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Didier Lardinois
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Eur J Cardiothorac Surg 2007;32:1-8. doi:10.1016/j.ejcts.2007.01.075
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

Editorial

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

Paul De Leyna,*, Didier Lardinoisb, Paul E. Van Schilc, Ramon Rami-Portad, Bernward Passlicke, Marcin Zielinskif, David A. Wallerg, Tony Leruta, Walter Wederb

a Department of Thoracic Surgery, University Hospitals Leuven, Belgium
b Department of Thoracic Surgery, University Hospital of Zurich, Switzerland
c Department of Thoracic Surgery, University Hospital of Antwerp, Belgium
d Department of Thoracic Surgery, Hopital Mutua de Terassa, Spain
e Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Germany
f Department of Thoracic Surgery, Pulmonary Hospital Zakopane, Poland
g Department of Thoracic Surgery, Glenfield Hospial Leicester, United Kingdom

Received 12 November 2006; received in revised form 28 January 2007; accepted 29 January 2007.

* Corresponding author. Address: Department of Thoracic Surgery, University Hospitals Leuven, Herestraat 49, B 3000 Leuven, Belgium. Tel.: +32 16 346822; fax: +32 16 346844. (Email: Paul.deleyn{at}uz.kuleuven.ac.be).

Abstract

Accurate preoperative staging and restaging of mediastinal lymph nodes in patients with non-small cell lung cancer (NSCLC) is of paramount importance. It will guide choices of treatment and determine prognosis and outcome. Over the last years, different techniques have become available. They vary in accuracy and procedure-related morbidity. The Council of the ESTS initiated a workshop on preoperative mediastinal lymph node staging. This resulted in guidelines for primary staging and restaging. For primary staging, mediastinoscopy remains the gold standard for the superior mediastinal lymph nodes. Invasive procedures can be omitted in patients with peripheral tumors and negative mediastinal positron emission tomography (PET) images. However, in case of central tumors, PET hilar N1 disease, low fluorodeoxyglucose uptake of the primary tumor and LNs ≥ 16 mm on CT scan, invasive staging remains indicated. PET positive mediastinal findings should always be cyto-histologically confirmed. Transbronchial needle aspiration (TBNA), ultrasound-guided bronchoscopy with fine needle aspiration (EBUS-FNA) and endoscopic esophageal ultrasound-guided fine needle aspiration (EUS-FNA) are new techniques that provide cyto-histological diagnosis and are minimally invasive. Their specificity is high but the negative predictive value is low. Because of this, if they yield negative results, an invasive surgical technique is indicated. However, if fine needle aspiration is positive, this result may be valid as proof for N2 or N3 disease. For restaging, invasive techniques providing cyto-histological information are advisable despite the encouraging results supported with the use of PET/CT imaging. Both endoscopic techniques and surgical procedures are available. If they yield a positive result, non-surgical treatment is indicated in most patients.

Key Words: Lung cancer • Preoperative staging • Intra-operative staging • Mediastinoscopy




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Copyright © 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier. All rights reserved.