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Craig C, Johnston J, Goodley P, Bishop P, Al-Najjar H, Brown L, Gallagher J, Sundar R, Upperton S, Callister M, Meek D, Succony L, Parvez W, Tufail M, Jayasekera G, Maclay J, Livesey A, Woolhouse I, Smith N, Bibby A, Evison M. What Is the Accuracy of Clinical Staging for Stage III-Single-station N2 NSCLC? A Multi-Centre UK Study. JTO Clin Res Rep 2024; 5:100694. [PMID: 39161961 PMCID: PMC11332836 DOI: 10.1016/j.jtocrr.2024.100694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 05/19/2024] [Accepted: 05/25/2024] [Indexed: 08/21/2024] Open
Abstract
Introduction Single-station N2 (ssN2) versus multi-station N2 has been used as a selection criterion for treatment recommendations between surgical versus non-surgical multimodality treatment in stage III-N2 NSCLC. We hypothesized that clinical staging would be susceptible to upstaging on pathologic staging and, therefore, challenge this practice. Methods A retrospective study of prospectively collected routine clinical data for patients with stage III-N2 NSCLC that had completed computed tomography (CT), positron emission tomography (PET), and staging endobronchial ultrasound (EBUS) and had been confirmed clinical stage III-ssN2 at multidisciplinary team discussion and went on to complete surgical resection as the first treatment to provide pathologic staging. The study was completed in two cohorts (A) across a single cancer alliance in England (Greater Manchester) January 1, 2015 to December 31, 2018 and (B) across five United Kingdom centers to validate the findings in part A January 1, 2016 to December 31, 2020. Results A total of 115 patients met the inclusion criteria across cohort A (56 patients) and cohort B (59 patients) across 15 United Kingdom hospitals. The proportion of cases in which clinical stage III-ssN2 was upstaged to pathologic stage III-multi-station N2 was 34% (19 of 56) in cohort A, 32% in cohort B (19 of 59), and 33% across the combined study cohort (38 of 115). Most patients had a single radiologically abnormal lymph node on CT and PET (88%, 105 of 115). In the majority, the reasons for missed N2 disease on staging EBUS were due to inaccessible (stations 5, 6, 8, 9) N2 nodes at EBUS (34%, 13 of 38) and accessible lymph nodes not sampled during staging EBUS as not meeting sampling threshold (40%, 15 of 38) rather than false-negative sampling during EBUS (26%, 10 of 38). Conclusions During multidisciplinary team discussions, clinicians must be aware that one-third of patients with stage III-ssN2 on the basis of CT, PET, and staging EBUS do not truly have ssN2 and this questions the use of this criterion to define treatment recommendations.
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Affiliation(s)
- Christopher Craig
- Lung Cancer & Thoracic Surgery Directorate, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Janet Johnston
- Lung Cancer & Thoracic Surgery Directorate, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Patrick Goodley
- Lung Cancer & Thoracic Surgery Directorate, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Paul Bishop
- Department of Thoracic Histopathology, Clinical Support Services, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Haider Al-Najjar
- Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Louise Brown
- North Manchester General Hospital, Manchester, United Kingdom
| | - Joanna Gallagher
- Macclesfield Hospital, East Cheshire NHS Trust, Macclesfield, United Kingdom
| | - Ramachandran Sundar
- Royal Albert Edward Infirmary, Wrightington, Wigan & Leigh NHS Foundation Trust, Wigan, United Kingdom
| | - Sara Upperton
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | | | - David Meek
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Laura Succony
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Wadood Parvez
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Muhammad Tufail
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Geeshath Jayasekera
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - John Maclay
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - Alana Livesey
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Ian Woolhouse
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | | | - Anna Bibby
- North Bristol NHS Trust, Bristol, United Kingdom
| | - Matthew Evison
- Lung Cancer & Thoracic Surgery Directorate, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Manchester Academic Health Science Centre (MAHSC), Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
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Bossé Y, Dasgupta A, Abadier M, Guthrie V, Song F, Saavedra Armero V, Gaudreault N, Orain M, Lamaze FC, Melton C, Nance T, Hung T, Hodgson D, Abbosh C, Joubert P. Prognostic implication of methylation-based circulating tumor DNA detection prior to surgery in stage I non-small cell lung cancer. Cancer Lett 2024; 594:216984. [PMID: 38797230 DOI: 10.1016/j.canlet.2024.216984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/14/2024] [Accepted: 05/21/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Circulating tumor DNA (ctDNA) positivity at diagnosis, which is associated with worse outcomes in multiple solid tumors including stage I-III non-small cell lung cancer (NSCLC), may have utility to guide (neo)adjuvant therapy. METHODS In this retrospective study, 260 patients with clinical stage I NSCLC (180 adenocarcinoma, 80 squamous cell carcinoma) were allocated (2:1) to high- and low-risk groups based on relapse versus disease-free status ≤5 years post-surgery. We evaluated the association of preoperative ctDNA detection by a plasma-only targeted methylation-based multi-cancer early detection (MCED) test with NSCLC relapse ≤5 years post-surgery in the overall population, followed by histology-specific subgroup analyses. RESULTS Across clinical stage I patients, preoperative ctDNA detection did not associate with relapse within 5 years post-surgery. Sub-analyses confined to lung adenocarcinoma suggested a histology-specific association between ctDNA detection and outcome. In this group, ctDNA positivity tended to associate with relapse within 2 years, suggesting prognostic implications of MCED test positivity may be histology- and time-dependent in stage I NSCLC. Preoperative ctDNA detection was associated with upstaging of clinical stage I to pathological stage II-III NSCLC. CONCLUSIONS Our findings suggest preoperative ctDNA detection in patients with resectable clinical stage I NSCLC using MCED, a pan-cancer screening test developed for use in an asymptomatic population, has no detectable prognostic value for relapse ≤5 years post-surgery. MCED detection may be associated with early adenocarcinoma relapse and increased pathological upstaging rates in stage I NSCLC. However, given the exploratory nature of these findings, independent validation is required.
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Affiliation(s)
- Yohan Bossé
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec City, Canada; Department of Molecular Medicine, Université Laval, Quebec City, Canada.
| | - Abhijit Dasgupta
- Oncology Data Science, Oncology R&D, AstraZeneca, Gaithersburg, MD, USA
| | - Michael Abadier
- Translational Medicine Early Oncology, AstraZeneca, Waltham, MA, USA
| | - Violeta Guthrie
- Oncology Data Science, Oncology R&D, AstraZeneca, Gaithersburg, MD, USA
| | - Florian Song
- Translational Medicine Early Oncology, AstraZeneca, Munich, Germany
| | - Victoria Saavedra Armero
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec City, Canada
| | - Nathalie Gaudreault
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec City, Canada
| | - Michèle Orain
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec City, Canada
| | - Fabien C Lamaze
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec City, Canada
| | | | | | | | - Darren Hodgson
- Translational Medicine Early Oncology, AstraZeneca, Cambridge, United Kingdom
| | - Chris Abbosh
- Translational Medicine Early Oncology, AstraZeneca, Cambridge, United Kingdom
| | - Philippe Joubert
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec City, Canada; Department of Molecular Biology, Pathology and Medical Biochemistry, Université Laval, Quebec City, Canada
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Hu X, Chirovsky D, Walker MS, Wang Y, Kaushiva A, Tepsick J, Samkari A. A retrospective analysis of treatment patterns, overall survival, and real-world disease-free survival in early-stage non-small cell lung cancer following complete resection. BMC Pulm Med 2024; 24:332. [PMID: 38987763 PMCID: PMC11234548 DOI: 10.1186/s12890-024-03138-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 06/30/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND Real-world data regarding patient characteristics, adjuvant treatment patterns, and long-term survival outcomes are needed to better understand unmet needs among patients with completely resected early-stage non-small cell lung cancer (NSCLC). METHODS Electronic medical records from the U.S.-based ConcertAI Patient360™ database were analyzed in patients with stage IB-IIIA NSCLC who underwent complete resection prior to March 1, 2016. Patients were followed until death or July 1, 2021. This study evaluated adjuvant chemotherapy use, and overall survival (OS) and real-world disease-free survival (rwDFS) outcomes using the Kaplan-Meier method. The correlation between OS and rwDFS was assessed using the Kendall rank test. Among patients who did not recur 5 years following surgery, landmark analyses of OS and rwDFS were conducted to understand the subsequent survival impact of remaining disease-free for at least 5 years. RESULTS Data from 441 patients with completely resected stage IB-IIIA NSCLC were included. About 35% of patients received adjuvant chemotherapy post-resection. Median OS and rwDFS from resection were 83.1 months and 42.4 months, respectively. The 5-year OS and rwDFS rates were 65.7% and 42.1%, respectively. OS and rwDFS were positively correlated (Kendall rank correlation coefficient = 0.67; p < 0.0001). Among patients without recurrence within 5 years after resection, the subsequent 5-year OS and rwDFS survival rates were 52.9% and 36.6%, respectively. CONCLUSIONS Use of adjuvant chemotherapy was low, and the overall 5-year OS rate remained low despite all patients having undergone complete resection. Patients who remained non-recurrent over time had favorable subsequent long-term survival.
