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Utility of Endosonographic Mediastinal Lymph Node Staging in Lung Cancer, Withdrawal of Inhaled Steroids in Chronic Obstructive Pulmonary Disease, and Use of Mepolizumab in Severe Eosinophilic Asthma.

Needle-based approaches (endobronchial ultrasound-guided transbronchial needle aspiration [EBUS-TBNA], endoscopic ultrasound needle aspiration [EUS-NA], or a combination of both techniques) are recommended by the American College of Chest Physicians as a first step for invasive mediastinal staging for non– small cell lung cancer (2). Mediastinoscopy should be considered if endosonography is negative and there remains a high clinical suspicion of nodal (N2/N3) disease. Using this approach of endosonography followed by mediastinoscopy, Annema and colleagues demonstrated more than 50% reduction in unnecessary thoracotomies (3). Prior studies have demonstrated a similar sensitivity of systematic EBUS-TBNA (e.g., sampling mediastinal lymph nodes .5 mm) and mediastinoscopy. However, the operating characteristics of combined selective staging with EBUS-TBNA and EUS-NA have not been directly compared with mediastinoscopy (4). Liberman and colleagues addressed this question by performing endosonography and mediastinoscopy in every patient (1). They enrolled 166 patients with suspected non–small cell lung cancer and no confirmed extrathoracic involvement and performed endosonography with selective (e.g., subjective selection of sites or sampling only sites abnormal on computed tomography or positron emission tomography scan) lymph node sampling followed by mediastinoscopy. A secondary outcome was the comparison of each technique with results of lymph node dissection at surgical resection. Endosonography identified 24 patients missed by mediastinoscopy, whereas 5 patients with negative endosonography had a positive mediastinoscopy, resulting in a 14% reduction in unnecessary thoracotomy. The sensitivity, negative predictive value, and accuracy of all techniques compared with mediastinoscopy were not significantly different based on the confidence intervals. One hundred fourteen patients underwent surgery. In this group of patients there was no difference in the sensitivity, negative predictive value, or accuracy of EBUS-TBNA, EUS-NA, or combined endosonography and mediastinoscopy compared with lymph node dissection. Liberman and colleagues conclude that endosonography may replace mediastinoscopy in surgically resectable patients. The trial is limited by the use of a selective, subjective approach to decidingwhich lymph node stations to biopsy. The trial was not powered to directly compare any endosonographic technique or mediastinoscopy to surgical lymph node dissection (secondary endpoint), so no conclusion can be drawn from the finding of no difference in any of the techniques versus lymph node dissection. However, this study clearly adds to the literature demonstrating a reduction in unnecessary thoracotomies with the use of endosonographic techniques and, in this case, with selective combined staging. n