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Journal of Clinical Oncology, Vol 24, No 33 (November 20), 2006: pp. 5338 © 2006 American Society of Clinical Oncology. DOI: 10.1200/JCO.2006.08.7577
Sensitivity of Remediastinoscopy: Influence of Adhesions, Multilevel N2 Involvement, or Surgical Technique?Department of Thoracic and Vascular Surgery, University of Antwerp, Edegem, Belgium
Department of Thoracic Surgery, Ruhrlandklinik, Essen, Germany To the Editor: We read with great interest the article by De Leyn and colleagues1 that compared positron emission tomography–computed tomography with remediastinoscopy (reMS) in the restaging of patients with proven stage IIIA-N2 non–small-cell lung cancer, and also the valuable comments on staging and restaging in the accompanying editorial by Goldstraw.2 As clearly stated, precise restaging of N2 or N3 disease after induction therapy is of utmost importance as patients with persisting mediastinal involvement will not benefit from a subsequent thoracotomy. In this respect, reMS, though technically more difficult and less accurate than the initial procedure, provides valuable pathologic information on the status of the mediastinal lymph nodes after induction therapy. In the De Leyn et al prospective series, the sensitivity of reMS was only 29%, the lowest figure reported in literature until now.1 In all other published series including ours, sensitivity of reMS was at least 70%.3,4 As possible explanations De Leyn et al mention the initial thorough exploration they performed resulting in dense adhesions, and the fact that one third of their patients had multilevel N2 disease.1 The authors also state that multilevel N2 disease "was not reported in the series of Van Schil et al."3 However, taking a closer look at Table 1 of our article, 10 of 11 patients with a positive reMS had multilevel N2 disease proven by reMS.3 This represents 37% of the patient population, a slightly higher figure than in the series of De Leyn et al.1 In a subsequent survival analysis, we were also able to show that prognosis depends on the status of the mediastinal lymph nodes at reMS, patients with proven mediastinal involvement having a grim prognosis.5 The low sensitivity in the series of De Leyn et al is largely explained by the fact that the subcarinal nodes (level 7) were not adequately biopsied in 20 patients (67%).1 In our series, nine of 11 patients with positive reMS had pathologic proof of subcarinal involvement, demonstrating that this level can be reached at reMS after induction therapy and a thorough initial mediastinoscopy. So, could surgical technique and equipment possibly matter? A probable explanation for the low sensitivity reported by De Leyn et al is the use of a videomediastinoscope for the initial and redo procedure. The videomediastinoscope is larger than the classical mediastinoscope, and the latter is more easily introduced into a space as narrow as the subcarinal region. As the surgeon is looking straight through the mediastinoscope, a three-dimensional view is still available, which is lost when looking at the monitor screen during videomediastinoscopy. The world's largest experience in reMS was recently reported by Stamatis et al,4 who are also in favor of using a classical mediastinoscope, especially for redo procedures. In this series, 165 of 279 reMS were performed after induction chemoradiotherapy, and a sensitivity of 74% and an accuracy of 93% were obtained.4 The 5-year survival rate was only 5% for patients with persisting N2 disease. In this very large series of reMS, excellent results were obtained using the smaller, less sophisticated, regular mediastinoscope, which is more practical for redo procedures. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest. REFERENCES
1. De Leyn P, Stroobants S, De Wever W, et al: Prospective comparative study of integrated positron emission tomography–computed tomography scan compared with remediastinoscopy in the assessment of residual mediastinal lymph node disease after induction chemotherapy for mediastinoscopy-proven stage IIIA-N2 non–small-cell lung cancer: A Leuven Lung Cancer Group study. J Clin Oncol 24
: 3333
-3339, 2006 2. Goldstraw P: Selection of patients for surgery after induction chemotherapy for N2 non–small-cell lung cancer. J Clin Oncol 24
: 3317
-3318, 2006 3. Van Schil P, van der Schoot J, Poniewierski J, et al: Remediastinoscopy after neoadjuvant therapy for non-small cell lung cancer. Lung Cancer 37 : 281 -285, 2002[CrossRef][Medline] 4. Stamatis G, Fechner S, Hillejan L, et al: Repeat mediastinoscopy as a restaging procedure. Pneumologie 59 : 862 -866, 2005[CrossRef][Medline] 5. De Waele M, Hendriks J, Lauwers P, et al: Nodal status at repeat mediastinoscopy determines survival in non-small cell lung cancer with mediastinal nodal involvement, treated by induction therapy. Eur J Cardiothorac Surg 29
: 240
-243, 2006
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Copyright © 2006 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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