Mediastinal staging with video-assisted mediastinoscopic lymphadenectomy after endobronchial ultrasound-guided transbronchial needle aspiration: real-world evidence in 228 patients.

[BACKGROUND] Accurate staging of mediastinal lymph nodes in patients with non-small-cell lung cancer (NSCLC) is essential to determine further management. Current guidelines recommend confirmatory mediastinoscopy for patients with suspicious mediastinal lymph node metastases in image-based staging but negative findings on endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). In clinical practice, adherence to these recommendations is low and many physicians omit invasive surgical staging. This study aimed to assess the results of subsequent video-assisted mediastinoscopic lymphadenectomy (VAMLA).

[METHODS] Retrospective single-center cohort analysis of patients who underwent surgery between 2015 and 2019. All patients were diagnosed with potentially resectable lung cancer or FDG-avid pulmonary nodule suspicious for NSCLC and underwent VAMLA following N0-N2 EBUS-TBNA for mediastinal staging.

[RESULTS] VAMLA was performed in 228 patients. Nodal upstaging after EBUS-TBNA occurred in 17.5 % of the cases (n = 40). During EBUS-TBNA, 1.72 (±1.06) lymph node stations were sampled, compared to 5.59 (±1.1) resected stations in VAMLA (p < 0.001). Clinical nodal status staged by PET/CT was significantly correlated with the occurrence of nodal upstaging by VAMLA, with an odds ratio of 7.69 in cN2 and 5.88 in patients with cN3, compared to cN0. Complications occurred in 8 patients (3.59 %). VAMLA was false negative in 1 patient (0.4 %).

[CONCLUSION] Subsequent VAMLA enables the accurate staging of patients after negative EBUS-TBNA. Overall, 17.5 % of cases had nodal upstaging and would otherwise not have received guideline-compliant treatment for NSCLC. These results underline the role of surgical mediastinal staging after negative EBUS-TBNA in patients with suspicious radiologic findings.