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Approach to the Solitary Pulmonary Nodule - New Staging System for NSCLC - Lymph Node Map-Update
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Approach to the Solitary Pulmonary Nodule - New Staging System for NSCLC - Lymph Node Map-Update

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Approach to the Solitary Pulmonary Nodule

Approach to the Solitary Pulmonary Nodule
New Staging System for NSCLC
Lymph Node Map-Update

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  • liked ii good presentation. Allow it to download for contribution to community for teaching purpose. pl discuss differential diagnosis also other than carcinoma
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    Approach to the Solitary Pulmonary Nodule - New Staging System for NSCLC - Lymph Node Map-Update Approach to the Solitary Pulmonary Nodule - New Staging System for NSCLC - Lymph Node Map-Update Presentation Transcript

    • Approach to the Solitary Pulmonary NoduleNew Staging System for NSCLCLymph Node Map-Update
      Bassel Ericsoussi, MD
      Fellow, Pulmonary and Critical Care
      University of Illinois Medical Center at Chicago
    • The Peripheral Pulmonary Nodule
      Small focal radiographic opacities that may be solitary or multiple
      The term “Coin Lesion” should be discouraged
      The solitary pulmonary nodule (SPN)
      Round lesion
      <3 cm (if > 3 cm called mass)
      Completely surrounded by pulmonary parenchyma
      2
      UIC Bassel Ericsoussi, MD
    • Prevalence
      Prevalence of SPNs in screening trials of populations at high risk for lung neoplasm
      8-51%
      Nodules detected in screening trials are different than those detected in clinical routine practice:
      Smaller
      Prevalence of malignancy is lower
      Tumor volume doubling time is longer
      Prevalence of malignancy in patients with SPNs:
      1.1-12% in screening trials
      46-82% in PET trials
      Wahidi, MM. Chest 2007; 132:94s-107s
      3
      UIC Bassel Ericsoussi, MD
    • The Dilemma
      Malignant SPN can represent a potentially curable form of lung cancer
      Stage I survival: > 60% at 5 years
      The flip side is unnecessary procedures and surgeries with resultant morbidities
      Cost implications
      4
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    • Detection
      5
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    • Evaluation
      ?
      6
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    • Tools
      Clinical History
      Chest CT
      Observation
      Bronchoscopy
      Old Films
      FDG-PET
      TTNA
      Surgery
      7
      UIC Bassel Ericsoussi, MD
    • Goal
      Likely Benign
      ?
      Indeterminate
      Likely Malignant
      8
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    • Management
      Follow
      Likely Benign
      ???
      Indeterminate
      Likely Malignant
      Take Action
      9
      UIC Bassel Ericsoussi, MD
    • First Steps
      Obtain old films and compare sizes
      Determine nodule growth
      Any evidence of growth should prompt immediate tissue diagnosis
      In every patient with an indeterminate SPN that is visible on CXR, Chest CT should be performed
      10
      UIC Bassel Ericsoussi, MD
    • Growth Rate of the SPN
      Growth rate is usually expressed in volume doubling time (VDT):
      One doubling in volume of SPN usually represents 26% increase in diameter on chest CT
      VDT for malignant nodules: 20-300 days
      Because VDT for malignant SPNs rarely exceed 300 days, a 2–year radiographic stability predicts a benign process
      For ground-glass nodules, longer follow-up is recommended (>2 years)
      Gould, MK. Chest 2007, 132:108s-130s
      11
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    • Adenocarcinoma
      (3 months) Relatively slow growth
      12
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    • Infection
      (2 weeks) Fast growth
      13
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    • Pure Ground-Glass Nodules
      More likely to be malignant than solid nodule (59-73% vs. 7-9%)
      Bronchoalveolar carcinoma is the most common histological subtype
      Longer VDT
      Better prognosis
      Wahidi, MM. Chest 2007; 132:94s-107s
      14
      UIC Bassel Ericsoussi, MD
    • Ground-Glass Opacities
      Pure Ground Glass (BAC) Part-Solid (Adenocarcinoma)
      15
      UIC Bassel Ericsoussi, MD
    • Pre-Test Probability
      In every patient with SPN, the clinical pre-test probability of malignancy should be estimated either:
