Mediastinal staging in NSCLC

Dr. Siddhant Singh

 History
• In the old (pre 1985) lung cancer classification,
stage I and II tumors were considered for
surgical management, and stage III tumors
were considered unresectable.

• Now, tumors with limited invasion of chest

wall and mediastinum can be considered as
potentially resectable, provided that vital
structures are not involved.
IASLC Nodal Chart – 8th edition
IASLC Nodal Chart – 8th edition
 Important changes
• The mediastinal oncological midline now lies
at the Left paratracheal margin  Effect on
2R, 2L, 4R, 4L

• The anatomical borders of the lymph node

(LN) stations are clearly defined now.

• The concept of Zones

 Why the need?
• When there are no distant metastases,
mediastinal lymph node (LN) involvement is the
most important prognostic factor in patients with
NSCLC and influences therapeutic strategies.

• The aim of mediastinal staging is to exclude

patients with mediastinal nodal disease since
these patients will not benefit from upfront
surgery.
 Why the need?
• Patients with preoperatively diagnosed
involved mediastinal LNs have a dismal
outcome when treated with surgery or
radiotherapy alone. In order to improve the
outcome in these patients, the concept of
multimodality treatment has been introduced.
In the subgroup of patients with IIIA-N2
disease induction chemotherapy, combined
with either surgery and/or radiotherapy has
proved to be effective.
 Why the need?
• N1 and N2 disease is considered resectable

• N3 disease is considered to be inoperable.

• It is important to describe the location and extent

of N2 disease, since these patients are treated
with neo-adjuvant chemotherapy followed by
definitive surgical resection. However, if the N2
disease is bulky and involves multiple nodal
stations, then a combination of chemotherapy
and radiotherapy might be preferred over
surgery.
 Why the need?
• In case of N3 disease, the treatment is mainly non-
surgical, and if the patient has a good performance
status, then he is treated with concurrent chemo-
radiation therapy. The exact description of the location
and extent of adenopathy is important as it helps the
radiation oncologist plan his radiation portals. If
mediastinal nodal disease is extensive, radiation fields
might become too large increasing the risk of radiation
toxicity; in such a scenario, radical chemo-radiation
therapy might be deferred and patients are treated
with palliative chemotherapy instead.
General outline for staging based
therapy in NSCLC
 General outline for staging based
therapy in NSCLC
• Early Localised (T1-3, N0-2)
– N0,N1 : Surgery
– N2 : NACT  Surgery

• Locoregional Advanced (T4, N3)

– Concurrent CT-RT

• Metastatic (M1)
– Palliative
 Mediastinal Staging

Non Invasive Minimally Invasive

Invasive
• CT scan • Mediastinoscopy
• PET scan • EBUS-TBNA • VATS
• PET-CT • EUS-NA • VAMLA
• TEMLA
 Non Invasive staging of the
mediastinum
• Chest CT scan
• PET scan
• PET-CT scan
 Chest CT scan
• Standard criterion used :
– Diameter > 1cm in short axis

• Drawback :
– Smaller nodes may contain mets in upto 20%
cases
– Larger nodes may be benign in upto 40 % cases
Classification of Mediastinal Disease
by Radiographic Characteristics

Invasive mediastinal
sampling is
necessary
 PET scan
• Principle : Detects increased glycolytic rate in
metabolically active tumors.

• Sn and NPV are comparable to Mediastinoscopy

• Drawback :
– False negative results in tumors with low metabolic
activity
– False positive results in benign conditions like
granulomatous, inflammatory and infectious diseases
 PET-CT scan
• PET-CT scan is more accurate than either
modality alone in characterizing solitary
pulmonary nodule as benign or malignant,
however in mediastinal lymph node staging, it
is as accurate as PET alone.
 Conclusion
Most of the times, non invasive modalities are
insufficient for clinical decision making, and in
many instances it is inappropriate to rely solely on
CT scan or PET scan for N-staging, but it can be of
help in selecting the most appropriate procedure
for tissue sampling of suspected LNs.
Diffusion Weighted MRI
 Diffusion Weighted MRI
• The pooled sensitivity for DWI was 0.95 (95% CI
0.85–0.98) and significantly better than for FDG-
PET–CT 0.89 (95% CI 0.85–0.91) showing
promising early results.

• However, at this moment, there are no large

prospective studies comparing the value of DWI
and FDG-PET and it is too early to determine the
true value of DWI in nodal staging in patients
with NSCLC.
Revised ESTS
guidelines for primary
mediastinal staging
 Key Points
N0 on CT/PET
AND
Tm ≤3 cm (T1) Surgery
AND
Peripherally located Tm
 Key Points
LN +ve on CT/PET
OR
Tm >3 cm Tissue
OR confirmation
Centrally located Tm
 Role of CT, PET in restaging after
Neoadjuvant therapy
• Studies evaluating the reliability of mediastinal
restaging by CT scan showed a lower sensitivity,
specificity and accuracy than by primary staging,
indicating that CT scan is not appropriate for
identifying patients with partial or complete
response of the involved mediastinal nodes.

• PET scan is less sensitive in the restaging of

mediastinal lymph nodes after chemotherapy or
chemoradiotherapy than before induction
treatment, with higher false-negative rates,
ranging from 28% to 36%.
 Role of CT, PET in restaging after
Neoadjuvant therapy
• Although experience is rather limited,
integrated PET–CT seems to be more accurate
for restaging.

• Patients with persisting mediastinal

involvement have a worse prognosis
compared with those with proven mediastinal
downstaging.
 Take home message
• No single imaging method alone is conclusive
in evaluating potential mediastinal
involvement

• Whenever enlarged lymph nodes are seen in

the mediastinum on chest CT scan, standard
practice is to perform a lymph node biopsy for
more accurate staging.
 Take home message
• Currently, all modalities are complementary to
each other in the comprehensive staging of
lung cancer. The radiologist can assist in
staging by guiding the interventional
pulmonologist and thoracic surgeon to
appropriate lymph node targets and
suggesting the best modality for sampling
those targets.