Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer

Abstract

Accurate preoperative staging and restaging of mediastinal lymph nodes in patients with potentially resectable non-small-cell lung cancer (NSCLC) is of paramount importance. In 2007, the European Society of Thoracic Surgeons (ESTS) published an algorithm on preoperative mediastinal staging integrating imaging, endoscopic and surgical techniques. In 2009, the International Association for the Study of Lung Cancer (IASLC) introduced a new lymph node map. Some changes in this map have an important impact on mediastinal staging. Moreover, more evidence of the different mediastinal staging technique has become available. Therefore, a revision of the ESTS guidelines was needed. In case of computed tomography (CT)-enlarged or positron emission tomography (PET)-positive mediastinal lymph nodes, tissue confirmation is indicated. Endosonography [endobronchial ultrasonography (EBUS)/esophageal ultrasonography (EUS)] with fine-needle aspiration (FNA) is the first choice (when available), since it is minimally invasive and has a high sensitivity to rule in mediastinal nodal disease. If negative, surgical staging with nodal dissection or biopsy is indicated. Video-assisted mediastinoscopy is preferred to mediastinoscopy. The combined use of endoscopic staging and surgical staging results in the highest accuracy. When there are no enlarged lymph nodes on CT and when there is no uptake in lymph nodes on PET or PET-CT, direct surgical resection with systematic nodal dissection is indicated for tumours ≤ 3 cm located in the outer third of the lung. In central tumours or N1 nodes, preoperative mediastinal staging is indicated. The choice between endoscopic staging with EBUS/EUS and FNA or video-assisted mediastinoscopy depends on local expertise to adhere to minimal requirements for staging. For tumours >3 cm, preoperative mediastinal staging is advised, mainly in adenocarcinoma with high standardized uptake value. For restaging, invasive techniques providing histological information are advisable. Both endoscopic techniques and surgical procedures are available, but their negative predictive value is lower compared with the results obtained in baseline staging. An integrated strategy using endoscopic staging techniques to prove mediastinal nodal disease and mediastinoscopy to assess nodal response after induction therapy needs further study.

Multicentric study of endobronchial ultrasound-transbronchial needle aspiration for lung cancer staging in Italy

“…The 2014 guidelines of the European Society of Thoracic Surgeons indicate endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) as the initial approach for pathological evaluation of mediastinal lymph nodes (1,2). In the last 15 years EBUS-TBNA has increasingly been used for minimally invasive diagnosis of mediastinal-hilar lymph node metastases in patients with NSCLC, and in selected cases this technique has replaced mediastinoscopy, videothoracoscopy and traditional transbronchial biopsy (2).…”

The role of bronchoscopy in the diagnosis of airway disease

“…However, a recent study showed that EBUS-TBNA was more sensitive (88% vs. 91%) and more accurate (92% vs. 89%) when compared to mediastinoscopy for evaluating lymph node stations 2R, 2L, 4R, 4L, and 7 (30). The European Society of Thoracic Surgeons have thus changed their guidelines to recommend EBUS-TBNA as first line method of mediastinal lymph node assessment in patients with nonsmall cell lung cancers greater than 3 cm, located centrally within the lung, or with suspected N2 disease based on preprocedure imaging (31).…”

Current advances of endobronchial ultrasonography in the diagnosis and staging of lung cancer

“…Therefore, several minimally invasive methods have been used for tissue sampling including conventional bronchoscopy with TBNA guided by fluoroscopy or EBUS RP, but the yield varied widely (38)(39)(40). After one large randomized control trial compared surgical staging or combined EBUS-TBNA and transesophageal ultrasound fine needle aspiration (EUS-FNA) followed by surgical staging (41), EBUS CP guided TBNA (EBUS-TBNA) is now the first choice for mediastinal LN staging (9,42). Another single arm study also supports that EBUS TBNA is better than mediastinoscopy (43).…”