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DOI: 10.1055/a-1478-0954
Mediastinales Staging

Ein gründliches mediastinales Staging ist von zentraler Bedeutung für die prognostische Einschätzung und Therapieplanung bei Patienten mit nicht-kleinzelligem Lungenkarzinom (NSCLC) ohne Fernmetastasierung. Leitlinien zum mediastinalen Staging fordern konsequent die Kombination aus radiologischen, nuklearmedizinischen und minimalinvasiven Methoden. Technik und Ergebnis der verschiedenen Methoden werden beschrieben und Algorithmen für unterschiedliche onkologische Situationen vorgestellt.
Abstract
Thorough mediastinal staging is pivotal for prognostic assessment and treatment planning in patients with non-small-cell lung cancer (NSCLC) without distant metastasis. It aims to answer the question of whether a technically and functionally feasible operation also makes sense from an oncological point of view. In case of a nodal-free mediastinum, primary surgical therapy can be considered. If the ipsilateral mediastinal lymph nodes are affected, multimodal therapy should be sought. Operating is usually no longer the first step, especially with extensive lymph node infestation. Surgery is recommended, if neoadjuvant (radio-)chemotherapy has achieved downstaging or major response. If the contralateral mediastinal lymph nodes are involved, curative surgery is no longer part of the therapeutic concept. The therapy of choice in this situation is definitive chemo-radiotherapy.
Guidelines for mediastinal staging consistently require to combine radiological, nuclear medicine and minimally invasive methods. Imaging with CT and PET allows an initial assessment of the mediastinal status. In most cases it has to be complemented with tissue confirmation. Echoendoscopic assessment of the mediastinum with needle biopsy is the minimally invasive method of first choice (“needle first”). Surgical staging methods are reserved for situations, that cannot be satisfactorily clarified by echoendoscopy.
Technique and outcome of the different methods are described and algorithms are presented for different oncological situations.
Publication History
Article published online:
06 September 2021
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Literatur
- 1 Farjah F, Flum DR, Ramsey SD. et al. Multi-modality mediastinal staging for lung cancer among medicare beneficiaries. J Thorac Oncol 2009; 4: 355-363
- 2 Silvestri GA, Gonzalez AV, Jantz MA. et al. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143: e211S-e250S
- 3 Bugalho A, de Santis M, Slubowski A. et al. Trans-esophageal endobronchial ultrasound-guided needle aspiration (EUS-B-NA): A road map for the chest physician. Pulmonology 2017;
- 4 De Leyn P, Dooms C, Kuzdzal J. et al. Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer. Eur J Cardiothorac Surg 2014; 45: 787-798
- 5 Vilmann P, Clementsen PF, Colella S. et al. Combined endobronchial and esophageal endosonography for the diagnosis and staging of lung cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline, in cooperation with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS). Endoscopy 2015; 47: c1
- 6 Detterbeck F, Puchalski J, Rubinowitz A. et al. Classification of the thoroughness of mediastinal staging of lung cancer. Chest 2010; 137: 436-442
- 7 Hylton DA, Turner S, Kidane B. et al. The Canada Lymph Node Score for prediction of malignancy in mediastinal lymph nodes during endobronchial ultrasound. J Thorac Cardiovasc Surg 2020; 159: 2499-2507.e3
- 8 Verhoeven RLJ, Trisolini R, Leoncini F. et al. Predictive Value of Endobronchial Ultrasound Strain Elastography in Mediastinal Lymph Node Staging: The E-Predict Multicenter Study Results. Respiration 2020; 99: 484-492
- 9 Carlens E. Mediastinoscopy: a method for inspection and tissue biopsy in the superior mediastinum. Dis Chest 1959; 36: 343-352
- 10 Coosemans W, Lerut T, Van Raemdonck D. Thoracoscopic surgery: the Belgian experience. Ann Thorac Surg 1993; 56: 721-730
- 11 Ergene G, Baysungur V, Okur E. et al. Superiority of video-assisted to standard mediastinoscopy in non-small-cell lung cancer staging. Thorac Cardiovasc Surg 2012; 60: 541-544
- 12 Ward PH. Mediastinoscopy under local anesthesia. A valuable diagnostic technique. Calif Med 1970; 112: 15-22
- 13 Ginsberg RJ, Rice TW, Goldberg M. Extended cervical mediastinoscopy: a single staging procedure for bronchogenic carcinoma of the left upper lobe. J Thorac Cardiovasc Surg 1987; 94: 673-678
- 14 Specht G. Erweiterte Mediastinoskopie. Thoraxchir Vask Chir 1965; 13: 401-407
- 15 Hürtgen M, Friedel G, Tomes H. et al. Radical video-assisted mediastinoscopic lymphadenectomy (VAMLA) – technique and first results. Eur J Cardiothorac Surg 2002; 21: 348-351
- 16 Kuzdzal J, Zielinsk M, Papla B. et al. Transcervical extended mediastinal lymphadenectomy – the new operative technique and early results in lung cancer staging. Eur J Cardiothorac Surg 2005; 27: 384-390
- 17 Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft DK, AWMF). Prävention, Diagnostik, Therapie und Nachsorge des Lungenkarzinoms. Langversion 1.0. AWMF-Registernummer: 020/007OL; Februar 2018. Im Internet (Stand: 22.06.2021): http://leitlinienprogramm-onkologie.de/Lungenkarzinom.98.0.html
