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Mediastinal staging of NSCLC with endoscopic and endobronchial ultrasound

Nature Reviews Clinical Oncology volume 6, pages 278–286 (2009)Cite this article

Abstract

Mediastinal staging of non-small-cell lung cancer (NSCLC) is of paramount importance. It distinguishes operable from inoperable disease, guides prognosis and allows accurate comparison of outcomes in clinical trials. Noninvasive imaging modalities for mediastinal staging include CT, PET and integrated PET-CT. Mediastinoscopy is considered the current gold standard; however, each of these techniques has limitations in sensitivity or specificity. These inadequacies mean that 10% of operations performed with curative intent in patients with NSCLC are futile, owing to inaccurate locoregional lymph-node staging. Endoscopic and endobronchial ultrasound-guided mediastinal lymph-node aspiration are important and promising innovative techniques with reported sensitivities and specificities higher than standard investigations. The role of these techniques in mediastinal lymph-node staging is evolving rapidly and early data suggest that they may diminish the need for invasive surgical staging of the mediastinum. Furthermore, these are outpatient procedures that do not require general anesthesia and may be combined safely in the same sitting, for optimal accuracy of mediastinal staging. We propose a new algorithm for the diagnosis and staging of NSCLC, based on the current evidence, which incorporates endoscopic and endobronchial ultrasound as a first investigation after CT in patients with intrathoracic disease.

Key Points

  • Current radiological and surgical techniques for mediastinal staging of non-small-cell lung cancer (NSCLC) do not identify all mediastinal metastases and result in futile thoracotomies

  • Mediastinoscopy is the current gold standard for mediastinal staging of NSCLC but cannot access the entire mediastinum and has a sensitivity of 78%

  • Endoscopic ultrasound allows minimally invasive sampling of posterior and left-sided mediastinal lymph nodes with a sensitivity of 84%

  • Endobronchial ultrasound is a new technique that allows staging of parabronchial lymph nodes with a sensitivity of 90%

  • Combined endoscopic and endobronchial ultrasound allows sampling of almost the entire mediastinum and may replace mediastinoscopy as the gold-standard investigation of mediastinal lymph nodes in patients with NSCLC

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Figure 1: Mediastinal lymph node stations, according to American Thoracic Society Regional Lymph Node Station criteria.
Figure 2: Devices used in endoscopic and endobronchial ultrasound.
Figure 3: An ultrasonographic image obtained during endobronchial ultrasound-guided transbronchial needle aspiration.
Figure 4: Novel diagnostic and staging algorithm for patients with suspected non-small-cell lung cancer, which incorporates endobronchial ultrasound-guided transbronchial needle aspiration, endoscopic ultrasound-guided fine-needle aspiration or the combined procedure as a first test after CT.

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Authors and Affiliations

  1. Centre for Respiratory Research, University College London, UK

    Neal Navani & Sam M. Janes

  2. Department of Thoracic Medicine, University College London Hospital, London, UK

    Stephen G. Spiro

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Correspondence to Sam M. Janes.

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Navani, N., Spiro, S. & Janes, S. Mediastinal staging of NSCLC with endoscopic and endobronchial ultrasound. Nat Rev Clin Oncol 6, 278–286 (2009). https://doi.org/10.1038/nrclinonc.2009.39

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