The following is a summary of “Mediastinal Staging in Non–Small-Cell Lung Cancer: Saying Goodbye to Mediastinoscopy,” published in the August 2023 issue of Oncology by Dunne, et al.

Accurately staging mediastinal lymph nodes in resectable non-small-cell lung cancer (NSCLC) is crucial for determining the overall stage of the tumor and guiding subsequent treatment decisions. While positron emission tomography (PET) or computed tomography imaging is commonly used for initial staging, tissue acquisition is necessary to confirm nodal disease. Mediastinoscopy was once considered the gold standard for nodal staging, but endobronchial ultrasound-guided (EBUS) fine-needle aspiration (FNA) has become the standard of care. EBUS-FNA and additional technologies like intranodal forceps biopsy and esophageal ultrasonography have shown high sensitivity and specificity for diagnosing nodal metastases. It can also assess N1 disease and provide adequate tissue for tumor genomic analysis, aiding in treatment planning.

The European Society of Thoracic Surgeons guidelines recommended confirmatory video mediastinoscopy in cases of negative EBUS findings. However, the necessity of confirmatory mediastinoscopy was a subject of debate, and it was not commonly performed in North America. To address the question, Bousema and colleagues conducted a randomized noninferiority trial to compare the rates of unforeseen nodal metastases between EBUS alone and EBUS with confirmatory mediastinoscopy in patients with resectable NSCLC. 

The study found that EBUS alone is non-inferior to EBUS with confirmatory mediastinoscopy detecting nodal metastases. As a result, the current practice of forgoing confirmatory mediastinoscopy after the findings have validated negative EBUS findings.

Source: ascopubs.org/doi/full/10.1200/JCO.23.00867