非小细胞肺癌的纵隔分期：告别纵隔镜检查

SCI

13 June 2023

Mediastinal Staging in Non–Small-Cell Lung Cancer: Saying Goodbye to Mediastinoscopy

(Journal of Clinical Oncology, IF: 50.717)

Elizabeth G. Dunne, Cameron N. Fick, and David R. Jones

CORRESPONDENCE TO: jonesd2@mskcc.org

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors’ suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

《肿瘤学大新闻》系列旨在将本期刊上发表的原始报告引入相关临床背景。在病例介绍之后，对疾病诊断和疾病管理挑战方面进行了描述，对相关文献进行了综述，并对作者提出的管理方法进行了总结。本系列的目的是帮助读者更好地了解如何将关键研究的结果，包括发表在《临床肿瘤学杂志》上的研究结果，应用于自己患者的临床实践中。

Accurate staging of the mediastinal lymph nodes in resectable non–small-cell lung cancer (NSCLC) is critically important to determine the overall stage of the tumor and guide subsequent management. The staging process typically begins with positron emission tomography (PET) or computed tomography imaging; however, imaging alone is inadequate, and tissue acquisition is required for confirmation of nodal disease. Mediastinoscopy was long considered the gold standard for staging of mediastinal lymph nodes, but, recently, endobronchial ultrasound–guided (EBUS) fine-needle aspiration (FNA) has become the standard of care. EBUS-FNA, in combination with supplementary technologies, such as intranodal forceps biopsy and esophageal ultrasonography, has a high sensitivity and specificity for the diagnosis of nodal metastases. EBUS-FNA is also capable of assessing N1 disease and obtaining adequate tissue for tumor genomic analysis to help guide treatment. In the case of negative findings on EBUS, a confirmatory video mediastinoscopy is still recommended by the European Society of Thoracic Surgeons guidelines. However, whether confirmatory mediastinoscopy is necessary is a matter of debate, and it is not commonly performed in North America. To address this question, Bousema and colleagues performed a randomized noninferiority trial to determine rates of unforeseen nodal metastases after EBUS alone versus EBUS with confirmatory mediastinoscopy in patients with resectable NSCLC. The authors concluded that EBUS alone is noninferior to EBUS with confirmatory mediastinoscopy. These findings affirm our current practice to forgo confirmatory mediastinoscopy after negative findings on EBUS.

可切除的非小细胞肺癌（NSCLC）纵隔淋巴结的准确分期对于确定肿瘤的总体分期和指导后续治疗至关重要。分期过程通常从正电子发射断层扫描（PET）或计算机断层扫描成像开始；然而，单独的影像证据是不够的，需要采集组织来确认淋巴结疾病转移状况。纵隔镜检查长期以来被认为是评估纵隔淋巴结分期的金标准，但最近，支气管内超声引导（EBUS）细针抽吸（FNA）已成为治疗的标准。EBUS-FNA结合其他辅助技术，如淋巴结内钳夹活检和食道超声检查，对淋巴结转移的诊断具有高灵敏度和特异性。EBUS-FNA还能够评估N1疾病并获得足够的组织用于肿瘤基因组分析以帮助指导治疗。在EBUS检查结果为阴性的情况下，欧洲胸科医生学会指南仍然建议进行确诊性视频纵隔镜检查。然而，是否有必要进行纵隔镜检查是一个有争议的问题，并且纵隔镜这种检查在北美并不常见。为了解决这个问题，Bousema及其同事进行了一项随机非劣效性试验，以确定可切除非小细胞肺癌患者在单独使用EBUS与使用EBUS及纵隔镜检查后未预见的淋巴结转移的发生率。作者得出的结论是，单独的EBUS并不劣于经纵隔镜检查明确淋巴结状况的的EBUS。这些发现证实了我们目前的做法是正确的，即在EBUS检查结果为阴性后放弃纵隔镜检查。

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