Lung cancer staging, the established role of bronchoscopy

Abstract

Purpose of reviewLung cancer is the leading cause of cancer-related deaths worldwide. In the absence of distant metastases, accurate mediastinal nodal staging determines treatment approaches to achieve most favourable outcomes for patients. Mediastinal staging differentiates N0/N1 disease from N2/N3 in surgical candidates. Likewise, presence of nodal involvement in nonsurgical candidates who are being considered for stereotactic body radiation therapy is also critical. This review article seeks to discuss the current options available for mediastinal staging in nonsmall cell lung cancer (NSCLC), particularly the role of bronchoscopy. Recent findingsAlthough several techniques are available to stage the mediastinum, bronchoscopy with EBUS-TBNA with or without EUS-FNA appears to be superior in most clinical situations based on its ability to concomitantly diagnose and stage at once, safety, accessibility to the widest array of lymph node stations, cost and low risk of complications. However, training and experience are required to achieve consistent diagnostic accuracy with EBUS-TBNA. SummaryEBUS-TBNA with or without EUS-FNA is considered the modality of choice in the diagnosis and staging of NSCLC in both surgical and nonsurgical candidates.

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“…EBUS-TBNA advantageously provides access to a wide array of lymph node stations (2R, 2L, 3p, 4R, 4L, 7, 10R, 10L, 11s, 11i, 11L, 12R, 12L). A method for nodal identification using EBUS and proper biopsy order has previously been described [ 34 , 35 ]. In some cases, sampling of a centrally located primary parenchymal lesion is also possible [ 36 ].…”

“…In some cases, sampling of a centrally located primary parenchymal lesion is also possible [ 36 ]. The median diagnostic sensitivity of EBUS-TBNA is reportedly 81–89% [ 35 ], with low complication risks.…”

“…The main advantages of this method, compared to EBUS-TBNA, include access to subdiaphragmatic sites. While EUS-FNA offers similar diagnostic sensitivity of 83–89%, routine use is limited only to augment EBUS-TBNA in select cases [ 35 ].…”

“…This method provides access to ipsilateral and contralateral pretracheal, paratracheal, and anterior subcarinal lymph nodes. Independently, it is generally reserved for circumstances when EBUS-TBNA/EUS-FNA fail to confirm disease in highly suspected cases [ 35 ]. A meta-analysis found the addition of mediastinoscopy following EBUS/EUS resulted in improved diagnostic sensitivity for N2/N3 disease with increased likelihood of upstaging [ 68 ].…”

“…Video-assisted thorascopic surgery (VATS) is the most common operative method used for lung cancer resection, providing access to the full tumor specimen along with a wide range of ipsilateral nodes; however, contralateral nodes are generally inaccessible [ 35 ]. Given ample attainable tissue, VATS has a 99% diagnostic sensitivity with improved ability for subsequent molecular analysis [ 35 , 69 ]. It can also provide information regarding pleural tumor involvement.…”