Invasive Mediastinal Staging of Non-Small-Cell Lung Cancer: A Clinical Practice Guideline

Abstract

Introduction: In non-small-cell lung cancer (nsclc), invasive mediastinal staging is typically used to guide treatment decision-making. Here, we present clinical practice guideline recommendations for invasive mediastinal staging in nsclc patients who have been staged T1–4, N0–3, with no distant metastases. Draft recommendations were formulated based on the best available evidence gathered by a systematic review and a consensus of expert opinion. The draft recommendations underwent an internal review by clinical and methodology experts, and an external review by clinical practitioners through a survey assessing the clinical relevance and overall quality of the guideline. Feedback from the internal and external reviews was integrated into the clinical practice guideline. In general, most clinical experts agreed with the guideline, approving it for methodologic rigour. More than 80% of the surveyed practitioners gave it a high quality rating. The expert reviewers also provided written comments, with some of the suggested changes being incorporated into the final version of the guideline. In the clinical practice guideline, invasive mediastinal staging of nsclc is recommended in all cases except those involving patients with normal-sized lymph nodes, negative combine positron-emission tomography and computed tomography, and peripheral clinical stage 1A tumour. When performing mediastinoscopy, 5 nodal stations (2R/L, 4R/L, and 7) should routinely be examined.

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“…In the Canadian context, those recommendations have largely been accepted and incorporated into Cancer Care Ontario's guidelines, although the latter guidelines mention additional factors that can increase the likelihood of N2 disease and warrant invasive or minimally invasive mediastinal staging. The additional factors include adenocarcinoma, tumour histology, degree of differentiation and size, primary tumours that are not avid for fluorodeoxyglucose, and certain welldifferentiated low-grade malignancies 8 .…”

“…The selection of the most appropriate treatment therefore relies on accurate staging of the mediastinum and assessment for distant metastases. An additional objective of accurate staging is to avoid inappropriate treatments: for example, noncurative lung resection ["futile thoracotomy" (ft)] in the context of a falsely negative mediastinum, or denial of potentially curative surgery because of a false-positive finding 8 .…”

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“…In contrast, because the incidence of false negative results is low (3-9 %) for combined CT/PET, invasive mediastinal staging can be omitted in cases where both CT and PET fail to provide any evidence of suspicious lymphadenopathy [4,5]. There is general agreement that a patient with a peripheral T1a tumor, negative clinical evaluation, and negative CT/PET can proceed to surgery without preoperative invasive mediastinal staging, if lymph node sampling is performed during the surgical procedure [10].…”

“…Because of the incidence of false-positive imaging, it is generally accepted that any suggestion of suspicious lymphadenopathy on CT or PET should result in prompt invasive mediastinal staging to seek pathological confirmation of lymph node spread [10]. In contrast, because the incidence of false negative results is low (3-9 %) for combined CT/PET, invasive mediastinal staging can be omitted in cases where both CT and PET fail to provide any evidence of suspicious lymphadenopathy [4,5].…”

“…It can be argued that invasive staging by mediastinoscopy is not recommended for this group, because the incidence of false-negative results for mediastinoscopy is higher than for non-invasive staging. Existing guidelines recommend omitting preoperative invasive staging for patients with clinical stage T1aN0M0 if mediastinal lymph node sampling is conducted during the surgical procedure [10]. For patients with tumors larger than T1a, invasive staging can be performed by EBUS-TBNA, EUS-FNA, or CUS.…”