Management of Mediastinal Malignancy with Local Invasion

Initial Staging and Assessment

Complete staging with PET-CT and brain imaging is required before any treatment decisions to rule out distant metastases and assess mediastinal nodal involvement, as recommended by the European Society for Medical Oncology 4
Invasive mediastinal staging is essential, with PET-positive mediastinal findings requiring pathological confirmation, preferably using EBUS or EUS as first-line procedures, according to the American College of Chest Physicians 4
Extrathoracic imaging is mandatory for patients being considered for curative resection, as stated by the National Comprehensive Cancer Network 2, 3

Mediastinal nodal involvement represents a contraindication to primary surgical resection and fundamentally changes the treatment approach, as recommended by the American College of Chest Physicians 1, 2, 3
The extent of local invasion matters less than nodal status, with T4N0-1 tumors having significantly better outcomes than smaller tumors with extensive mediastinal nodal involvement, according to the European Society for Medical Oncology 7

For T4N0-1 disease, surgical resection at a specialized center is the preferred approach when complete resection is achievable, as recommended by the National Comprehensive Cancer Network 2, 3, 7
Every effort must be made to achieve complete resection, which may require extended operations, including resection of invaded mediastinal structures, according to the American College of Chest Physicians 2, 3, 7
Systematic mediastinal lymph node sampling or complete dissection is mandatory at the time of resection, as stated by the American College of Chest Physicians 1
Post-operative mortality should not exceed 2-3% for lobectomy and 3-5% for pneumonectomy, and these procedures should be restricted to high-volume experienced centers, according to the European Society for Medical Oncology 8

Platinum-based chemotherapy is recommended if occult N2 disease is found at resection, as recommended by the American College of Chest Physicians 1
Sequential adjuvant radiotherapy is suggested when concern for local recurrence is high, though it reduces local recurrence without clear survival benefit, according to the American College of Chest Physicians 1

Definitive concurrent chemotherapy and radiotherapy is recommended for patients with good performance status, as stated by the National Comprehensive Cancer Network 2, 3
Unresectability is determined by inability to achieve complete resection, multiple sites of chest wall invasion, or extensive mediastinal nodal involvement, according to the National Comprehensive Cancer Network 9

For malignant pleural mesothelioma with local invasion, management by a multidisciplinary team with mesothelioma experience is mandatory, as recommended by the National Comprehensive Cancer Network 9
Surgical options include pleurectomy/decortication with mediastinal lymph node sampling or extrapleural pneumonectomy, according to the National Comprehensive Cancer Network 9
First-line chemotherapy: pemetrexed 500 mg/m² plus cisplatin 75 mg/m² every 3 weeks, as recommended by the National Comprehensive Cancer Network 9

Never proceed with surgical resection without thorough preoperative mediastinal staging, as recommended by the American College of Chest Physicians 1
Do not perform primary surgical resection for preoperatively identified discrete N2 disease outside of clinical trials, according to the American College of Chest Physicians 1
Incomplete resection has poor outcomes, and if complete resection is not technically possible, abort surgery and proceed with definitive chemoradiotherapy, as stated by the American College of Chest Physicians 1, 2