Invasive Mediastinal Staging of Lung Cancer: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)

doi:10.1378/chest.07-1362

Chest

Volume 132, Issue 3, Supplement, September 2007, Pages 202S-220S

https://doi.org/10.1378/chest.07-1362 Get rights and content

Background

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.

Methods

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.

Results

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.

Conclusions

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.

Section snippets

Materials and Methods

The data presented here are based on a systematic search and evaluation of the published literature from January 1980 through June 2006. Articles published prior to July 2001 were identified according to the criteria laid out in the previous version of the American College of Chest Physicians lung cancer guidelines.¹ Subsequent literature was identified by the authors using the same search strategy and selection criteria (briefly, studies published in the English language, peer-reviewed,

Mediastinoscopy

Mediastinoscopy is performed in the operating room, usually under general anesthesia, and in most United States centers patients are discharged from the hospital the same day.2, 3, 4 The procedure involves an incision just above the suprasternal notch, insertion of a mediastinoscope alongside the trachea, and biopsy of the mediastinal nodes. Rates of morbidity and mortality as a result of this procedure are low (2% and 0.08%, respectively).⁵ Right and left high and low paratracheal nodes

Mediastinal Infiltration

In patients with extensive mediastinal infiltration, the radiographic evidence of mediastinal involvement is quite universally considered adequate. There are no data to prove this, because invasive confirmation is not done. However, even though staging is not an issue, tissue is needed to confirm the diagnosis and to establish what type of cancer is present (eg, NSCLC vs SCLC). In this case, it does not matter whether tissue is obtained from the primary tumor or from a mediastinal site.

Recommendation

1
For patients with extensive mediastinal infiltration of tumor and no distant metastases, radiographic (CT scan) assessment of the mediastinal stage is usually sufficient without invasive confirmation. Grade of recommendation, 2C

Discrete Mediastinal Lymph Node Enlargement

Many patients present with a CT scan demonstrating the enlargement of discrete mediastinal (N2,3) lymph nodes. An extensive literature³² demonstrates that enlargement seen on CT scan alone carries an FP rate of approximately 40% (see chapter 12). The PET scan literature has only recently become detailed enough to begin to define FN and FP rates in subgroups of patients such as those with discrete nodal enlargement seen on a CT scan. The FP rate for PET scanning in the mediastinum has been

Recommendations

2
For patients with discrete mediastinal lymph node enlargement (and no distant metastases), invasive confirmation of the radiographic stage is recommended (regardless of whether a PET scan finding is positive or negative in the mediastinal nodes). Grade of recommendation, 1B
3
For patients with discrete mediastinal lymph node enlargement (and no distant metastases), many invasive techniques for the confirmation of the N2,3 node status are suggested as reasonable approaches (eg, mediastinoscopy,

Central and Clinical N1 Tumors

Patients with no evidence of mediastinal node enlargement but with a central tumor or N1 node involvement represent another distinct group (group C). It is reasonable to consider patients with central tumors together with those with N1 node enlargement, because it is usually difficult to assess the N1 nodes in the case of a central tumor. Extensive data indicate that the FN rate of a CT scan with respect to the mediastinal nodes is 20 to 25% (see chapter 12 on noninvasive staging).³² More

Recommendations

5
For patients with a radiographically normal mediastinum (by CT scan) and a central tumor or N1 lymph node enlargement (and no distant metastases), invasive confirmation of the radiographic stage is recommended (regardless of whether a PET scan finding is positive or negative in the mediastinal nodes). Grade of recommendation, 1C
6
For patients with a central tumor or N1 lymph node enlargement (and no distant metastases), invasive staging is recommended. In general, mediastinoscopy is suggested,

Peripheral Clinical Stage I Tumors

Patients with peripheral tumors in whom there is no enlargement of N1 or N2,3 nodes seen on CT scans, the FN rate of this radiographic assessment in the mediastinum is approximately 10%.³² The incidence is lower in patients with T1 tumors (9%) than in those with T2 tumors (13%).³² Whether this incidence is viewed as being high enough to justify performing mediastinoscopy or PET scanning is a matter of judgment. A negative PET scan finding in the mediastinum carries a FN rate of approximately 5%

