Author:

Keywords:

Science & Technology, Life Sciences & Biomedicine, Cardiac & Cardiovascular Systems, Respiratory System, Surgery, Cardiovascular System & Cardiology, Non-small-cell lung cancer, Central tumour, Nodal upstaging, cN0, pN1, pN2, ESTS GUIDELINES, OPEN SURGERY, RISK-FACTORS, N2 DISEASE, METASTASIS, MODEL, INVOLVEMENT, VALIDATION, PATTERN, SCAN, Aged, Carcinoma, Non-Small-Cell Lung, Female, Fluorodeoxyglucose F18, Humans, Lung Neoplasms, Lymphatic Metastasis, Male, Mediastinum, Middle Aged, Neoplasm Staging, Pneumonectomy, Positron Emission Tomography Computed Tomography, Predictive Value of Tests, Radiopharmaceuticals, Retrospective Studies, Risk Factors, Leuven Lung Cancer Group, 1102 Cardiorespiratory Medicine and Haematology, 3201 Cardiovascular medicine and haematology

Abstract:

OBJECTIVES: Current guidelines recommend preoperative invasive mediastinal staging in centrally located tumours with negative mediastinum on positron emission tomography-computed tomography, based on a 20-30% prevalence of occult mediastinal disease (pN2-3). However, a uniform definition of central tumour location is lacking. Our objective was to determine the best definition in predicting occult pN2-3. METHODS: A single-institution database was queried for patients with (suspected) non-small-cell lung cancer staged cN0 after positron emission tomography-computed tomography and referred to invasive staging and/or primary surgery. We evaluated 5 definitions: inner 1/3, inner 2/3, contact with bronchovascular structures, ≤2 cm from bronchus or endobronchial visualization. RESULTS: Between 2005 and 2015, 813 patients were eligible (cT1: 42%, cT2: 28%, cT3: 17% and cT4: 11%). Invasive mediastinal staging and resection were performed in 30% and 97% of patients, respectively. Any nodal upstaging (pN+) was found in 21% of patients, of whom pN2-3 was found in 8%. Central tumour location demonstrated 4 times higher odds for any pN+ [for inner 1/3 vs outer 2/3, odds ratio 3.90 (95% confidence interval 2.24-6.77), P < 0.001], whereas no significantly different odds was observed for pN2-3. The discriminative ability for pN+ was not significantly different between the several definitions. CONCLUSIONS: The prevalence of occult pN2-3 was only 8% when modern fusion positron emission tomography-computed tomography imaging pointed at clinical N0 non-small-cell lung cancer. None of the 5 verified definitions of centrality was predictive for occult pN2-3. However, each definition of centrality was related to any pN+ at a prevalence of 21%, without significant differences in discriminative ability between definitions. These data question whether indication for preoperative invasive mediastinal staging should be based on centrality alone.