul RC, Dooms C, Deschepper E, Dekkers OM, et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA. 2010;304(20):2245–52.

  3 Wallace MB, Pascual JM, Raimondo M, et al. Minimally Minimally invasive endoscopic staging of suspected lung cancer. JAMA. 2008;299(5):540–6.

  4 Annema JT, Versteegh MI, Veseliç M, Voigt P, Rabe KF. Endoscopic ultrasound-guided fine-needle aspiration in the diagnosis and staging of lung cancer and its impact on surgical staging. J Clin Oncol. 2005;23(33):8357–61.

  5 Annema JT, Versteegh MI, Veseliç M, et al. Endoscopic ultrasound added to mediastinoscopy for preoperative staging of patients with lung cancer. JAMA. 2005;294(8):931–6.

  6 Tournoy KG, De Ryck F, Vanwalleghem LR, et al. Endoscopic ultrasound reduces surgical mediastinal staging in lung cancer: a randomized trial. Am J Respir Crit Care Med. 2008;177(5):531–5.

  7 Steinfort DP, Liew D, Conron M, Hutchinson AF, Irving LB. Cost-benefit of minimally invasive staging of non-small cell lung cancer: a decision tree sensitivity analysis. J Thorac Oncol. 2010;5(10):1564–70.

  8 Nakajima T, Yasufuku K. How I do it – optimal methodology for multidirectional analysis of endobronchial ultrasound-guided transbronchial needle aspiration samples. J Thorac Oncol. 2011;6(1):203–6.

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