Is there still a role for mediastinoscopy as the first mediastinal staging procedure in lung cancer?

Abstract

Lung cancer staging has evolved with the advent of endobronchial and endoscopic ultrasound (EBUS and EUS) as an alternative to mediastinoscopy and other surgical staging techniques. This has led to the debate now as to what the first-line staging investigation should be. Mr Waller makes the case that although EBUS and EUS are welcomed staging techniques, mediastinoscopy still has an important role as the first-line staging investigation in specific scenarios (when there is potentially surgically resectable mediastinal disease). Dr Skwarski argues that EBUS and EUS should be used in conjunction with CT-PET and considered as a complete alternative to mediastinoscopy. In the face of increasing evidence of the efficacy of endoluminal ultrasonic biopsy methods (endobronchial ultrasound-guided transbronchial needle aspiration [EBUS-TBNA] and endoscopic ultrasound-guided fine needle aspiration [EUS-FNA]) it would seem perverse to argue that a more invasive surgical operation such as mediastinoscopy should be preferred as a first-line investigation. However, more careful study of the indication for staging and developments in the technique of mediastinoscopy will identify specific scenarios where this may be appropriate and will challenge the idiom that EBUS-TBNA and EBUS-FNA is always first choice. © 2013 Royal College of Physicians of Edinburgh.