. Step 9 of 41
Clinical Stem 1
Non-smoking female with a new right upper lobe lung mass and three PET-positive mediastinal lymph nodes

Answer B
Diagnostic yield from either conventional TBNA or EBUS-TBNA is highest from subcarinal station 7 nodes. While this might support initial sampling of the subcarinal node in most instances, the first station that should be sampled in this patient is station 4L because the patient has a right upper lobe mass. A positive 4L, in this case a contra-lateral mediastinal node, would confirm N3 disease. The patient might also have positive nodes at levels 7 and 4R consistent with N2 disease. Should the contralateral node be negative, then stations 7 and 4R could be sampled. If either of these N2 nodes is positive, the patient's tumor would be staged III A using the revised IASLC classification.
If N3 nodes are positive for malignancy following rapid on-site cytological evaluation, and if the procedure is performed for diagnosis and mediastinal staging only, the procedure could be stopped and the tumor would be staged III B.

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References:
  1. Rusch VW, Asamura H, Watanabe H, et al; Members of IASLC Staging Committee. The IASLC lung cancer staging project: a proposal for a new international lymph node map in the forthcoming seventh edition of the TNM classification for lung cancer. J Thorac Oncol. 2009; 4: 568?577
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