title: Preoperative mediastinal lymph node staging for non-small cell lung cancer: 2014 update of the 2007 ESTS guidelines.
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. Over the last years more evidence of the different mediastinal staging technique has become available. Therefore, a revision of the ESTS guidelines was needed. In case of CT-enlarged or PET-positive mediastinal lymph nodes, tissue confirmation is indicated. Endosonography (EBUS/EUS) with fine needle aspiration 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 over 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 tumors ≤3 cm located in the outer third of the lung. In central tumors or N1 nodes, preoperative mediastinal staging is indicated. The choice between endoscopic staging with EBUS/EUS and fine needle aspiration or video-assisted mediastinoscopy depends on local expertise to adhere to minimal requirements for staging. For tumors larger than 3 cm, preoperative mediastinal staging is advised, mainly in adenocarcinoma with high SUV uptake.
authors: 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland.
authors: Paul
authors: P
authors: De Leyn
authors: 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland.
authors: Christophe
authors: C
authors: Dooms
authors: 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland.
authors: Jaroslaw
authors: J
authors: Kuzdzal
authors: 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland.
authors: Didier
authors: D
authors: Lardinois
authors: 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland.
authors: Bernward
authors: B
authors: Passlick
authors: 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland.
authors: Ramon
authors: R
authors: Rami-Porta
authors: 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland.
authors: Akif
authors: A
authors: Turna
authors: 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland.
authors: Paul
authors: P
authors: Van Schil
authors: 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland.
authors: Frederico
authors: F
authors: Venuta
authors: 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland.
authors: David
authors: D
authors: Waller
authors: 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland.
authors: Walter
authors: W
authors: Weder
authors: 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland.
authors: Marcin
authors: M
authors: Zielinski
keywords: Lung cancer; endoscopic staging; preoperative staging; surgical staging