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Divisi D, Di Leonardo G, Venturino M, Scarnecchia E, Gonfiotti A, Viggiano D, Lucchi M, Mastromarino MG, Bertani A, Crisci R. Endobronchial Ultrasound/Transbronchial Needle Aspiration-Biopsy for Systematic Mediastinal lymph Node Staging of Non-Small Cell Lung Cancer in Patients Eligible for Surgery: A Prospective Multicenter Study. Cancers (Basel) 2023; 15:4029. [PMID: 37627057 PMCID: PMC10452056 DOI: 10.3390/cancers15164029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/06/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND The treatment of lung cancer depends on histological and/or cytological evaluation of the mediastinal lymph nodes. Endobronchial ultrasound/transbronchial needle aspiration-biopsy (EBUS/TBNA-TBNB) is the only minimally invasive technique for a diagnostic exploration of the mediastinum. The aim of this study is to analyze the reliability of EBUS in the preoperative staging of non-small cell lung cancer (NSCLC). METHODS A prospective study was conducted from December 2019 to December 2022 on 217 NSCLC patients, who underwent preoperative mediastinal staging using EBUS/TBNA-TBNB according to the ACCP and ESTS guidelines. The following variables were analyzed in order to define the performance of the endoscopic technique-comparing the final staging of lung cancer after pulmonary resection with the operative histological findings: clinical characteristics, lymph nodes examined, number of samples, and likelihood ratio for positive and negative outcomes. RESULTS No morbidity or mortality was noted. All patients were discharged from hospital on day one. In 201 patients (92.6%), the preoperative staging using EBUS and the definitive staging deriving from the evaluation of the operative specimen after lung resection were the same; the same number of patients were detected in downstaging and upstaging (8 and 8, 7.4%). The sensitivity, specificity, positive and negative predictive value, and diagnostic accuracy were 90%, 90%, 82%, 94%, and 90%, respectively. The likelihood ratio for positive and negative results was 9 and 0.9, respectively, confirming cancer when present and excluding it when absent. CONCLUSIONS EBUS is the only low-invasive and easy procedure for mediastinal staging. The possibility to check the method in each of its phases-through direct visualization of the vessels regardless of their location in relation to the lymph nodes-makes it safe both for the endoscopist and for the patient. Certainly, the cytologist/histologist and/or operator must have adequate expertise in order not to negatively affect the outcome of the method, although three procedures appear to reduce the impact of the individual professional involved on performance.
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Affiliation(s)
- Duilio Divisi
- Department of Life, Health and Environmental Sciences, Thoracic Surgery Unit, University of L’Aquila, 67100 L’Aquila, Italy
| | - Gabriella Di Leonardo
- Department of Life, Health and Environmental Sciences, Thoracic Surgery Unit, University of L’Aquila, 67100 L’Aquila, Italy
| | | | - Elisa Scarnecchia
- Department of Thoracic Surgery, Cuneo General Hospital, 12100 Cuneo, Italy
| | - Alessandro Gonfiotti
- Thoracic Surgery Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy
| | - Domenico Viggiano
- Thoracic Surgery Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy
| | - Marco Lucchi
- Division of Thoracic Surgery, University Hospital of Pisa, 56124 Pisa, Italy
| | | | - Alessandro Bertani
- Division of Thoracic Surgery and Lung Transplantation, IRCCS ISMETT-UPMC, 90127 Palermo, Italy
| | - Roberto Crisci
- Department of Life, Health and Environmental Sciences, Thoracic Surgery Unit, University of L’Aquila, 67100 L’Aquila, Italy
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Ashok A, Jiwnani SS, Karimundackal G, Bhaskar M, Shetty NS, Tiwari VK, Niyogi DM, Pramesh CS. Controversies in Mediastinal Staging for Nonsmall Cell Lung Cancer. Indian J Med Paediatr Oncol 2021. [DOI: 10.1055/s-0041-1739345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
AbstractMediastinal lymph nodal involvement in nonsmall cell lung cancer plays a crucial role in deciding treatment strategy. Survival falls markedly with increasing involvement of mediastinal nodal stations. Hence, accurate staging of the mediastinum with lowest morbidity is of utmost importance. A wide array of invasive and noninvasive modalities that complement each other in assessing the nodes are available at our disposal. Guidelines recommend noninvasive imaging as the initial step in the staging algorithm for all tumors, followed by invasive staging. No single modality has proven to be the ideal method to stage the mediastinum when used alone. In the present decade, minimally invasive endobronchial ultrasound (EBUS) has challenged the position of surgical mediastinoscopy, which has been the gold standard, historically. However, a negative EBUS needs to be confirmed by surgical mediastinoscopy. Video-assisted mediastinoscopic lymphadenectomy has also come to the forefront in last two decades and has shown exceptional results, when performed in experienced centers. This review details the various modalities of mediastinal staging and the controversies surrounding the optimal method of staging, restaging after neoadjuvant therapy, and the most cost-effective strategy.
