Mediastinales Staging

Ein gründliches mediastinales Staging ist von zentraler Bedeutung für die prognostische Einschätzung und Therapieplanung bei Patienten mit nicht-kleinzelligem Lungenkarzinom (NSCLC) ohne Fernmetastasierung. Leitlinien zum mediastinalen Staging fordern konsequent die Kombination aus radiologischen, nuklearmedizinischen und minimalinvasiven Methoden. Technik und Ergebnis der verschiedenen Methoden werden beschrieben und Algorithmen für unterschiedliche onkologische Situationen vorgestellt.

Abstract

Thorough mediastinal staging is pivotal for prognostic assessment and treatment planning in patients with non-small-cell lung cancer (NSCLC) without distant metastasis. It aims to answer the question of whether a technically and functionally feasible operation also makes sense from an oncological point of view. In case of a nodal-free mediastinum, primary surgical therapy can be considered. If the ipsilateral mediastinal lymph nodes are affected, multimodal therapy should be sought. Operating is usually no longer the first step, especially with extensive lymph node infestation. Surgery is recommended, if neoadjuvant (radio-)chemotherapy has achieved downstaging or major response. If the contralateral mediastinal lymph nodes are involved, curative surgery is no longer part of the therapeutic concept. The therapy of choice in this situation is definitive chemo-radiotherapy.

Guidelines for mediastinal staging consistently require to combine radiological, nuclear medicine and minimally invasive methods. Imaging with CT and PET allows an initial assessment of the mediastinal status. In most cases it has to be complemented with tissue confirmation. Echoendoscopic assessment of the mediastinum with needle biopsy is the minimally invasive method of first choice (“needle first”). Surgical staging methods are reserved for situations, that cannot be satisfactorily clarified by echoendoscopy.

Technique and outcome of the different methods are described and algorithms are presented for different oncological situations.

Kernaussagen

• Im Falle eines nodalfreien Mediastinums kann eine primär chirurgische Therapie in Betracht gezogen werden. Sind die ipsilateralen mediastinalen Lymphknoten befallen, sollte eine multimodale Therapie angestrebt werden. Insbesondere bei ausgedehntem Lymphknotenbefall ist die Operation nicht mehr der erste Schritt.

• Eine Operation wird empfohlen, wenn durch eine neoadjuvante (Radio-)Chemotherapie ein Downstaging oder ein gutes Ansprechen erreicht wurde.

• Sind die kontralateralen mediastinalen Lymphknoten befallen, gehört die kurative Operation nicht mehr zum therapeutischen Konzept; die Therapie der Wahl ist in dieser Situation die definitive Radiochemotherapie.

• Die Bildgebung mit CT und PET erlaubt eine erste Einschätzung des mediastinalen Status. In den meisten Fällen muss sie durch eine Gewebebestätigung ergänzt werden.

• Die endosonografische endoskopische Beurteilung des Mediastinums mit Nadelbiopsie ist die minimalinvasive Methode der ersten Wahl („needle first“).

• Chirurgische Stagingmethoden sind Situationen vorbehalten, die durch endosonografische endoskopische Techniken nicht zufriedenstellend abgeklärt werden können.

Publication History

Article published online:
07 December 2021

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