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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    • "halen hiçbir invaziv veya noninvaziv teknik mediastinoskopinin etkinlik değerlerine ulaşamamıştır. Mediastinoskopi akciğer kanserinin mediastinal evrelemesinde birçok non-invaziv yönteme göre en yüksek hassasiyet ve negatif öngörü değerine (NÖD) sahip altın standart yöntem olarak kabul edilmektedir.456Mediastinal evrelemeye yardımcı toraks bilgisayarlı tomografisi (BT) ve entegre pozitron emisyon tomografi/bilgisayarlı tomografinin (PET/BT) biyopsi açısından hedef belirtme ve de yol gösterici olabilmesi nedeni ile mediastinoskopinin etkinlik değerlerinde artma olacağı beklenmektedir.[4,7]Düzenli "
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    ABSTRACT: Amaç: Bu çalışmada küçük hücreli dışı akciğer kanserinin (KHDAK) mediastinal evrelemesinde mediastinoskopinin etkinliği araştırıldı. Çalışma planı: Nisan 1995 - Mayıs 2011 tarihleri arasında KHDAK’nin evrelenmesi amacı ile mediastinoskopi uygulanan 1226 hastanın (1162 erkek, 64 kadın; ort. yaş 56.8±7.5 yıl; dağılım 26-81 yıl) verileri retrospektif olarak incelendi. Ortalama örneklenen lenf nodu (LN) istasyonu sayısı, komplikasyonlar ve lenf nodu negatif (cN0) olup torakotomi uygulanan hastalar için varsa yanlış negatif oranı kaydedildi. Hastalar 1995-2001 arası (ilk dönem, n=295), 2001-2006 arası (ikinci dönem, n=316) ve 2006-2011 arası (son dönem, n=615) olmak üzere üç döneme ayrıldı. Bulgular: Hasta başına örneklenen ortalama LN istasyonu sayısı 3.8±1.0 idi ve dönemler arasında istatistiksel olarak anlamlı farklılık var idi (p<0.001). İlk ve ikinci döneme kıyasla (sırasıyla, n=3.4±1.3 ve n=3.8±0.8) son dönemde (n=4.0±0.8) istatistiksel olarak anlamlı şekilde daha fazla istasyondan örneklem yapıldı (p<0.001). Toplam 224 hastada (%18.2) mediastinoskopi ile mediastinal LN metastazı saptandı. Torakotomi geçiren cN0 8 68 h astanın 7 1’inde ( %8.1) y anlış negatiflik saptandı. Yanlış negatif oranı son döneme göre (n=23, %5.2) ilk dönem (n=28, %14.1) ve ikinci dönemde (n=20, 8.6%) daha yüksek idi (p<0.001). Mediastinal lenf nodu metastazı prevalansı yıllar geçtikçe azalma eğiliminde idi (p=0.08). Hassasiyet, negatif öngörü değeri ve doğruluk ilk dönem için sırası ile 0.66, 0.85, 0.89; ikinci dönem için 0.74, 0.91, 0.93; son dönem için 0.83, 0.94 ve 0.96 idi. Toplam komplikasyon oranı %4 idi (n=49). Dönemler arasında komplikasyon açısından istatistiksel olarak anlamlı farklılık yoktu (p=0.441). En yaygın komplikasyon ses kısıklığı idi (n=30, %2.4). Pulmoner arter hemorajisi olan bir hastada mortalite gelişti (%0.08). Sonuç: Çalışma sonuçlarımıza göre, KHDAK’nin evrelenmesinde mediastinoskopinin etkinliği yıllar geçtikçe artmıştır. Deneyim ve örneklenen LN istasyonu sayısı arttıkça yanlış negatif oranı azalmış ve gerçek doğruluk artmıştır.
    Full-text · Article · Jul 2015 · Turkish Journal of Thoracic and Cardiovascular Surgery
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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.
    Full-text · Article · Sep 2014 · Multimedia Manual of Cardiothoracic Surgery
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    • "There are currently no accepted standards regarding mediastinal restaging, and many strategies, based on radiological, minimally invasive and surgical techniques are advocated [14]. According to the recent European Society of Thoracic Surgeons' and American College of Chest Physicians' guidelines, minimally invasive procedures , including EBUS-TBNA and EUS-FNA, may be alternatively used, but mediastinoscopy or remediastinoscopy should be preferably reserved for restaging [14] [15] [16] [17]. "
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    ABSTRACT: The aim of this prospective trial was to assess the diagnostic utility of combined endobronchial (EBUS) and endoscopic (EUS) ultrasound-guided needle aspiration by use of a single ultrasound bronchoscope (CUSb-NA) in non-small-cell lung cancer (NSCLC) restaging in patients after induction therapy. In a consecutive group of NSCLC patients with pathologically confirmed N2 disease (clinical stage IIIa and IIIb) who underwent induction chemotherapy, CUSb-NA was performed. All of the patients with negative or suspected for metastases (uncertain) diagnosed by endoscopy underwent subsequently transcervical extended mediastinal lymphadenectomy (TEMLA) as a confirmatory test. From January 2009 to December 2012, 106 patients met the inclusion criteria and underwent restaging CUSb-NA under mild sedation, in whom 286 (mean 2.7, range 2-5) lymph node stations were biopsied, 127 (mean 1.2, range 1-3) by EBUS-transbronchial needle aspiration (TBNA) and 159 (mean 1.5, range 1-4) by EUS-fine needle aspiration (FNA). The CUSb-NA revealed metastatic lymph node involvement in 37/106 patients (34.9%). In 69 (65.1%) patients with negative and uncertain CUSb-NA in 4 (3.8%) out of them, who underwent subsequent TEMLA metastatic nodes were found in 18 patients (17.0%) and there were single lymph nodes found only in one mediastinal station (minimal N2) in 10 (9.4%) out of them. False-positive results were found in 2 (1.9%) patients. In 9 (8.5%) patients CUSb-NA occurred to be false negative in Stations 2R and 4R (only accessible for EBUS), exclusively in small nodes and in 4 (3.8%) patients in Station 5-not accessible for CUSb-NA. The prevalence of mediastinal lymph node metastases in the present study was 51.9%. Diagnostic sensitivity, specificity, total accuracy, positive predictive value and negative predictive value (NPV) of the restaging CUSb-NA were 67.3% (95% CI [confidence interval]-53-79), 96.0% (95% CI-86-99), 81.0% (95% CI-73-87), 95.0% (95% CI-83-99) and 73.0% (95% CI-61-83), respectively. The sensitivity, accuracy and NPV of CUSb-NA were higher compared with EBUS-TBNA and EUS-FNA alone. No complications of CUSb-NA were observed. The CUSb-NA is a reasonable and safe technique in mediastinal restaging in NSCLC patients after induction therapy. Following our data, in patients with negative result of CUSb-NA, a surgical restaging of the mediastinum should be considered.
    Preview · Article · Jan 2014 · European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery
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