INTEGRATION OF INVASIVE STAGING TECHNIQUES

The varied techniques of tissue staging ought to be viewed as
complementary and not as competitive procedures. forty one there
are several reasons for this. 1st of all, one can't compare
the performance characteristics ( sensitivity, specificity, and
fn and fp rates ) of 2 tests unless they're being applied
to a similar patient population. five it's quite clear that in most
printed studies, the patient populations included don't seem to be
a similar. they differ relative to whether or not lymph nodes were
enlarged or normal sized, that node stations were most
s uspicious, and whether or not the issue at hand was merely to establish
a diagnosis or to establish a tissue stage. furthermore,
in a very ssessing the r esults of a localityicular technique, it's important
to r ecognize that the performance characteristics are
d ifferent in patients with enlarged or normal-sized mediastinal
nodes. one mustn't use information from patients with enlarged
nodes to e stimate the price of a take a look at for a patient with
n ormal-sized nodes. so, patient characteristics are important
d eterminants in choice of the simplest technique of tissue
staging.
the results of staging procedures are conjointly strongly affected
by the expertise of the physicians performing the take a look at. it's likely
that the distinction between a similar procedure performed by
an professional with a dedicated interest and a fewone who performs
the procedure solely often is so much bigger than differences
between completely different tests. so, appropriate integration of
staging procedures is dependent on the native expertise. this
should be evaluated critically, ideally in a very multidisciplinary manner
and based mostly on actual native information.
a advised algorithm ( table 29. three ) is to perform mediastinoscopy
because the typically preferred tissue staging technique in
patients with normal-sized mediastinal nodes ( e. g., in patients
with a central tumor or n1 node enlargement who have a 20%
to 25% incidence of n2 involvement ). this can be as a result of the primary
issue is to rule out node involvement, and needle-based
techniques carry a high fn rate, particularly in normal-sized
nodes. as a result of a negative needle biopsy ( eus-na, ebusna,
or tbna ) ought to be followed by a mediastinoscopy, most
patients would endure each tests if a needle technique is employed
because the 1st step. on the opposite hand, a needle-based approach
could also be an honest 1st step in patients with enlarged nodes, because
it's going to spare several patients the would like on behalf of mediastinoscopy ;
but, a negative needle take a look at in patients with enlarged
nodes ought to typically still be followed by a mediastinoscopy.
in fact, these recommendations are affected by the locations
of the nodes that are most in question further because the local
expertise, as previously discussed.