CHEST Guidelines-Endosonographic-Staging-for-N1-Disease

Endosonographic-Staging-for-N1-Disease_chest

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In a letter to the editor concerning a study published in <em>CHEST</em> by Dooms et al., Dr. Jouke T. Annema addresses the efficacy of endosonography for mediastinal nodal staging in lung cancer patients suspected of N1 involvement from CT and PET imaging. Annema congratulates the authors but highlights a critical insight about the study’s low sensitivity of endosonography in detecting N2 disease, citing a sensitivity rate of just 38% with a negative predictive value of 81%. He notes that, especially in smaller, PET-nonavid nodes, the sensitivity was inferior compared to larger, PET-avid nodes.

The letter emphasizes the potential improvement of outcomes if patients had undergone a combined approach using endobronchial ultrasound (EBUS) followed by endoscopic ultrasound (EUS), or EUS performed with the EBUS scope (EUS-B). Annema stresses that this approach could increase detection sensitivity to approximately 70%. In the original study, 14 patients were staged as false-negative, and metastases in some cases were within reach of the EUS-B technique.

Moreover, Annema mentions that subcentimeter node sampling might be more efficiently conducted via a transesophageal (EUS-B) approach rather than a transbronchial (EBUS) approach, which was more commonly adopted due to conscious sedation challenges like coughing. He refers to previous research, such as the ASTER study and various meta-analyses, demonstrating the superior efficacy of combined EBUS+EUS staging in sensitivity compared to EBUS alone. Annema argues that EBUS, especially in patients with adenocarcinoma, should routinely be followed by EUS-B to optimize staging accuracy. Overall, Annema advocates for further investigation into this combined approach and its possible benefits alongside confirmatory procedures like mediastinoscopy.

The response from the study authors acknowledges Annema's commentary and reaffirms the potential benefit of adding EUS to EBUS in the staging of lung cancer.

Keywords

endosonography

mediastinal nodal staging

lung cancer

N1 involvement

sensitivity

endobronchial ultrasound

endoscopic ultrasound

EUS-B

transesophageal approach

adenocarcinoma