Recommendations

7
For patients with a peripheral clinical stage I tumor in whom a PET scan shows uptake in mediastinal nodes (and not distant metastases), invasive staging is recommended. In general, mediastinoscopy is suggested, but EUS-NA or EBUS-NA may be a reasonable alternative if nondiagnostic results are followed by mediastinoscopy. Grade of recommendation, 1C
8
For patients with a peripheral clinical stage I tumor, invasive confirmation of the mediastinal nodes is not needed if the findings of a PET scan of

Patients With LUL Tumors

Patients with tumors in the LUL deserve special mention because the aortic arch raises technical issues of access to the mediastinal nodes in the APW (station 5). This node station is the most likely mediastinal nodal area to be involved in the case of an LUL tumor, whereas it is extremely unlikely to be involved in patients with a tumor in any of the other lobes. Of course, mediastinal nodal involvement from an LUL tumor can also extend to other node stations such as the subcarinal (station 7)

Recommendation

9
For patients with an LUL cancer in whom invasive mediastinal staging is indicated, as defined by the previous recommendations, it is suggested that invasive mediastinal staging include assessment of the APW nodes (via Chamberlain procedure, thoracoscopy, extended cervical mediastinoscopy, EUS-NA, or EBUS-NA) if other mediastinal node stations are found to be uninvolved. Grade of recommendation, 2C

Conclusion

Accurate mediastinal staging is crucial to the selection of the optimal therapy for patients without distant metastases. Imaging studies are not sufficiently reliable in many situations, making invasive staging tests an important part of appropriate staging. Many different invasive staging tests, which should be viewed as complementary to one another because they are applicable to particular nodal stations and patient groups, are available. It is helpful to separate patients into different

REFERENCES (112)

TolozaEM et al.
Invasive staging of non-small cell lung cancer: a review of the current evidence
Chest
(2003)
CybulskyIJ et al.
Mediastinoscopy as a routine outpatient procedure
Ann Thorac Surg
(1994)
VallièresE et al.
Ambulatory mediastinoscopy and anterior mediastinotomy
Ann Thorac Surg
(1991)
VenissacN et al.
Video-assisted mediastinoscopy: experience from 240 consecutive cases
Ann Thorac Surg
(2003)
CoughlinM et al.
Role of mediastinoscopy in pretreatment staging of patients with primary lung cancer
Ann Thorac Surg
(1985)
Van den BoschJMM et al.
Exploratory thoracotomy in bronchial carcinoma
J Thorac Cardiovasc Surg
(1983)
HammoudZT et al.
The current role of mediastinoscopy in the evaluation of thoracic disease
J Thorac Cardiovasc Surg
(1999)
LardinoisD et al.
Postinduction video-mediastinoscopy is as accurate and safe as video-mediastinoscopy in patients without pretreatment for potentially operable non-small cell lung cancer
Ann Thorac Surg
(2003)
KimuraH et al.
A prospective study of indications for mediastinoscopy in lung cancer with CT findings, tumor size, and tumor markers
Ann Thorac Surg
(2003)
ChoiYS et al.
Mediastinoscopy in patients with clinical stage I non-small cell lung cancer
Ann Thorac Surg
(2003)

Fritscher-RavensA et al.

Role of transesophageal endosonography-guided fine-needle aspiration in the diagnosis of lung cancer

Chest

(2000)

SilvestriGA et al.

Endoscopic ultrasound with fine-needle aspiration in the diagnosis and staging of lung cancer

Ann Thorac Surg

(1996)

WallaceMB et al.

Endoscopic ultrasound-guided fine needle aspiration for staging patients with carcinoma of the lung

Ann Thorac Surg

(2001)

WallaceMB et al.

Endoscopic ultrasound in lung cancer patients with a normal mediastinum on computed tomography

Ann Thorac Surg

(2004)

Fritscher-RavensA et al.

Mediastinal lymph node involvement in potentially resectable lung cancer: comparison of CT, positron emission tomography, and endoscopic ultrasonography with and without fine-needle aspiration

Chest

(2003)

EloubeidiMA et al.

