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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)
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.
In
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
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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).