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Affiliation(s)
- Xiaohan Hu
- Merck & Co., Inc., P.O. Box 2000, 126 East Lincoln Avenue, Rahway, NJ, 07065, USA.
| | - Diana Chirovsky
- Merck & Co., Inc., P.O. Box 2000, 126 East Lincoln Avenue, Rahway, NJ, 07065, USA
| | - Mark S Walker
- ConcertAI, LLC, 1120 Massachusetts Ave., Cambridge, MA, 02138, USA
| | - Yuexi Wang
- ConcertAI, LLC, 1120 Massachusetts Ave., Cambridge, MA, 02138, USA
| | - Alpana Kaushiva
- ConcertAI, LLC, 1120 Massachusetts Ave., Cambridge, MA, 02138, USA
| | - Jon Tepsick
- ConcertAI, LLC, 1120 Massachusetts Ave., Cambridge, MA, 02138, USA
| | - Ayman Samkari
- Merck & Co., Inc., P.O. Box 2000, 126 East Lincoln Avenue, Rahway, NJ, 07065, USA
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Abbosh C, Hodgson D, Doherty GJ, Gale D, Black JRM, Horn L, Reis-Filho JS, Swanton C. Implementing circulating tumor DNA as a prognostic biomarker in resectable non-small cell lung cancer. Trends Cancer 2024; 10:643-654. [PMID: 38839544 DOI: 10.1016/j.trecan.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/16/2024] [Accepted: 04/24/2024] [Indexed: 06/07/2024]
Abstract
Systemic treatment of resectable non-small cell lung cancer (NSCLC) is evolving with emerging neoadjuvant, perioperative, and adjuvant immunotherapy approaches. Circulating tumor DNA (ctDNA) detection at clinical diagnosis, during neoadjuvant therapy, or after resection may discern high-risk patients who might benefit from therapy escalation or switch. This Review summarizes translational implications of data supporting ctDNA-based risk determination in NSCLC and outstanding questions regarding ctDNA validity/utility as a prognostic biomarker. We discuss emerging ctDNA capabilities to refine clinical tumor-node-metastasis (TNM) staging in lung adenocarcinoma, ctDNA dynamics during neoadjuvant therapy for identifying patients deriving suboptimal benefit, and postoperative molecular residual disease (MRD) detection to escalate systemic therapy. Considering differential relapse characteristics in landmark MRD-negative/MRD-positive patients, we propose how ctDNA might integrate with pathological response data for optimal postoperative risk stratification.
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Affiliation(s)
- Chris Abbosh
- Cancer Biomarker Development, Early Oncology AstraZeneca, Cambridge, UK
| | - Darren Hodgson
- Cancer Biomarker Development, Early Oncology AstraZeneca, Cambridge, UK
| | | | - Davina Gale
- Cancer Biomarker Development, Early Oncology AstraZeneca, Cambridge, UK
| | - James R M Black
- Cancer Research UK Lung Cancer Centre of Excellence, University College London Cancer Institute, London, UK; Cancer Evolution and Genome Instability Laboratory, The Francis Crick Institute and University College London Cancer Institute, London, UK
| | - Leora Horn
- Clinical Development, Late Oncology, AstraZeneca, Nashville, TN, USA
| | - Jorge S Reis-Filho
- Cancer Biomarker Development, Early Oncology, AstraZeneca, Gaithersburg, MD, USA
| | - Charles Swanton
- Cancer Research UK Lung Cancer Centre of Excellence, University College London Cancer Institute, London, UK; Cancer Evolution and Genome Instability Laboratory, The Francis Crick Institute and University College London Cancer Institute, London, UK; Department of Medical Oncology, University College London Hospitals, London, UK.
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Poston LM, Bassiri A, Kloos J, Linden J, Jiang B, Sinopoli J, Tapias Vargas L, Towe CW. Inaccurate Clinical Stage is Common and Associated With Poor Survival in Patients With Lung Cancer. J Surg Res 2024; 301:154-162. [PMID: 38936244 DOI: 10.1016/j.jss.2024.05.041] [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: 02/27/2024] [Revised: 05/14/2024] [Accepted: 05/18/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION Clinical staging in lung cancer has implications for treatment planning and prognosis. We sought to determine the rate of inaccurate clinical stage (relative to pathologic), identify risk factors for inaccuracy, and evaluate the association of inaccuracy on survival. We hypothesized that inaccurate staging was associated with poor survival. METHODS In this retrospective cohort study, adult patients who received surgical resection without neoadjuvant treatment for nonsmall cell lung cancer from 2004 to 2020 in the National Cancer Database were categorized by accuracy of clinical stage (relative to pathologic stage). Multivariate models were used to determine risk factors for inaccuracy. The association between inaccuracy and overall survival was also analyzed. RESULTS We identified 255,598 patients with lung cancer, including 84,543 patients (33.1%) who were inaccurately staged. Stage inaccuracy was associated with higher tumor, node, metastasis stage (T-category 3: odds ratio [OR] = 1.2, 95% confidence interval [CI] 1.15-1.28; N-category 2: OR = 2.6, 95% CI 2.47-2.79), greater quantity of lymph nodes evaluated, and more extensive resection (extended lobectomy/bilobectomy: OR = 1.3, 95% CI 1.20-1.37; pneumonectomy: OR = 1.6, 95% CI 1.54-1.74). Patients undergoing robotic surgery were less likely to be inaccurately staged (OR = 0.89, 95% CI 0.852-0.939). Inaccurate staging was associated with worse overall survival (5-y 67.5% accurate versus 55.4% inaccurate, P < 0.001). Inaccurate staging was also associated with worse survival in a multivariate Cox model (hazard ratio [HR] = 1.3, 95% CI 1.29-1.33). Both "understaging" (path > clinical) and "overstaging" (clinical > path) were associated with inferior survival. CONCLUSIONS Inaccurate clinical stage (relative to pathologic) occurs in one-third of patients receiving surgery for lung cancer. Inaccuracy is associated with poor survival. Quality improvement initiatives should focus on improving clinical staging accuracy.
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Affiliation(s)
- Lauren M Poston
- Case Western Reserve University School of Medicine, Cleveland, Ohio.
| | - Aria Bassiri
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jacqueline Kloos
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jessica Linden
- Columbia University Irving Medical Center, New York, New York
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jillian Sinopoli
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Leonidas Tapias Vargas
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Christopher W Towe
- Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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Etienne H, Battilana B, Spicer J, Werner RS, Opitz I. Defining resectability: When do you try to take it out? JTCVS OPEN 2024; 19:338-346. [PMID: 39015436 PMCID: PMC11247203 DOI: 10.1016/j.xjon.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 03/14/2024] [Accepted: 03/20/2024] [Indexed: 07/18/2024]
Affiliation(s)
- Harry Etienne
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Bianca Battilana
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Jonathan Spicer
- Department of Surgery, McGill University Health Center, Montreal, Québec, Canada
| | - Raphael S. Werner
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
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Lee JM, To TM, Wang S, Lin CW, Johnson A, Meyer CS, Lee JS. Clinical and economic outcomes associated with lymph node examination status in early-stage non-small cell lung cancer: a real-world US study using the SEER-Medicare linked database. Transl Cancer Res 2024; 13:1821-1833. [PMID: 38737679 PMCID: PMC11082658 DOI: 10.21037/tcr-23-1388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 01/07/2024] [Indexed: 05/14/2024]
Abstract
Background Clinical practice guidelines recommend adjuvant therapy for patients with early non-small cell lung cancer (eNSCLC), especially those with lymph node metastasis. This study evaluated the prevalence of lymph node examination and its association with adjuvant treatment rates, overall survival (OS), and healthcare costs among United States (US) Medicare patients with resected eNSCLC. Methods This retrospective observational cohort study used Surveillance, Epidemiology, and End Results cancer registry data linked with Medicare claims data. Eligible patients were aged ≥65 years with newly diagnosed non-small cell lung cancer (NSCLC) stages IA to IIIB [the American Joint Committee on Cancer (AJCC) Cancer Staging Manual, 7th edition] between January 2010 and December 2017 with surgery ≤1 month prior to or ≤12 months after diagnosis. Patients were grouped by lymph node examination status: no examination (pNX), examination and no metastasis (pN0), or metastasis staging in N1 (pN1) or N2 (pN2). OS and costs were evaluated by examination status and number of lymph node examined. OS was analyzed using extended Cox proportional hazards models for specific time periods and time interaction with examination status, and adjusted for patient characteristics. Adjusted post-surgical healthcare costs per patient per month (PPPM) were analyzed using gamma-log regression models. Results Among the 14,648 patients included in the study, approximately 11% were pNX, whereas most were pN0 (68%), followed by pN1 (11%) and pN2 (10%). Adjuvant treatment rates were higher for pNX (35%) than pN0 (18%), but lower than pN1 (68%) and pN2 (74%) patients (P<0.001). Unadjusted OS for pNX patients was nearly identical to pN2, and significantly worse compared to pN0 and pN1 (P<0.0001). After adjusting for patient characteristics, pNX patients had higher risk of death relative to pN0 patients (P<0.001). Marginal mean adjusted total costs were comparable across pNX ($15,827 PPPM), pN0 ($12,712 PPPM) and pN1 ($17,089 PPPM), but significantly less for pN0 compared to pN2 ($23,566 PPPM) (P=0.002). Conclusions Inadequate lymph node examination is associated with underutilization of adjuvant treatment and poor OS in resected NSCLC. In the current era of targeted and immunotherapies, lymph node examination is more important than ever, implicating the need for Quality Improvement practices and multidisciplinary coordination.
