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Ann Thorac Surg 2005;80:1239-1240
© 2005 The Society of Thoracic Surgeons
Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F-24, Cleveland, OH44195
(Email: murthys1{at}ccf.org).
Accurate mediastinal lymph node staging is critical for proper management of non-small cell lung cancer, as only those patients without evidence of mediastinal (N2) involvement can be clearly shown to benefit from up-front resection. Several techniques are available for evaluating the mediastinum, each with its own inherent liabilities. It will likely take a synergistic blending of these existing techniques to arrive at the most complete assessment of the mediastinum.
To this end, the authors [1] have woven endoscopic ultrasound-guided (EUS) fine-needle aspiration (FNA) into a staging protocol for lung cancer. To understand the possible utility of EUS-FNA, the deficiencies of other standard staging tests must be understood.
The computed tomographic scan (CT scan) and the positron emission tomographic scan (PET scan) are noninvasive options that provide considerable information on the primary lesion, the mediastinum, and the metastatic survey. Although no tissue diagnosis is afforded, these scans (when fused) provide correct information concerning mediastinal involvement roughly 70% to 80% of the time. Overstaging (by virtue of the low positive predictive value) tends to be the greatest problem.
Mediastinoscopy clearly provides the most accurate information when appropriately used, but unfortunately there is a highly variable general application of the procedure. This is attributable to the difficulty of the procedure itself, as well as to the difficulty of teaching the technique to others. Mediastinoscopy fails to acquire information from the aortopulmonary window (station 5), deep in the subcarinal space (deep level 7), at the periesophageal station (level 8), and in the inferior pulmonary ligament (level 9).
Transthoracic and transbronchial FNA are currently useful in highly selected cases, although endobronchial ultrasound-guided FNA is still in its infancy.
These authors have used EUS-FNA in situations where the uncertainties or failures of other procedures can be addressed and rectified. The procedure is safe and certainly less morbid and risky than mediastinoscopy. Perhaps, most importantly, treatment decisions were altered in a surprisingly large proportion of cases when EUS-FNA was used.
The real challenge remains how to integrate this new staging tool into the existing armament. When should we use EUS-FNA? Clearly, complex algorithms will need to be generated and cost-and-benefits analyses will be required. Finally, who should perform the procedure? Is this another procedure for the gastroenterologist or another tool for the surgeon?
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