      Qualitatively by clinical judgment
      Quantitatively by using validated quantitative model
      The SPN calculator: http://www.chestx-ray.com/spn/spnprob.html
      This facilitates the selection and interpretation of subsequent diagnostic tests
      16
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    • Clinical Factors Influence Pre-Test Clinical Probability of Malignancy
      Size
      Calcification
      Margins
      Morphology
      17
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    • SPN Size
      Wahidi, MM. Chest 2007; 132:94s-107s
      18
      UIC Bassel Ericsoussi, MD
    • Calcification Patterns of SPN
      SPNs that are calcified in a clearly benign pattern do not warrant additional diagnostic evaluation
      Benign calcification patterns:
      Diffuse
      Central
      Popcorn
      Laminated
      Potentially malignant calcification patterns:
      Stippled
      Eccentric
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    • “Popcorn” Calcification
      Hamartoma
      20
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    • Benign Calcifications
      Diffuse: Benign granuloma
      Central: Benign disease
      Laminated
      21
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    • Markedly Enhancing Nodule
      Pulmonary Arteriovenous Malformation
      22
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    • Malignant Calcifications
      Eccentric
      Speckled
      Adenocarcinoma
      Adenocarcinoma
      Carcinoid tumor
      23
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    • Margins
      Risk of malignancy is 20-30% in nodules with smooth edges
      Risk of malignancy is 33-100% in nodules with irregular, lobulated, or spiculated borders
      Wahidi, MM. Chest 2007; 132:94s-107s
      24
      UIC Bassel Ericsoussi, MD
    • Margins
      Cavitary
      SCC
      Lobulated
      SCC
      Spiculated
      BAC
      Smooth
      Granuloma
      25
      UIC Bassel Ericsoussi, MD
    • Managements
      Low clinical pre-test probability of malignancy (<5%): serial chest CT at 3, 6, 12 and 24 months
      High clinical pre-test probability of malignancy (>60%): proceed to surgical resection
      Indeterminate clinical pre-test probability of malignancy (5-60%): careful consideration of options in conjunction with patient’s preferences
      26
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    • Talk to Your Patient
      Discuss the risks and benefits of alternative management strategies and elicit patient preferences
      27
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    • Choice of Sampling Modality
      TTNA if nodule is peripherally located
      Bronchoscopy:
      Air-bronchogram or bronchus sign are present
      Experience with advanced tools exists:
      Electromagnatic Navigation
      Radial EBUS
      CT-guided biopsy
      28
      UIC Bassel Ericsoussi, MD
    • Small Subcentimeter Pulmonary Nodules(<8 mm)
      For patients with no risk factors for lung cancer:
      Nodules < 4 mm
      No further follow up
      Nodules 4-6 mm
      Reevaluate with a chest CT at 12 months
      No further follow-up if unchanged at 12 months
      Nodules 6-8 mm
      Reevaluate with a chest CT between 6-12 months and between 18-24 months
      29
      UIC Bassel Ericsoussi, MD
    • Small Subcentimeter Pulmonary Nodules(<8 mm)
      For patients with risk factors for lung cancer:
      Nodules < 4 mm
      Reevaluate with a chest CT at 12 months
      Nodules 4-6 mm
      Reevaluate with a chest CT between 6-12 months and between 18-24 months
      Nodules 6-8 mm
      Reevaluate with a chest CT between 3-6, between 9-12 months, and between 18-24 months
      30
      UIC Bassel Ericsoussi, MD
    • Summary
      SPN is a common problem and can present a diagnostic dilemma
      Best strategy is determined on assessment of the risk of cancer in an individual patient
      Determine patient’s risk of malignancy
      Low risk: serial chest CTs
      High risk: surgical resection
      Indeterminate risk: consider PET scan, diagnostic sampling, or surgical resection
      Discuss risks and benefits of various strategies and elicit patient’s preferences
      31
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    • Clinical Scenario: Low Clinical Pre-Test Probability of Malignancy
      A 44 Y.O. man with history of HTN
      Had a fall and developed chest pain
      A chest CT was done and showed a 5 mm nodule in the LUL
      Patient has never smoked
      Analysis of case:
      Likelihood of malignancy is very low
