Letter to the editor

DOI: https://doi.org/10.4414/smw.2011.13289

Garnier von, T Geiser

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

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.


  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.