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Affiliation(s)
- Apurva Ashok
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Sabita S. Jiwnani
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - George Karimundackal
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Maheema Bhaskar
- Department of Pulmonology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Nitin S. Shetty
- Division of Interventional Radiology, Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Virendra Kumar Tiwari
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Devayani M. Niyogi
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - C. S. Pramesh
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
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3
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Lozekoot PWJ, Daemen JHT, van den Broek RR, Maessen JG, Gronenschild MHM, Vissers YLJ, Hulsewé KWE, de Loos ER. Surgical mediastinal lymph node staging for non-small-cell lung carcinoma. Transl Lung Cancer Res 2021; 10:3645-3658. [PMID: 34584863 PMCID: PMC8435384 DOI: 10.21037/tlcr-21-364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 06/30/2021] [Indexed: 12/25/2022]
Abstract
Background The current preferred approach for surgical mediastinal staging of non-small-cell lung carcinoma is video-assisted mediastinoscopy. An alternative technique in which lymph nodes are resected instead of biopsied is video-assisted mediastinoscopic lymphadenectomy (VAMLA) that is suggested to be superior in detecting N2 disease. Yet, evidence is conflicting and furthermore limited by sample size. The objective was to compare mediastinal staging through VAMLA and video-assisted mediastinoscopy. Methods A single-center cohort study was conducted. All consecutive patients that underwent surgical mediastinal staging of non-small-cell lung carcinoma by VAMLA (2011 to 2018) were compared to historic video-assisted mediastinoscopy controls (2007 to 2011). Patients with negative surgical mediastinal staging underwent subsequent anatomical resection with systematic regional lymphadenectomy. Primary outcome was the sensitivity and negative predictive value for detecting N2 disease. Results Two-hundred-sixty-nine video-assisted mediastinoscopic lymphadenectomies and 118 video-assisted mediastinoscopies were performed. The prevalence of N2 disease was 20% and 26% respectively in the VAMLA and video-assisted mediastinoscopy group, while the rate of unforeseen pN2 resulting from lymph node dissection during anatomical resection was 4% and 11%, respectively. Invasive staging using VAMLA demonstrated superior sensitivity of 0.82 and a negative predictive value of 0.96 when compared to video-assisted mediastinoscopy (0.62 and 0.89, respectively), offering a 64% decrease in risk of unforeseen pN2 following anatomical resection. However, VAMLA is also associated with a 75% risk increase on complications (P=0.36). Conclusions We conclude that performing invasive mediastinal lymph node assessment for staging of non-small-cell lung carcinoma, VAMLA should be the preferred technique with superior sensitivity and negative predictive value in detecting N2 disease. Though, VAMLA is also associated with an increased risk of complications.
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Affiliation(s)
- Pieter W J Lozekoot
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Jean H T Daemen
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands.,Faculty of Health, Medicine and Life Sciences (FHML), School for Oncology and Developmental Biology (GROW), Maastricht, The Netherlands
| | - Robert R van den Broek
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Faculty of Health, Medicine and Life Sciences (FHML), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | | | - Yvonne L J Vissers
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Karel W E Hulsewé
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Erik R de Loos
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
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4
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Diebels I, Hendriks JMH, Van Meerbeeck JP, Lauwers P, Janssens A, Yogeswaran SK, Van Schil PEY. Evaluation of mediastinoscopy in mediastinal lymph node staging for non-small-cell lung cancer. Interact Cardiovasc Thorac Surg 2021; 32:270-275. [PMID: 33257953 DOI: 10.1093/icvts/ivaa263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 08/12/2020] [Accepted: 09/17/2020] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES The purpose of this study was to assess the quality of video-assisted cervical mediastinoscopy (VACM) in the staging of non-small-cell lung cancer (NSCLC) at the Antwerp University Hospital with a focus on test effectiveness indicators, morbidity and unforeseen pN2 results. METHODS All consecutive VACM workups of cases of NSCLC performed between January 2010 and December 2015 were included to assess overall test quality and effectiveness. Quality assurance was performed in accordance with the recommendations of the European Society of Gastrointestinal Endoscopy and European Society of Thoracic Surgeons (ESTS) where appropriate. RESULTS A total of 168 video-assisted cervical mediastinoscopies were included. A total of 91.7% of the procedures were performed in accordance with the ESTS guideline. An unforeseen pN2 staging was identified in 10 anatomical lung resections (8.6%). Statistical analysis showed no significant association between VACM performed in accordance with the ESTS guideline and the presence of pN2 positive lymph nodes [χ2 (1) = 0.61; P = 0.57] and no association between VACM performed in accordance with the ESTS guideline and overall futile thoracotomy [χ2 (1) = 0.76; P = 0.50]. Calculations revealed a sensitivity of 81.8 [95% confidence interval (CI) 69.1-90.9], specificity of 100%, positive predictive value of 100%, negative predictive value of 91.9% (95% CI 86.6-95.2) and diagnostic accuracy of 94.1% (95% CI 89.33-97.11). CONCLUSIONS Overall, 91.7% of the VACM were performed in accordance with the ESTS guideline. This process resulted in a sensitivity of 81.8%, a negative predictive value of 91.9% and an unforeseen pN2 rate of 8.6%.
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Affiliation(s)
- Ian Diebels
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Jeroen M H Hendriks
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Jan P Van Meerbeeck
- Department of Pulmonology and Thoracic Oncology, Antwerp University Hospital, Antwerp, Belgium
| | - Patrick Lauwers
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Annelies Janssens
- Department of Pulmonology and Thoracic Oncology, Antwerp University Hospital, Antwerp, Belgium
| | - Suresh K Yogeswaran
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Paul E Y Van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Antwerp, Belgium
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5
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Fu Y, Chen Q, Yu Z, Dong H, Li X, Chen Q, Hu B, Li H, Miao J. Clinical application of ultrasound-guided mediastinal lymph node biopsy through cervical mediastinoscopy. Thorac Cancer 2020; 12:297-303. [PMID: 33141499 PMCID: PMC7862788 DOI: 10.1111/1759-7714.13717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/10/2020] [Accepted: 10/11/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Cervical mediastinoscopy is useful for diagnosing lung and mediastinal disease. Ultrasound is a safe real-time diagnostic tool widely employed in many surgical fields. Ultrasound was used in cervical mediastinoscopy in our cohort with satisfactory results. This study investigated the safety, feasibility, and availability of video-assisted mediastinoscopy (VAM) combined with ultrasound for mediastinal lymph node biopsy. METHODS A total of 87 cases involving cervical mediastinal lymph node biopsy performed from November 2015 to May 2020, with complete clinical and pathological information, were retrospectively analyzed in the Department of Thoracic Surgery at Beijing Chaoyang Hospital. The cohort was divided into two groups: ultrasound-guided biopsy under video-assisted mediastinoscopy (UVAM) (44 cases) and routine VAM (43 cases). Operation time, biopsy number and nodal stations, postoperative complications, pathological conditions, and surgical difficulty were compared between the two nodal stations. RESULTS UVAM was significantly shorter and more lymph node specimens were obtained than with VAM. There was one case of fatal bleeding and two cases of right recurrent laryngeal nerve injury in the VAM group, and no postoperative complications in the UVAM group. CONCLUSIONS When used with cervical VAM, ultrasound guidance assists physicians assess the space between lymph nodes, surrounding tissues, and large vessels systematically, making biopsy safer and easier, improving lymph node sampling, and decreasing postoperative complications. Furthermore, surgeons can easily learn and master this method. KEY POINTS Significant findings of the study: Ultrasound was used in combination with cervical mediastinoscopy and the results showed that ultrasound guidance makes biopsy in patients safer and easier, improves lymph node sampling, and decreases postoperative complications. WHAT THIS STUDY ADDS Surgeons can easily learn and master this method.
