Mediastinal staging of non-small-cell lung cancer

Figures & data

Figure 1. International Association for the Study of Lung Cancer nodal chart with stations and zones.

Adapted with permission courtesy of the International Association for the Study of Lung Cancer. Copyright © 2009 Memorial Sloan-Kettering Cancer Center, NY, USA.

Figure 2. An overview of the clinical approach to mediastinal staging of non-small-cell lung cancer.

This should be tailored to individual patient and institution-specific factors as discussed in the text.

^†Enlarged or PET positive N2 nodes.

^‡This choice depends on the practicing physician.

CT: Computed tomography; EBUS: Endobronchial ultrasound; EUS: Endoscopic ultrasound; FNA: Fine-needle aspiration; TEMLA: Transcervical extended mediastinal lymphadenectomy; TBNA: Transbronchial needle aspiration.

Table 1. Lymph node station accessibility of various invasive procedures.

	2R	2L	3a	3p	4R	4L	5	6	7	8	9	10R	10L	11R	11L
EBUS	+	+	-	+	+	+	-	-	+	-	-	+	+	+	+
EUS	+/-	+/-	-	+	+/-	+	+/-	+/-	+	+	+	+/-	+/-	-	-
EBUS + EUS	+	+	-	+	+	+	+/-	-	+	+	+	+	+	+	+
EMN	+	+	-	+	+	+	-	-	+	-	-	+	+	+	+
TTNA	+	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Cervical mediastinoscopy	+	+	-	-	+	+	-	-	+	-	-	+	-	-	-
Extended mediastinoscopy	+	+	-	-	+	+	+	+	+	-	-	-	-	-	-
Chamberlain	-	-	-	-	-	-	+	+	-	-	-	-	-	-	-
Left VATS	-	-	-	-	-	+	+	+	+	+	+	-	+	-	+
Right VATS	+	-	+	+	+	-	-	-	+	+	+	+	-	+	-
VAMLA	+	+	-	-	+	+	-	-	+	+	-	-	-	-	-
TEMLA	+	+	+	+	+	+	+	+	+	+	+	+	-	-	-

+: Accessible; -: Inaccessible; EBUS: Endobronchial ultrasound; EMN: Electromagnetic navigation bronchoscopy; EUS: Endoscopic ultrasound; TEMLA: Transcervical extended mediastinal lymphadenectomy; TTNA: Transthoracic needle aspiration; VAMLA: Video-assisted mediastinal lymphadenectomy; VATS: Video-assisted thoracic surgery.

Table 2. Overview of common invasive mediastinal staging techniques^†.

Investigation	Sensitivity (%)	Specificity (%)	FP (%)	FN (%)	Median prevalence (%)
TBNA	78	99	1	28	75
EBUS	93	100	0	9	63
EUS	84	99.5	0.7	19	61
TTNA	89	100	0		81
Cervical mediastinoscopy	78	100	0	11	39
Chamberlain^‡	87	100	0	8	38
VATS	75	100	0	7	44

^†The values apply only for specific situations and lymph node locations for which the procedures were performed.

^‡Values for Chamberlain performed in addition to routine cervical mediastinoscopy.

EBUS: Endobronchial ultrasound; EUS: Endoscopic ultrasound; FP: False positive; FN: False negative; TBNA: Transbronchial needle aspiration; TTNA: Transthoracic needle aspiration; VATS: Video-assisted thoracic surgery.

The values have been obtained from the information in ACCP guidelines of 2007 [9,38] and updated values for EBUS have been obtained from Gomez et al.[52].

Table 3. Strengths and weaknesses of common mediastinal staging procedures.

Procedure	Strengths	Weakness
CT	Best anatomic study of thorax Guides the site of biopsy	Low accuracy for detecting malignant disease
PET	Detects unexpected distant metastasis in 5–20% cases Guides site of biopsy Assists in staging, restaging, treatment response High NPV value for stage I NSCLC	False negative in lesions <1 cm or PET-negative tumors 25% false positive
TBNA	Minimally invasive, simple and cost effective	Not well utilized Relatively low yield Yield highly dependent on prevalence
EBUS	Minimally invasive Permits direct visualization of node Doppler feature allows identification of vessels and landmarks for nodal stations Excellent access for stations 2, 4, 7, 10 and 11 Allows simultaneous airway inspection and regular bronchoscopy to biopsy lung lesions if needed	Unable to access stations 5, 6, 8 and 9 Special equipment and training needed
EUS	Minimally invasive Permits direct visualization of nodes Doppler feature allows identification of vessels and landmarks for nodal stations Excellent access to para-esophageal nodes and inferior mediastinum Can access stations 8 and 9 and sometimes 5 and 6, which are generally hard to reach Able to access left adrenal, left lobe of liver and celiac nodes	Unable to access right-sided station 2R and 4R and unable to access stations 10 and 11 Does not allow airway inspections Occasional false positives due to inability to distinguish main tumor from lymph node Special equipment and training needed
TTNA	Able to access almost all nodal stations Broad availability	High risk of pneumothorax Small nodes difficult to biopsy Wide variation in practice pattern of interventional radiologist
Cervical mediastinoscopy	Traditional ‘gold standard’ Excellent for stations 2 and 4 Improved detection of micrometastasis and extracapsular spread	Limited accessibility of other lymph node stations Not great for posterior subcarinal station Suboptimal sampling common Almost 10% false-negative rate
Chamberlain	Allows sampling of stations 5 and 6	More invasive Performed by few surgeons
VATS	Allows simultaneous resection of tumor Allows sampling of stations 5 and 6 Allows sampling of inferior mediastinal stations 8 and 9	Relatively more invasive Anterior and superior mediastinum not well accessed
TEMLA	Allows reliable sampling of almost all nodal stations Can detect micrometastasis and extracapsular spread Permits complete lymphadenectomy	More invasive More postoperative pain than routine mediastinoscopy

CT: Computed tomography; EBUS: Endobronchial ultrasound; EUS: Endoscopic ultrasound; NPV: Negative predictive value; NSCLC: Non-small-cell lung cancer; TEMLA: Transcervical extended mediastinal lymphadenectomy; TBNA: Transbronchial needle aspiration; TTNA: Transthoracic needle aspiration; VATS: Video-assisted thoracic surgery.

Activity Evaluation: Where 1 is strongly disagree and 5 is strongly agree

	1	2	3	4	5
1. The activity supported the learning objectives.
2. The material was organized clearly for learning to occur.
3. The content learned from this activity will impact my practice.
4. The activity was presented objectively and free of commercial bias.

Gomez M, Silvestri GA. Endobronchial ultrasound for the diagnosis and staging of lung cancer. Proc. Am. Thorac. Soc.6(2), 180–186 (2009).

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