Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer.
01 May 2014-European Journal of Cardio-Thoracic Surgery (Oxford University Press)-Vol. 45, Iss: 5, pp 787-798
TL;DR: A revision of the ESTS guidelines was needed because more evidence of the different mediastinal staging technique has become available and both endoscopic techniques and surgical procedures are available, but their negative predictive value is lower compared with the results obtained in baseline staging.
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.
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TL;DR: The Clatterbridge Cancer Centre and Liverpool Heart and Chest Hospital, Liverpool; University of Aberdeen, Aberdeen, UK; Center for Medical Imaging, University of Groningen, Groningen; Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands; and Department of Thoracic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK.
1,498 citations
320 citations
University of Duisburg-Essen1, Katholieke Universiteit Leuven2, University of Zurich3, Institut Gustave Roussy4, Heidelberg University5, Hebron University6, University Hospital of Lausanne7, University of Aberdeen8, University of Maryland, Baltimore9, The Chinese University of Hong Kong10, Trinity College, Dublin11, University of Turin12, University of Basel13, VU University Amsterdam14, Aarhus University15, Roswell Park Cancer Institute16, Aberdeen Royal Infirmary17, University of Antwerp18, Imperial College London19
TL;DR: A total of 35 experts met to address several questions on non-small-cell lung cancer in each of four areas: pathology and molecular biomarkers, first-line/second and further lines of treatment in advanced disease, early-stage disease and locally advanced disease.
295 citations
Cites background or methods from "Revised ESTS guidelines for preoper..."
...If surgical staging of the mediastinum is indicated, VAMS is the preferred technique for upper mediastinal lymph nodes and VATS is preferred for aortopulmonary lymph nodes [35]....
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...If the results of these diagnostic procedures are negative despite a high suspicion of mediastinal node involvement, surgical staging of the mediastinum is clearly indicated [35]....
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TL;DR: This is an official guideline of the European Society of Gastrointestinal Endoscopy, produced in cooperation with the European Respiratory Society, and addresses the benefit and burden associated with combined endobronchial and esophageal mediastinal nodal staging of lung cancer.
Abstract: This is an official guideline of the European Society of Gastrointestinal Endoscopy (ESGE), produced in cooperation with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS). It addresses the benefit and burden associated with combined endobronchial and esophageal mediastinal nodal staging of lung cancer. The Scottish Intercollegiate Guidelines Network (SIGN) approach was adopted to define the strength of recommendations and the quality of evidence.The article has been co-published with permission in the European Journal of Cardio-Thoracic Surgery and the European Respiratory Journal. Recommendations 1 For mediastinal nodal staging in patients with suspected or proven non-small-cell lung cancer (NSCLC) with abnormal mediastinal and/or hilar nodes at computed tomography (CT) and/or positron emission tomography (PET), endosonography is recommended over surgical staging as the initial procedure (Recommendation grade A). The combination of endobronchial ultrasound with real-time guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic (esophageal) ultrasound with fine needle aspiration, with use of a gastrointestinal (EUS-FNA) or EBUS (EUS-B-FNA) scope, is preferred over either test alone (Recommendation grade C). If the combination of EBUS and EUS-(B) is not available, we suggest that EBUS alone is acceptable (Recommendation grade C).Subsequent surgical staging is recommended, when endosonography does not show malignant nodal involvement (Recommendation grade B). 2 For mediastinal nodal staging in patients with suspected or proven non-small-cell peripheral lung cancer without mediastinal involvement at CT or CT-PET, we suggest that EBUS-TBNA and/or EUS-(B)-FNA should be performed before therapy, provided that one or more of the following conditions is present: (i) enlarged or fluorodeoxyglucose (FDG)-PET-avid ipsilateral hilar nodes; (ii) primary tumor without FDG uptake; (iii) tumor size ≥ 3 cm (Fig. 3a - c) (Recommendation grade C). If endosonography does not show malignant nodal involvement, we suggest that mediastinoscopy is considered, especially in suspected N1 disease (Recommendation grade C).If PET is not available and CT does not reveal enlarged hilar or mediastinal lymph nodes, we suggest performance of EBUS-TBNA and/or EUS-(B)-FNA and/or surgical staging (Recommendation grade C). 3 In patients with suspected or proven < 3 cm peripheral NSCLC with normal mediastinal and hilar nodes at CT and/or PET, we suggest initiation of therapy without further mediastinal staging (Recommendation grade C). 4 For mediastinal staging in patients with centrally located suspected or proven NSCLC without mediastinal or hilar involvement at CT and/or CT-PET, we suggest performance of EBUS-TBNA, with or without EUS-(B)-FNA, in preference to surgical staging (Fig. 4) (Recommendation grade D). If endosonography does not show malignant nodal involvement, mediastinoscopy may be considered (Recommendation grade D). 5 For mediastinal nodal restaging following neoadjuvant therapy, EBUS-TBNA and/or EUS-(B)-FNA is suggested for detection of persistent nodal disease, but, if this is negative, subsequent surgical staging is indicated (Recommendation grade C). 6 A complete assessment of mediastinal and hilar nodal stations, and sampling of at least three different mediastinal nodal stations (4 R, 4 L, 7) (Fig. 1, Fig. 5) is suggested in patients with NSCLC and an abnormal mediastinum by CT or CT-PET (Recommendation grade D). 7 For diagnostic purposes, in patients with a centrally located lung tumor that is not visible at conventional bronchoscopy, endosonography is suggested, provided the tumor is located immediately adjacent to the larger airways (EBUS) or esophagus (EUS-(B)) (Recommendation grade D). 8 In patients with a left adrenal gland suspected for distant metastasis we suggest performance of endoscopic ultrasound fine needle aspiration (EUS-FNA) (Recommendation grade C), while the use of EUS-B with a transgastric approach is at present experimental (Recommendation grade D). 9 For optimal endosonographic staging of lung cancer, we suggest that individual endoscopists should be trained in both EBUS and EUS-B in order to perform complete endoscopic staging in one session (Recommendation grade D). 10 We suggest that new trainees in endosonography should follow a structured training curriculum consisting of simulation-based training followed by supervised practice on patients (Recommendation grade D). 11 We suggest that competency in EBUS-TBNA and EUS-(B)-FNA for staging lung cancer be assessed using available validated assessment tools (Recommendation Grade D).