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Affiliation(s)
- Yili Fu
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Qingshan Chen
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zexing Yu
- Department of Ultrasound Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Honghong Dong
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xin Li
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Qirui Chen
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Bin Hu
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Hui Li
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jinbai Miao
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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6
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Bolletta E, Mastrofilippo V, Invernizzi A, Aldigeri R, Spaggiari L, Besutti G, Borrelli R, Lo Coco F, Ricchetti T, Rapicetta C, Cavazza A, Musci G, De Simone L, Gozzi F, Salvarani C, Pipitone N, Paci M, Cimino L. Clinical Relevance of Subcentimetric Lymph Node Biopsy in the Diagnosis of Ocular Sarcoidosis. Ocul Immunol Inflamm 2020; 30:717-720. [PMID: 33016855 DOI: 10.1080/09273948.2020.1817503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate the clinical relevance of subcentimetric lymph node biopsy via mediastinoscopy in patients with presumed ocular sarcoidosis (OS). METHODS Retrospective study of consecutive patients who underwent biopsy via mediastinoscopy for suspected OS. The biopsy outcomes and clinical features of patients with subcentimetric nodes and of those with lymph nodes >1 cm were compared. RESULTS A total of 67 patients with presumed OS were included. Forty-two patients (63%) had lymph nodes ≥1 cm in diameter, while 25(37%) showed subcentimetric lymph nodes. Biopsy was consistent with sarcoidosis in 83% of patients with lymph nodes ≥1 cm and in 76% of patients with subcentimetric lymph nodes (p = .60). Patients with OS who had subcentimetric lymph nodes had less lymphopenia (p = .01), lower lysozyme values (p = .03) and a longer diagnostic delay compared to those with larger lymph nodes. CONCLUSIONS The biopsy of subcentimetric lymph nodes via mediastinoscopy may provide a histological diagnosis and reduce diagnostic delay.
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Affiliation(s)
- Elena Bolletta
- Ocular Immunology Unit, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | | | - Alessandro Invernizzi
- Eye Clinic, Department of Biomedical and Clinical Science "L. Sacco", Luigi Sacco Hospital, University of Milan, Milan, Italy.,Save Sight Institute, University of Sydney, Sydney, Australia
| | | | - Lucia Spaggiari
- Department of Radiology, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Giulia Besutti
- Department of Radiology, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Roberto Borrelli
- Thoracic Surgery Unit, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Filippo Lo Coco
- Thoracic Surgery Unit, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Tommaso Ricchetti
- Thoracic Surgery Unit, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Cristian Rapicetta
- Thoracic Surgery Unit, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Alberto Cavazza
- Pathology Unit, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Giovanni Musci
- Pathology Unit, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Luca De Simone
- Ocular Immunology Unit, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Fabrizio Gozzi
- Ocular Immunology Unit, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Carlo Salvarani
- Division of Rheumatology, University of Modena and Reggio Emilia, Modena, Italy.,Department of Rheumatology, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Nicolò Pipitone
- Department of Rheumatology, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Massimiliano Paci
- Pathology Unit, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Luca Cimino
- Ocular Immunology Unit, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
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7
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Yazgan S, Ucvet A, Gursoy S, Ceylan KC, Yıldırım Ş. Surgical Experience of Video-Assisted Mediastinoscopy for Nonlung Cancer Diseases. Thorac Cardiovasc Surg 2020; 69:189-193. [PMID: 32634834 DOI: 10.1055/s-0040-1713138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Video-assisted mediastinoscopy (VAM) is a valuable method in the investigation of diseases with mediastinal lymphadenopathy or those localized in the mediastinum. The aim of this study was to determine the diagnostic value of VAM in the investigation of mediastinal involvement of nonlung cancer diseases and to describe our institutional surgical experience. METHODS Clinical parameters such as age, sex, histological diagnosis, morbidity, and mortality of all patients who underwent VAM for the investigation of mediastinal involvement of diseases except lung cancer between January 2006 and July 2018 were retrospectively reviewed, and the diagnostic efficacy of VAM was determined statistically. RESULTS During the study period, 388 patients underwent VAM, and 536 lymph nodes were sampled for histopathological evaluation of mediastinum due to mediastinal lymphadenopathy or paratracheal lesions. The most common diagnoses were sarcoidosis (n = 178 [45.9%]), tuberculous lymphadenitis (n = 108 [27.8%]), lymphadenitis with anthracosis (n = 72 [18.6%]), and lymphoma (n = 15 [3.9%]). CONCLUSION The results of the study show that VAM should be used because of its high diagnostic benefit in mediastinal lymphadenopathies, which are difficult to diagnose, or mediastinal lesions located in the paratracheal region. Despite the increase in the number of new diagnostic modalities, VAM is still the most effective method and a gold standard.