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Affiliation(s)
- Jay M. Lee
- University of California, Los Angeles Health, Los Angeles, CA, USA
| | - Tu My To
- Genentech Inc., South San Francisco, CA, USA
| | - Shu Wang
- Genesis Research, Hoboken, NJ, USA
| | | | - Ann Johnson
- Genentech Inc., South San Francisco, CA, USA
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Gwon HR, La Woo A, Yong SH, Park Y, Kim SY, Kim EY, Jung JY, Kang YA, Park MS, Park SY, Lee SH. Factors affecting accuracy of clinical staging in resectable non-small cell lung cancer in a real-world study. Thorac Cancer 2024; 15:730-737. [PMID: 38380557 PMCID: PMC10961224 DOI: 10.1111/1759-7714.15253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND The clinical staging of non-small cell lung cancer (NSCLC) is well known to be related to their prognosis. However, there is usually a discrepancy between clinical staging and pathological staging. There are few analyses of clinical staging accuracy in patients with NSCLC. We compared the concordance rate between clinical and pathological staging of NSCLC and evaluated factors affecting the accuracy in real-world data. METHODS Altogether, 811 patients with primary NSCLC who had undergone curative lung resection surgery in Severance Hospital from January 2019 to December 2020 were retrospectively reviewed. We used the eighth edition of the American Joint Committee on Cancer TNM staging. RESULTS Among 811 patients, endobronchial ultrasound (EBUS) and positron emission tomography (PET-CT) were performed in 31.6% and 96.7%, respectively. The concordance rates between clinical and pathological TNM staging, T factor, and N factor, were 68.7%, 77.7%, and 85.8%, respectively. With multivariable logistic regression analysis, current smokers (OR 0.49; 95% CI: 0.32-0.76, p = 0.001) and a higher clinical stage (p < 0.001) contributed to the clinical staging inaccuracy. Additionally, the presence of a bronchoscopy specialist was significantly associated with clinical staging accuracy (OR 1.53; 95% CI: 1.10-2.13, p = 0.011). CONCLUSION Clinical staging accuracy in NSCLC improved compared to before the widespread use of PET-CT and EBUS in clinical staging work-up. Smoking history and absence of expert bronchoscopy specialists showed a meaningful correlation with the inaccuracy of clinical staging. Thus, training more bronchoscopy experts would improve the staging accuracy of NSCLC, which could positively affect the prognosis of NSCLC.
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Affiliation(s)
- Hye Ran Gwon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance HospitalYonsei University College of MedicineSeoulRepublic of Korea
- Division of PulmonologyNational Cancer CenterGoyangKorea
| | - A. La Woo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance HospitalYonsei University College of MedicineSeoulRepublic of Korea
| | - Seung Hyun Yong
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance HospitalYonsei University College of MedicineSeoulRepublic of Korea
| | - Youngmok Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance HospitalYonsei University College of MedicineSeoulRepublic of Korea
| | - Song Yee Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance HospitalYonsei University College of MedicineSeoulRepublic of Korea
| | - Eun Young Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance HospitalYonsei University College of MedicineSeoulRepublic of Korea
| | - Ji Ye Jung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance HospitalYonsei University College of MedicineSeoulRepublic of Korea
| | - Young Ae Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance HospitalYonsei University College of MedicineSeoulRepublic of Korea
| | - Moo Suk Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance HospitalYonsei University College of MedicineSeoulRepublic of Korea
| | - Seong Yong Park
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical CenterSungkyunkwan University School of MedicineSeoulRepublic of Korea
| | - Sang Hoon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance HospitalYonsei University College of MedicineSeoulRepublic of Korea
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Lin JT, Li XM, Zhong WZ, Hou QY, Liu CL, Yu XY, Ye KY, Cheng YL, Du JY, Sun YQ, Zhang FG, Yan HH, Liao RQ, Dong S, Jiang BY, Liu SY, Wu YL, Yang XN. Impact of preoperative [ 18F]FDG PET/CT vs. contrast-enhanced CT in the staging and survival of patients with clinical stage I and II non-small cell lung cancer: a 10-year follow-up study. Ann Nucl Med 2024; 38:188-198. [PMID: 38145431 DOI: 10.1007/s12149-023-01888-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 11/21/2023] [Indexed: 12/26/2023]
Abstract
OBJECTIVES To elucidate the impact of [18F]FDG positron emission tomography/computed tomography (PET/CT) vs. CT workup on staging and prognostic evaluation of clinical stage (c) I-II NSCLC. METHODS We retrospectively identified 659 cI-II NSCLC who underwent CT (267 patients) or preoperative CT followed by PET/CT (392 patients), followed by curative-intended complete resection in our hospital from January 2008 to December 2013. Differences were assessed between preoperative and postoperative stage. Five-year disease-free survival (DFS) and overall survival (OS) rates were calculated using the Kaplan-Meier approach and compared with log-rank test. Impact of preoperative PET/CT on survival was assessed by Cox regression analysis. RESULTS The study included 659 patients [mean age, 59.5 years ± 10.8 (standard deviation); 379 men]. The PET/CT group was superior over CT group in DFS [12.6 vs. 6.9 years, HR 0.67 (95% CI 0.53-0.84), p < 0.001] and OS [13.9 vs. 10.5 years, HR 0.64 (95% CI 0.50-0.81), p < 0.001]. In CT group, more patients thought to have cN0 migrated to pN1/2 disease as compared with PET/CT group [26.4% (66/250) vs. 19.2% (67/349), p < 0.001], resulting in more stage cI cases being upstaged to pII-IV [24.7% (49/198) vs. 16.1% (47/292), p = 0.02], yet this was not found in cII NSCLC [27.5% (19/69) vs. 27.0% (27/100), p = 0.94]. Cox regression analysis identified preoperative PET/CT as an independent prognostic factor of OS and DFS (p = 0.002, HR = 0.69, 95% CI 0.54-0.88; p = 0.004, HR = 0.72, 95% CI 0.58-0.90). CONCLUSION Addition of preoperative [18F]FDG PET/CT was associated with superior DFS and OS in resectable cI-II NSCLC, which may result from accurate staging and stage-appropriate therapy.
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Affiliation(s)
- Jun-Tao Lin
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, No. 106 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Xiang-Meng Li
- Cancer Institute, Southern Medical University, Guangzhou, China
| | - Wen-Zhao Zhong
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, No. 106 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Qing-Yi Hou
- Department of PET Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Chun-Ling Liu
- Department of Radiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Xin-Yue Yu
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, No. 106 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Kai-Yan Ye
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, No. 106 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Yi-Lu Cheng
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, No. 106 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Jia-Yu Du
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, No. 106 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Yun-Qing Sun
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, No. 106 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Fu-Gui Zhang
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, No. 106 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Hong-Hong Yan
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, No. 106 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Ri-Qiang Liao
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, No. 106 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Song Dong
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, No. 106 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Ben-Yuan Jiang
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, No. 106 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Si-Yang Liu
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, No. 106 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Yi-Long Wu
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, No. 106 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China.
| | - Xue-Ning Yang
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, No. 106 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China.
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10
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Rodriguez-Quintero JH, Elbahrawy MM, Montal AM, Jindani R, Vimolratana M, Kamel MK, Stiles BM, Chudgar NP. Minimally invasive surgery for clinical T4 non-small-cell lung cancer: national trends and outcomes. Eur J Cardiothorac Surg 2024; 65:ezae009. [PMID: 38263602 PMCID: PMC11007735 DOI: 10.1093/ejcts/ezae009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/15/2023] [Accepted: 01/04/2024] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVES Recent randomized data support the perioperative benefits of minimally invasive surgery (MIS) for non-small-cell lung cancer (NSCLC). Its utility for cT4 tumours remains understudied. We, therefore, sought to analyse national trends and outcomes of minimally invasive resections for cT4 cancers. METHODS Using the 2010-2019 National Cancer Database, we identified patients with cT4N0-1 NSCLC. Patients were stratified by surgical approach. Multivariable logistic analysis was used to identify factors associated with use of a minimally invasive approach. Groups were matched using propensity score analysis to evaluate perioperative and survival end points. RESULTS The study identified 3715 patients, among whom 64.1% (n = 2381) underwent open resection and 35.9% (n = 1334) minimally invasive resection [robotic-assisted in 31.5% (n = 420); and video-assisted in 68.5% (n = 914)]. Increased MIS use was noted among patients with higher income [≥$40 227, odds ratio (OR) 1.24; 95% confidence interval (CI) 1.01-1.51] and those treated at academic hospitals (OR 1.25; 95% CI 1.07-1.45). Clinically node-positive patients (OR 0.68; 95% CI 0.55-0.83) and those who underwent neoadjuvant therapy (OR 0.78; 95% CI 0.65-0.93) were less likely to have minimally invasive resection. In matched groups, patients undergoing MIS had a shorter median length of stay (5 vs 6 days, P < 0.001) and no significant differences between 30-day readmissions or 30/90-day mortality. MIS did not compromise overall survival (log-rank P = 0.487). CONCLUSIONS Nationally, the use of minimally invasive approaches for patients with cT4N0-1M0 NSCLC has increased substantially. In these patients, MIS is safe and does not compromise perioperative outcomes or survival.
