Mediastinoscopy vs Endosonography for Mediastinal Nodal Staging of Lung Cancer A Randomized Trial

Annema JT, van Meerbeeck JP, Rintoul RC, et al. — Wed, 24 Nov 2010 00:00:00 GMT

Context

Mediastinal nodal staging is recommended for patients with resectable non–small cell lung cancer (NSCLC). Surgical staging has limitations, which results in the performance of unnecessary thoracotomies. Current guidelines acknowledge minimally invasive endosonography followed by surgical staging (if no nodal metastases are found by endosonography) as an alternative to immediate surgical staging.

Objective

To compare the 2 recommended lung cancer staging strategies.

Design, Setting, and Patients

Randomized controlled multicenter trial (Ghent, Leiden, Leuven, Papworth) conducted between February 2007 and April 2009 in 241 patients with resectable (suspected) NSCLC in whom mediastinal staging was indicated based on computed or positron emission tomography.

Intervention

Either surgical staging or endosonography (combined transesophageal and endobronchial ultrasound [EUS-FNA and EBUS-TBNA]) followed by surgical staging in case no nodal metastases were found at endosonography. Thoracotomy with lymph node dissection was performed when there was no evidence of mediastinal tumor spread.

Main Outcome Measures

The primary outcome was sensitivity for mediastinal nodal (N2/N3) metastases. The reference standard was surgical pathological staging. Secondary outcomes were rates of unnecessary thoracotomy and complications.

Results

Two hundred forty-one patients were randomized, 118 to surgical staging and 123 to endosonography, of whom 65 also underwent surgical staging. Nodal metastases were found in 41 patients (35%; 95% confidence interval [CI], 27%-44%) by surgical staging vs 56 patients (46%; 95% CI, 37%-54%) by endosonography (P = .11) and in 62 patients (50%; 95% CI, 42%-59%) by endosonography followed by surgical staging (P = .02). This corresponded to sensitivities of 79% (41/52; 95% CI, 66%-88%) vs 85% (56/66; 95% CI, 74%-92%) (P = .47) and 94% (62/66; 95% CI, 85%-98%) (P = .02). Thoracotomy was unnecessary in 21 patients (18%; 95% CI, 12%-26%) in the mediastinoscopy group vs 9 (7%; 95% CI, 4%-13%) in the endosonography group (P = .02). The complication rate was similar in both groups.

Conclusions

Among patients with (suspected) NSCLC, a staging strategy combining endosonography and surgical staging compared with surgical staging alone resulted in greater sensitivity for mediastinal nodal metastases and fewer unnecessary thoracotomies.

Trial Registration

clinicaltrials.gov Identifier: NCT00432640

Lung Transplantation

Torpy JM, Lynm C, Glass RM. — Wed, 15 Dec 2010 00:00:00 GMT

The lungs are vital organs where oxygen enters the bloodstream and carbon dioxide leaves the blood during the breathing process. If the lungs are severely diseased, the body does not receive enough oxygen to function properly. When medical treatments are not sufficient to ease the symptoms of severe lung disease, a lung transplant may be considered for some patients. Lungs for transplantation come from a brain-dead person, if that person had requested organ donation or if the family members give consent for organ donation. Because the lung tissue needed for transplantation must be suitable for a recipient (the person who will receive the lungs), tests are performed on the donor lungs before they are offered for transplantation. Donated lungs available for transplantation are scarce. The December 15, 2010, issue of JAMA contains an article about lung transplantation.

JAMA: Thoracic Surgery Topic Collection

Mediastinoscopy vs Endosonography for Mediastinal Nodal Staging of Lung Cancer A Randomized Trial

Lung Transplantation