Does the mediastinum of patients with non-small cell lung cancer require histologic staging? Future standards for computed tomography.

We asked whether noninvasive staging of the mediastinum is a reasonable alternative to invasive staging in patients with non-small cell lung cancer. Decision analysis was used to compare strategies relying upon mediastinoscopy, bronchoscopy with transbronchial needle aspiration, and/or thoracotomy for histologic or cytologic confirmation of mediastinal stage to two strategies primarily relying upon computed tomography for assessing the mediastinum. Life expectancy was the outcome of interest. Extensive sensitivity analysis showed that, if the specificity of computed tomography for mediastinal disease was above 0.90, a strategy primarily relying upon computed tomography to stage the mediastinum would provide a life expectancy within 1 month of that provided by invasive testing. The difference in life expectancy between the invasive and noninvasive staging strategies decreased further as the prior probability of unresectable disease increased. Surprisingly, the sensitivity of computed tomography for mediastinal disease was of little importance in determining overall life expectancy. These results suggest that noninvasive imaging techniques might reliably replace invasive mediastinal staging if their specificity exceeds 0.90.