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Routine Mediastinoscopy and Esophageal Ultrasound Fine Needle Aspiration in Patients with Non-Small Cell Lung Cancer who are Clinically N2 Negative: A Prospective Study
R. J. Cerfolio, A. S. Bryant. University of Alabama at Birmingham, Birmingham, AL,
BACKGROUND:Despite normal mediastinal (N2) nodes on positron emission tomography (PET) and computed tomography (CT), some routinely perform mediastinoscopy and/or endoscopic-ultrasound (EUS-FNA) in patients with non-small cell lung cancer (NSCLC).
METHODS: A prospective trial on patients with NSCLC clinically staged N2 negative by both integrated PET/CT and CT scans. All underwent mediastinoscopy and EUS-FNA. If N2 negative underwent thoracotomy with thoracic lymphadenectomy.
RESULTS: There were 153 patients (107 men) and 136 were clinically staged N0. Five (3.7%) had a positive EUS-FNA (three in the subcarinal node), four (2.9%) had a positive mediastinoscopy (all in the #4R node, one was N3). Six of the remaining 127 (4.7%) had N2 disease after resection. Seventeen patients were clinically staged as N1 by integrated PET/CT. Four patients (23.5%) had a positive EUS-FNA (2 in the subcarinal node), three (17.6%) had a positive mediastinoscopy (#4R node, two were N2 one was N3), and none of the remaining 10 patients had N2 disease after resection. Patients with unsuspected N2 disease were twice as likely (RR=2.1, p< 0.05) to have a maxSUV >10 and poorly differentiated cancer. There was no statistically significant difference in the incidence of adenocarcinoma or lobar location of tumor.
CONCLUSIONS: We do not recommend routine mediastinoscopy or EUS-FNA in patients who are clinically staged as N0 after both integrated PET/CT and CT. However, these procedures should both be considered in patients clinically staged as N1 after PET/CT, and/or in those with adenocarcinoma, upper lobe tumors or tumors with a maxSUV of 10 or greater.
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