EUS-FNA and EBUS-TBNA; the pulmonologist’s and surgeon's perspective

Introduction

Lung cancer is the leading cancer related cause of death in the western world [1]. The prognosis is directly related to the stage of the disease. Treatment strategies are largely based on the cell type of the tumor, i. e. either small cell lung cancer (SCLC) or non-small cell lung cancer (NSCLC), and the presence of mediastinal involvement or distant spread of the tumor [1] [2]. The treatment of SCLC is mainly chemotherapy whereas NSCLC treatment is fully stage dependent ranging from surgery only to down-staging chemotherapy with subsequent surgery or entirely experimental chemotherapy/radiotherapy.

Non-small cell lung cancer (NSCLC) usually metastasizes first to hilar and mediastinal lymph nodes. Subsequently, hematogenous metastasis to distant sites may occur. Because survival is inversely correlated with stage, a meticulous staging procedure is required to determine the treatment and prognosis [3] [4]. For staging of NSCLC, the TNM classification has been developed, in which T stands for local tumor extension, N for lymph node metastasis, and M for distant metastasis. The lymph node map by Mountain et al, and its revisions are often used for the description of the N factor of the TNM classification [5] (Table [1] and [2]).

Table 1 TNM classification of lung Cancer Primary tumor · Tis - Carcinoma in situ · TX - Positive malignant cytologic findings, no lesion observed · T1 - diameter of 3 cm or smaller and surrounded by lung or visceral pleura (see Image 1) or endobronchial tumor distal to the lobar bronchus · T2 - Diameter greater than 3 cm (see Images 2 - 3); extension to the visceral pleura, atelectasis, or obstructive pneumopathy involving less than 1 lung; lobar endobronchial tumor; or tumor of a main bronchus more than 2 cm from the carina · T3 - Tumor at the apex (see Image 5); total atelectasis of 1 lung; endobronchial tumor of main bronchus within 2 cm of the carina but not invading it; or tumor of any size with direct extension to the adjacent structures such as the chest wall mediastinal pleura (see Image 8), diaphragm, pericardium parietal layer, or mediastinal fat of the phrenic nerve · T4 - Invasion of the mediastinal organs, including the esophagus trachea, carina (see Image 11), great vessels (see Image 13), and/or heart; obstruction of the superior vena cava; involvement of a vertebral body; recurrent nerve involvement; malignant pleural or pericardial effusion; or satellite pulmonary nodules within the same lobe as the primary tumor • Regional lymph node involvement · N0 - No lymph nodes involved · N1 - Ipslateral bronchopulmonary or hilar nodes involved · N2 - Ipsilateral mediastinal nodes or ligament involved - Upper paratracheal lower paratracheal nodes - Pretracheal (see Image 4, Image 7, Image 10) and retrotracheal nodes - Aortic and aortic window nodes - Para-aortic nodes - Para-esophageal nodes - Pulmonary ligament - Subcarinal nodes (see Images 12 - 17) · N3 - contralateral mediastinal or hilar nodes involved (see image 19) or any scalene or supraclavicular nodes involved • Metastatic involvement · M0 - No metastases · M1 - Metastases present (see Images 20 - 27)

Table 2 Stage groupings • IA - T1N0M0 • IB - T2N0M0 • IIA - T1N1M0 • IIB - T2N1M0 or T3N0M0 • IIIA - T1-3N2M0 or T3N1M0 • IIIB - Any T4 or any N3M0 • IV - Any M1

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