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Ann Thorac Surg 2004;77:1877-1878
© 2004 The Society of Thoracic Surgeons
Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai 400012, India
e-mail: cspramesh{at}vsnl.net
To the Editor:
We read with interest the article by Choi and colleagues [1] advocating routine preoperative mediastinoscopy in clinical stage I non–small-cell lung cancer (NSCLC), even in patients without enlarged mediastinal lymph nodes on computed tomography (CT). We agree with the authors that accurate staging of mediastinal lymph nodes is desirable in NSCLC. However, the recommendation that effectively all patients with operable NSCLC require a preoperative staging mediastinoscopy seems extreme. Choi and colleagues quote a 6.9% (20/291 patients) incidence of positive mediastinal nodes as enough reason to perform routine mediastinoscopy in stage I NSCLC. However, in their study, 18 of the 20 patients with disease thus detected had N2 disease with nodes smaller than 10 mm on CT scan. These patients were subsequently given neoadjuvant chemotherapy (NACT), thereby "justifying" mediastinoscopy because it changed treatment decisions. This conclusion is simplistic, because there is no consensus regarding this change of decision. There is a clear distinction in choice of treatment between minimal N2 disease, for which primary surgery is recommended, and extensive N2 disease, for which neoadjuvant chemotherapy is beneficial [2]. There is no reliable evidence that survival or locoregional control improves with NACT in this subgroup of patients with microscopic positive N2 disease, and probably an equal number of surgeons would operate on these patients per primum [2]. Hence, the conclusion that preoperative mediastinoscopy dramatically changed treatment decisions or outcome is not unchallenged.
It is interesting to note that pathologic N2 disease was missed in 25 patients on mediastinoscopy for various reasons, thereby seriously undermining the usefulness of the procedure (sensitivity, 44.4%). Although the numbers are small, it would be worthwhile to note how these 25 patients fared (overall and disease-free survival) compared with the 44 patients with pN1 disease who underwent resectional operations. We also do not understand how, after either partial response or stable disease in 14 of these 18 patients who underwent NACT, the prethoracotomy CT scans showed node-positive disease in 5 patients when the premediastinoscopy scans showed stage I (T1 N0) disease.
We agree that mediastinoscopy in experienced hands has low morbidity and negligible mortality, but that would not justify an invasive procedure in cases in which it is not indicated. A large multi-institutional randomized controlled trial did not show any advantage with mediastinoscopy in terms of "thoracotomies without cure" [3]. The recommendations were that all patients with operable NSCLC undergo a routine chest CT scan, with mediastinoscopy reserved for patients with CT-demonstrated nodes larger than 1 cm. We do not think that the findings of this study merit a revision of that recommendation.
References
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