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Affiliation(s)
| | - Mostafa M Elbahrawy
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Anne Michelle Montal
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Rajika Jindani
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Marc Vimolratana
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mohamed K Kamel
- Division of Thoracic and Foregut Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Brendon M Stiles
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Neel P Chudgar
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
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11
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Taylor O, Boardman G, Bentel J, Laycock A. Discordance between clinical and pathologic staging and the timeliness of care of non-small cell lung cancer patients diagnosed with operable tumors. Asia Pac J Clin Oncol 2023; 19:706-714. [PMID: 36707405 DOI: 10.1111/ajco.13934] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 12/02/2022] [Accepted: 01/07/2023] [Indexed: 01/29/2023]
Abstract
AIM This study was performed to evaluate concordance between clinical and pathologic staging of non-small cell lung cancer (NSCLC) in our hospital network. METHODS We retrospectively reviewed records of 417 patients with NSCLC who received curative surgery and whose pathology was evaluated in our hospital between 2016 and 2021. Cytology, tissue pathology, and associated clinical, surgical, and imaging information were retrieved from hospital digital records. RESULTS The cohort included 214 female and 203 male patients aged 20.6-85.8 years. Median times among staging computed tomography and surgery (105 days [interquartile range (IQR) 77.0-143.0]), positron emission tomography and surgery (78.5 days [IQR 56.0-109.0]), and endobronchial ultrasound-guided transbronchial needle aspiration and surgery (59 days [IQR 42-94]) indicated that Australian guidelines of <42 days between original referral and commencement of treatment were not being met in the majority of cases. Discordance between clinical TNM (cTNM) and pathologic TNM staging was 25.9%, including 18.4% cases that were clinically understaged and two patients with undetected stage IVA disease. cTNM understaging was significantly associated with time between the final staging investigation and surgery (p = .023), pleural (p < .05) and vessel (p < .05) invasion, and diagnosis of high-grade adenocarcinoma (p = .001). CONCLUSION Discordance between clinical and pathologic staging of NSCLC is associated with tumor histopathologic characteristics and treatment delays. Although tumor factors that lead to discordant staging cannot be controlled, reduced time to surgery may have resulted in better outcomes for some patients in this potentially curable lung cancer cohort.
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Affiliation(s)
- Oliver Taylor
- PathWest Anatomical Pathology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- School of Medicine, The University of Notre Dame, Fremantle, Western Australia, Australia
| | - Glenn Boardman
- Clinical Service Planning & Population Health, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Jacqueline Bentel
- PathWest Anatomical Pathology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Andrew Laycock
- PathWest Anatomical Pathology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- School of Medicine, The University of Notre Dame, Fremantle, Western Australia, Australia
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12
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Nagano T, Takamori S, Hashinokuchi A, Matsydo K, Kohno M, Miura N, Takenaka T, Kamitani T, Shimokawa M, Ishigami K, Oda Y, Yoshizumi T. Comparison of radiological and pathological tumor sizes in resected non-small cell lung cancer. Gen Thorac Cardiovasc Surg 2023; 71:708-714. [PMID: 37191811 DOI: 10.1007/s11748-023-01938-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/25/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVES In non-small cell lung cancer (NSCLC), T factor plays an important role in determining staging. The present study aimed to determine the validity of preoperative evaluation of clinical T (cT) factor by comparing radiological and pathological tumor sizes. METHODS Data for 1,799 patients with primary NSCLC who underwent curative surgery were investigated. The concordance between cT and pathological T (pT) factors was analyzed. Furthermore, we compared groups with an increase or decrease of ≥ 20% and groups with an increase or decrease of < 20% in the size change between preoperative radiological and pathological diameters. RESULTS The mean sizes of the radiological solid components and the pathological invasive tumors were 1.90 cm and 1.99 cm, respectively, correlation degree = 0.782. The group with increased pathological invasive tumor size (≥ 20%) compared with the radiologic solid component was significantly more likely female, consolidation tumor ratio (CTR) ≤ 0.5, and within cT1. Multivariate logistic analysis identified CTR < 1, cT ≤ T1, and adenocarcinoma as independent risk factors for increased pT factor. CONCLUSION The radiological invasive area of tumors with cT1, CTR < 1, or adenocarcinoma on preoperative CT may be underestimated compared with pathological invasive diameter.
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Affiliation(s)
- Taichi Nagano
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Shinkichi Takamori
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan.
| | - Asato Hashinokuchi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Kyoto Matsydo
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Mikihiro Kohno
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Naoko Miura
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Tomoyoshi Takenaka
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Takeshi Kamitani
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Mototsugu Shimokawa
- Department of Biostatistics, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Kousei Ishigami
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshinao Oda
- Department of Anatomical Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
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13
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West H, Hu X, Chirovsky D, Walker MS, Wang Y, Kaushiva A, Tepsick J, Samkari A. Clinical and economic impact of recurrence in early-stage non-small-cell lung cancer following complete resection. Future Oncol 2023; 19:1415-1427. [PMID: 37218514 DOI: 10.2217/fon-2023-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
Aim: Real-world data on outcomes for early-stage non-small-cell lung cancer (NSCLC) are needed to better understand the benefits of new therapies. Methods: In this retrospective study using the ConcertAI Patient360™ database, overall survival and healthcare resource utilization were compared among patients with recurrent and non-recurrent completely resected stage IB-IIIA NSCLC. Results: Recurrence was associated with a shorter median overall survival compared with non-recurrence (31.5 months vs 75.6 months, respectively), lower survival probability 5-years post-resection, and higher healthcare resource utilization. Patients with late recurrence had a longer restricted mean survival time versus patients with early recurrence. Conclusion: Results from this real-world study highlight the potential value of preventing or delaying recurrence in patients with early-stage NSCLC.
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Affiliation(s)
- Howard West
- City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Xiaohan Hu
- Merck & Co., Inc., 126 East Lincoln Avenue, P.O. Box 2000, Rahway, NJ 07065, USA
| | - Diana Chirovsky
- Merck & Co., Inc., 126 East Lincoln Avenue, P.O. Box 2000, Rahway, NJ 07065, USA
| | - Mark S Walker
- ConcertAI, 1120 Massachusetts Ave., Cambridge, MA 02138, USA
| | - Yuexi Wang
- ConcertAI, 1120 Massachusetts Ave., Cambridge, MA 02138, USA
| | - Alpana Kaushiva
- ConcertAI, 1120 Massachusetts Ave., Cambridge, MA 02138, USA
| | - Jon Tepsick
- ConcertAI, 1120 Massachusetts Ave., Cambridge, MA 02138, USA
| | - Ayman Samkari
- Merck & Co., Inc., 126 East Lincoln Avenue, P.O. Box 2000, Rahway, NJ 07065, USA
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14
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Liu L, Yu H, Bai J, Xu Q, Zhang Y, Zhang X, Yu Z, Liu Y. Positive Association of Serum Vitamin B6 Levels with Intrapulmonary Lymph Node and/or Localized Pleural Metastases in Non-Small Cell Lung Cancer: A Retrospective Study. Nutrients 2023; 15:nu15102340. [PMID: 37242223 DOI: 10.3390/nu15102340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/12/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
The relationship between vitamin B levels and the development and progression of lung cancer remains inconclusive. We aimed to investigate the relationship between B vitamins and intrapulmonary lymph nodes as well as localized pleural metastases in patients with non-small cell lung cancer (NSCLC). This was a retrospective study including patients who underwent lung surgery for suspected NSCLC at our institution from January 2016 to December 2018. Logistic regression models were used to evaluate the associations between serum B vitamin levels and intrapulmonary lymph node and/or localized pleural metastases. Stratified analysis was performed according to different clinical characteristics and tumor types. A total of 1498 patients were included in the analyses. Serum vitamin B6 levels showed a positive association with intrapulmonary metastasis in a multivariate logistic regression (odds ratio (OR) of 1.016, 95% confidence interval (CI) of 1.002-1.031, p = 0.021). After multivariable adjustment, we found a high risk of intrapulmonary metastasis in patients with high serum vitamin B6 levels (fourth quartile (Q4) vs. Q1, OR of 1.676, 95%CI of 1.092 to 2.574, p = 0.018, p for trend of 0.030). Stratified analyses showed that the positive association between serum vitamin B6 and lymph node metastasis appeared to be stronger in females, current smokers, current drinkers, and those with a family history of cancer, squamous cell carcinoma, a tumor of 1-3 cm in diameter, or a solitary tumor. Even though serum vitamin B6 levels were associated with preoperative NSCLC upstaging, B6 did not qualify as a useful biomarker due to weak association and wide confidence intervals. Thus, it would be appropriate to prospectively investigate the relationship between serum vitamin B6 levels and lung cancer further.
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Affiliation(s)
- Lu Liu
- Department of Nutrition, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Hang Yu
- Department of Respiratory and Critical Medicine, Medical School of Chinese People's Liberation Army, Beijing 100853, China
| | - Jingmin Bai
- Department of Radiotherapy, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Qing Xu
- Department of Nutrition, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Yong Zhang
- Department of Nutrition, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Xinsheng Zhang
- Department of Nutrition, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Zhimeng Yu
- Department of Nutrition, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Yinghua Liu
- Department of Nutrition, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
- National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
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15
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Baudoux N, Friedlaender A, Addeo A. Evolving Therapeutic Scenario of Stage III Non-Small-Cell Lung Cancer. Clin Med Insights Oncol 2023; 17:11795549231152948. [PMID: 36818454 PMCID: PMC9932776 DOI: 10.1177/11795549231152948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/09/2023] [Indexed: 02/16/2023] Open
Abstract
Lung cancer remains the leading cause of cancer-related death with an incidence that continues to increase in both sexes and all ages. However, 80% to 90% of lung cancers are non-small cell lung cancer (NSCLC) and the remaining 10% to 20% are small cell lung cancer. Adenocarcinoma is the most common histologic subtype of lung cancer worldwide. More frequently, lung cancer diagnosis is made in advanced stages. Stage III NSCLC refers to locoregionally advanced disease without metastases and represents about 30% NSCLC cases. Despite the absence of metastases at diagnosis, the outcome is generally poor. Stage III comprises a heterogeneous group and optimal management requires the input of a multidisciplinary team. All modalities of oncologic treatment are involved: surgery, chemotherapy, radiotherapy, and more recently, immunotherapy and targeted therapy. We will discuss the different therapeutic options in stage III NSCLC, both in operable and inoperable scenarios, and the role of immunotherapy and targeted therapy.
