Staging lung cancer requires a physiological as well as pathological assessment. It is laborious, and many patients are unsuitable for resection. There are some ‘grey’ areas where definite recommendations cannot be made, and each centre needs to review its own results. Lymphadenopathy can be assessed by mediastinoscopy, bronchoscopy, CT-guided needle biopsy and/or thoracoscopy. There is evidence for ‘selective’ mediastinoscopy, but there is also strong support for ‘routine’ mediastinoscopy. Thoracoscopy can be viewed in the same fashion. The definition of what constitutes a ‘physiological’ high risk patient also varies between centres. Despite all of these issues, there are three basic ‘guidelines’.
1. No patient can be considered automatically ‘unresectable’ when chest radiography and/or CT demonstrates adenopathy or only suggests local invasion.
2. Clinical and/or radiographical evidence suggesting extensive local or metastatic disease should be evaluated as completely as possible before subjecting the patient to a possible ‘nontheraputic’ thoracotomy.
3. In some cases, thoracotomy is required to determine definitively whether the lesion is ‘completely’ resectable.
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