Endoscopic ultrasound-guided fine needle aspiration of mediastinal lymph node in patients with suspected lung cancer after positron emission tomography and computed tomography scans

Ann Thorac Surg

(2005)

LarsenSS et al.

Endoscopic ultrasound guided biopsy versus mediastinoscopy for analysis of paratracheal and subcarinal lymph nodes in lung cancer staging

Lung Cancer

(2005)

AnnemaJT et al.

Towards a minimally invasive staging strategy in NSCLC: analysis of PET positive mediastinal lesions by EUS-FNA

Lung Cancer

(2004)

Le BlancJK et al.

Endoscopic ultrasound in non-small cell lung cancer and negative mediastinum on computed tomography

Am J Respir Crit Care Med

(2005)

WallaceM et al.

Complete “medical mediastinoscopy” under conscious sedation: a prospective blinded comparison of endoscopic and endobronchial ultrasound to bronchoscopic fine needle aspiration for malignant mediastinal lymph nodes [abstract]

Gastrointest Endosc

(2006)

VaradarajuluS et al.

Accuracy of EUS in staging of T4 lung cancer

Gastrointest Endosc

(2004)

HarewoodG et al.

Cost-minimization analysis of alternative diagnostic approaches in a modeled patient with non-small cell lung cancer and subcarinal lymphadenopathy

Mayo Clin Proc

(2002)

GarpestadE et al.

CT fluoroscopy guidance for transbronchial needle aspiration: an experience in 35 patients

Chest

(2001)

RattoGB et al.

The prognostic significance of preoperative assessment of mediastinal lymph nodes in patients with lung cancer

Chest

(1988)

ShureD et al.

The role of transcarinal needle aspiration in the staging of bronchogenic carcinoma

Chest

(1984)

Feller-KopmanD et al.

Autofluorescence bronchoscopy and endobronchial ultrasound: a practical review

Ann Thorac Surg

(2005)

Sebastian-QuetglasF et al.

Clinical value of video-assisted thoracoscopy for preoperative staging of non-small cell lung cancer: a prospective study of 105 patients

Lung Cancer

(2003)

LandreneauRJ et al.

Thoracoscopic mediastinal lymph node sampling: useful for mediastinal lymph node stations inaccessible by cervical mediastinoscopy

J Thorac Cardiovasc Surg

(1993)

RobertsJR et al.

Prospective comparison of radiologic, thoracoscopic, and pathologic staging in patients with early non-small cell lung cancer

Ann Thorac Surg

(1999)

WainJC

Video-assisted thoracoscopy and the staging of lung cancer

Ann Thorac Surg

(1993)

De GiacomoT et al.

Thoracoscopic staging of IIIB non-small cell lung cancer before neoadjuvant therapy

Ann Thorac Surg

(1997)

PattersonGA et al.

Significance of metastatic disease in subaortic lymph nodes

Ann Thorac Surg

(1987)

BestL-A et al.

The contribution of anterior mediastinotomy in the diagnosis and evaluation of diseases of the mediastinum and lung

Ann Thorac Surg

(1987)

GinsbergRJ et al.

Extended cervical mediastinoscopy: a single staging procedure for bronchogenic carcinoma of the left upper lobe

J Thorac Cardiovasc Surg

(1987)

UrschelJD et al.

Cerebrovascular accident complicating extended cervical mediastinoscopy

Ann Thorac Surg

(1994)

LopezL et al.

Extended cervical mediastinoscopy: prospective study of fifty cases

Ann Thorac Surg

(1994)

LopezL et al.

Extended cervical mediastinoscopy: prospective study of fifty cases

Ann Thorac Surg

(1994)

CerfolioRJ et al.

Improving the inaccuracies of clinical staging of patients with NSCLC: a prospective trial

Ann Thorac Surg

(2005)

DetterbeckFC et al.

Seeking a home for a PET: part 3. Emerging applications of positron emission tomography imaging in the management of patients with lung cancer

Chest

(2004)

Van SchilP et al.