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Affiliation(s)
- Serkan Yazgan
- Department of Thoracic Surgery, Dr Suat Seren Chest Diseases and Surgery Medical Practice Research Center, University of Health Sciences, Izmir, Turkey
| | - Ahmet Ucvet
- Department of Thoracic Surgery, Dr Suat Seren Chest Diseases and Surgery Medical Practice Research Center, University of Health Sciences, Izmir, Turkey
| | - Soner Gursoy
- Department of Thoracic Surgery, Dr Suat Seren Chest Diseases and Surgery Medical Practice Research Center, University of Health Sciences, Izmir, Turkey
| | - Kenan Can Ceylan
- Department of Thoracic Surgery, Dr Suat Seren Chest Diseases and Surgery Medical Practice Research Center, University of Health Sciences, Izmir, Turkey
| | - Şener Yıldırım
- Department of Thoracic Surgery, Dr Suat Seren Chest Diseases and Surgery Medical Practice Research Center, University of Health Sciences, Izmir, Turkey
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D'Andrilli A, Maurizi G, Venuta F, Rendina EA. Mediastinal staging: when and how? Gen Thorac Cardiovasc Surg 2019; 68:725-732. [PMID: 31797211 DOI: 10.1007/s11748-019-01263-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 11/21/2019] [Indexed: 12/19/2022]
Abstract
Mediastinal staging for lung cancer includes both the assessment of mediastinal lymph nodes status before treatment and the postoperative pathological staging obtained by lymph-node removal performed during surgery. In patients with early stage NSCLC, the aim is to exclude with the highest certainty and the lowest morbidity the presence of mediastinal node involvement. Before treatment, mediastinal staging is based on imaging techniques, endoscopic techniques, and surgical procedures. Final pathological staging is based on lymph-node removal performed with lung resection according with different modalities (sampling, systematic dissection, etc.) and various approaches (thoracotomy, VATS, robotic). Data and indications from literature evidences are reported and discussed.
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Affiliation(s)
- Antonio D'Andrilli
- Department of Thoracic Surgery, Sapienza University, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189, Rome, Italy.
| | - Giulio Maurizi
- Department of Thoracic Surgery, Sapienza University, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189, Rome, Italy
| | - Federico Venuta
- Department of Thoracic Surgery, Sapienza University, Policlinico Umberto I, Rome, Italy
| | - Erino A Rendina
- Department of Thoracic Surgery, Sapienza University, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189, Rome, Italy
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Divisi D, Zaccagna G, Barone M, Gabriele F, Crisci R. Endobronchial ultrasound-transbronchial needle aspiration (EBUS/TBNA): a diagnostic challenge for mediastinal lesions. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:92. [PMID: 29666815 DOI: 10.21037/atm.2017.12.19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Lung cancer is one of the most frequent neoplastic diseases. To date, most lung cancer is diagnosed at an advanced stage, making it difficult to choose the diagnostic and therapeutic strategy. Surgical resection represents the best therapeutic solution. However, the best results are obtained only in the early stages of the disease. Lymph node involvement conditions the treatment (surgical or non-surgical approach). Mediastinoscopy is an effective and widely used method for mediastinal staging but does not allow us to reach many mediastinal lymph nodes. Endobronchial ultrasound/transbronchial needle aspiration (EBUS-TBNA) allows us to reach more lymph nodes and is referred to as a first-choice exam for mediastinal staging.
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Affiliation(s)
- Duilio Divisi
- Thoracic Surgery Unit, University of L'Aquila, "G. Mazzini" Hospital, Teramo, Italy
| | - Gino Zaccagna
- Thoracic Surgery Unit, University of L'Aquila, "G. Mazzini" Hospital, Teramo, Italy
| | - Mirko Barone
- Thoracic Surgery Unit, University of L'Aquila, "G. Mazzini" Hospital, Teramo, Italy
| | - Francesca Gabriele
- Thoracic Surgery Unit, University of L'Aquila, "G. Mazzini" Hospital, Teramo, Italy
| | - Roberto Crisci
- Thoracic Surgery Unit, University of L'Aquila, "G. Mazzini" Hospital, Teramo, Italy
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10
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Yendamuri S, Battoo A, Attwood K, Dhillon SS, Dy GK, Hennon M, Picone A, Nwogu C, Demmy T, Dexter E. Concomitant Mediastinoscopy Increases the Risk of Postoperative Pneumonia After Pulmonary Lobectomy. Ann Surg Oncol 2018; 25:1269-1276. [PMID: 29488189 DOI: 10.1245/s10434-018-6397-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Mediastinoscopy is considered the gold standard for preresectional staging of lung cancer. We sought to examine the effect of concomitant mediastinoscopy on postoperative pneumonia (POP) in patients undergoing lobectomy. METHODS All patients in our institutional database (2008-2015) undergoing lobectomy who did not receive neoadjuvant therapy were included in our study. The relationship between mediastinoscopy and POP was examined using univariate (Chi square) and multivariate analyses (binary logistic regression). In order to validate our institutional findings, lobectomy data in the National Surgical Quality Improvement Program (NSQIP) from 2005 to 2014 were analyzed for these associations. RESULTS Of 810 patients who underwent a lobectomy at our institution, 741 (91.5%) surgeries were performed by video-assisted thoracic surgery (VATS) and 487 (60.1%) patients underwent concomitant mediastinoscopy. Univariate analysis demonstrated an association between mediastinoscopy and POP in patients undergoing VATS [odds ratio (OR) 1.80; p = 0.003], but not open lobectomy. Multivariate analysis retained mediastinoscopy as a variable, although the relationship showed only a trend (OR 1.64; p = 0.1). In the NSQIP cohort (N = 12,562), concomitant mediastinoscopy was performed in 9.0% of patients, with 44.5% of all the lobectomies performed by VATS. Mediastinoscopy was associated with POP in patients having both open (OR1.69; p < 0.001) and VATS lobectomy (OR 1.72; p = 0.002). This effect remained in multivariate analysis in both the open and VATS lobectomy groups (OR 1.46, p = 0.003; and 1.53, p = 0.02, respectively). CONCLUSIONS Mediastinoscopy may be associated with an increased risk of POP after pulmonary lobectomy. This observation should be examined in other datasets as it potentially impacts preresectional staging algorithms for patients with lung cancer.