      Best strategy is observation with serial chest CTs
      32
      UIC Bassel Ericsoussi, MD
    • Clinical Scenario: High Clinical Pre-Test Probability of Malignancy
      A 64 Y.O. woman developed an episode of bronchitis
      RUL nodule was found incidentally on CXR
      A prior CXR a year ago showed no abnormalities
      30 pack-year tobacco use, quit a year ago
      A chest CT showed a 1.3 cm spiculated pulmonary nodule
      33
      UIC Bassel Ericsoussi, MD
    • Clinical Scenario: High Clinical Pre-Test Probability of Malignancy
      Her physician ordered a PET scan which showed increased FDG uptake in the nodule
      He performed a bronchoscopy with BAL growing klebsiella and negative biopsy
      He decided to treat patient with antibiotics and to follow with serial chest CTs
      Analysis of the case:
      The likelihood of malignancy was very high (100% in the SPN calculator)
      Smoking history
      Age
      Growth of nodule
      Increased metabolic activity on PET scan
      Best course of action is surgical resection
      34
      UIC Bassel Ericsoussi, MD
    • Indeterminate Pre-Test Probability of Malignancy
      Obtain PET scan
      Consider management options:
      Radiographic observation if:
      Clinical probability is low (30-40%) and no activity on PET
      Sampling by bronchoscopy or TTNA if:
      Discordance between clinical pre-test probability and imaging tests (high suspicion but lesion is not active on PET)
      A benign diagnosis is suspected that requires specific treatment (fungal infection)
      A fully-informed patient desires proof of malignancy diagnosis prior to surgery
      Surgery is high risk
      35
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    • Rational for Staging
      Aid in planning treatment
      Indicate prognosis
      Assist in evaluating results of treatment
      Facilitate exchange of information between treatment centers
      Cancer research
      36
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    • STAGING OF LUNG CANCER HAS CHANGED AS OF JANUARY 1, 2010
      37
      UIC Bassel Ericsoussi, MD
    • Problem with the Previous System
      • Lack of validation for individual T, N, and M descriptors
      • Multiple discrepancies in published literature, particularly with T stage
      • Relatively small database from a single institution series
      • 2,155 patients from the MD Anderson Cancer Center in Houston, TX
      • Mainly surgical based
      38
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    • 39
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    • 40
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    • International Association for the Study of Lung Cancer (IASLC)
      100,869 cases from 45 sources in 20 countries
      81,015 cases included in analyses
      16% SCLC: 13290
      84% NSCLC: 67,725
      41
      UIC Bassel Ericsoussi, MD
    • Treatment Modalities – 67,725 NSCLC
      54% involved surgery
      Surgery
      42%
      Surgery
      RT
      5%
      Surgery
      Chemo
      4%
      Tri-modality
      3%
      RT
      8%
      Chemo
      15%
      Chemo
      RT
      12%
      42
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    • Stage Groupings
      The major determinant is the overall survival, based on the best stage
      Pathologic, if available; otherwise clinical
      43
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    • Prognosis According to Size Category
      44
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    • Prognosis According to Additional Nodules, T4 Invasion, and Pleural Dissemination
      45
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    • T Descriptor
      • T0: No primary tumor
      • T1: (T1a < 2 cm, T1b 2-3 cm) (used to be T1)
      • Not more proximal than the lobar bronchus
      • T2: (T2a 3-5, T2b 5-7 cm) (used to be T2) or
      • In the main bronchus > 2 cm distal to the carina
      • Invades visceral pleura
      • Atelectasis/obstructive pneumonia but not involving the entire lung
      • T3 > 7 cm or
      • Central location: In the main bronchus < 2 cm distal to the carina
      • Invasion: chest wall, diaphragm, phrenic nerve, mediastinal pleura, or parietal pericardium (used to be T4)
      • Atelectasis/obstructive pneumonitis of entire lung
      • Satellite nodules: separate tumor nodules in the same lobe (used to be T4)
      • T4 any size tumor
      • Invades heart, great vessels, trachea, carina, recurrent laryngeal nerve, esophagus, vertebral body
      • Separate tumor nodules in a different ipsilateral lobe (used to be M1)
