The usefulness of confirmatory mediastinoscopy following tumor-negative results on endoscopic ultrasound still remains debatable among researchers. This procedure is often employed for mediastinal staging in patients with resectable non-small cell lung cancer (NSCLC) who have a high likelihood of mediastinal nodal involvement. Critics argue that mediastinoscopy offers limited nodal metastasis detection, poses potential health risks, and may cause delays in initiating lung cancer treatment. Now, new research has confirmed that endoscopic ultrasound can eliminate the need for confirmatory mediastinoscopy following negative systematic findings in patients with resectable NSCLC.

Researchers led by Máxima Medical Center (Eindhoven, The Netherlands) found that bypassing confirmatory mediastinoscopy and moving directly to lung tumor resection resulted in a minor unforeseen N2 rate - cancer present in the lymph nodes - post-definitive surgical lung tumor resection. It's important to note that the effect of excluding mediastinoscopy from the procedure has not been examined in a randomized setting. Earlier studies also indicate that endoscopic ultrasound exhibits high sensitivity in this context.

The researchers aimed to determine if endosonography alone could suffice for effective mediastinal staging in patients with resectable NSCLC. They analyzed data from 360 patients with presumed resectable NSCLC and an indication for mediastinal staging following negative systematic endosonography. These patients were randomly divided into two groups: immediate lung tumor resection (n = 178) or confirmatory mediastinoscopy followed by tumor resection (n = 182). They utilized a non-inferiority margin of 8%, which previously demonstrated no adverse effect on survival. Unforeseen N2 disease following tumor resection with lymph node dissection served as the primary outcome.

The research team found that mediastinoscopy identified metastases in 8% of patients. Furthermore, they observed a non-inferior unforeseen N2 rate of 8.8% following immediate resection, compared to 7.7% with mediastinoscopy first, in both intention-to-treat (pnon-inferior = 0.0144) and per-protocol analyses (pnon-inferior = 0.0157). The slight reduction in unforeseen N2 rate by 1.03% due to confirmatory mediastinoscopy was offset by a 10-day delay for lung tumor resection, morbidity in 6.3% of cases, mortality in 0.6% of cases, and the requirement of repeat general anesthesia for all patients. In addition, major morbidity and 30-day mortality rates were 12.9% following immediate resection versus 15.4% after initial mediastinoscopy (p = 0.4940). Based on these results, the researchers propose that confirmatory mediastinoscopy following negative systematic endoscopic ultrasound may be unnecessary for these patients.

"Implementation of the current findings prevents patients from morbidity of confirmatory mediastinoscopy, it reduces the lung cancer staging period, and it probably saves health care costs," stated Dr. Jelle Bousema from Máxima Medical Center. 

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