Open Issues in Staging for Lung Cancer: Invasive vs. non Invasive Techniques

Background. In lung cancer, staging determines the extent of disease and helps in dividing patients into therapeutic and prognostic groups. The rationale for staging is to select patients who will benefit from surgical resection, presently the best hope for cure. Both non invasive and invasive procedures are necessary to achieve an adequate staging. Methods. A consecutive series of 381 patients underwent surgical staging procedures for lung cancer over a 15 year period. An overall amount of 145 mediastinoscopies, 210 video-assisted thoracoscopies (VAT), and 26 anterior mediastinotomies were performed, respectively. In 151 patients VAS was performed independently from CT findings (routine VAT). Results. Mediastinoscopy achieved a sensitivity of 87% and 52% for N2-3 and N1 staging, respectively. In 59 patients undergone non routine VATS upon CT findings overall sensitivity was 80% for N2-3, 91% for N1, 54% for T1-2-3 and 100% for T4-M1. In 151 patients undergone routine VATS, sensitivity was 77% for N2-3, 79% for N1, 93% for T1-2-3 and 100% for T4-M1. Resectability rate was 94% for negative and 39% for positive mediastinoscopy while for mediastinotomy alone (n=17) it was 89% and 33%. In 210 patients undergone VAT resectability rate was 95% and 76% for negative and positive findings respectively. Conclusions. Invasive staging still provides better selection for surgical candidates in lung cancer. Non invasive techniques help in better defining border line situations but cannot replace histological sampling, especially for N status that is the key to survival perspectives.