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Affiliation(s)
- Nathalie Baudoux
- Oncology Department, Geneva University
Hospitals, Geneva, Switzerland
| | - Alex Friedlaender
- Oncology Department, Geneva University
Hospitals, Geneva, Switzerland
- Oncology Service, Clinique Générale
Beaulieu, Geneva, Switzerland
| | - Alfredo Addeo
- Oncology Department, Geneva University
Hospitals, Geneva, Switzerland
- Alfredo Addeo, Oncology Department, Geneva
University Hospitals, Geneva, 1205, Switzerland.
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16
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Heiden BT, Eaton DB, Chang SH, Yan Y, Schoen MW, Patel MR, Kreisel D, Nava RG, Meyers BF, Kozower BD, Puri V. Assessment of Updated Commission on Cancer Guidelines for Intraoperative Lymph Node Sampling in Early Stage NSCLC. J Thorac Oncol 2022; 17:1287-1296. [PMID: 36049657 DOI: 10.1016/j.jtho.2022.08.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 07/18/2022] [Accepted: 08/02/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The American College of Surgeons Commission on Cancer recently updated its sampling recommendations for early stage NSCLC from at least 10 lymph nodes to at least one N1 (hilar) and three N2 (mediastinal) lymph node stations. Nevertheless, intraoperative lymph node sampling minimums remain subject to debate. We sought to evaluate these guidelines in patients with early stage NSCLC. METHODS We performed a cohort study using a uniquely compiled data set from the Veterans Health Administration. We manually abstracted data from operative notes and pathology reports of patients with clinical stage I NSCLC receiving surgery (2006-2016). Adequacy of lymph node sampling was defined using count-based (≥10 lymph nodes) and station-based (≥three N2 and one N1 nodal stations) minimums. Our primary outcome was recurrence-free survival. Secondary outcomes were overall survival and pathologic upstaging. RESULTS The study included 9749 patients. Count-based and station-based sampling guidelines were achieved in 3302 (33.9%) and 2559 patients (26.3%), respectively, with adherence to either sampling guideline increasing over time from 35.6% (2006) to 49.1% (2016). Adherence to station-based sampling was associated with improved recurrence-free survival (multivariable-adjusted hazard ratio = 0.815, 95% confidence interval: 0.667-0.994, p = 0.04), whereas adherence to count-based sampling was not (adjusted hazard ratio = 0.904, 95% confidence interval: 0.757-1.078, p = 0.26). Adherence to either station-based or count-based guidelines was associated with improved overall survival and higher likelihood of pathologic upstaging. CONCLUSIONS Our study supports station-based sampling minimums (≥three N2 and one N1 nodal stations) for early stage NSCLC; however, the marginal benefit compared with count-based guidelines is minimal. Further efforts to promote widespread adherence to intraoperative lymph node sampling minimums are critical for improving patient outcomes after curative-intent lung cancer resection.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri.
| | | | - Su-Hsin Chang
- VA St. Louis Health Care System, St. Louis, Missouri; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Yan Yan
- VA St. Louis Health Care System, St. Louis, Missouri; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Martin W Schoen
- VA St. Louis Health Care System, St. Louis, Missouri; Division of Hematology and Medical Oncology, Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, Missouri
| | | | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri; VA St. Louis Health Care System, St. Louis, Missouri
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri; VA St. Louis Health Care System, St. Louis, Missouri
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri; VA St. Louis Health Care System, St. Louis, Missouri
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17
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Mitzman B, Varghese TK, Kuchta K, Krantz SB. National guideline concordance and outcomes for pathologic N2 disease in non-small cell lung cancer. J Thorac Dis 2022; 14:1360-1373. [PMID: 35693597 PMCID: PMC9186219 DOI: 10.21037/jtd-21-1845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/22/2022] [Indexed: 11/29/2022]
Abstract
Background Real-world treatment practices for positive mediastinal nodal disease in non-small cell lung cancer (NSCLC) continues to vary despite guidelines. We aim to assess national trends in the treatment of pathologic-N2 disease, and evaluate the association with clinical nodal staging and timing of systemic therapy. Methods The National Cancer Database was queried for patients with NSCLC who underwent lobectomy and had pathologic-N2 disease from 2010-2017. National Comprehensive Cancer Network (NCCN) guideline concordance was evaluated. cN2 patients were analyzed based on timing of systemic therapy and response. Multivariable logistic regression evaluated outcomes by type of systemic therapy. Survival analysis utilized Cox proportional hazards regression and Kaplan-Meier methods. Results 10,225 patients met inclusion criteria. Fifty-four percent of patients were understaged prior to surgery as either cN0 or cN1. Of clinically staged N2 patients, 56% received NCCN recommended neoadjuvant therapy. Annual guideline concordance increased until 2016 to a max of 62.9%. Neoadjuvant and adjuvant systemic therapy showed an overall survival benefit compared with no systemic therapy (HR 0.54 & 0.57), but no difference when compared against each other. Complete response after neoadjuvant therapy was associated with improved survival (5-year OS 56.1%, P<0.001), while partial response, no-response, and adjuvant therapy were similar. All systemic treatment strategies improved survival compared with no systemic therapy (5-year OS 24.5%). Conclusions Guideline concordance for treatment of cN2 disease has been increasing, but still not followed in over 1/3 of patients. Responsiveness to neoadjuvant therapy appears to be a predictor of survival, and may become a prognostic adjunct for determining which patients would benefit from additional systemic therapy.
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Affiliation(s)
- Brian Mitzman
- Division of Cardiothoracic Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Thomas K. Varghese
- Division of Cardiothoracic Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Kristine Kuchta
- Department of Surgery, NorthShore University Health System, Evanston, IL, USA
| | - Seth B. Krantz
- Division of Thoracic Surgery, NorthShore University Health System, Evanston, IL, USA
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18
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Hu D, Li S, Zhang H, Wu N, Lu X. Using Natural Language Processing and Machine Learning to Preoperatively Predict Lymph Node Metastasis for Non-Small Cell Lung Cancer With Electronic Medical Records: Development and Validation Study. JMIR Med Inform 2022; 10:e35475. [PMID: 35468085 PMCID: PMC9086872 DOI: 10.2196/35475] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/31/2022] [Accepted: 04/11/2022] [Indexed: 11/21/2022] Open
Abstract
Background Lymph node metastasis (LNM) is critical for treatment decision making of patients with resectable non–small cell lung cancer, but it is difficult to precisely diagnose preoperatively. Electronic medical records (EMRs) contain a large volume of valuable information about LNM, but some key information is recorded in free text, which hinders its secondary use. Objective This study aims to develop LNM prediction models based on EMRs using natural language processing (NLP) and machine learning algorithms. Methods We developed a multiturn question answering NLP model to extract features about the primary tumor and lymph nodes from computed tomography (CT) reports. We then combined these features with other structured clinical characteristics to develop LNM prediction models using machine learning algorithms. We conducted extensive experiments to explore the effectiveness of the predictive models and compared them with size criteria based on CT image findings (the maximum short axis diameter of lymph node >10 mm was regarded as a metastatic node) and clinician’s evaluation. Since the NLP model may extract features with mistakes, we also calculated the concordance correlation between the predicted probabilities of models using NLP-extracted features and gold standard features to explore the influence of NLP-driven automatic extraction. Results Experimental results show that the random forest models achieved the best performances with 0.792 area under the receiver operating characteristic curve (AUC) value and 0.456 average precision (AP) value for pN2 LNM prediction and 0.768 AUC value and 0.524 AP value for pN1&N2 LNM prediction. And all machine learning models outperformed the size criteria and clinician’s evaluation. The concordance correlation between the random forest models using NLP-extracted features and gold standard features is 0.950 and improved to 0.984 when the top 5 important NLP-extracted features were replaced with gold standard features. Conclusions The LNM models developed can achieve competitive performance using only limited EMR data such as CT reports and tumor markers in comparison with the clinician’s evaluation. The multiturn question answering NLP model can extract features effectively to support the development of LNM prediction models, which may facilitate the clinical application of predictive models.
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Affiliation(s)
- Danqing Hu
- College of Biomedical Engineering and Instrumental Science, Zhejiang University, Hangzhou, China
| | - Shaolei Li
- Department of Thoracic Surgery II, Peking University Cancer Hospital and Institute, Beijing, China
| | - Huanyao Zhang
- College of Biomedical Engineering and Instrumental Science, Zhejiang University, Hangzhou, China
| | - Nan Wu
- Department of Thoracic Surgery II, Peking University Cancer Hospital and Institute, Beijing, China
| | - Xudong Lu
- College of Biomedical Engineering and Instrumental Science, Zhejiang University, Hangzhou, China
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Huang W, Deng HY, Xu K, Lin MY, Li P, Yuan C, Zhou Q. Initial treatment of early-stage small-sized non-small cell lung cancer for octogenarians: a population-based study. Updates Surg 2022; 74:1461-1470. [PMID: 35386041 DOI: 10.1007/s13304-022-01281-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/17/2022] [Indexed: 02/05/2023]
Abstract
The objectives of this study is to figure out the appropriate initial treatment and criteria for clinical decision for early-stage small-sized non-small cell lung cancer (NSCLC) among octogenarians. Elderly patients (≥80 years) with stage I NSCLC (<3 cm) were identified between 2004 and 2015 in the Surveillance, Epidemiology, and End Results database. Patients were divided into four cohorts regarding treatment modalities, and overall survival and cancer-specific survival were evaluated via Kaplan-Meier analysis and Cox proportional hazard model. The propensity score matching method was introduced in the subgroup analysis stratified by four clinical characteristics to identify the preferable treatment. A total of 7861 patients were included with a median overall survival of 43 months (range 1-155 months). In younger patients (80-85 years), lobectomy was superior in improving the survival (versus segmentectomy, HR = 0.68, 95%CI 0.55-0.84; versus wedge resection, HR = 0.77; 95%CI 0.67-0.88). While in those over 85 years, lobectomy was superior to wedge resection (HR = 0.72; 95%CI 0.53-0.98), and all other treatments were comparable. As stratified by T stage in those over 85 years, lobectomy was superior to wedge resection (P = 0.023) for T1 disease, and the four treatments were all comparable in overall survival for T2 disease. In conclusions, the favored treatment of early stage NSCLC for octogenarians may be evaluated by age and T stage. Lobectomy might be preferred in patients between 80 and 85 years whenever possible. Among those over 85 years, radiotherapy might lead to a comparable prognosis and could be recommended as the prior treatment, while should surgery be recommended, lobectomy might be preferred for T1 disease and wedge resection for T2 disease.
