{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,24]],"date-time":"2026-10-24T01:01:46Z","timestamp":1792803706638,"version":"4.5.0"},"reference-count":31,"publisher":"MDPI AG","issue":"11","license":[{"start":{"date-parts":[[2026,5,28]],"date-time":"2026-05-28T00:00:00Z","timestamp":1779926400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Australian National Health and Medical Research Council Leadership Investigator Grants","award":["2008317"],"award-info":[{"award-number":["2008317"]}],"id":[{"id":"https:\/\/ror.org\/011kf5r70","id-type":"ROR","asserted-by":"crossref"}]},{"award":["2008317"],"award-info":[{"award-number":["2008317"]}],"id":[{"id":"https:\/\/ror.org\/011kf5r70","id-type":"ROR","asserted-by":"publisher"}]},{"name":"Cancer Council of Victoria Colebatch Fellowship"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cancers"],"abstract":"<jats:p>Introduction: Systematic endoscopic mediastinal lymph node (LN) staging in early stage non-small-cell lung cancer (NSCLC) is widely recommended for optimal pre-operative staging due to imperfect accuracy of PET\/CT. The SEISMIC study utilized synoptic reporting of findings during systematic endoscopic staging to inform radiotherapy planning in patients with locally advanced NSCLC and established a significant rate of discordance between PET-identified extent of disease and observed findings following EBUS. International guidelines recommend systematic LN staging in patients with clinical nodal stage (cN) 1\u20133 disease as a quality indicator, though performance metrics for quality assessment of systematic endoscopic mediastinal staging in NSCLC have not been described. Methods: A post hoc analysis of 155 participants with locally advanced NSCLC recruited to the SEISMIC study who underwent systematic endoscopic mediastinal staging, with sampling of all LN \u2265 6 mm, prior to planning of radical or high-dose palliative radiation, was completed. Synoptic procedural reports and pre-procedure PET imaging were examined to determine the number of LN sampled, as well as the number of radiologically normal LN (&lt;10 mm diameter, no PET-avidity) sampled, and to establish the completeness of mediastinal staging. Results: Sampling was performed from a median two LN per patient. Sampling from at least one radiologically normal LN was performed in 92\/155 (59%) participants, with \u22652 radiologically normal LN sampled in 47 participants (30%). PET-occult LN disease was identified in 18 of 92 (20%) of patients who underwent sampling of radiologically normal LN. The number of LN sampled in individual patients was largely influenced by the number of observed LN \u2265 6 mm in the short-axis dimension. Among these 76 participants staged cN2a by PET, EBUS identified PET-occult metastases in seven (9%), with four (5%) upstaged to cN2b and three (4%) to cN3. In only three patients (2% of cohort) were LN &gt; 6 mm at higher station than the highest LN identified by PET not sampled endoscopically, confirming a high rate of complete mediastinal assessment. Conclusions: Quality of systematic staging in the SEISMIC study was high. Synoptic reporting supports high quality systematic endoscopic mediastinal LN staging in NSCLC and enables performance monitoring of systematic EBUS staging. Novel quality metrics are proposed for quality assessment, and consistent use of these may encourage more extensive LN sampling.<\/jats:p>","DOI":"10.3390\/cancers18111766","type":"journal-article","created":{"date-parts":[[2026,5,28]],"date-time":"2026-05-28T12:09:07Z","timestamp":1779970147000},"page":"1766","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Lymph Node Sampling Patterns and Completeness of Staging During Systematic Mediastinal Lymph Node Staging in Patients with Locally Advanced Non-Small-Cell Lung Cancer: A Post Hoc Analysis from the SEISMIC Study"],"prefix":"10.3390","volume":"18","author":[{"given":"Kanishka","family":"Rangamuwa","sequence":"first","affiliation":[{"name":"Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, 300 Grattan Street, Melbourne, VIC 3050, Australia"},{"name":"Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Parkville, VIC 3010, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6562-2626","authenticated-orcid":false,"given":"Ashleigh","family":"Witt","sequence":"additional","affiliation":[{"name":"Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, 300 Grattan Street, Melbourne, VIC 3050, Australia"},{"name":"Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Parkville, VIC 3010, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joseph M.","family":"Curran","sequence":"additional","affiliation":[{"name":"Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, 