      46
      UIC Bassel Ericsoussi, MD
    • Special Situations
      TX: Status not able to be assessed
      Tis: Focus of in situ cancer
      T1ss: Superficial spreading tumor of any size but confined to the wall of the trachea or mainstem bronchus
      47
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    • Prognosis According to the N Category
      48
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    • N Descriptor
      • N0: no LN involvement
      • N1: (stations 10-14)
      Ipsilateral peribronchial LN
      Ipsilateral perihilar LN
      Ipsilateral intrapulmonary nodes
      • N2
      Ipsilateral mediastinal LN
      Subcarinal LN (station 7)
      • N3
      Contralateral mediastinal LN
      Contralateral hilar LN
      Scalene LN
      Supraclavicular LN (station 1)
      49
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    • The Effect of Skip Metastases
      Involvement of N2 node station with/without involvement of any N1 nodes have same survival
      50
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    • M Descriptor
      M0: No distant metastasis
      M1a:
      Separate tumor nodules in a contralateral lobe (used to be M1)
      Tumor with pleural nodules or malignant pleural dissemination (used to be T4)
      M1b: Distant metastasis (used to be M1)
      51
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    • Stage Groups According to TNM Descriptor and Subgroups
      52
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    • Overall Survival by Clinical Stage
      53
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    • Overall Survival by Pathologic Stage
      54
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    • 55
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    • 56
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    • 57
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    • 58
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    • 59
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    • Lymph Node Map Update
      The International Association for the Study of Lung Cancer (IASLC) Lymph Node Map 2009
      60
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    • 61
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    • Supraclavicular Nodes(Station 1R/1L)
      • Includes:
      • Low cervical
      • Supraclavicular
      • Sternal notch
      • Upper border: lower margin of cricoid
      • Lower border: clavicles and upper border of manubrium
      • The midline of the trachea serves as border between 1R and 1L
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    • 63
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    • Upper Paratracheal(stations 2R/2L)
      2R. Right Upper ParatrachealUpper border: upper border of manubriumLower border: intersection of the innominate (left brachiocephalic) vein with the trachea
      2L. Left Upper ParatrachealUpper border: upper border of manubriumLower border: superior border of aortic arch
      2R nodes extend to the left lateral border of the trachea
      64
      UIC Bassel Ericsoussi, MD
    • Prevascular and Prevertabral nodes(Stations 3A/3P)
      3A anterior to the vessels
      3P posterior to the esophagus, which lies prevertebrally
      3A not accessible with mediastinoscopy
      3P accessible with EUS
      65
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      • 2R node in front of the trachea
      • Prevascular 3A (not accessible with mediastinoscopy)
      66
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    • Prevascular 3A node (not accessible with mediastinoscopy)
      Lower paratracheal 4R nodes
      67
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    • Right Lower Paratracheal(Station 4R)
      4R. Right Lower ParatrachealUpper border: intersection of the innominate (left brachiocephalic) vein with the tracheaLower border: lower border of azygos vein
      4R nodes extend to the left lateral border of the trachea
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      • 4R paratracheal nodes
      • Station 6 node: aortic node lateral to the aortic arch
      69
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    • Left Lower Paratracheal(Station 4L)
      Located left of the left tracheal border, medially to the ligamentum arteriosum
      Station 5 (AP-window) nodes are located laterally to the ligamentum arteriosum
      70
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    • Just above the level of the pulmonary trunk
      4R/4L lower paratracheal nodes
      Station 3 node
      Station 5 (AP window) nodes.