Remediastinoscopy after neoadjuvant therapy for non-small cell lung cancer

Lung Cancer

(2002)

MeersschautD et al.

Repeat mediastinoscopy in the assessment of new and recurrent lung neoplasm

Ann Thorac Surg

(1992)

VerhagenAFT et al.

FDG-PET in staging lung cancer: how does it change the algorithm?

Lung Cancer

(2004)

LukeWP et al.

Prospective evaluation of mediastinoscopy for assessment of carcinoma of the lung

J Thorac Cardiovasc Surg

(1986)

JollyPC et al.

Routine computed tomographic scans, selective mediastinoscopy, and other factors in evaluation of lung cancer

J Thorac Cardiovasc Surg

(1991)

RattoGB et al.

Improving clinical efficacy of computed tomographic scan in the preoperative assessment of patients with non-small cell lung cancer

J Thorac Cardiovasc Surg

(1990)

RongF et al.

CT scan directed transbronchial needle aspiration biopsy for mediastinal nodes

Chest

(1998)

PatelliM et al.

Role of fiberscopic transbronchial needle aspiration in the staging of N2 disease due to non-small cell lung cancer

Ann Thorac Surg

(2002)

UtzJP et al.

The role of transcarinal needle aspiration in the staging of bronchogenic carcinoma

Chest

(1993)

SchenkDA et al.

Utility of the Wang 18-gauge transbronchial histology needle in the staging of bronchogenic carcinoma

Chest

(1989)

SelcukZT et al.

The diagnostic yield of transbronchial needle aspiration in superior vena cava syndrome

Lung Cancer

(2003)

Cited by (659)

