Mediastinal staging for non-small cell lung cancer

Abstract

The staging of mediastinal lymph nodes for lung cancer is crucial for planning treatments or reinterventions. In potentially curable patients the aim of mediastinal staging is to exclude the presence of malignancy in mediastinal lymph nodes with a high level of accuracy while also considering clinical factors and the balance of the benefits and risks of tissue sampling techniques. Mediastinal staging is based on computed tomography (CT) and positron emission tomography (PET) and can be sufficient when no mediastinal abnormalities are present and the probability of unforeseen N2 disease is low. In the case of bulky lymph nodes with a high probability of malignancy in PET-CT, tissue confirmation is not normally required. If mediastinal sampling is needed it can be achieved by endosonographic techniques, including endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) or a combination of the two. Positive results do not need further confirmation. In the case of negative results, surgical techniques still play a role in the selected cases discussed by multidisciplinary lung cancer committees. New mediastinal surgical techniques including video-assisted cervical mediastinoscopy (VACM), video-assisted mediastinoscopic lymphadenectomy (VAMLA), and transcervical extended mediastinal lymphadenectomy (TEMLA) have been shown to be useful in selected patients. Final pathological staging is based on lymph node removal during surgery and can be achieved by taking one of two approaches: lymph node sampling or systematic lymph node sampling.The accuracy of PET-CT and mediastinal endosonography is lower for mediastinal restaging than it is for surgical techniques; their false positive and false negative (FN) rate is high and so, they require histological confirmation. Here we explain and revise the results from the most recent studies and current international guidelines.

The impact of staging FDG-PET/CT on treatment for stage III NSCLC - an analysis of population-based data from Ontario, Canada

“…Targeting FDG-PET/CT positive lymph nodes with mediastinal biopsy has demonstrated reduced false-negative and false positive rates ( 19 ) and provides more accurate staging information than either modality alone ( 20 ). The observed trend of increasing EBUS usage when compared to mediastinoscopy for histopathological diagnosis is not a surprising finding given the less-invasive nature, lack of requirement for general anesthesia, and the lower complication rate of EBUS biopsies ( 21 – 23 ). The role that FDG-PET/CT may play in the increased adoption of EBUS is less clear.…”

A deep learning–based system for mediastinum station localization in linear EUS (with video)

“…Treatment of non–small cell lung cancer is stage dependent, and EUS helps sample lymph nodes at stations 4 L, 5, 7, 8, 9, as well as the celiac and the left adrenal nodes. [ 20 ] A biopsy can also be safely performed on the primary lung tumors in a periesophageal location and those invading the mediastinum. [ 21 ] EUS provides for biopsy of these enlarged nodes easily, safely, and with a high diagnostic yield.…”

Sublobar Resection of Non-Small-Cell Lung Cancer: Wedge Resection vs. Segmentectomy

“…Imaging is sufficient for mediastinal staging if no mediastinal abnormalities are seen and the risk of N2 is low-but if sampling is indicated, similarly to tissue biopsy, EBUSguided transbronchial needle aspiration and endoscopic ultrasound-guided fine needle aspiration can be utilized. For selected patients with negative results, cervical mediastinoscopy serves as a more invasive, but highly sensitive (80%) and specific (100%) procedure [6,7].…”