Accurate assessment of lymph node status is an integral part of the staging of patients with non-small cell lung cancer (NSCLC). The objective of this study is to delineate the current practice of Canadian thoracic surgeons in the nodal staging of patients with potentially curable NSCLC in comparison to published guidelines. 

An online questionnaire was sent out to all Canadian Association of Thoracic Surgeons members (n=86). Items in the questionnaire addressed the use of imaging, thresholds and methods for invasive staging (IS), and intraoperative nodal staging. Comparison was made against National Comprehensive Cancer Network, American College of Chest Physicians and European Society of Thoracic Surgeons guidelines.

47 thoracic surgeons completed the survey (55%): 31 practiced in an academic setting and 15 had a community practice. Most had been in practice >10years (67%). 

Most respondents order a positron emission tomography (PET) scan in every patient (87.2%).  Most respondents perform IS more selectively (87.2%). Indications for IS were highly variable; the most commonly identified were suspected nodal involvement on imaging (80.5%), tumor within the central third of the lung (67.5%) and tumor >3cm (34.2%). Endobronchial ultrasound (EBUS), was selected as the initial IS procedure of choice by 47.9% of respondents, while 43.5% selected mediastinoscopy first. Of surgeons selecting mediastinoscopy, most (61.9%) reported a lack of availability of EBUS. There was also wide variation in which nodes respondents routinely harvested intraoperatively for given lobectomies.  A sizeable minority of surgeons (13%) did not routinely harvest any lymph nodes during resection for NSCLC.

The selection of NSCLC patients for curative-intent therapy relies on proper staging.  Although most surgeons stated they derived their practices in nodal staging from one or more established guidelines, a significant proportion of respondents’ practices did not reflect those recommendations. This may result in inaccurate staging and suboptimal care.

Patterns of practice in mediastinal lymph node staging for non-small cell lung cancer in Canada