Systematic Vs Hit-And-Run Endosonographic Staging Of Lung Cancer

Introduction: Guidelines recommend endosonography for mediastinal nodal staging. The value of a systematic nodal evaluation vs targeted sampling of the suspected nodes based on CT-PET findings is unknown. Aim: To investigate whether systematic endosonographic staging (assessment of all nodal regions) results in improved loco-regional nodal staging compared to PET-CT directed assessment (ie targeted approach). Methods: A prospective, international multicenter study in patients with (suspected) Non-Small Cell Lung Cancer (NSCLC) and an indication for mediastinal nodal staging. Prior to endoscopy, nodal target(s) were defined based on CT-PET reports. Intervention: A systematic EBUS evaluation followed by systematic EUS-B (EBUS scope in esophagus). Both target nodes as well as sonographically suspected and/or nodes with a short axis greater than 8 mm were sampled. Surgery with nodal dissection was the reference standard. Results: 80 patients with (suspected) NSCLC (mean age 65 years, 50 male) were investigated according to protocol. Final diagnosis was NSCLC, SCLC, benign and other in 68, 6, 4 and 2 patients, respectively. The prevalence of mediastinal nodal metastases was 33/80 (41%). In 7 patients (9%) systematic nodal staging resulted in an added value in comparison to the targeted approach (1 N1, 5 N2, 1 N3 disease). False negative findings were present in 6 patients. Conclusion and implications: Systematic endosonographic staging (assessment of all nodal regions) results in improved loco-regional staging compared to PET-CT directed hit-and-run approach and should be the preferred endoscopic staging strategy of NSCLC.