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Affiliation(s)
- Sai Yendamuri
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA. .,Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA.
| | - Athar Battoo
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Kris Attwood
- Department of Biostatistics, Roswell Park Cancer Institute, Buffalo, NY, USA
| | | | - Grace K Dy
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Mark Hennon
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA.,Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Anthony Picone
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA.,Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Chukwumere Nwogu
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA.,Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Todd Demmy
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA.,Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Elisabeth Dexter
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA.,Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
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11
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Abstract
INTRODUCTION The field of interventional pulmonology (IP) is a rapidly maturing subspecialty of pulmonary medicine, which emphasizes advanced diagnostic and therapeutic bronchoscopy for the evaluation and management of central airway obstruction, mediastinal/hilar adenopathy and lung nodules/masses, as well as minimally invasive diagnostic and therapeutic pleural procedures. Areas covered: This review describes advances in diagnostic and therapeutic bronchoscopic techniques. Expert commentary: In the past decade, there has been a remarkable growth in available technology and equipment, as well as clinical and translational research efforts focused on patient-centered outcomes. Furthermore, the recent establishment of a uniform accreditation standard for all IP fellowship programs in the United States was an important step in the continued evolution of this subspecialty of pulmonary medicine.
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Affiliation(s)
- Diana H Yu
- a School of Medicine, Division of Pulmonary/Critical Care Medicine, Section of Interventional Pulmonology , Johns Hopkins University , Baltimore , USA
| | - David Feller-Kopman
- a School of Medicine, Division of Pulmonary/Critical Care Medicine, Section of Interventional Pulmonology , Johns Hopkins University , Baltimore , USA
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12
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Miao J, Li M, Fu Y, Hu X, Hu B, Li H. Ultrasound-Guided Video-Assisted Mediastinoscopic Biopsy: A Novel Approach. Ann Thorac Surg 2017; 102:e465-e467. [PMID: 27772612 DOI: 10.1016/j.athoracsur.2016.03.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 03/05/2016] [Accepted: 03/14/2016] [Indexed: 12/24/2022]
Abstract
Video-assisted mediastinoscopy (VAM) is the most commonly used invasive method for the preoperative mediastinal staging of lung cancer and for the diagnosis of other mediastinal diseases. However, VAM has the risk of causing life-threatening bleeding consequent to the specific mediastinal anatomy. We adopted the ultrasonic technique for VAM biopsies that can easily distinguish the lymph nodes from the surrounding great vessels and thus makes the procedure easier and safer.
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Affiliation(s)
- Jinbai Miao
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Affiliated With Capital Medical University, Beijing, China
| | - Mei Li
- Department of Ultrasound Medicine, Beijing HaiDian Hospital, Beijing Haidian Section of Peking University Third Hospital, Beijing, China
| | - Yili Fu
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Affiliated With Capital Medical University, Beijing, China
| | - Xiaoxing Hu
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Affiliated With Capital Medical University, Beijing, China
| | - Bin Hu
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Affiliated With Capital Medical University, Beijing, China
| | - Hui Li
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Affiliated With Capital Medical University, Beijing, China.
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13
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Wang W, Cui M, Ma HX, Zhang H, Zhang ZH, Cui YB. A large schwannoma of the middle mediastinum: A case report and review of the literature. Oncol Lett 2016; 11:1719-1721. [PMID: 26998067 PMCID: PMC4774518 DOI: 10.3892/ol.2016.4148] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 10/19/2015] [Indexed: 11/29/2022] Open
Abstract
Schwannoma of the mediastinum is a rare and typically benign type of tumor. The present study describes the case of a 61-year-old woman who presented with a continuous cough and facial edema. Pre-operative chest radiography, enhanced computed tomography (CT) and three-dimensional CT scans identified a well-circumscribed mass. The large cyst, measuring 6.5×6.1×5.0 cm, was located anterior to the trachea and posterior to the superior vena cava. The mass was observed to be in close proximity to the right pulmonary hilum and the superior vena cava was flattened due to the pressure on the right vagus nerve. Therefore, the encapsulated tumor was completely resected under thoracoscopy and was subsequently diagnosed as a benign schwannoma upon pathological examination. The respiratory tract symptoms and facial edema resolved immediately after the surgery, and no recurrence was observed during the 6-month follow-up period. At the time of writing, the patient remained alive. The present study records the rarely successful resection of a middle mediastinal tumor by video-assisted thoracoscopy.