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Affiliation(s)
- Weijia Huang
- Lung Cancer Center, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, People's Republic of China
| | - Han-Yu Deng
- Lung Cancer Center, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, People's Republic of China
| | - Kai Xu
- Lung Cancer Center, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, People's Republic of China.,West China School of Medicine, Sichuan University, Chengdu, People's Republic of China
| | - Ming-Ying Lin
- West China School of Medicine, Sichuan University, Chengdu, People's Republic of China
| | - Peiwei Li
- West China School of Medicine, Sichuan University, Chengdu, People's Republic of China
| | - Chi Yuan
- West China School of Medicine, Sichuan University, Chengdu, People's Republic of China
| | - Qinghua Zhou
- Lung Cancer Center, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, People's Republic of China.
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20
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Colombi D, Petrini M, Rapacioli F, Bodini FC, Chiesa S, Franco C, Citterio C, Cavanna L, Zangrandi A, Sverzellati N, Michieletti E. Role of visceral pleural invasion and tumor sizing at CT of resected NSCLC in clinical-radiological and pathological T agreement. TUMORI JOURNAL 2022; 109:215-223. [PMID: 35341397 DOI: 10.1177/03008916221083702] [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: 11/16/2022]
Abstract
OBJECTIVE To describe in non-small cell lung cancer (NSCLC) the impact of visceral pleural invasion (VPI) and of tumor sizing assessed at computed tomography (CT) on the agreement between clinical-radiological and pathological T staging and its prognostic value. METHODS Patients affected by NSCLC treated by surgery in the period from January 2017 to September 2020 were retrospectively evaluated. Exclusion criteria were: (1) baseline CT not performed in our hospital; (2) failure of software segmentation at CT of the primary lesion. Clinical-radiological T (cT) was assessed at baseline CT, evaluating in particular T size by semi-automatic tool and VPI (cVPI) visually. Pathological T (pT) and VPI (pVPI) were recorded by pathological report and obtained after formalin-fixation and eventual elastic stain on surgical specimen. The agreement between cT and pT was evaluated by calculating the weighted kappa by Cohen (κw); the association between progression free survival (PFS) with both cT and pT was assessed by the Cox regression analysis. RESULTS The study included 84 NSCLC in 82 patients (median age 71 years, IQR 63-76 years; females 22/82, 27%). The agreement between cT and pT was poor (κw 0.302, 95%CI 0.158-0.447). The main causes of disagreement were CT oversizing (21%) and false positive cVPI (29%). A significant association was found between PFS and pT2-T3 (HR 2.75, 95%CI 1.21-6.25, p=0.015) but not with cT2-T3 (not retained in the model). CONCLUSIONS False positive cVPI and oversizing at CT are causes of disagreement between cT and pT in around one-third of resected NSCLC. PFS was significantly associated with pT but not with cT.
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Affiliation(s)
- Davide Colombi
- Department of Radiological Functions, Radiology Unit, "Guglielmo da Saliceto" Hospital, Piacenza, Italy
| | - Marcello Petrini
- Department of Radiological Functions, Radiology Unit, "Guglielmo da Saliceto" Hospital, Piacenza, Italy
| | - Fausto Rapacioli
- Department of Radiological Functions, Radiology Unit, "Guglielmo da Saliceto" Hospital, Piacenza, Italy
| | - Flavio C Bodini
- Department of Radiological Functions, Radiology Unit, "Guglielmo da Saliceto" Hospital, Piacenza, Italy
| | - Sara Chiesa
- Emergency Department, Pneumology Unit, "Guglielmo da Saliceto" Hospital, Piacenza, Italy
| | - Cosimo Franco
- Emergency Department, Pneumology Unit, "Guglielmo da Saliceto" Hospital, Piacenza, Italy
| | - Chiara Citterio
- Department of Oncology-Hematology, Oncology Unit, "Guglielmo da Saliceto" Hospital, Piacenza, Italy
| | - Luigi Cavanna
- Department of Oncology-Hematology, Oncology Unit, "Guglielmo da Saliceto" Hospital, Piacenza, Italy
| | - Adriano Zangrandi
- Department of Oncology-Hematology, Pathology Unit, "Guglielmo da Saliceto" Hospital, Piacenza, Italy
| | - Nicola Sverzellati
- Department of Medicine and Surgery (DiMeC), Radiological Sciences, University of Parma, Parma, Italy
| | - Emanuele Michieletti
- Department of Radiological Functions, Radiology Unit, "Guglielmo da Saliceto" Hospital, Piacenza, Italy
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Henderson LM, Farjah F, Detterbeck F, Smith RA, Silvestri GA, Rivera MP. Pretreatment Invasive Nodal Staging in Lung Cancer: Knowledge, Attitudes, and Beliefs Among Academic and Community Physicians. Chest 2022; 161:826-832. [PMID: 34801593 PMCID: PMC9069181 DOI: 10.1016/j.chest.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/24/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Pretreatment invasive nodal staging is paramount for appropriate treatment decisions in non-small cell lung cancer. Despite guidelines recommending when to perform staging, many studies suggest that invasive nodal staging is underused. Attitudes and barriers to guideline-recommended staging are unclear. The National Lung Cancer Roundtable initiated this study to better understand the factors associated with guideline-adherent nodal staging. RESEARCH QUESTION What are the knowledge gaps, attitudes, and beliefs of thoracic surgeons and pulmonologists about invasive nodal staging? What are the barriers to guideline-recommended staging? STUDY DESIGN AND METHODS A web-based survey of a random sample of pulmonologists and thoracic surgeons identified as members of American College of Chest Physicians (CHEST) was conducted in 2019. Survey domains included knowledge of invasive nodal staging guidelines, attitudes and beliefs toward implementation, and perceived barriers to guideline adherence. RESULTS Among 453 responding physicians, 29% were unaware that invasive nodal staging guidelines exist. Among the 320 physicians who knew guidelines exist, attitudes toward the guidelines were favorable, with 91% agreeing guidelines are generalizable and 90% agreeing that recommendations improved their staging and treatment decisions. Approximately 80% responded that guideline recommendations are based on satisfactory levels of scientific evidence, and 50% stated a lack of evidence linking adherence to guidelines to changes in management or better patient outcomes. Nearly 9 in 10 physicians reported at least one barrier to guideline adherence. The most common barriers included patient anxiety associated with treatment delays (62%), difficulty implementing guidelines into routine practice (52%), and time delays of additional testing (51%). INTERPRETATION Among physicians who responded to our survey, more than one-quarter were unaware of invasive nodal staging guidelines. Attitudes toward guideline recommendations were positive, although 20% reported insufficient evidence to support staging algorithms. Most physicians reported barriers to implementing guidelines. Multilevel interventions are likely needed to increase rates of guideline-recommended invasive nodal staging.
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Affiliation(s)
- Louise M. Henderson
- Departments of Radiology and Epidemiology, University of North Carolina, Chapel Hill, NC,CORRESPONDENCE TO: Louise M. Henderson, PhD
| | - Farhood Farjah
- Department of Surgery, University of Washington, Seattle, WA
| | | | | | - Gerard A. Silvestri
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC
| | - M. Patricia Rivera
- Division of Pulmonary and Critical Care Medicine, University of North Carolina, Chapel Hill, NC
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22
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Pages PB, Cottenet J, Bonniaud P, Tubert-Bitter P, Piroth L, Cadranel J, Bernard A, Quantin C. Impact of the SARS-CoV-2 Epidemic on Lung Cancer Surgery in France: A Nationwide Study. Cancers (Basel) 2021; 13:cancers13246277. [PMID: 34944896 PMCID: PMC8699699 DOI: 10.3390/cancers13246277] [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: 09/30/2021] [Revised: 11/30/2021] [Accepted: 12/10/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Few studies have investigated the link between SARS-CoV-2 and health restrictions and its effects on the health of lung cancer (LC) patients. This study aimed to assess the impact of SARS-CoV-2 on activity volume, postoperative complications and in-hospital mortality (IHM) for LC resections in 2020 at the national level in France. Our study shows a decrease in the volume of LC resections, especially during the first lockdown. We also show that only 0.43% of patients hospitalized for LC surgery during 2020 developed a SARS-CoV-2 infection, but this low rate is counterbalanced by a high IHM (21%) in these 51 patients. Our findings suggest that, even if the IHM is high, LC surgery is feasible during a pandemic provided that the general guidance protocols edited by the surgical societies are respected. Therefore, this study provides further arguments to encourage teams to test for COVID-19 prior to surgery and patients to be vaccinated. Abstract Few studies have investigated the link between SARS-CoV-2 and health restrictions and its effects on the health of lung cancer (LC) patients. The aim of this study was to assess the impact of the SARS-CoV-2 epidemic on surgical activity volume, postoperative complications and in-hospital mortality (IHM) for LC resections in France. All data for adult patients who underwent pulmonary resection for LC in France in 2020, collected from the national administrative database, were compared to 2018–2019. The effect of SARS-CoV-2 on the risk of IHM and severe complications within 30 days among LC surgery patients was examined using a logistic regression analysis adjusted for age, sex, comorbidities and type of resection. There was a slight decrease in the volume of LC resections in 2020 (n = 11,634), as compared to 2018 (n = 12,153) and 2019 (n = 12,227), with a noticeable decrease in April 2020 (the peak of the first wave of epidemic in France). We found that SARS-CoV-2 (0.43% of 2020 resections) was associated with IHM and severe complications, with, respectively, a sevenfold (aOR = 7.17 (3.30–15.55)) and almost a fivefold (aOR = 4.76 (2.31–9.80)) increase in risk. Our study suggests that LC surgery is feasible even during a pandemic, provided that general guidance protocols edited by the surgical societies are respected.
