American College of Chest Physicians. Invasive Mediastinal Staging of Lung Cancer. ACCP Evidence-Based Clinical Practice Guidelines

Division of Thoracic Surgery, Department of Surgery, Yale University, 330 Cedar St, FMB 128, New Haven, CT 06520-8062, USA.
Chest (Impact Factor: 7.48). 10/2007; 132(3 Suppl):202S-220S. DOI: 10.1378/chest.07-1362
Source: PubMed


The treatment of non-small cell lung cancer (NSCLC) is determined by accurate definition of the stage. If there are no distant metastases, the status of the mediastinal lymph nodes is critical. Although imaging studies can provide some guidance, in many situations invasive staging is necessary. Many different complementary techniques are available.
The current guidelines and medical literature that are applicable to this issue were identified by computerized search and were evaluated using standardized methods. Recommendations were framed using the approach described by the Health and Science Policy Committee of the American College of Chest Physicians.
Performance characteristics of invasive staging interventions are defined. However, a direct comparison of these results is not warranted because the patients selected for these procedures have been different. It is crucial to define patient groups, and to define the need for an invasive test and selection of the best test based on this.
In patients with extensive mediastinal infiltration, invasive staging is not needed. In patients with discrete node enlargement, staging by CT or positron emission tomography (PET) scanning is not sufficiently accurate. The sensitivity of various techniques is similar in this setting, although the false-negative (FN) rate of needle techniques is higher than that for mediastinoscopy. In patients with a stage II or a central tumor, invasive staging of the mediastinal nodes is necessary. Mediastinoscopy is generally preferable because of the higher FN rates of needle techniques in the setting of normal-sized lymph nodes. Patients with a peripheral clinical stage I NSCLC do not usually need invasive confirmation of mediastinal nodes unless a PET scan finding is positive in the nodes. The staging of patients with left upper lobe tumors should include an assessment of the aortopulmonary window lymph nodes.

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    • "Mediastinal staging is a key tool in the management of nonsmall-cell lung cancer (NSCLC) patients and changes the type of treatment completely. Invasive mediastinal staging is proved to be superior to non-invasive methods (computed tomography— CT and positron emission tomography—PET) in selecting possible surgical candidates and should always be performed in suspect cases [1]. Mediastinoscopy has always been the 'gold standard' and paramount in the mediastinal staging of lung cancer patients. "
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    ABSTRACT: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has changed the way mediastinal staging is performed in lung cancer patients. EBUS-TBNA is probably the most important non-invasive procedure for mediastinal staging and the currently preferred approach in many reference cancer centres worldwide. EBUS-TBNA is a less invasive technique than mediastinoscopy with low morbidity and no mortality and can be performed in an outpatient setting with excellent results. This study describes the technical aspects of EBUS-TBNA and our personal experience with the procedure.
    Multimedia Manual of Cardiothoracic Surgery 09/2014; 2014. DOI:10.1093/mmcts/mmu021
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    • "In more recent studies, this difference seems to narrow down, but still a staging strategy including PET/CT appears more sensitive with regard to mediastinal disease (de Wever et al., 2007; Fischer et al., 2011). It has been suggested that mediastinoscopy or other invasive staging can be omitted in cases where mediastinum is PET negative (Detterbeck et al., 2007; de Leyn et al., 2007). But by doing this, 16% of the patients have occult N2 disease (Al-Sarraf et al., 2008). "
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    ABSTRACT: Lung cancer represents an increasingly frequent cancer diagnosis worldwide. An increasing awareness on smoking cessation as an important mean to reduce lung cancer incidence and mortality, an increasing number of therapy options and a steady focus on early diagnosis and adequate staging have resulted in a modestly improved survival. For early diagnosis and precise staging, imaging, especially positron emission tomography combined with CT (PET/CT), plays an important role. Other functional imaging modalities such as dynamic contrast-enhanced CT (DCE-CT) and diffusion-weighted MR imaging (DW-MRI) have demonstrated promising results within this field. The purpose of this review is to provide the reader with a brief and balanced introduction to these three functional imaging modalities and their current or potential application in the care of patients with lung cancer.
    Clinical Physiology and Functional Imaging 12/2013; 34(5). DOI:10.1111/cpf.12104 · 1.44 Impact Factor
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    • "Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an established modality used for preoperative lymph node staging of lung cancer [5]. It is a safe, minimally invasive, and validated procedure [6, 7]. "
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    ABSTRACT: Objective Nodal staging of lung cancer is important for selecting surgical candidates. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was evaluated as a modality for nodal staging of patients with potentially node-positive non-small cell lung cancer (NSCLC). Methods Endobronchial ultrasound-guided transbronchial needle aspiration was used for nodal staging of NSCLC patients with radiological N2/3 disease (short axis >10 mm on computed tomography and/or standardized positron emission uptake value >2.5 on 2-deoxy-2[F-18] fluoro-d-glucose positron emission tomography), T-stage ≥ T2, or positive serum carcinoembryonic antigen. Data on eligible patients were extracted from the database of our institution and analyzed for differences in nodal stages between radiological staging (RS) and EBUS-TBNA-integrated staging (ES), with validation by pathological staging of patients who had undergone surgery. Results Of 480 eligible patients, there were 135 N0/1 and 345 N2/3 patients according to RS. Out of the 345 patients staged as N2/3 by RS, 113 (33 %) were downgraded to N0/1 by ES. Out of the 135 patients staged as N0/1 by RS, 12 (9 %) were upgraded to N2/3 by ES. Patients were restaged as N0/1 in 236 cases and N2/3 in 244 cases by ES, and the distributions of nodal stage between RS and ES were significantly different (p < 0.001). Finally, 215 out of the 236 ES-N0/1 patients underwent lung resection, and 195 (90.7 %) and 20 patients were staged by pathology as N0/1 and N2, respectively. Conclusions Endobronchial ultrasound-guided transbronchial needle aspiration is more accurate for lymph node staging compared to radiological staging. EBUS-TBNA can identify patients who are true candidates for surgery.
    General Thoracic and Cardiovascular Surgery 06/2013; 61(9). DOI:10.1007/s11748-013-0263-z
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