300 Grattan Street, Melbourne, VIC 3050, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gargi","family":"Kothari","sequence":"additional","affiliation":[{"name":"Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia"},{"name":"The Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC 3010, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Neil","family":"Wallace","sequence":"additional","affiliation":[{"name":"Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia"},{"name":"The Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC 3010, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicholas","family":"Hardcastle","sequence":"additional","affiliation":[{"name":"Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia"},{"name":"The Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC 3010, Australia"},{"name":"Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW 2500, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5670-0132","authenticated-orcid":false,"given":"Shaun","family":"Yo","sequence":"additional","affiliation":[{"name":"Department of Lung and Sleep, Monash Health, Melbourne, VIC 3168, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Farzad","family":"Bashirdazeh","sequence":"additional","affiliation":[{"name":"Department of Thoracic Medicine, Royal Brisbane and Women\u2019s Hospital, Brisbane, QLD 4006, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Phan","family":"Nguyen","sequence":"additional","affiliation":[{"name":"Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA 5000, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9037-7914","authenticated-orcid":false,"given":"Barton R.","family":"Jennings","sequence":"additional","affiliation":[{"name":"Department of Lung and Sleep, Monash Health, Melbourne, VIC 3168, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David","family":"Fielding","sequence":"additional","affiliation":[{"name":"Department of Thoracic Medicine, Royal Brisbane and Women\u2019s Hospital, Brisbane, QLD 4006, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laurence","family":"Crombag","sequence":"additional","affiliation":[{"name":"Department of Pulmonology, Amsterdam University Medical Centres, University of Amsterdam, 1012 WP Amsterdam, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kazuhiro","family":"Yasufuku","sequence":"additional","affiliation":[{"name":"Division of Thoracic Surgery, Toronto General Hospital, Toronto, ON M5G 2C4, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jouke T.","family":"Annema","sequence":"additional","affiliation":[{"name":"Department of Pulmonology, Amsterdam University Medical Centres, University of Amsterdam, 1012 WP Amsterdam, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6351-5552","authenticated-orcid":false,"given":"David","family":"Ost","sequence":"additional","affiliation":[{"name":"Department of Pulmonary Medicine, MD Anderson Cancer Center, The University of Texas, Houston, TX 78712, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2840-0658","authenticated-orcid":false,"given":"Shankar","family":"Siva","sequence":"additional","affiliation":[{"name":"Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia"},{"name":"The Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC 3010, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8998-2949","authenticated-orcid":false,"given":"Daniel P.","family":"Steinfort","sequence":"additional","affiliation":[{"name":"Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, 300 Grattan Street, Melbourne, VIC 3050, Australia"},{"name":"Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Parkville, VIC 3010, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,5,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e211S-50S","DOI":"10.1378\/chest.12-2355","article-title":"Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines","volume":"143","author":"Silvestri","year":"2013","journal-title":"Chest"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"787","DOI":"10.1093\/ejcts\/ezu028","article-title":"Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer","volume":"45","author":"Dooms","year":"2014","journal-title":"Eur. J. Cardio Thorac. Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"40","DOI":"10.1183\/09031936.00064515","article-title":"Combined endobronchial and oesophageal endosonography for the diagnosis and staging of lung cancer","volume":"46","author":"Vilmann","year":"2015","journal-title":"Eur. Respir. J."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1016\/j.athoracsur.2021.05.051","article-title":"American College of Surgeons Commission on Cancer Standard for Curative-intent Pulmonary Resection","volume":"113","author":"Nissen","year":"2022","journal-title":"Ann. Thorac. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"152","DOI":"10.1111\/resp.14182","article-title":"EBUS versus EUS-B for diagnosing sarcoidosis: The International Sarcoidosis Assessment (ISA) randomized clinical trial","volume":"27","author":"Crombag","year":"2021","journal-title":"Respirology"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"722","DOI":"10.1111\/resp.14549","article-title":"Proposed quality indicators and recommended standard reporting items in performance of EBUS bronchoscopy: An official World Association for Bronchology and Interventional Pulmonology Expert Panel consensus statement","volume":"28","author":"Steinfort","year":"2023","journal-title":"Respirology"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1097\/LBR.0000000000000545","article-title":"Preoperative Staging by EBUS in cN0\/N1 Lung Cancer","volume":"26","author":"Leong","year":"2019","journal-title":"J. Bronc. Interv. Pulmonol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1309","DOI":"10.1016\/j.athoracsur.2026.03.043","article-title":"Comparing Nodal Upstaging Rates and Morbidity and Mortality of Common Nodal Sampling Guidelines in the STS General Thoracic Surgery Database","volume":"121","author":"Potter","year":"2026","journal-title":"Ann. Thorac. Surg."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Magouliotis, D.E., Androutsopoulou, V., Cioffi, U., Minervini, F., Sicouri, N., Xanthopoulos, A., and Scarci, M. (2026). Optimizing Lymph Node Staging in Non-Small Cell Lung Cancer Surgery: Evidence, Guidelines, and Quality Improvement Strategies. J. Clin. Med., 15.","DOI":"10.3390\/jcm15020831"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"2048","DOI":"10.1016\/j.athoracsur.2015.05.100","article-title":"Pathologic Upstaging in Patients Undergoing Resection for Stage I Non-Small Cell Lung Cancer: Are There Modifiable Predictors?","volume":"100","author":"Bott","year":"2015","journal-title":"Ann. Thorac. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"344","DOI":"10.1016\/j.jtho.2019.10.019","article-title":"The IASLC Lung Cancer Staging Project: Analysis of Resection Margin Status and Proposals for Residual Tumor Descriptors for Non-Small Cell Lung Cancer","volume":"15","author":"Edwards","year":"2020","journal-title":"Journal of thoracic oncology: Off. Publ. Int. Assoc. Study Lung Cancer"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"467","DOI":"10.1016\/S2213-2600(24)00010-9","article-title":"Systematic endoscopic staging of mediastinum to guide radiotherapy planning in patients with locally advanced non-small-cell lung cancer (SEISMIC): An international, multicentre, single-arm, clinical trial","volume":"12","author":"Steinfort","year":"2024","journal-title":"Lancet Respir. Med."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12890-022-02159-9","article-title":"Systematic endoscopic staging of mediastinum to determine impact on radiotherapy for locally advanced lung cancer (SEISMIC): Protocol for a prospective single arm multicentre interventional study","volume":"22","author":"Steinfort","year":"2022","journal-title":"BMC Pulm. Med."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"790","DOI":"10.1378\/chest.09-2149","article-title":"Combined Endoscopic-Endobronchial Ultrasound-Guided Fine-Needle Aspiration of Mediastinal Lymph Nodes Through a Single Bronchoscope in 150 Patients with Suspected Lung Cancer","volume":"138","author":"Herth","year":"2010","journal-title":"Chest"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"508","DOI":"10.1159\/000507096","article-title":"An International Survey of Mediastinal Staging Practices amongst Interventional Bronchoscopists","volume":"99","author":"Guinde","year":"2020","journal-title":"Respiration"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1124","DOI":"10.1016\/j.ejcts.2008.03.014","article-title":"Does endoesophageal ultrasound-guided fine-needle aspiration replace mediastinoscopy in mediastinal staging of thoracic malignancies?","volume":"33","author":"Witte","year":"2008","journal-title":"Eur. J. Cardio Thorac. Surg."},{"key":"ref_17","unstructured":"O\u2019Dowd, E.H.B., and Evison, M. (2025). BTS Audit of Quality in Endobronchial Ultrasound Pilot Audit Report 2024, British Thoracic Society. Available online: https:\/\/www.brit-thoracic.org.uk\/clinical-resources\/clinical-audits\/ebus-pilot-audit-2024\/."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"102","DOI":"10.1038\/ajg.2014.387","article-title":"Quality Indicators for EUS","volume":"110","author":"Wani","year":"2015","journal-title":"Am. J. Gastroenterol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"878","DOI":"10.1016\/j.amjsurg.2023.01.003","article-title":"Synoptic operative reporting in cancer surgery: A scoping review","volume":"225","author":"Watanabe","year":"2023","journal-title":"Am. J. Surg."