270 citations
Cites background or methods from "Revised ESTS guidelines for preoper..."
...According to the ESTS guidelines, for centrally located lung tumors exploration of mediastinal lymph nodes is indicated [21]....
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...Recently, endosonography has been recommended in guidelines as the initial test of choice over surgical staging [21, 22], because it improves nodal tissue staging, reduces the number of futile thoracotomies [18], and is cost-effective [23, 24]....
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...In line with the ESTS guidelines [21], we recommend that at least three stations should be assessed (subcarinal, left paratracheal, and right paratracheal) and biopsy samples should be taken if possible...
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TL;DR: An updated review of past and current literature for the roles of surgery, chemotherapeutic agents, radiation therapy, and targeted therapy for stage III NSCLC patients are presented.
Abstract: Lung cancer is the leading cause of cancer death worldwide. Majority of newly diagnosed lung cancers are non-small cell lung cancer (NSCLC), of which up to half are considered locally advanced at the time of diagnosis. Patients with locally advanced stage III NSCLC consists of a heterogeneous population, making management for these patients complex. Surgery has long been the preferred local treatment for patients with resectable disease. For select patients, multi-modality therapy involving systemic and radiation therapies in addition to surgery improves treatment outcomes compared to surgery alone. For patients with unresectable disease, concurrent chemoradiation is the preferred treatment. More recently, research into different chemotherapy agents, targeted therapies, radiation fractionation schedules, intensity-modulated radiotherapy, and proton therapy have shown promise to improve treatment outcomes and quality of life. The array of treatment approaches for locally advanced NSCLC is large and constantly evolving. An updated review of past and current literature for the roles of surgery, chemotherapeutic agents, radiation therapy, and targeted therapy for stage III NSCLC patients are presented.
175 citations
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3,466 citations
TL;DR: Recommendations for classifying regional lymph node stations for lung cancer staging have been adopted by the American Joint Committee on Cancer and the Union Internationale Contre le Cancer, and provides for consistent, reproducible, lymph node mapping that is compatible with the international staging system for Lung cancer.
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"Revised ESTS guidelines for preoper..." refers methods in this paper
...There are several modifications compared with the previous Naruke and Mountain and Dresler maps [5, 6], but probably the most important modification from the clinical point of view is the shift of the anatomical mediastinal midline to the left paratracheal margin, the so-called mediastinal oncological midline [3]....
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TL;DR: It is demonstrated that PET scanning is more accurate than CT scanning, but tissue biopsy is still required to confirm PET scan findings, and evidence suggests that more complete staging improves patient outcomes.
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TL;DR: To achieve uniformity and to promote future analyses of a planned prospective international database, the International Association for the Study of Lung Cancer proposes a new lymph node map which reconciles differences among currently used maps, and provides precise anatomic definitions for all lymph node stations.
976 citations
"Revised ESTS guidelines for preoper..." refers background or methods in this paper
...There are several modifications compared with the previous Naruke and Mountain and Dresler maps [5, 6], but probably the most important modification from the clinical point of view is the shift of the anatomical mediastinal midline to the left paratracheal margin, the so-called mediastinal oncological midline [3]....
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...introduced a new lymph node map of the lungs and mediastinum that resulted from an international and multidisciplinary consensus [3]....
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...EBUS is able to visualize superior and inferior mediastinal LNs at stations 2R/2L, 4R/4L and 7, as well as hilar LNs at stations 10, 11 and even 12, as described on the new LN map [3]....
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TL;DR: There was a significant difference for patients who had metastases to the subcrainal lymph nodes as compared to the prognosis for those who did not, and no significant difference in survival was detected between patients who were given adjuvant therapy and those who were not.
752 citations
"Revised ESTS guidelines for preoper..." refers methods in this paper
...There are several modifications compared with the previous Naruke and Mountain and Dresler maps [5, 6], but probably the most important modification from the clinical point of view is the shift of the anatomical mediastinal midline to the left paratracheal margin, the so-called mediastinal oncological midline [3]....
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