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The Challenge of Mediastinal Staging Figure 2: Simplified Algorithm for Mediastinal Study Positive


PET positive (6–15)


Positive (21–28) (6–40%)


Peripheral T1 (N2 probability <20%) CT


Negative (72–79) (1–9%)


(21–71%)


PET negative (13–15) (1–7%)


EBUS/EUS FNA


Negative (4–5)


(2–13%) Surgery Stop


Mediastinoscopy?


Surgery Positive


PET positive (19–25) (85–90%)


Positive (32–36) (58–68%)


PET negative (11–13) (14–20%)


Peripheral T2, central T, ↑CEA, ADK with


pleural involvement (N2 probability <30–40%)


CT


EBUS/EUS FNA


EBUS/EUS FNA


Negative (4–5)


(25–34%) Positive


Negative (4–5)


(14–17%) Positive


PET positive (13–15) (69–78%)


Negative (64–68) (17–25%)


PET negative (49–55) (5–8%)


Surgery


EBUS/EUS FNA


Negative (4–5)


(14–17%) Stop Stop Stop


Mediastinoscopy


Surgery


Mediastinoscopy


Positive


Positive (35–49) (87–94%)


N1 (N2 probability 40–60%) PET Positive


Negative (71–75) (15–17%)


EBUS/EUS FNA


Negative (56–65) (1–2%)


Stop


EBUS/EUS FNA


Negative (7)


(30–49%)


Stop


Mediastinoscopy


Surgery


Endobronchial ultrasound/endoscopic ultrasound-guided (EBUS/EUS) if tumour (T) standardised uptake value (SUV) >10; patient’s age <65 years; right upper lobe of lung (RUL). Red value range = percentage of positive or negative results depending on the pre-test probability considered. Blue value range = post-test probability of mediastinal involvement by the examinations performed.


ADK = adenocarcinoma; CEA = carcinoembryonic antigen; CT = computed tomography; FNA = fine-needle aspiration; PET = positron emission tomography.


believe that CT and PET negativity on the mediastinum allows biopsy and surgery to be avoided, except in cases of T3 or adenocarcinoma, where mediastinal metastasis gives a poor prognosis. In addition, one must keep in mind that PET alone cannot easily distinguish between the central tumour and mediastinal metastasis.70–72


New Developments


Many of the mediastinal approaches discussed above take into account to some degree of the a priori probability that a given tumour will produce mediastinal metastasis, thus identifying different situations in which the same test can be conclusive for a surgical


EUROPEAN ONCOLOGY & HAEMATOLOGY


decision or, conversely, where the probability of occult mediastinal metastasis remains high even in the case of a negative result. Moreover, there is general agreement that a negative cytological result must always be confirmed surgically. However, only a few works have looked for objective criteria to distinguish a negative from an inadequate sample and have suggested different evaluation methods in the two cases.36,37


No work, to our knowledge, has ever


tried to integrate the performance of all diagnostic tests and negative prognostic factors to build up one synthetic model in which the evaluation of negative results (including negative cytological results) is not absolute, but is related to pre-test data and therefore to the


33


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