Using sound not surgery to assess spread of lung cancer

Credit: Robina Weermeijer/Unsplash

Lung cancer, the most common cause of cancer death worldwide, kills >35,000 people in the UK each year. Optimal treatment requires determination of whether cancer has spread to lymph nodes in the chest. Historically, this has been assessed using a surgical approach termed mediastinoscopy. Mediastinoscopy is invasive, requiring general anaesthesia, an incision in the neck and surgical sampling of multiple lymph nodes.

Robert Rintoul led research that demonstrated endosonography-based techniques are less invasive, just as accurate, better tolerated and more cost-effective than mediastinoscopy.

Previously Rintoul was among the first investigators to develop an endosonography technique called linear Endobronchial Ultrasound (EBUS) as a method to stage lung cancer (the process of determining how much cancer is within the body and if it has spread). During EBUS, lymph nodes are visualised by ultrasound through the wall of the airway and biopsied using a small needle passed down the windpipe. A similar endosonography approach, Endoscopic Ultrasound (EUS), can be used to visualise and biopsy additional lymph nodes via the oesophagus.

On moving to the University of Cambridge in 2006, Rintoul pioneered EBUS to assess disease relapse in patients previously treated for lung cancer. Importantly, these initial clinical studies showed that combined EBUS/EUS was well tolerated, could be performed as a day-case under sedation rather than general anaesthetic, and patients were discharged within four hours with complete recovery in 24 hours.

Between 2007 and 2009, Rintoul led an international randomised clinical trial (ASTER), funded by the National Institute for Health Research, to determine the safety, efficacy and cost effectiveness of combined endosonography techniques EBUS and EUS to stage lung cancer relative to standard surgical mediastinoscopy. The ASTER trial demonstrated that combined EBUS/EUS is better tolerated, less likely to result in inappropriate surgical treatment and less expensive than mediastinoscopy.

As a direct consequence, day-case endosonography has replaced mediastinoscopy as the first-line test to stage lung cancer in the National Health Service (NHS) and other global healthcare systems including those in the USA, Europe, Ireland and New Zealand.

In the NHS, this has resulted in 58-80% fewer mediastinoscopy operations and savings of approximately £1.9 million per year.

The widespread use of endosonography techniques has also led to significant improvements in patient quality-of-life during lung cancer staging. Patients now experience staging under sedation as a day case, rather than under general anaesthetics as inpatients for one to two days.