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 twothirds 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.