},{"key":"ref_20","first-page":"e1033","article-title":"Inadequate Procedural Reporting Impairs Reporting of Quality Indicators in Bronchoscopy with Endobronchial Ultrasound","volume":"32","author":"Witt","year":"2025","journal-title":"J. Bronc. Interv. Pulmonol."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Witt, A., Rankin, N.M., Siu, H., Wilsmore, N., Yo, S., Lyne, C., Sun, K., Rangamuwa, K., Leong, T., and Hocking, A. (2026). Synoptic Reporting Improves Quality of Endobronchial Ultrasound (EBUS): An Australian Multicentre Study. Cancers, 18.","DOI":"10.3390\/cancers18101528"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1675","DOI":"10.1097\/JTO.0000000000000678","article-title":"The International Association for the Study of Lung Cancer Lung Cancer Staging Project: Proposals for the Revision of the N Descriptors in the Forthcoming 8th Edition of the TNM Classification for Lung Cancer","volume":"10","author":"Asamura","year":"2015","journal-title":"J. Thorac. Oncol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"4789","DOI":"10.1177\/17588359251344789","article-title":"The IASLC uncertain resection, general overview, current evidence, and future prospects: A systematic review and meta-analysis","volume":"17","author":"Hu","year":"2025","journal-title":"Ther. Adv. Med. Oncol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1382","DOI":"10.1016\/j.chest.2021.11.032","article-title":"Long-term Survival According to N Stage Diagnosed by Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Non-small Cell Lung Cancer","volume":"161","author":"Hwangbo","year":"2022","journal-title":"Chest"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"2001549","DOI":"10.1183\/13993003.01549-2020","article-title":"Trends in mediastinal nodal staging and its impact on unforeseen N2 and survival in lung cancer","volume":"57","author":"Bousema","year":"2020","journal-title":"Eur. Respir. J."},{"key":"ref_26","first-page":"3805","article-title":"Endosonography with or Without Confirmatory Mediastinoscopy for Resectable Lung Cancer: A Randomized Clinical Trial","volume":"41","author":"Bousema","year":"2023","journal-title":"J. Clin. Oncol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"108462","DOI":"10.1016\/j.lungcan.2025.108462","article-title":"Two-year survival and disease recurrence after endosonography with or without confirmatory mediastinoscopy for resectable lung cancer (a short communication of the MEDIASTrial follow-up)","volume":"202","author":"Bousema","year":"2025","journal-title":"Lung Cancer"},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Zhu, J., Bricknell, M., Watson, J.M., Leong, T.L., and Steinfort, D.P. (2026). Rates of nodal-upstaging following Systematic Endobronchial Ultrasound Lymph Node Staging in Non-Metastatic Non-Small Cell Lung Cancer: A Systematic Review and Meta-Analysis. Respiration, 1\u201323.","DOI":"10.1159\/000551141"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1180","DOI":"10.1016\/j.ejcts.2009.11.014","article-title":"Endobronchial ultrasound-guided needle aspiration in non-small-cell lung cancer restaging verified by the transcervical bilateral extended mediastinal lymphadenectomy\u2014A prospective study","volume":"37","author":"Szlubowski","year":"2010","journal-title":"Eur. J. Cardio Thorac. Surg."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1701102","DOI":"10.1183\/13993003.01102-2017","article-title":"Endoscopic ultrasound fine-needle aspiration by experienced pulmonologists: A cusum analysis","volume":"50","author":"Leong","year":"2017","journal-title":"Eur. Respir. J."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"960","DOI":"10.1016\/S2213-2600(16)30317-4","article-title":"Added value of combined endobronchial and oesophageal endosonography for mediastinal nodal staging in lung cancer: A systematic review and meta-analysis","volume":"4","author":"Korevaar","year":"2016","journal-title":"Lancet Respir. Med."}],"container-title":["Cancers"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6694\/18\/11\/1766\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,28]],"date-time":"2026-05-28T12:19:13Z","timestamp":1779970753000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6694\/18\/11\/1766"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,28]]},"references-count":31,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["cancers18111766"],"URL":"https:\/\/doi.org\/10.3390\/cancers18111766","relation":{},"ISSN":["2072-6694"],"issn-type":[{"value":"2072-6694","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,28]]}}}