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Invasive Mediastinal Staging of Lung Cancer^*

ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)

^* From the Division of Thoracic Surgery (Dr. Detterbeck), Yale University, New Haven, CT; Division of Pulmonary and Critical Care Medicine (Dr. Jantz), University of Florida, Gainesville, FL; Mayo Clinic (Dr. Wallace), Jacksonville, FL; Division of Pulmonary Medicine (Dr. Vansteenkiste), Catholic University, Leuven Belgium; and Division of Pulmonary and Critical Care Medicine (Dr. Silvestri), Medical University of South Carolina, Charleston, SC.

Correspondence to: Frank C. Detterbeck, MD, FCCP, Division of Thoracic Surgery, Department of Surgery, Yale University, 330 Cedar St, FMB 128, New Haven, CT 06520-8062; e-mail: frank.detterbeck{at}yale.edu

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.

Key Words: anterior mediastinotomy • bronchoscopy • Chamberlain procedure • clinical staging • endobronchial ultrasound • esophageal ultrasound • mediastinal lymph nodes • mediastinoscopy • N2 • N3 • pathologic staging • staging • transbronchial needle aspiration • transthoracic needle aspiration • video-assisted thoracic surgery

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