      71
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    • At the level of the lower trachea just above the carina
      4L nodes are between the pulmonary trunk and the aorta, but are not located in the AP-window, because they lie medially to the ligamentum arteriosum
      The node lateral to the pulmonary trunk is a station 5
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    • 73
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    • Subaortic and Para-aortic Nodes(Stations 5,6)
      • 5. Subaortic nodes (AP window nodes) are lateral to the ligamentum arteriosum 6. Para-aortic nodes located anteriorly and laterally to the ascending aorta and the aortic arch from the upper margin to the lower margin of the aortic arch
      74
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    • 75
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    • Subcarinal Nodes(Station 7)
      • Located caudally to the carina of the trachea
      • On the right they extend to the lower border of the bronchus intermedius
      • On the left they extend to the upper border of the lower lobe bronchus
      76
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    • Station 7 subcarinal node to the right of the esophagus
      77
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    • Paraesophageal Nodes(Station 8)
      Below the subcarinal nodes and extend to the diaphragm
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    • Station 8 node to the right of the esophagus
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      • PET scan: FDG uptake in a station 8 node
      • On the corresponding CT image the node is not enlarged
      • The probability that this is a lymph node metastasis is extremely high since the specificity of PET in unenlarged nodes is higher than in enlarged nodes
      80
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    • Pulmonary Ligament Nodes(Station 9)
      The pulmonary ligament is the inferior extension of the mediastinal pleural reflections
      81
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    • 82
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    • 83
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    • Hilar, Interlobar, Lober, Segmental, and SubsegmentalNodes (Station 10, 11-14)
      • Adjacent to the main stem bronchus
      • On the right they extend from the lower rim of the azygos vein to the interlobar region
      • On the left they extend from the upper rim of the pulmonary artery to the interlobar region
      Nodes in station 10 - 14 are all N1-nodes, since they are not located in the mediastinum
      84
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    • 85
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    • Conventional Mediastinoscopy
      2R and 2L: right and left upper paratracheal nodes
      4R and 4 L: right and left lower paratracheal nodes
      Station 7: subcarinal nodes (but not 7 posterior)
      Does not access :
      1R and 1L: supraclavicular nodes
      3A: prevascular nodes
      5-6: Subaortic (AP window), para-aortic nodes
      7 posterior
      8: paraesophageal nodes
      9: pulmonary ligaments nodes
      86
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    • Conventional Mediastinoscopy
      Necessary to confirm negative endoscopic biopsies
      Sensitivity 85.2%
      Specificity 100%
      Morbidity 2%
      Mortality 0.08%
      Complications
      Death - Pneumothorax
      Esophageal perforation - Hypotension
      Pulmonary artery laceration - IV fluid extravasation
      Excessive bleeding - Arrhythmia
      Hammoud et al. J Thoracic Cardiovasc Surg. 1999; 118:894-9
      87
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    • Extended MediastinoscopyLeft Anterior MediastinoscopyChamberlain Procedure
      Station 5: subaortic (AP window) LN
      Station 6: paraaortic nodes
      Contraindications:
      Calcified aorta
      Post operative aorta
      Far less easy and therefore less routinely performed than conventional mediastinoscopy
      • Mobidity 8%
      • Mortality < 1%
      88
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    • Endoscopic Ultrasound with Fine Needle Aspiration EUS-FNA
      Lower mediastinum LN
      • Station 7: subcarinal, including posterior subcarinal
      • Station 8: paraesophageal
      • Station 9: Pulmonary ligament
      • 3P: prevertebral
      • Left adrenal gland
      • Left liver lobe
      89
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    • Endobronchial Ultrasound Transbronchial Needle AspirationEBUS-TBNA
      90
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