Comparison of cryobiopsy and forceps biopsy for the diagnosis of mediastinal lesions: A randomised clinical trial
2024, Pulmonology
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the standard approach for lung cancer staging. However, its diagnostic utility for other mediastinal diseases might be hampered by the limited tissue retrieved. Recent evidence suggests the novel sampling strategies of forceps biopsy and cryobiopsy as auxiliary techniques to EBUS-TBNA, considering their capacity for larger diagnostic samples.
This study determined the added value of forceps biopsy and cryobiopsy for the diagnosis of mediastinal diseases. Consecutive patients with mediastinal lesions of 1 cm or more in the short axis were enrolled. Following completion of needle aspiration, three forceps biopsies and one cryobiopsy were performed in a randomised pattern. Primary endpoints included diagnostic yield defined as the percentage of patients for whom mediastinal biopsy led to a definite diagnosis, and procedure-related complications.
In total, 155 patients were recruited and randomly assigned. Supplementing EBUS-TBNA with either forceps biopsy or cryobiopsy increased diagnostic yield, with no significant difference between EBUS-TBNA plus forceps biopsy and EBUS-TBNA plus cryobiopsy (85.7 % versus 91.6 %, P = 0.106). Yet, samples obtained by additional cryobiopsies were more qualified for lung cancer molecular testing than those from forceps biopsies (100.0 % versus 89.5 %, P = 0.036). When compared directly, the overall diagnostic yield of cryobiopsy was superior to forceps biopsy (85.7 % versus 70.8 %, P = 0.001). Cryobiopsies produced greater samples in shorter procedural time than forceps biopsies. Two (1.3 %) cases of postprocedural pneumothorax were detected.
Transbronchial mediastinal cryobiopsy might be a promising complementary tool to supplement traditional needle biopsy for increased diagnostic yield and tissue harvesting.
ChiCTR2000030373
EBUS-guided cryobiopsy in the diagnosis of thoracic disorders
2024, Pulmonology
Endobronchial Ultrasound (EBUS) has emerged as a crucial tool for diagnosing intrathoracic disorders, particularly in the staging of lung cancer. However, its diagnostic capabilities in the context of benign and rare diseases remain a subject of debate.
to investigate the diagnostic yield and safety of EBUS-transbronchial mediastinal cryobiopsy (EBUS-TMC) in comparison to EBUS-transbronchial needle aspiration (TBNA) for a broad spectrum of intrathoracic diseases.
a single-centre retrospective observational study conducted on 48 patients who underwent both EBUS-TBNA and endobronchial ultrasound-transbronchial mediastinal cryobiopsy (EBUS-TMC) in the same procedure between August 2021 and October 2023.
The overall diagnostic yield of EBUS-TMC surpassed that of EBUS-TBNA (95.8% vs 54.1 %), notably excelling in the diagnosis of sarcoidosis (92.8% vs 78.5 %), rare mediastinal disorders (100% vs 0 %), hyperplastic lymphadenopathy (100% vs 0 %), and lymphoproliferative disease (100% vs 0 %). No significant differences were observed in the diagnosis of NSCLC and SCLC. Samples obtained through EBUS-TMC facilitated the acquisition of NGS and immunohistochemical analyses more readily.
EBUS-TMC may contribute to the precise diagnosis and subtyping of mediastinal diseases, especially lymphomas and rare mediastinal tumors, thereby reducing the number of non-diagnostic procedures.
Prediction Models for Mediastinal Metastasis and Its Detection by Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Potentially Operable Non-Small Cell Lung Cancer: A Prospective Study
2023, Chest
Prediction models for mediastinal metastasis and its detection by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) have not been developed using a prospective cohort of potentially operable patients with non-small cell lung cancer (NSCLC).
Can mediastinal metastasis and its detection by EBUS-TBNA be predicted with prediction models in NSCLC?
For the prospective development cohort, 589 potentially operable patients with NSCLC were evaluated (July 2016-June 2019) from five Korean teaching hospitals. Mediastinal staging was performed using EBUS-TBNA (with or without the transesophageal approach). Surgery was performed for patients without clinical N (cN) 2-3 disease by endoscopic staging. The prediction model for lung cancer staging-mediastinal metastasis (PLUS-M) and a model for mediastinal metastasis detection by EBUS-TBNA (PLUS-E) were developed using multivariable logistic regression analyses. Validation was performed using a retrospective cohort (n = 309) from a different period (June 2019-August 2021).
The prevalence of mediastinal metastasis diagnosed by EBUS-TBNA or surgery and the sensitivity of EBUS-TBNA in the development cohort were 35.3% and 87.0%, respectively. In PLUS-M, younger age (< 60 years and 60-70 years compared with ≥ 70 years), nonsquamous histology (adenocarcinoma and others), central tumor location, tumor size (> 3-5 cm), cN1 or cN2-3 stage by CT, and cN1 or cN2-3 stage by PET-CT were significant risk factors for N2-3 disease. Areas under the receiver operating characteristic curve (AUCs) for PLUS-M and PLUS-E were 0.876 (95% CI, 0.845-0.906) and 0.889 (95% CI, 0.859-0.918), respectively. Model fit was good (PLUS-M: Hosmer-Lemeshow P = .658, Brier score = 0.129; PLUS-E: Hosmer-Lemeshow P = .569, Brier score = 0.118). In the validation cohort, PLUS-M (AUC, 0.859 [95% CI, 0.817-0.902], Hosmer-Lemeshow P = .609, Brier score = 0.144) and PLUS-E (AUC, 0.900 [95% CI, 0.865-0.936], Hosmer-Lemeshow P = .361, Brier score = 0.112) showed good discrimination ability and calibration.
