INVASIVE STAGING AND RESTAGING IN NON-SMALL CELL LUNG CANCER

Bronchogenic carcinoma is the leading cause of cancer related death in Western countries. When a diagnosis of lung cancer is made, staging and restaging are important to determine prognosis and to decide on subsequent therapeutic strategies. Concerning staging of mediastinal lymph nodes in non-small cell lung cancer, a positive result of a noninvasive procedure should be histologically or cytologically confirmed. Minimally invasive techniques are complementary to surgical invasive staging techniques with a high specificity but low negative predictive value. Therefore, an invasive surgical technique is indicated if they yield negative results. If needle aspiration is positive, this result may be valid as proof for N2 or N3 disease. Restaging in non-small cell lung cancer remains a controversial issue. Downstaging of mediastinal lymph nodes determines survival in stage IIIA-B non-small cell lung cancer. Different restaging techniques (noninvasive, minimally invasive and invasive) do exist and the level of concurrent use still has to be further explored. At this moment, minimally invasive techniques are especially useful for primary staging. Mediastinoscopy and repeat mediastinoscopy provide the largest tissue samples. Although remediastinoscopy is technically difficult, it remains of utmost importance as part of the restaging process. For thoracic surgeons having no experience with repeat mediastinoscopy, an alternative approach consists of the initial use of a minimally invasive staging procedure to obtain cytological proof of mediastinal nodal involvement. After induction therapy, patients are subsequently restaged by mediastinoscopy. In this way, a technically more demanding remediastinoscopy can be avoided.