Chest
Volume 147, Issue 1, January 2015, Pages 209-215
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Original Research: Lung Cancer
Endosonography for Mediastinal Nodal Staging of Clinical N1 Non-small Cell Lung Cancer

https://doi.org/10.1378/chest.14-0534Get rights and content

BACKGROUND

Patients with clinical N1 (cN1) lung cancer based on imaging are at risk for malignant mediastinal nodal involvement (N2 disease). Endosonography with a needle technique is suggested over surgical staging as a best first test for preoperative invasive mediastinal staging. The addition of a confirmatory mediastinoscopy seems questionable in patients with a normal mediastinum on imaging. This prospective multicenter trial investigated the sensitivity of preoperative linear endosonography and mediastinoscopy for mediastinal nodal staging of cN1 lung cancer.

METHODS

Consecutive patients with operable and resectable cN1 non-small cell lung cancer underwent a lobe-specific mediastinal nodal staging by endosonography. The primary study outcome was sensitivity to detect N2 disease. The secondary end points were the prevalence of N2 disease, the negative predictive value (NPV) of both endosonography and endosonography with confirmatory mediastinoscopy, and the number of patients needed to detect one additional N2 disease with mediastinoscopy.

RESULTS

Of the 100 patients with cN1 on imaging, 24 patients were diagnosed with N2 disease. Invasive mediastinal nodal staging with endosonography alone has a sensitivity of 38%, which can be increased to 73% by adding a mediastinoscopy. NPV was 81% and 91%, respectively. Ten mediastinoscopies are needed to detect one additional N2 disease missed by endosonography.

CONCLUSIONS

Endosonography alone has an unsatisfactory sensitivity to detect mediastinal nodal metastasis in cN1 lung cancer, and the addition of a confirmatory mediastinoscopy is of added value.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT01456429; URL: www.clinicaltrials.gov

Section snippets

Materials and Methods

Patients with operable and resectable (suspected) NSCLC were eligible for the study if they had cN1 disease after an integrated whole-body PET/CT scan. The cN1 was based on either an enlarged hilar N1 lymph node on CT scan or visual FDG uptake on PET scan in a hilar N1 lymph node. The FDG uptake within the lymph node was compared with the background FDG accumulation in the mediastinal vessel pool and reported positive whenever an FDG uptake higher than the background uptake in the mediastinal

Results

Between December 2009 and September 2013, 100 consecutive patients with operable and resectable (suspected) cN1 NSCLC were included (Fig 1). The clinical patient characteristics are shown in Table 1.

Discussion

The most important findings of this study are that one in four patients with cN1 lung cancer on imaging ends up with N2 disease and that invasive staging with endosonography alone has a sensitivity of 38% to detect N2 disease, which can be increased to 73% by adding a mediastinoscopy. The recommendation to use endosonography as the preoperative mediastinal staging tool of choice for all patients with lung cancer with a suspicion for mediastinal nodal involvement is based on data from several

Acknowledgments

Author contributions: C. D. is responsible for the overall content. C. D., K. G. T., and P. D. L. contributed to planning of the work and C. D., K. G. T., O. S., H. D., F. D. R., A. V., R. B., E. v. d. H., and P. D. L. contributed to the study and the drafting, review, and approval of the manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr van der Heijden has received a research grant from Pentax Medical and travel

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Drs Dooms and Tournoy contributed equally to this manuscript.

FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

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

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