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Affiliation(s)
- Wei Wang
- Department of Thoracic Surgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Ming Cui
- Department of Thoracic Surgery, Peking University First Hospital, Beijing 100034, P.R. China
| | - Hong Xi Ma
- Department of Pathology, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Hong Zhang
- Department of Thoracic Surgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Zhen-Hua Zhang
- Department of Thoracic Surgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - You-Bin Cui
- Department of Thoracic Surgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
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14
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Endobronchial ultrasound versus mediastinoscopy for mediastinal nodal staging of non-small-cell lung cancer. J Thorac Oncol 2015; 10:331-7. [PMID: 25611227 DOI: 10.1097/jto.0000000000000388] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Correct mediastinal staging is critical for determination of the most appropriate management strategy in patients with non-small-cell lung cancer (NSCLC). The purpose of this study was to compare the diagnostic performance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) with that of mediastinoscopy in patients with NSCLC. METHODS A prospective trial was conducted in a tertiary referral center in Korea. Patients with histologically proven NSCLC and suspicion for N1, N2, or N3 metastasis were enrolled. Each patient underwent EBUS-TBNA followed by mediastinoscopy. Surgical resection and complete lymph node dissection were conducted in patients for whom no evidence of mediastinal metastasis was apparent after mediastinoscopy. RESULTS In total, 138 patients underwent EBUS-TBNA and 127 completed both EBUS-TBNA and mediastinoscopy. N2/N3 disease was confirmed in 59.1% of the patients. The diagnostic sensitivity, specificity, accuracy, positive predictive value, and negative predictive value (NPV) of EBUS-TBNA on a per-person analysis were 88.0%, 100%, 92.9%, 100%, and 85.2%, respectively. The diagnostic sensitivity, specificity, accuracy, positive predictive value, and NPV of mediastinoscopy on a per-person analysis were 81.3%, 100%, 89.0%, 100%, and 78.8%, respectively. Significant differences in the sensitivity, accuracy, and NPV were evident between EBUS-TBNA and mediastinoscopy (p < 0.005). CONCLUSIONS EBUS-TBNA was superior to mediastinoscopy in terms of its diagnostic performance for mediastinal staging of cN1-3 NSCLC. Because EBUS-TBNA is both less invasive and affords superior diagnostic sensitivity, it should be the first-line procedure performed in patients with NSCLC.
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15
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Belfontali V, Vidal Fortuny J, Guigard S, Karenovics W, Triponez F. Video-Assisted Mediastinoscopy Under Continuous Intraoperative Neuromonitoring for Surgical Management of an Ectopic Parathyroid Adenoma: A Case Report. VideoEndocrinology 2015. [DOI: 10.1089/ve.2015.0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Valentina Belfontali
- Thoracic and Endocrine Surgery Unit, University Hospitals of Geneva, Geneva, Switzerland
| | - Jordi Vidal Fortuny
- Thoracic and Endocrine Surgery Unit, University Hospitals of Geneva, Geneva, Switzerland
| | - Sebastien Guigard
- Thoracic and Endocrine Surgery Unit, University Hospitals of Geneva, Geneva, Switzerland
| | - Wolfram Karenovics
- Thoracic and Endocrine Surgery Unit, University Hospitals of Geneva, Geneva, Switzerland
| | - Frédéric Triponez
- Thoracic and Endocrine Surgery Unit, University Hospitals of Geneva, Geneva, Switzerland
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16
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De Leyn P, Dooms C, Kuzdzal J, Lardinois D, Passlick B, Rami-Porta R, Turna A, Van Schil P, Venuta F, Waller D, Weder W, Zielinski M. Preoperative mediastinal lymph node staging for non-small cell lung cancer: 2014 update of the 2007 ESTS guidelines. Transl Lung Cancer Res 2015; 3:225-33. [PMID: 25806304 DOI: 10.3978/j.issn.2218-6751.2014.08.05] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 08/08/2014] [Indexed: 12/25/2022]
Abstract
Accurate preoperative staging and restaging of mediastinal lymph nodes in patients with potentially resectable non-small cell lung cancer (NSCLC) is of paramount importance. In 2007, the European Society of Thoracic Surgeons (ESTS) published an algorithm on preoperative mediastinal staging integrating imaging, endoscopic and surgical techniques. Over the last years more evidence of the different mediastinal staging technique has become available. Therefore, a revision of the ESTS guidelines was needed. In case of CT-enlarged or PET-positive mediastinal lymph nodes, tissue confirmation is indicated. Endosonography (EBUS/EUS) with fine needle aspiration is the first choice (when available) since it is minimally invasive and has a high sensitivity to rule in mediastinal nodal disease. If negative, surgical staging with nodal dissection or biopsy is indicated. Video-assisted mediastinoscopy is preferred over mediastinoscopy. The combined use of endoscopic staging and surgical staging results in the highest accuracy. When there are no enlarged lymph nodes on CT and when there is no uptake in lymph nodes on PET or PET-CT, direct surgical resection with systematic nodal dissection is indicated for tumors ≤3 cm located in the outer third of the lung. In central tumors or N1 nodes, preoperative mediastinal staging is indicated. The choice between endoscopic staging with EBUS/EUS and fine needle aspiration or video-assisted mediastinoscopy depends on local expertise to adhere to minimal requirements for staging. For tumors larger than 3 cm, preoperative mediastinal staging is advised, mainly in adenocarcinoma with high SUV uptake.
