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Lung cancer is the leading cause of cancer-related mortality, accounting for 26% of all deaths from malignancy in the United States annually.1 When a patient is known or suspected to have non–small-cell lung cancer (NSCLC), determining the extent of the disease spread or stage is necessary to choosing the optimal treatment strategy. If no evidence of extrathoracic disease exists, understanding the involvement of the mediastinal lymph nodes is critical to assigning stage. Since treatment recommendations for NSCLC rely heavily on tumor stage, it seems intuitive that accurate staging would be standard. However, it has been repeatedly demonstrated that proper staging of NSCLC is not routinely performed.24

A variety of noninvasive staging modalities, such as computed tomography (CT scan), positron-emission tomography (PET scan), PET-CT scans, and magnetic resonance imaging (MRI), are readily available to most clinicians today. However, these imaging techniques often do not have the required sensitivity and specificity on which to base treatment decisions, and invasive staging, including mediastinoscopy, endobronchial ultrasound (EBUS), esophageal endoscopic ultrasound (EUS), and video-assisted thoracoscopic surgery (VATS) become necessary. Frequently, minimally invasive endoscopic staging tools can be used simultaneously to diagnose and stage a patient with NSCLC. Therefore, the thoracic surgeon should play a central role in evaluating patients with suspected lung cancer. Multiple consensus-based guidelines have been established to promote safe, cost-effective, and efficient processes to accurately determine the stage of a patient with NSCLC.5,6

In 2018, the 8th edition of the TNM staging system for lung cancer (Tables 68-1 and 68-2) replaced the 7th edition, which had been in place since 2009.7 Although the revision introduces a number of substantial changes, the basic tenets and modalities used for staging lung cancer patients remain the same. Novel techniques, such as sentinel lymph node biopsy and blood-based biomarker panels, may augment our ability to accurately stage patients in the future. This chapter serves to summarize the noninvasive and invasive modalities available for the staging and restaging of NSCLC. A thorough understanding of the strengths and limitations of each technique is necessary for appropriate clinical decision making.


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