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Lymph Node Sampling Patterns and Completeness of Staging During Systematic Mediastinal Lymph Node Staging in Patients
Kanishka Rangamuwa1,2, Ashleigh Witt1,2, Joseph M Curran1
1Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, 300 Grattan Street, Melbourne, VIC 3050, Australia.
Cancers
|June 12, 2026
Summary
Systematic endoscopic lymph node staging in non-small-cell lung cancer (NSCLC) using EBUS provides high-quality mediastinal assessment, identifying PET-occult disease and enabling performance monitoring for improved staging accuracy.
Area of Science:
- Thoracic Oncology
- Pulmonology
- Medical Imaging
Background:
- Systematic endoscopic mediastinal lymph node (LN) staging is crucial for early-stage non-small-cell lung cancer (NSCLC) due to PET/CT limitations.
- International guidelines recommend systematic LN staging for clinical nodal stage (cN) 1-3 disease, but quality assessment metrics are lacking.
- The SEISMIC study explored synoptic reporting during endoscopic staging to inform radiotherapy planning and assess discordance with PET/CT findings.
Purpose of the Study:
- To evaluate the quality and completeness of systematic endoscopic mediastinal LN staging in locally advanced NSCLC.
- To assess the utility of synoptic reporting in monitoring the performance of systematic endobronchial ultrasound (EBUS) staging.
- To propose novel quality metrics for systematic EBUS staging in NSCLC.
Main Methods:
- A post hoc analysis of 155 locally advanced NSCLC patients from the SEISMIC study who underwent systematic endoscopic mediastinal staging.
- Sampling of all lymph nodes (LN) ≥ 6 mm, including radiologically normal LN (<10 mm, no PET-avidity).
- Examination of synoptic procedural reports and PET imaging to determine LN sampled, completeness of staging, and PET-occult disease detection.
Main Results:
- A median of two LN were sampled per patient, with 59% undergoing sampling of at least one radiologically normal LN.
- PET-occult LN disease was found in 20% of patients with sampled normal LN; 9% of cN2a patients were upstaged by EBUS.
- A high rate (98%) of complete mediastinal assessment was confirmed, with minimal discrepancies between PET findings and endoscopic sampling.
Conclusions:
- Systematic endoscopic mediastinal LN staging, supported by synoptic reporting, demonstrates high quality in NSCLC.
- Synoptic reporting facilitates performance monitoring of systematic EBUS staging and supports the identification of PET-occult disease.
- Proposed novel quality metrics can enhance the assessment and encourage more comprehensive LN sampling in NSCLC staging.
