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Letter to the Editor
Video-mediastinoscopy is still the gold standard
A video-mediastinoscopia é ainda o gold-standard
M. Guerra
Serviço de Cirurgia Cardiotorácica, Centro Hospitalar de Vila Nova de Gaia/Espinho, EPE, Vila Nova de Gaia, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with great interest the article by Bugalho et al&#46;&#44; entitled &#8220;Endobronchial ultrasound-guided transbronchial needle aspiration for lung cancer diagnosis and staging in 179 patients&#8221;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> as well as the editorial by Herth entitled &#8220;Access to the mediastinum&#8212;The standard has changed&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In fact&#44; for patients with lung cancer&#44; despite improvements in the accuracy of imaging modalities over the last decade&#44; invasive mediastinal lymph node staging remains necessary in cases of mediastinal lymph node enlargement&#44; positron emission tomography &#40;PET&#41; positive mediastinal and&#47;or hilar lymph nodes and&#47;or a centrally located tumor&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> For a long time&#44; cervical mediastinoscopy has been considered the gold standard in mediastinal staging&#44; given the high negative predictive value &#40;NPV&#41; if well performed&#46; However&#44; during the last decade&#44; oesophageal ultrasound-guided fine needle aspiration &#40;EUS-FNA&#41; followed by endobronchial ultrasound-guided transbronchial needle aspiration &#40;EBUS-TBNA&#41; has emerged as a minimally invasive alternative&#44; reducing the need for a cervical mediastinoscopy as a first-line staging procedure&#46; Nevertheless&#44; when the result of endoscopic staging appears negative&#44; a subsequent mediastinoscopy is currently recommended to exclude mediastinal lymph node metastases in patients with clinical suspicion&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> But&#44; since the sensitivity of EBUS-FNA seems to exceed that of mediastinoscopy&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> there is a tendency to cut down on the need for surgical confirmation&#46; Accordingly&#44; in routine practice an additional mediastinoscopy is often regarded as overdone&#46; However&#44; only recently the combination of endosonography followed by mediastinoscopy was shown to be more accurate in mediastinal nodal staging than just mediastinoscopy alone&#46; In patients with non-small-cell lung cancer and an indication for mediastinal staging&#44; performing a cervical mediastinoscopy after a negative result of endosonography reduced the number of futile thoracotomies by 50&#37;&#46; Overall&#44; an average of 8&#46;8 patients had to undergo an additional mediastinoscopy to find one false-negative result of endosonography&#44; but when only patients with suspicious mediastinal lymph nodes on FDG-PET are taken into account&#44; this NNT comes down to 6&#46;1 patients&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We agree with Dr&#46; Herth&#46; The standard has changed&#46; In fact&#44; EBUS and EUS should be used in conjunction with PET and considered as an alternative to mediastinoscopy&#46; However&#44; the gold standard is still video-mediastinoscopy&#44; because in patients with a high probability of mediastinal metastases&#44; a cervical mediastinoscopy should not be omitted after a negative result of endosonography&#44; not even when the aspirate seems representative&#44; based on the presence of a sufficient number and maturation of lymphocytes&#46;</p></span>"
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Article information
ISSN: 08732159
Original language: English
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