Mediastinoscopy in the era of endobronchial ultrasound: when should it be performed?

Accurate mediastinal lymph node staging is critical for patients with non-small cell lung cancer (NSCLC). Although cervical mediastinoscopy has been regarded as the method of choice for mediastinal staging in NSCLC, emergence of minimally invasive sonography, for example endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound fine needle aspiration (EUS-FNA), has led to questions about the routine use of mediastinoscopy. EBUS-TBNA has access to all the mediastinal lymph nodes accessible by mediastinoscopy but also extends to the N1 nodes. EUS-FNA enables access to paraesophageal (station 8) and pulmonary ligament (station 9) lymph nodes, which are not accessible by either mediastinoscopy or EBUS-TBNA. On the basis of current evidence, sonographic staging is the recommended choice for patients with high pretest probability of lymph node metastatic involvement; all negative results should, however, be verified by mediastinoscopy, especially in centers with low expertise. For patients with low pretest probability, mediastinoscopy may be omitted.