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Affiliation(s)
- Paul De Leyn
- 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | - Christophe Dooms
- 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | - Jaroslaw Kuzdzal
- 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | - Didier Lardinois
- 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | - Bernward Passlick
- 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | - Ramon Rami-Porta
- 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | - Akif Turna
- 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | - Paul Van Schil
- 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | - Frederico Venuta
- 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | - David Waller
- 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | - Walter Weder
- 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | - Marcin Zielinski
- 1 Department of Thoracic Surgery, 2 Department of Pneumology, University Hospitals Leuven, Leuven, Belgium ; 3 Department of Thoracic Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland ; 4 Division of Thoracic Surgery, University Hospital Basel, Basel, Switzerland ; 5 Department of Thoracic Surgery, Albert-Ludwigs-University Freiburg, Freiburg, Germany ; 6 Department of Thoracic Surgery, University Hospital Mutua de Terrassa and CIBERES Lung Cancer Group, Terrassa, Barcelona, Spain ; 7 Department of Thoracic Surgery, University Hospital Istanbul, Istanbul, Turkey ; 8 Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium ; 9 Department of Thoracic Surgery, Sant Andrea Hospital, University of Rome La Sapienza, Rome, Italy ; 10 Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK ; 11 Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland ; 12 Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
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17
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The Safety and Efficacy of Mediastinoscopy When Performed by General Thoracic Surgeons. Ann Thorac Surg 2014; 97:1878-83; discussion 1883-4. [DOI: 10.1016/j.athoracsur.2014.02.049] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 02/20/2014] [Accepted: 02/25/2014] [Indexed: 11/21/2022]
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18
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De Leyn P, Dooms C, Kuzdzal J, Lardinois D, Passlick B, Rami-Porta R, Turna A, Van Schil P, Venuta F, Waller D, Weder W, Zielinski M. Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer. Eur J Cardiothorac Surg 2014; 45:787-98. [PMID: 24578407 DOI: 10.1093/ejcts/ezu028] [Citation(s) in RCA: 511] [Impact Index Per Article: 51.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Accurate preoperative staging and restaging of mediastinal lymph nodes in patients with potentially resectable non-small-cell lung cancer (NSCLC) is of paramount importance. In 2007, the European Society of Thoracic Surgeons (ESTS) published an algorithm on preoperative mediastinal staging integrating imaging, endoscopic and surgical techniques. In 2009, the International Association for the Study of Lung Cancer (IASLC) introduced a new lymph node map. Some changes in this map have an important impact on mediastinal staging. Moreover, more evidence of the different mediastinal staging technique has become available. Therefore, a revision of the ESTS guidelines was needed. In case of computed tomography (CT)-enlarged or positron emission tomography (PET)-positive mediastinal lymph nodes, tissue confirmation is indicated. Endosonography [endobronchial ultrasonography (EBUS)/esophageal ultrasonography (EUS)] with fine-needle aspiration (FNA) is the first choice (when available), since it is minimally invasive and has a high sensitivity to rule in mediastinal nodal disease. If negative, surgical staging with nodal dissection or biopsy is indicated. Video-assisted mediastinoscopy is preferred to mediastinoscopy. The combined use of endoscopic staging and surgical staging results in the highest accuracy. When there are no enlarged lymph nodes on CT and when there is no uptake in lymph nodes on PET or PET-CT, direct surgical resection with systematic nodal dissection is indicated for tumours ≤ 3 cm located in the outer third of the lung. In central tumours or N1 nodes, preoperative mediastinal staging is indicated. The choice between endoscopic staging with EBUS/EUS and FNA or video-assisted mediastinoscopy depends on local expertise to adhere to minimal requirements for staging. For tumours >3 cm, preoperative mediastinal staging is advised, mainly in adenocarcinoma with high standardized uptake value. For restaging, invasive techniques providing histological information are advisable. Both endoscopic techniques and surgical procedures are available, but their negative predictive value is lower compared with the results obtained in baseline staging. An integrated strategy using endoscopic staging techniques to prove mediastinal nodal disease and mediastinoscopy to assess nodal response after induction therapy needs further study.
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Affiliation(s)
- Paul De Leyn
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
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19
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Vyas KS, Davenport DL, Ferraris VA, Saha SP. Mediastinoscopy: trends and practice patterns in the United States. South Med J 2013; 106:539-44. [PMID: 24096946 DOI: 10.1097/smj.0000000000000000] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Historically, mediastinoscopy has been the gold standard for the staging of lung cancer. A practice gap exists as the result of a variation in knowledge concerning current trends and practice patterns of mediastinoscopy usage. In addition, there are regional variations in practice-based learning and patient care. Lessons learned during surgeries performed on patients with lung cancer and other advances such as positron emission tomography and endobronchial ultrasound could be universally applied to improve surgeons' management of patient care. The purpose of this study was to assess contemporary practices in the staging of lung cancer. METHODS We queried the Society of Thoracic Surgeons National Database for data regarding mediastinoscopy usage, yield, and variation, both by year and region. RESULTS Cases with mediastinoscopy, as a percentage of all cases performed in the database, have significantly decreased from 14.6% in 2006 to 11.4% in 2010 (P < 0.001). The 5-year median rate of mediastinoscopy in lung cancer patients at 163 centers was 15.3% (interquartile range 5.2%-31.7%), indicating significant variation among centers. The overall median center rate also decreased over time from 21.4% (2006) to 10.0% (2010). CONCLUSIONS With advances in minimally invasive procedures and imaging, mediastinoscopy usage has declined significantly. Our findings are likely to be relevant to both clinical practice and practice guidelines.
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Affiliation(s)
- Krishna S Vyas
- From the College of Medicine, and the Department of Surgery, University of Kentucky, Lexington
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20
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Shim YM, Cho JH. Reply. Ann Thorac Surg 2012. [DOI: 10.1016/j.athoracsur.2012.03.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Complication Rates in Mediastinoscopy and Training: Video Versus Conventional Mediastinoscopy. Ann Thorac Surg 2012; 94:337; author reply 337-8. [DOI: 10.1016/j.athoracsur.2012.01.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2011] [Revised: 12/06/2011] [Accepted: 01/09/2012] [Indexed: 11/20/2022]
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22
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Nasir B, Cerfolio RJ, Bryant AS. Endobronchial ultrasound (EBUS) with tranbronchial needle aspiration (TBNA) versus mediastinoscopy for mediastinal staging in non-small cell lung cancer (NSCLC) thoracic cancer. Thorac Cancer 2012; 3:131-138. [DOI: 10.1111/j.1759-7714.2011.00106.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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23
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Rami-Porta R, Call S. Invasive staging of mediastinal lymph nodes: mediastinoscopy and remediastinoscopy. Thorac Surg Clin 2011; 22:177-89. [PMID: 22520285 DOI: 10.1016/j.thorsurg.2011.12.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Nodal status in lung cancer is essential for planning therapy and assessing prognosis. The involvement of ipsilateral and contralateral mediastinal lymph nodes is associated with poor prognosis and usually excludes patients from upfront surgical treatment. Mediastinoscopy is a time-honored procedure that allows the surgeon to access the upper mediastinal lymph nodes for either biopsy or removal. Remediastinoscopy is mainly indicated to assess objective tumor response in mediastinal lymph nodes after induction therapy for locally advanced lung cancer and to indicate further therapy.
