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• W2028011441 abstract "The intrathoracic staging of lung cancer has evolved to include information obtained from bronchoscopy , mediastinoscopy , and thoracoscopy . Through the use of imaging studies to guide the application of these techniques, valuable staging information can be obtained to facilitate planning for multimodality therapy. Bronchoscopy, mediastinoscopy, and video-assisted thoracoscopic techniques can provide histologic sampling of the primary tumor and potential metastatic sites. Equally important, this information can be obtained while limiting the morbidity of surgical staging. Surgical staging of the primary tumor is determined primarily by the location of the tumor (Table 1) . Primary tumors are staged as T3 or T4 independent of size, but dependent on the relative resectability of the contiguous tissue structures. 13 Tumors that directly invade the chest wall, diaphragm, mediastinal pleura , or parietal pericardium are considered potentially resectable and are clinically staged as T3. T3 tumors also include tumors in the main stem within 2 cm (but not involving) of the carina or tumors that are associated with atelectasis or obstructive pneumonitis of the entire lung. Tumors that invade unresectable structures such as the heart, great vessels, trachea, esophagus vertebral bodies , or carina are staged as T4. Malignant effusions associated with an ipsilateral tumor are also considered stage T4. The stage grouping defined by the American Joint Committee on Cancer (AJCC) has included T3 tumors in stage IIIA and T4 tumors in stage IIIB in the absence of distant metastases . 1 , 15 Because of the success of surgery in treating many T3 tumors without metastatic disease , the stage grouping of T3 tumors is currently being re-examined. The most common sites of metastatic spread of lung cancer are the contiguous lymph nodes in the lung and mediastinum . The segmental lymph nodes are commonly the first site of regional lymph node metastases . Involvement of the ipsilateral segmental and peribronchial lymph nodes is classified as N1 disease. These lymph nodes are within the visceral pleural envelope and are potentially resectable with an anatomic lung resection . Metastases beyond the visceral pleura are usually found in the ipsilateral mediastinal and/or subcarinal lymph nodes. Lymph node metastases in these areas are considered N2 disease. Progression of the nodal metastases to the contralateral mediastinum or either scalene or supraclavicular lymph node areas is considered N3 disease. The AJCC stage groupings have included N2 disease in stage IIIA and N3 disease in stage IIIB. 1 , 15 The prognosis of patients with stage III disease, in the absence of multimodality therapy, is poor. Although clinical series staging patients radiographically have reported 3-year survival greater than 30%, 9 , 10 studies using mediastinoscopy to document stage III disease have estimated the actuarial 3-year survival to be below 20%. 18 , 19 The prognostic uncertainty of patients with mediastinal lymph node metastases led Naruke and colleagues 16 to propose a lymph node mapping schema. The proposed lymph node map documented the potential sites and level of lymph node metastases based on 270 patients who had undergone radical resection followed by careful pathologic examination. The lymph node map and numbering system has been widely adopted as a practical method for identifying the lymph node groups in the lung and mediastinum. The lymph node map also provides a useful method of recording and classifying the extent of lymph node metastases assessed both radiographically and pathologically. The original lymph node map has been refined by the American Thoracic Society 2 (Fig. 1) . The radiographic evaluation of a patient with lung cancer typically involves CT scans . These scans are potentially useful in evaluating both the primary tumor and the potential sites of spread. CT scans of the primary tumor can identify contiguous structures and areas of potential invasion, but they are relatively insensitive at detecting invasion as compared with surgical staging. 5 In the evaluation of lymph node metastases, CT scanning has demonstrated sensitivity of 79% for mediastinal adenopathy . The specificity for metastatic lung cancer, however, drops to 65% when compared with surgical staging. 20 These findings suggest that CT scanning can be most useful in providing a preliminary assessment of clinical stage that can be confirmed by a minimally invasive staging procedure. Several instruments are available for minimally invasive staging procedures. Fiberoptic bronchoscopy can be performed on an outpatient basis with topical anesthesia or in conjunction with a surgical procedure under general anesthesia . Bronchoscopy can provide a visual assessment of endobronchial primary tumors as well as evaluate the possibility of a second primary tumor. Masses that involve the trachea or carina can be immediately staged as T4 (stage IIIB). 14 Similarly, lung cancers extending to the lobar orifice may suggest the consideration of sleeve lobectomy or pneumonectomy. The visual assessment of the primary tumor can also provide a clinically useful estimate of the probability of tumor complications such as airway obstruction, postobstructive pneumonia, and/or hemoptysis . Bronchoscopy can also be used to obtain a tissue or cytologic diagnosis . Bronchoscopy has a more limited role in the assessment of mediastinal lymph nodes . Enlarged peribronchial lymph nodes may be suggested by extrinsic airway compression. Similarly, a widened carina may suggest subcarinal lymphadenopathy. In patients with subcarinal adenopathy, transcarinal needle biopsy has been used as a supplement to conventional bronchoscopy. 3 , 21 Bronchoscopic needle aspirates are limited by the small cytologic sample, and the use of this procedure is usually restricted to large subcarinal masses." @default.
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• W2028011441 date "1997-06-01" @default.
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• W2028011441 title "MEDIASTINOSCOPY, THORACOSCOPY, AND VIDEO-ASSISTED THORACIC SURGERY IN THE DIAGNOSIS AND STAGING OF LUNG CANCER" @default.
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