- 18 Smulders SA, Smeenk FW, Janssen-Heijnen ML. et al. Surgical mediastinal staging in daily practice. Lung Cancer 2005; 47: 243-251
- 19 Leschber G, Sperling D, Klemm W. et al. Does video-mediastinoscopy improve the results of conventional mediastinoscopy?. Eur J Cardiothorac Surg 2008; 33: 289-293
- 20 Yasufuku K, Fujisawa T. Staging and diagnosis of non-small cell lung cancer: invasive modalities. Respirology 2007; 12: 173-183
- 21 Luke WP, Pearson FG, Todd TR. et al. Prospective evaluation of mediastinoscopy for assessment of carcinoma of the lung. J Thorac Cardiovasc Surg 1986; 91: 53-56
- 22 Lim E, Baldwin D, Beckles M. et al. Guidelines on the radical management of patients with lung cancer. Thorax 2010; 65 (Suppl. 03) iii1-iii27
- 23 Postmus PE, Kerr KM, Oudkerk M. et al. Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2017; 28: iv1-iv21
- 24 National Comprehensive Cancer Network (NCCN). Clinical Practice Guidelines in Oncology – Non-Small Cell Lung Cancer. 2021 Im Internet (Stand: 22.06.2021): https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf
- 25 Hoffmann H, Passlick B, Ukena D. et al. Surgical Therapy for Lung Cancer: Why it Should be Performed in High Volume Centres. Zentralbl Chir 2019; 144: 62-70
- 26 Robold T, Ried M, Neu R. Mindestmengen in der chirurgischen Behandlung des Lungenkarzinoms. Chirurg 2020; 91: 1053-1061
- 27 Antonia SJ, Villegas A, Daniel D. Durvalumab after Chemoradiotherapy in Stage III Non-Small-Cell Lung Cancer. N Engl J Med 2017; 377: 1919-1929
- 28 Gray JE, Villegas A, Daniel D. Three-Year Overall Survival with Durvalumab after Chemoradiotherapy in Stage III NSCLC – Update from PACIFIC. J Thorac Oncol 2020; 2: 288-293
- 29 Salah S, Tanvetyanon T, Abbasi S. Metastatectomy for extra-cranial extra-adrenal non-small cell lung cancer solitary metastases: systematic review and analysis of reported cases. Lung Cancer 2012; 75: 9-14
- 30 Opitz I, Patella M, Payrard L. Prognostic factors of oligometastatic non-small-cell lung cancer following radical therapy: a multicentre analysis. Eur J Cardiothoracic Surg 2020; 57: 1166-1172
- 31 Tönnies M, Pfannsschmidt J, Bauer T. Metastasectomy for synchronous solitary non-small cell lung cancer metastases. Ann Thorac Surg 2014; 98: 249-256
- 32 Marulli G, Battistella L, Mammana M. et al. Superior sulcus tumors (Pancoast tumors). Ann Transl Med 2016; 4: 239
- 33 Detterbeck FC. Changes in the treatment of Pancoast tumors. Ann Thorac Surg 2003; 75: 1990-1997
- 34 Rusch VW, Giroux DJ, Kraut MJ. et al. Induction chemoradiation and surgical resection for superior sulcus non-small-cell lung carcinomas: long-term results of Southwest Oncology Group Trial 9416 (Intergroup Trial 0160). J Clin Oncol 2007; 25: 313-318
- 35 Marra A. Modernes Management des Pancoast-Tumors. Zentralbl Chir 2018; 143: 316-330
- 36 Hellman S. Oligometastases. J Clin Oncol 1995; 13: 8-10
- 37 Gomez DR, Tang C, Zhang J. Local consolidative therapy vs. Maintenance therapy or observation for patients with oligometastatic non-small-cell lung cancer: Long-term results of a multi-institutional, phase II, randomized study. J Clin Oncol 2019; 37: 1558-1565
- 38 Lynegar P, Wardak Z, Gerber DE. Consolidative radiotherapy for limited metastatic non-small-cell lung cancer: A phase 2 randomized clinical trial. JAMA Oncol 2017; 4: 1-8
- 39 Palma DA, Olson R, Harrow S. Stereotactic ablative radiotherapy versus standard of care palliative treatment in patients with oligometastatic cancers (SABR-COMET): a randomised, phase 2, open-label trial. Lancet 2019; 393: 2051-2058
- 40 Yano T, Okamoto T, Haro A. Local treatment of oligometastatic recurrence in patients with resected non-small cell lung cancer. Lung Cancer 2013; 82: 431-435
- 41 De Leyn P, Stroobants S, De Wever W. et al. Prospective comparative study of integrated positron emission tomography-computed tomography scan compared with remediastinoscopy in the assessment of residual mediastinal lymph node disease after induction chemotherapy for mediastinoscopy-proven stage IIIA-N2 Non-small-cell lung cancer: a Leuven Lung Cancer Group Study. J Clin Oncol 2006; 24: 3333-3339
- 42 Herth FJ, Annema JT, Eberhardt R. et al. Endobronchial ultrasound with transbronchial needle aspiration for restaging the mediastinum in lung cancer. J Clin Oncol 2008; 26: 3346-3350
- 43 Szlubowski A, Herth FJ, Soja J. et al. Endobronchial ultrasound-guided needle aspiration in non-small-cell lung cancer restaging verified by the transcervical bilateral extended mediastinal lymphadenectomy – a prospective study. Eur J Cardiothorac Surg 2010; 37: 1180-1184
- 44 Stamatis G. Staging of lung cancer: the role of noninvasive, minimally invasive and invasive techniques. Eur Respir J 2015; 46: 521-531
- 45 Genestreti G, Burgio MA, Matteucci F. Endobronchial/Endoesophageal Ultrasound (EBUS/EUS) Guided Fine Needle Aspiration (FNA) and 18F-FDG PET/CT Scanning in Restaging of Locally Ad-vanced Non-small Cell Lung Cancer (NSCLC) Treated with Chemo-radiotherapy: A Mono-institutional Pilot Experience. Technol Cancer Res Treat 2014; 14: 721-727