Remediastinoscopy after neoadjuvant therapy for non-small cell lung cancer P. Van Schil a, *, J. van der Schoot a , J. Poniewierski a , M. Pauwels a,1 , L. Carp b , P. Germonpre ´ c , W. De Backer c a Department of Thoracic and Vascular Surgery, University Hospital of Antwerp, Wilrijkstraat 10, B-2650 Edegem, (Antwerp), Belgium b Department of Nuclear Medicine, University Hospital of Antwerp, Wilrijkstraat 10, B-2650 Edegem, (Antwerp), Belgium c Department of Pulmonary Diseases, University Hospital of Antwerp, Wilrijkstraat 10, B-2650 Edegem, (Antwerp), Belgium Received 29 January 2002; received in revised form 19 March 2002; accepted 20 March 2002 Abstract Despite technical difficulties due to mediastinal fibrosis, remediastinoscopy can be a valuable tool in the restaging of non-small cell lung cancer after neoadjuvant therapy. The aim of our study was to evaluate the feasibility, sensitivity and accuracy of remediastinoscopy. From November 1994 to July 2001 we performed a remediastinoscopy in 27 patients after neoadjuvant therapy. Their age ranged from 35 to 80 years (mean 61.99 /11.9). In all 27 patients it was possible to perform a remediastinoscopy without major technical difficulties and take biopsies of the lymph nodes that were initially invaded by tumour. Remediastinoscopy was positive in 11 patients (40.7%) and negative in 16 (59.3%). In the 11 patients with a positive remediastinoscopy a complete resection was not judged possible and therefore, an unnecessary thoracotomy was avoided. In four patients, remediastinoscopy turned out to be false negative. So, in our series, sensitivity was 73%, specificity 100% and accuracy 85%. The positive and negative predictive values were 100 and 75%, respectively. Previous mediastinoscopy is no contra-indication for a repeat one after neoadjuvant therapy. Although sensitivity and accuracy are lower than that of a first mediastinoscopy, remediastinoscopy is useful to select patients for surgical resection after induction therapy. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Lung cancer; Staging; Induction therapy; Remediastinoscopy; Computed tomography; Positron emission tomography 1. Introduction Restaging of non-small cell lung cancer (NSCLC) after induction chemo- or chemoradio-therapy remains a difficult issue. Even for primary staging computed tomographic (CT) scanning has only a limited accuracy [1]. Positron emission tomography (PET) is a promising new modality in lung cancer staging but its accuracy in restaging has not been determined in a prospective comparative way [2,3]. Repeat mediastinoscopy or remediastinoscopy, although technically more difficult, offers the advantage of providing histological evidence of response after induction therapy. Our initial experi- ence with remediastinoscopy for all indications was published in 1998 [4]. In this group of 15 patients there were only seven undergoing remediastinoscopy after induction therapy. As there is an ongoing discussion on the feasibility and accuracy of remediastinoscopy, we updated our experience with remediastinoscopy after neoadjuvant therapy for histologically proven NSCLC with mediastinal lymph node involvement. 2. Material and methods Recently we reviewed our experience in patients with lung cancer and a positive mediastinoscopy [5]. During a 5-year period 361 cervical mediastinoscopies were per- formed of which 81 (22.5 %) were positive. Patients who entered a neoadjuvant study had no remediastinoscopy and response was only judged on imaging techniques according to the protocol. Some patients were treated outside a clinical protocol. These were offered a repeat * Corresponding author. Tel.:  /32-3-8213330; fax:  /32-3-8251308 E-mail address: paul.van.schil@uza.be (P. Van Schil). 1 Dr. M. Pauwels who was a senior surgical resident died after a car accident in 2000. Lung Cancer 37 (2002) 281  /285 www.elsevier.com/locate/lungcan 0169-5002/02/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII:S0169-5002(02)00101-0