Mediastinal Staging of Non-Small-Cell Lung Cancer

Christian Lloyd, MD, and Gerard A. Silvestri, MD, FCCP, Division of Pulmonary and Critical Care Medicine at the Medical University of South Carolina, Charleston.

Cancer Control. 2001;8(4)

Mediastinoscopy

If mediastinal adenopathy on CT is present, a surgical mediastinal procedure is often performed prior to thoracotomy. Mediastinoscopy is the historic gold standard for staging the mediastinum. Mediastinoscopy is most often used to sample lymphatics in the paratracheal (station 4) and anterior subcarinal (station 7) region (Fig 1). The subcarinal area is more difficult to sample and has a lower yield. The aortopulmonary (station 5) region is accessible by extended cervical mediastinoscopy.Finally, anterior mediastinotomy is needed to sample lymphatics in the subaortic and lateral aortic region.^[29] Overall, mediastinoscopy has a reported sensitivity of 87% and specificity of 100%.^[30] In addition to this superior sensitivity and specificity, mediastinoscopy may be able to differentiate between stage IIIA and IIIB mediastinal involvement. As more is learned about lung cancer treatment, this will be important for prognosis and for potential therapy.

(Enlarge Image)

Figure 1.

Regional lymph node stations. Ao = aorta, PA = pulmonary artery. From Shields TW, LoCicero J III, Ponn RB, eds. General Thoracic Surgery. Philadelphia: Lippincott Williams & Wilkins; 2000:1302. Reprinted with permission.

As with any surgical procedure, mediastinoscopy has risks and limitations. It requires general anesthesia and has a morbidity of 1% and a mortality of 0.2%. The procedure adds considerable expense to the staging workup. The estimated current cost is $1,700 for the procedure alone and $7,500 for a mediastinoscopy with a 2-day hospital stay.^[29,31]

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Table Computed Tomography vs Positron Emission Tomography in the Mediastinal Staging of NSCLC
Author	Number of Patients	Malignant/Benign (Type of Evaluation)	PET Sensitivity (%)	PET Specificity (%)	CT Sensitivity (%) (Size Criteria)	CT Specificity (%)
Pieterman et al^[13]	102	32/70 (patients)	91	86	75 (1.0 cm)	66
Valk et al^[16]	74	24/52 (sides)	83	94	63 (1.0 cm)	73
Chin et al^[18]	30	9/21 (patients)	78	81	56 (1.5 cm)	86
Wahl et al^[19]	23	11/16 (sides)	82	81	64 (1.0 cm)	44
Patz et al^[20]	42	12/39 (stations)	83	82	43 (1.0 cm)	85
Scott et al^[21]	62	10/65 (stations)	100	98	60 (1.0 cm)	93
Sasaki et al^[22]	29	17/54 (stations)	76	98	65 (1.0 cm)	87
Steinert et al^[23]	47	58/133 (stations)	93	99	72 (0.7-1.1 cm)	94
Sazon et al^[24]	37	16/16 (patients)	100	100	81 (1.0 cm)	56
Vansteenkiste et al^[25]	50	14/36 (patients)	67	97	67 (1.5 cm)	63
			93*	97*
Guhlmann et al^[26]	32	20/12 (patients)	80	100	50 (1.0 cm)	75
Bury et al^[27]	50	21/19 (patients)	90	86	72 (1.0 cm)	81

CT = computed tomography

PET = positron emission tomography

*PET plus CT

Adapted with permission from the Society of Thoracic Surgeons. Lowe VJ, Maunheim KS. Positron emission tomography in lung cancer.
The Annals of Thoracic Surgery, 1998;65:1821-1829.

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Mediastinal Staging of Non-Small-Cell Lung Cancer

Mediastinoscopy

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