Clinical value of ESTS guidelines on preoperative lymph node staging for NSCLC.
01 Aug 2011-European Journal of Cardio-Thoracic Surgery (Oxford University Press)-Vol. 40, Iss: 2, pp 280-281
TL;DR: In patients with non-small-cell lung cancer, mediastinal lymph node (LN) involvement is the most important prognostic factor and influences therapeutic strategies and there is a need for invasive staging of positive LNs on PET scan.
Abstract: In patients with non-small-cell lung cancer (NSCLC), mediastinal lymph node (LN) involvement is the most important prognostic factor and influences therapeutic strategies. Nowadays, several methods of mediastinal staging are available. In 2007, the European Society of Thoracic Surgeons (ESTS) published guidelines for preoperative LN staging for NSCLC [1]. According to these guidelines, invasive mediastinal staging is recommended in patients with positron emission tomography (PET)-positive mediastinal or hilar LNs. In patients with PET-negative LNs, invasive staging is recommended in computed tomography (CT)-enlarged mediastinal LNs ( 1.5 cm) and in patients with central tumours. Gunluoglu et al. [2, in this issue] very finely assessed the validity of these guidelines in 168 patients with potentially operable NSCLC. The prevalence of mediastinal LN metastasis was 29.2%, which is very representative for patients with potentially operable disease. In all patients, pathology of mediastinal LNs was available (mediastinoscopy 100% or thoracotomy 76%). Based on these data, the authors simulated the accuracy of the ESTS guidelines. When these guidelines were followed, unforeseen mediastinal LN disease was detected in eight patients (4.7%), the negative predictive value being as high as 94%. Their study well describes the results of invasive staging for the different indications as described by the ESTS guidelines. In patients with PET-positive hilar LNs, mediastinoscopy was positive in 25% of patients despite PET scan being negative on the mediastinal LNs. The positive predictive value of PET for mediastinal LN disease was 50%. This clearly illustrates the need for invasive staging of positive LNs on PET scan. The accuracy of mediastinal LN staging technique depends not only on the technique used but also on the completeness of intra-operative LN dissection. Unfortunately, either the technique of LN dissection or further details on complete respectability are not described in this article. In this study, all invasive staging techniques were performed by cervical mediastinoscopy. Data on complications of mediastinoscopy are not available.
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TL;DR: Preliminary data demonstrating the feasibility of performing real-time elastography during endobronchial US (EBUS) and a potential application of this technique for selection of LNs for EBUS-guided transbronchia needle aspiration in patients with lung cancer and extrathoracic malignancies are reviewed.
Abstract: Elastographic techniques have recently become available as advanced diagnostic tools for tissue characterization. Strain elastography is a real-time technique used with transcutaneous ultrasound (US) and endoscopic US. Convincing evidence is available demonstrating a significant value of strain elastography for the discrimination of benign and malignant lymph nodes (LNs). This paper reviews preliminary data demonstrating the feasibility of performing real-time elastography during endobronchial US (EBUS) and a potential application of this technique for selection of LNs for EBUS-guided transbronchial needle aspiration in patients with lung cancer and extrathoracic malignancies.
43 citations
Cites background from "Clinical value of ESTS guidelines o..."
...[4,5] The value of all available US technologies for mediastinal LN staging[4-6] and lung US[7] have been recently published....
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TL;DR: Endobronchial ultrasound (EBUS) has gained importance for mediastinal lymph node staging and Contrast-enhanced EBUS is so far not a discussed technique including contrast-enhancing high mechanical index (MI)-EBUS and potentially contrast -enhanced low MI-EBUS.
Abstract: Endobronchial ultrasound (EBUS) has gained importance for mediastinal lymph node staging. Contrast-enhanced EBUS is so far not a discussed technique including contrast-enhanced high mechanical index (MI)-EBUS and potentially contrast-enhanced low MI-EBUS. Possible use could include characterization of mediastinal lymph nodes for better selection of biopsies, differential diagnosis of the primary tumor, and evaluation of thrombosis or tumor in vein infiltration.
19 citations
Cites background from "Clinical value of ESTS guidelines o..."
...[1-4] The value of conventional ultrasound technologies for mediastinal lymph node staging has been recently published.[3,4,6,7]...
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TL;DR: Socioeconomic differences in diagnostic intensity, multidisciplinary team assessment, stereotactic radiotherapy and mortality in patients with NSCLC in Sweden are found, underscore the need for improved adherence to national guidelines.
16 citations
TL;DR: The thoracoscopic approach is currently considered the gold standard for the evaluation and treatment of suspected or known pleural effusion and in the diagnosis of indeterminate pulmonary nodules and its role continues to evolve with regard to the management of lung cancer.