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Affiliation(s)
- Ramón Rami-Porta
- Thoracic Surgery Service, Hospital Universitari Mutua Terrassa, University of Barcelona, Plaza Drive Robert 5, 08221 Terrassa, Barcelona, Spain.
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Zakkar M, Tan C, Hunt I. Is video mediastinoscopy a safer and more effective procedure than conventional mediastinoscopy? Interact Cardiovasc Thorac Surg 2011; 14:81-4. [PMID: 22108943 DOI: 10.1093/icvts/ivr044] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether video-assisted mediastinoscopy (VAM) is a more effective procedure than conventional mediastinoscopy (CM). A total of 108 papers were identified using the search as discussed below. Of which, eight papers presented the best evidence to answer the clinical question as they included a sufficient number of patients to reach conclusions regarding the issues of interest for this review. Complications, complication rates, number of lymph nodes biopsies, number of stations sampled and training opportunities were included in the assessment. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the papers are tabulated. Literature search revealed that CM is a safe procedure associated with low mortality (0-0.05%) and morbidity (0-5.3%). CM has high levels of accuracy (83.8-97.2%) and negative predictive value (81-95.7%). Training in CM can be difficult as the limited vision means that the trainer cannot monitor directly the dissection and the areas biopsied by the trainee as one operator and effectively see at any time. VAM is also a safe procedure with comparable results to that of CM in term of mortality (0%), morbidity (0.83-2.9%), accuracy (87.9-98.9%) and negative predictive values (83-98.6%). The main advantage is higher number of biospsies taken (VAM, 6-8.5; CM, 5-7.13) and number of mediastinal lymph node stations sampled (VAM, 1.9-3.6; CM, 2.6-2.98). VAM can be associated with more aggressive dissecting and that can lead to more complications. The use of VAM can provide a better and safer training opportunity since both trainer and trainee can share the magnified image on the monitor. All studies available are comparing heterogeneous groups of non-matched group of patients which can bias the outcomes reported. There is a lack of comprehensive randomized studies to compare both procedures and to support any preference towards VAM over CM. We conclude that there is actually very little objective evidence of VAM superiority over CM.
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Affiliation(s)
- Mustafa Zakkar
- Department of Cardiothoracic Surgery, St. George's Hospital, London, UK.
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Invited commentary. Ann Thorac Surg 2011; 92:1011. [PMID: 21871291 DOI: 10.1016/j.athoracsur.2011.03.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 03/16/2011] [Accepted: 03/18/2011] [Indexed: 10/17/2022]
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Noble HB, Porter M, Qian K, Tan QY, Wang RW, Deng B, Zhou JH. The role of the team physician in school athletics. BMC Pulm Med 1982; 18:146. [PMID: 30176840 PMCID: PMC6122670 DOI: 10.1186/s12890-018-0713-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/23/2018] [Indexed: 12/15/2022] Open
Abstract
Background Convenient approaches for accurate biopsy are extremely important to the diagnosis of lung cancer. We aimed to systematically review the clinical updates and development trends of approaches for biopsy, i.e., CT-guided PTNB (Percutaneous Transthoracic Needle Biopsy), ENB (Electromagnetic Navigation Bronchoscopy), EBUS-TBNA (Endobroncheal Ultrasonography-Transbronchial Needle Aspiration), mediastinoscopy and CTC (Circulating Tumor Cell). Methods Medline and manual searches were performed. We identified the relevant studies, assessed study eligibility, evaluated methodological quality, and summarized diagnostic yields and complications regarding CT-guided PTNB (22 citations), ENB(31 citations), EBUS-TBNA(66 citations), Mediastinoscopy(15 citations) and CTC (19 citations), respectively. Results The overall sensitivity and specificity of CT-guided PTNB were reported to be 92.52% ± 3.14% and 97.98% ± 3.28%, respectively. The top two complications of CT-guided PTNB was pneumothorax (946/4170:22.69%) and hemorrhage (138/1949:7.08%). The detection rate of lung cancer by ENB increased gradually to 79.79% ± 15.34% with pneumothorax as the top one complication (86/1648:5.2%). Detection rate of EBUS-TBNA was 86.06% ± 9.70% with the top three complications, i.e., hemorrhage (53/8662:0.61%), pneumothorax (46/12432:0.37%) and infection (34/11250:0.30%). The detection rate of mediastinoscopy gradually increased to 92.77% ± 3.99% with .hoarseness as the refractory complication (4/2137:0.19%). Sensitivity and specificity of CTCs detection by using PCR (Polymerase Chain Reaction) were reported to be 78.81% ± 14.72% and 90.88% ± 0.53%, respectively. Conclusion The biopsy approaches should be chosen considering a variety of location and situation of lesions. CT-guided PTNB is effective to reach lung parenchyma, however, diagnostic accuracy and incidence of complications may be impacted by lesion size or needle path length. ENB has an advantage for biopsy of smaller and deeper lesions in lung parenchyma. ENB plus EBUS imaging can further improve the detection rate of lesion in lung parenchyma. EBUS-TBNA is relatively safer and mediastinoscopy provides more tissue acquisition and better diagnostic yield of 4R and 7th lymph node. CTC detection can be considered for adjuvant diagnosis.
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Affiliation(s)
| | | | - Kai Qian
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Army Medical University, Chongqing, 400042, People's Republic of China
| | - Qun-You Tan
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Army Medical University, Chongqing, 400042, People's Republic of China
| | - Ru-Wen Wang
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Army Medical University, Chongqing, 400042, People's Republic of China
| | - Bo Deng
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Army Medical University, Chongqing, 400042, People's Republic of China.
| | - Jing-Hai Zhou
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Army Medical University, Chongqing, 400042, People's Republic of China.
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