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Affiliation(s)
- Pierre-Benoit Pages
- Department of Thoracic Surgery, Centre Hospitalier Universitaire Dijon, Bocage Central, 21079 Dijon, France; (P.-B.P.); (A.B.)
- INSERM UMR 1231, Centre Hospitalier Universitaire Bocage, University of Burgundy, 21079 Dijon, France
| | - Jonathan Cottenet
- Biostatistics and Bioinformatics (DIM), Dijon University Hospital, University of Burgundy Franche-Comté, BP 77908, 21079 Dijon, France;
| | - Philippe Bonniaud
- Faculty of Medicine, University of Bourgogne-Franche-Comté, 21000 Dijon, France; (P.B.); (L.P.)
- Reference Center for Rare Pulmonary Diseases, Pulmonary Medicine and Intensive Care Unit Department, Dijon University Hospital, BP 77908, 21079 Dijon, France
| | - Pascale Tubert-Bitter
- High-Dimensional Biostatistics for Drug Safety and Genomics, Paris-Saclay University, UVSQ, Inserm, CESP, 94800 Villejuif, France;
| | - Lionel Piroth
- Faculty of Medicine, University of Bourgogne-Franche-Comté, 21000 Dijon, France; (P.B.); (L.P.)
- Clinical Investigation Center, Clinical Epidemiology/Clinical Trials Unit, Dijon University Hospital, 21079 Dijon, France
- Infectious Diseases Department, Dijon University Hospital, BP 77908, 21079 Dijon, France
| | - Jacques Cadranel
- Chest Department and Constitutive Center for Rare Pulmonary Disease, Hôpital Tenon, AP-HP, Inflammation-Immunopathology-Biotherapy Department (DHU i2B) and Sorbonne University, 75020 Paris, France;
| | - Alain Bernard
- Department of Thoracic Surgery, Centre Hospitalier Universitaire Dijon, Bocage Central, 21079 Dijon, France; (P.-B.P.); (A.B.)
| | - Catherine Quantin
- Biostatistics and Bioinformatics (DIM), Dijon University Hospital, University of Burgundy Franche-Comté, BP 77908, 21079 Dijon, France;
- High-Dimensional Biostatistics for Drug Safety and Genomics, Paris-Saclay University, UVSQ, Inserm, CESP, 94800 Villejuif, France;
- Clinical Investigation Center, Clinical Epidemiology/Clinical Trials Unit, Dijon University Hospital, 21079 Dijon, France
- Correspondence: ; Tel.: +(33)-3-80-29-34-65; Fax: +(33)-3-80-29-39-73
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Hu D, Zhang H, Li S, Wang Y, Wu N, Lu X. Automatic Extraction of Lung Cancer Staging Information From Computed Tomography Reports: Deep Learning Approach. JMIR Med Inform 2021; 9:e27955. [PMID: 34287213 PMCID: PMC8339987 DOI: 10.2196/27955] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/27/2021] [Accepted: 06/07/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Lung cancer is the leading cause of cancer deaths worldwide. Clinical staging of lung cancer plays a crucial role in making treatment decisions and evaluating prognosis. However, in clinical practice, approximately one-half of the clinical stages of lung cancer patients are inconsistent with their pathological stages. As one of the most important diagnostic modalities for staging, chest computed tomography (CT) provides a wealth of information about cancer staging, but the free-text nature of the CT reports obstructs their computerization. OBJECTIVE We aimed to automatically extract the staging-related information from CT reports to support accurate clinical staging of lung cancer. METHODS In this study, we developed an information extraction (IE) system to extract the staging-related information from CT reports. The system consisted of the following three parts: named entity recognition (NER), relation classification (RC), and postprocessing (PP). We first summarized 22 questions about lung cancer staging based on the TNM staging guideline. Next, three state-of-the-art NER algorithms were implemented to recognize the entities of interest. Next, we designed a novel RC method using the relation sign constraint (RSC) to classify the relations between entities. Finally, a rule-based PP module was established to obtain the formatted answers using the results of NER and RC. RESULTS We evaluated the developed IE system on a clinical data set containing 392 chest CT reports collected from the Department of Thoracic Surgery II in the Peking University Cancer Hospital. The experimental results showed that the bidirectional encoder representation from transformers (BERT) model outperformed the iterated dilated convolutional neural networks-conditional random field (ID-CNN-CRF) and bidirectional long short-term memory networks-conditional random field (Bi-LSTM-CRF) for NER tasks with macro-F1 scores of 80.97% and 90.06% under the exact and inexact matching schemes, respectively. For the RC task, the proposed RSC showed better performance than the baseline methods. Further, the BERT-RSC model achieved the best performance with a macro-F1 score of 97.13% and a micro-F1 score of 98.37%. Moreover, the rule-based PP module could correctly obtain the formatted results using the extractions of NER and RC, achieving a macro-F1 score of 94.57% and a micro-F1 score of 96.74% for all the 22 questions. CONCLUSIONS We conclude that the developed IE system can effectively and accurately extract information about lung cancer staging from CT reports. Experimental results show that the extracted results have significant potential for further use in stage verification and prediction to facilitate accurate clinical staging.
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Affiliation(s)
- Danqing Hu
- College of Biomedical Engineering and Instrumental Science, Zhejiang University, Hangzhou, China
- Key Laboratory for Biomedical Engineering, Ministry of Education, Hangzhou, China
| | - Huanyao Zhang
- College of Biomedical Engineering and Instrumental Science, Zhejiang University, Hangzhou, China
- Key Laboratory for Biomedical Engineering, Ministry of Education, Hangzhou, China
| | - Shaolei Li
- Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing, China
| | - Yuhong Wang
- College of Biomedical Engineering and Instrumental Science, Zhejiang University, Hangzhou, China
- Key Laboratory for Biomedical Engineering, Ministry of Education, Hangzhou, China
| | - Nan Wu
- Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing, China
| | - Xudong Lu
- College of Biomedical Engineering and Instrumental Science, Zhejiang University, Hangzhou, China
- Key Laboratory for Biomedical Engineering, Ministry of Education, Hangzhou, China
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Storebø OJ, Ribeiro JP, Kongerslev MT, Stoffers-Winterling J, Sedoc Jørgensen M, Lieb K, Bateman A, Kirubakaran R, Dérian N, Karyotaki E, Cuijpers P, Simonsen E. Individual participant data systematic reviews with meta-analyses of psychotherapies for borderline personality disorder. BMJ Open 2021; 11:e047416. [PMID: 34155077 PMCID: PMC8217922 DOI: 10.1136/bmjopen-2020-047416] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 06/04/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The heterogeneity in people with borderline personality disorder (BPD) and the range of specialised psychotherapies means that people with certain BPD characteristics might benefit more or less from different types of psychotherapy. Identifying moderating characteristics of individuals is a key to refine and tailor standard treatments so they match the specificities of the individual participant. The objective of this is to improve the quality of care and the individual outcomes. We will do so by performing three systematic reviews with meta-analyses of individual participant data (IPD). The aim of these reviews is to investigate potential predictors and moderating patient characteristics on treatment outcomes for patients with BPD. METHODS AND ANALYSIS We performed comprehensive searches in 22 databases and trial registries up to October 6th 2020. These will be updated with a top-up search up until June 2021. Our primary meta-analytic method will be the one-stage random-effects approach. To identify predictors, we will use the one-stage model that accounts for interaction between covariates and treatment allocation. Heterogeneity in case-mix will be assessed with a membership model based on a multinomial logistic regression where study membership is the outcome. A random-effects meta-analysis is chosen to account for expected levels of heterogeneity. ETHICS AND DISSEMINATION The statistical analyses will be conducted on anonymised data that have already been approved by the respective ethical committees that originally assessed the included trials. The three IPD reviews will be published in high-impact factor journals and their results will be presented at international conferences and national seminars. PROSPERO REGISTRATION NUMBER CRD42021210688.