PLUS-M and PLUS-E can be used effectively for decision-making for invasive mediastinal staging in NSCLC.
ClinicalTrials.gov; No.: NCT02991924; URL: www.clinicaltrials.gov
The American Association for Thoracic Surgery (AATS) 2023 Expert Consensus Document: Staging and multidisciplinary management of patients with early-stage non–small cell lung cancer
2023, Journal of Thoracic and Cardiovascular Surgery
Endobronchial ultrasound-guided cryobiopsy—when it is indicated? – Authors' reply
2023, The Lancet Respiratory Medicine
Transbronchial needle aspiration combined with cryobiopsy in the diagnosis of mediastinal diseases: a multicentre, open-label, randomised trial
2023, The Lancet Respiratory Medicine
Transbronchial mediastinal cryobiopsy is a novel sampling technique for mediastinal disease. Despite the possibility of lung cancer misdiagnosis, the improved diagnostic yield of this approach for non-lung-cancer lesions compared with standard endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) highlights its diagnostic potential as a complementary technique to conventional biopsy. We aimed to evaluate the safety profile and added value of the combined use of transbronchial mediastinal cryobiopsy and standard EBUS-TBNA for the diagnosis of mediastinal diseases.
We conducted an open-label, randomised trial at three hospital sites in Europe and Asia. Eligible patients were aged 15 years or older, with at least one mediastinal lesion of 1 cm or longer in the short axis that required diagnostic bronchoscopy. Participants were randomly assigned (1:1) using a block randomisation scheme generated by a computer (block size of four participants based on a random table from an independent statistician) to the combined use of EBUS-TBNA and transbronchial mediastinal cryobiopsy (combined group) or EBUS-TBNA alone (control group). Because of the nature of the intervention, neither participants nor investigators were masked to group assignment. The coprimary outcomes were differences in procedure-related complications and diagnostic yield (defined as the proportion of participants for whom mediastinal biopsy led to a definitive diagnosis), assessed in the full analysis set, including all the patients who met the eligibility criteria and had a biopsy. A fully paired, intraindividual diagnostic analysis in participants who had both needle aspiration and mediastinal cryobiopsy was conducted, in addition to interindividual comparisons. This trial is now complete and is registered with ClinicalTrials.gov, NCT04572984.
Between Oct 12, 2020, and Sept 9, 2021, 297 consecutive patients were assessed for eligibility and 271 were enrolled and randomly assigned to the combined group (n=136) or the control group (n=135). The addition of cryobiopsy to standard sampling significantly increased the overall diagnostic yield for mediastinal lesions, as shown by both interindividual (126 [93%] of 136 participants in the combined group vs 109 [81%] of 135 in the control group; risk ratio [RR] 1·15 [95% CI 1·04–1·26]; p=0·0039) and intraindividual (126 [94%] of 134 vs 110 [82%] of 134; RR 1·15 [95% CI 1·05–1·25]; p=0·0026) analyses. In subgroup analyses in the intraindividual population, diagnostic yields were similar for mediastinal metastasis (68 [99%] of 69 participants in the combined group vs 68 [99%] of 69 in the control group; RR 1·00 [95% CI 0·96–1·04]; p=1·00), whereas the combined approach was more sensitive than standard needle aspiration in benign disorders (45 [94%] of 48 vs 32 [67%] of 48; RR 1·41 [95% CI 1·14–1·74]; p=0·0009). The combined approach also resulted in an improved suitability of tissue samples for molecular and immunological analyses of non-small-cell lung cancer. The incidence of adverse events related to the biopsy procedure did not differ between trial groups, as grade 3–4 airway bleeding occurred in three (2%) patients in the combined group and two (1%) in the control group (RR 0·67 [95% CI 0·11–3·96]; p=1·00). There were no severe complications causing death or disability.
The addition of mediastinal cryobiopsy to standard EBUS-TBNA resulted in a significant improvement in diagnostic yield for mediastinal lesions, with a good safety profile. These data suggest that this combined approach is a valid first-line diagnostic tool for mediastinal diseases.
National Natural Science Foundation of China.

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The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

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Chest

DIAGNOSIS AND MANAGEMENT OF LUNG CANCER: ACCP GUIDELINES (2ND EDITION)Invasive Mediastinal Staging of Lung Cancer: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)

Background

Methods

Results

Conclusions

Section snippets

Materials and Methods

Mediastinoscopy

Mediastinal Infiltration

Recommendation

Discrete Mediastinal Lymph Node Enlargement

Recommendations

Central and Clinical N1 Tumors

Recommendations

Peripheral Clinical Stage I Tumors

Recommendations

Patients With LUL Tumors

Recommendation

Conclusion

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Am J Respir Crit Care Med

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Mayo Clin Proc

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DIAGNOSIS AND MANAGEMENT OF LUNG CANCER: ACCP GUIDELINES (2ND EDITION)
Invasive Mediastinal Staging of Lung Cancer: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)