Abstract: Aim-Background
During the staging process of lung cancer, accurate mediastinal lymph node staging is one of the more important factors to affect patient outcome. Accurate staging of the disease is important not only in determining prognosis but also in deciding the optimal treatment plan. The most significant treatment decision is establishing which patients can benefit from surgical resection and which should receive chemotherapy, radiation, or both. This paper reviews indications and current data regarding minimally invasive approaches for diagnosis and staging of lung cancer. In addition, current advances in diagnostic endoscopy for lung cancer will be reviewed.
2 citations
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TL;DR: 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.
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 > or = 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.
489 citations
"Clinical value of ESTS guidelines o..." refers background in this paper
...European Journal of Cardio-thora www.elsevier.com/locate/ejcts cic Surgery 40 (2011) 280—281 Editorial Clinical value of ESTS guidelines on preoperative lymph node staging for NSCLC Keywords: Lung cancer; Staging; Mediastinoscopy; Endoscopic staging In patients with non-small-cell lung cancer (NSCLC), mediastinal lymph node (LN) involvement is the most important prognostic factor and influences therapeutic strategies....
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...In 2007, the European Society of Thoracic Surgeons (ESTS) published guidelines for preoperative LN staging for NSCLC [1]....
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...Gunluoglu et al. [2, in this issue] very finely assessed the validity of these guidelines in 168 patients with potentially operable NSCLC....
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...In conclusion, this study clearly validates the ESTS guidelines in preoperative LN staging for NSCLC....
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TL;DR: EUS-FNA reduces the need for surgical staging procedures in patients with (suspected) lung cancer in whom a mediastinal exploration is needed, and the rate of surgical staging interventions was low.
Abstract: Rationale: Assessment of mediastinal lymph nodes is recommended in patients with non–small cell lung cancer without distant metastases. Linear transesophageal endoscopic ultrasound with real-time guided fine-needle aspiration (EUS-FNA) is a promising, nonsurgical tool for mediastinal staging.Objectives: We conducted a randomized controlled trial comparing surgical staging with EUS-FNA.Methods: Patients with proven or suspected non–small cell lung cancer in whom mediastinal exploration was required were randomly assigned to undergo EUS-FNA or the appropriate surgical staging procedure. When EUS-FNA did not show malignant lymph node invasion, a confirmatory surgical staging procedure was done. A negative surgical staging procedure was followed by thoracotomy with systematic lymph node sampling. The primary endpoint was the rate of surgical staging interventions. The secondary endpoints were test performance of EUS-FNA and surgical staging, morbidity, and length of hospital stay, considering surgical staging...
105 citations
Additional excerpts
...Implementation of these new techniques can reduce surgical invasive procedures by 68% [3]....
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TL;DR: The preoperative LNSGs for NSCLC proposed by the ESTS are effective and the sensitivity, specificity, and positive and negative predictive values of the guidelines were calculated as 84%, 100%, 100% and 94%, respectively.
Abstract: Objective: The European Society of Thoracic Surgeons (ESTS) has proposed preoperative lymph-node staging guidelines (LNSGs) for non-smallcell lung cancer (NSCLC) based on the introduction of new staging modalities into clinical practice. The validity of these guidelines was assessed. Methods: Among the patients (n = 185) with histologically confirmed NSCLC diagnosed between 2007 and 2009, who were suitable for thoracotomy, the 168 who underwent computed tomography (CT) of the chest and CT-integrated positron emission tomography (PET-CT) were included in the study. The preoperative mediastinal stage was confirmed by mediastinoscopy in all patients. A thoracotomy was done for mediastinoscopy-negative patients. The mediastinal staging results were adapted to the ESTS-LNSG (direct thoracotomy for T1—2 N0 tumour according to CT and PET-CT and invasive staging for others) and the validity of the guidelines was tested. Results: In this series, the overall mediastinal lymph-node metastasis (MLNM) prevalence was 29.2%. If the guidelines had been applied, thoracotomy without invasive mediastinal stagingwould have been done in only11 (6.5%) patients, and no MLNMwould have been detected.Mediastinoscopy would have been performed in 157 patients and MLNM would have been found in 41 (26%). In the 116 mediastinoscopy-negative patients, MLNM would have been detected after thoracotomy in an additional eight patients. Thus, the sensitivity, specificity, and positive and negative predictive values of the guidelines were calculated as 84%, 100%, 100% and 94%, respectively. Conclusions: The preoperative LNSGs for NSCLC proposed by the ESTS are effective. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
26 citations