Minimally Invasive Mediastinal Staging of Non–Small-Cell Lung Cancer

Emphasis on Ultrasonography-Guided Fine-Needle Aspiration

Cynthia L. Harris, MD; Eric M. Toloza, MD, PhD; Jason B. Klapman, MD; Shivakumar Vignesh, MD; Kathryn Rodriguez, BS; Frank J. Kaszuba, MD


Cancer Control. 2014;21(1):15-20. 

In This Article

Abstract and Introduction


Background: Mediastinal staging in patients with non–small-cell lung cancer (NSCLC) is crucial in dictating surgical vs nonsurgical treatment. Cervical mediastinoscopy is the "gold standard" in mediastinal staging but is invasive and limited in assessing the posterior subcarinal, lower mediastinal, and hilar lymph nodes. Less invasive approaches to NSCLC staging have become more widely available.

Methods: This article reviews several of these techniques, including noninvasive mediastinal staging of NSCLC, endobronchial ultrasound (EBUS) and fine-needle aspiration (FNA), endoscopic ultrasound (EUS) and FNA, and the combination of EBUS/EUS.

Results: Noninvasive mediastinal staging with computed tomography and positron-emission tomography scans has significant false-negative and false-positive rates and requires lymph node tissue confirmation. FNA techniques, with guidance by EBUS and EUS, have become more widely available. The combination of EBUS-FNA and EUS-FNA of mediastinal lymph nodes can be a viable alternative to surgical mediastinal staging. Current barriers to the dissemination of these techniques include initial cost of equipment, lack of access to rapid on-site cytology, and the time required to obtain sufficient skills to duplicate published results.

Conclusions: Within the last decade, these approaches to NSCLC staging have become more widely available. Continued study into these noninvasive techniques is warranted.


Assessment of the mediastinum is a crucial component in the initial staging of patients with newly diagnosed non–small-cell lung cancer (NSCLC) and is important for the documentation of recurrent disease. The results of mediastinal staging often dictate whether a patient is a candidate for surgical treatment options.

Prior to the mid-2000s, the primary means of diagnosis and tissue procurement within the medias-tinum was cervical mediastinoscopy or open surgical procedures. Cervical mediastinoscopy continues to maintain low morbidity rates, generally ranging from 0.5% to 2%, with what has long been considered the reference "gold standard" of diagnostic accuracy in the invasive staging of patients. Its widespread use and persistence remain today due to its ease of ac-cess and diagnostic success, but limitations include access to certain nodal groups such as those in the posterior subcarinal region, lower mediastinum, and hilar regions.

Interest in both noninvasive and minimally in-vasive techniques for staging of NSCLC is ongoing and increasing. The more recent techniques include computed (axial) tomography (CAT or CT), positron-emission tomography/computed tomography (PET-CT), endobronchial ultrasound (EBUS), and endoscopic ultrasound (EUS).