Restaging of the mediastinum

Patients diagnosed with stage IIIA lung cancer because of N2 positive disease are generally considered to have a short survival. However, recent studies have shown that patients who are downstaged via neoadjuvant therapy and subsequently undergo resection may have a significant increased 5-year survival rate (as high as 40-50%) when compared with patients who have residual N2 disease. The identification of patients who are N2 negative after the completion of their neoadjuvant therapy is a critical component of proper patient selection and counseling for thoracotomy and resection, especially if a pneumonectomy needs to be considered.

The question, how to reassess patients with stage IIIA non-small-cell lung cancer after neoadjuvant therapy, is broader than just looking at downstaging of mediastinal lymph nodes, but also involves prediction of partial or complete pathologic response on the primary tumor and long-term outcome prediction. On the basis of the published data every technique has indications and limitations. The comparison of the different techniques is still problematic for various reasons.

In this article we review the best ways to restage patients with N2 disease after they have completed their neoadjuvant therapy.