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Affiliation(s)
- Ole Jakob Storebø
- Psychiatric Department, Region Zealand Psychiatry, Psychiatric Research Unit, Slagelse, Denmark
- Department of Psychology, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | - Johanne Pereira Ribeiro
- Psychiatric Department, Region Zealand Psychiatry, Psychiatric Research Unit, Slagelse, Denmark
| | | | - Jutta Stoffers-Winterling
- Department of Psychiatry and Psychotherapy, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Rheinland-Pfalz, Germany
| | - Mie Sedoc Jørgensen
- Psychiatric Department, Region Zealand Psychiatry, Psychiatric Research Unit, Slagelse, Denmark
| | - Klaus Lieb
- Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Anthony Bateman
- Royal Free and University College Medical School, London, UK
- Halliwick Day Unit, St. Ann's Hospital, London, UK
| | - Richard Kirubakaran
- Prof BV Moses Centre for Evidence-Informed Healthcare and Health Policy, Vellore, India
| | - Nicolas Dérian
- Data and Development Support Unit, Region Zealand, Køge, Denmark
| | - Eirini Karyotaki
- Department of Clinical Psychology, VU University Amsterdam, Amsterdam, The Netherlands
| | - Pim Cuijpers
- Department of Clinical Psychology, VU University Amsterdam, Amsterdam, The Netherlands
| | - Erik Simonsen
- Psychiatric Department, Region Zealand Psychiatry, Psychiatric Research Unit, Slagelse, Denmark
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Wu DY, de Hoyos A, Vo DT, Hwang H, Spangler AE, Seiler SJ. Clinical Non-Small Cell Lung Cancer Staging and Tumor Length Measurement Results From U.S. Cancer Hospitals. Acad Radiol 2021; 28:753-766. [PMID: 32563559 DOI: 10.1016/j.acra.2020.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/13/2020] [Accepted: 04/03/2020] [Indexed: 11/29/2022]
Abstract
RATIONALE AND OBJECTIVES Examine the accuracy of clinical non-small cell lung cancer staging and tumor length measurements, which are critical to prognosis and treatment planning. MATERIALS AND METHODS Compare clinical and pathological staging and lengths using 10,320 2016 National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) and 559 2010-2018 non-SEER single-institute surgically-treated cases, and analyze modifiable causes of disagreement. RESULTS The SEER clinical and pathological group-stages agree only 62.3% ± 0.9% over all stage categories. The lymph node N-stage agrees much better at 83.0% ± 1.0%, but the tumor length-location T-stage agrees only 57.7% ± 0.8% with approximately 29% of the cases having a greater pathology than clinical T-stage. Individual T-stage category agreements with respect to the number of pathology cases are Tis, T1a, T1b, T2a, T2b, T3, T4: 89.9% ± 10.0%; 78.7% ± 1.7%; 51.8% ± 1.9%; 46.1% ± 1.3%; 40.5% ± 3.1%; 44.1% ± 2.2%; 56.4% ± 4.7%, respectively. Most of the single-institute results statistically agree with SEER's. Excluding Tis cases, the mean difference in SEER tumor length is ∼1.18 ± 9.26 mm (confidence interval: 0.97-1.39 mm) with pathological lengths being longer than clinical lengths except for small tumors; the two measurements correlate well (Pearson-r >0.87, confidence interval: 0.86-0.87). Reasons for disagreement include the use of family-category descriptors (e.g., T1) instead of their subcategories (e.g., T1a and T1b), which worsens the T-stage agreement by over 15%. Disagreement is also associated with higher tumor grade, larger resected specimens, higher N-stage, patient age, and periodic biases in clinical and pathological tumor size measurements. CONCLUSIONS By including preliminary non-small cell lung cancer clinical stage values in their evaluation, diagnostic radiologists can improve the accuracy of staging and standardize tumor-size measurements, which improves patient care.
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Affiliation(s)
- Dolly Y Wu
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9248; California Institute of Technology, Pasadena, California.
| | | | - Dat T Vo
- Department of Radiation Oncology
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26
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Wang YQ, Liu XD, Bai WL, Li SQ. Identification of Resectable N2 in NSCLC: A Single Center Experience and Review of the SEER Database. Front Oncol 2021; 11:647546. [PMID: 33981606 PMCID: PMC8108988 DOI: 10.3389/fonc.2021.647546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/29/2021] [Indexed: 12/25/2022] Open
Abstract
Background Non-small cell lung carcinoma (NSCLC) with ipsilateral and/or subcarinal mediastinal lymphatic spread (N2) is a heterogeneous disease. The role of surgical resection in patients with N2 NSCLC remains controversial and no survival-based definition of “resectable N2” exists. The purpose of this study is to evaluate the factors that potentially affect the survival of N2 NSCLC patients who receive surgical resection and to define “resectable N2” based on the survival benefits. Methods Data from the open Surveillance, Epidemiology, and End Results (SEER) database from the National Cancer Institute in the United States were used to construct a nomogram. Patients who received surgery between 2010 and 2015 for N2 NSCLC were included. Independent prognostic factors for survival identified through Cox regression analysis were used to create the nomogram. The C-index, receiver operating characteristics (ROC) analyses, calibration curves, and risk stratification were used to evaluate the nomogram. The nomogram was also validated using data from 222 patients from Peking Union Medical College Hospital (PUMCH). Furthermore, lung cancer–related deaths were compared using competitive risk analysis. Results In total, 4267 patients were included in the SEER cohort. Male gender, old age, high T stage and grade, adenosquamous and squamous cell carcinoma, lower lobe and overlapping lesions, extended lobe or bilobectomy and pneumonectomy, no chemotherapy, radiation before and after surgery, positive number of lymph nodes, and lymph node ratio (LNR) were identified as independent risk factors for higher mortality. The nomogram was created using these parameters. The C-index was 0.665 (95% confidence interval (CI), 0.651-0.679) and 0.722 (95% CI, 0.620-0.824) in the SEER and PUMCH cohorts, respectively. The calibration curves showed satisfactory consistency between the predicted and actual survival status in both the SEER and PUMCH cohorts. Competitive risk analysis confirmed that the variables in the nomogram, except radiation, are risk factors for prognosis. Conclusions “Resectable N2” should be assessed by a multidisciplinary team. The novel nomogram developed in this study may help with clinical decision-making for this patient population.
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Affiliation(s)
- Yan-Qing Wang
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xu-Dong Liu
- Medical Science Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wen-Liang Bai
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Shan-Qing Li
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Udelsman BV, Madariaga ML, Chang DC, Kozower BD, Gaissert HA. Concordance of Clinical and Pathologic Nodal Staging in Resectable Lung Cancer. Ann Thorac Surg 2021; 111:1125-1132. [DOI: 10.1016/j.athoracsur.2020.06.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 05/17/2020] [Accepted: 06/13/2020] [Indexed: 02/06/2023]
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Abstract
For stage III non-small cell lung cancer (NSCLC), approximately a third of patients survive up to 5 years, with decreasing 5-year survival rates for stage IIIB and stage IIIC disease. Although curable, stage III NSCLC encompasses a diverse range of disease presentation, with an equally complex range of multi-modal treatment options, including systemic and local therapies for distant and local disease control, respectively. This complexity results in a number of challenges for the multi-disciplinary team (MDT) in achieving optimal treatment outcomes for patients. As multi-modality treatment is the preferred treatment strategy for all stage III disease, the focus of this article is the key surgical, chemotherapy and radiotherapy clinical trials as well as guidelines that currently outline radical therapy options for patients with both potentially resectable and unresectable stage III NSCLC.
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Wu DY, Spangler AE, Vo DT, de Hoyos A, Seiler SJ. Simplified, standardized methods to assess the accuracy of clinical cancer staging. Cancer Treat Res Commun 2020; 25:100253. [PMID: 33310370 DOI: 10.1016/j.ctarc.2020.100253] [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: 08/30/2020] [Revised: 11/19/2020] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Hospitals lack intuitive methods to monitor their accuracy of clinical cancer staging, which is critical to treatment planning, prognosis, refinements, and registering quality data. METHODS We introduce a tabulation framework to compare clinical staging with the reference-standard pathological staging, and quantify systematic errors. As an example, we analyzed 9,644 2016 U.S. National Cancer Institute SEER surgically-treated non-small cell lung cancer (NSCLC) cases, and computed concordance with different denominators to compare with incompatible past results. RESULTS The concordance for clinical versus pathological lymph node N-stage is very good, 83.4 ± 1.0%, but the tumor length-location T-stage is only 58.1 ± 0.9%. There are intuitive insights to the causes of discordance. Approximately 29% of the cases are pathological T-stage greater than clinical T-stage, and 12% lower than the clinical T-stage, which is due partly to the fact that surgically-treated NSCLC are typically lower-stage cancer cases, which results in a bounded higher probability for pathological upstaging. Individual T-stage categories Tis, T1a, T1b, T2a, T2b, T3, T4 invariant percent-concordances are 85.2 ± 9.7 + 10.3%; 72.7 ± 1.6 + 11.3%; 46.6 ± 1.8 + 10.9%; 54.6 ± 1.6 - 20.5%; 41.6 ± 3.3 - 0.1%; 54.7 ± 2.8 - 24.1%; 55.2 ± 4.7 + 2.6%, respectively. Each percent-concordance is referenced to an averaged number of pathological and clinical cases. The first error number quantifies statistical fluctuations; the second quantifies clinical and pathological staging biases. Lastly, comparison of over and under staging versus clinical characteristics provides further insights. CONCLUSIONS Clinical NSCLC staging accuracy and concordance with pathological values can improve. As a first step, the framework enables standardizing comparing staging results and detecting possible problem areas. Cancer hospitals and registries can implement the efficient framework to monitor staging accuracy.
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Affiliation(s)
- Dolly Y Wu
- Volunteer Services, University of Texas Southwestern Medical Center, Dallas, TX, United States; California Institute of Technology, Pasadena, CA, United States.
| | - Ann E Spangler
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Dat T Vo
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Alberto de Hoyos
- Department of Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Stephen J Seiler
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, United States
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Abstract
Anatomic staging is a critical step in evaluation of patients with lung cancer. Accurate identification of stage based on features of primary tumor (T), regional nodes (N), and metastatic disease (M) is fundamental to determining appropriate care. In this article, the TNM components of the anatomic staging system and a framework for description of lung cancer with multiple pulmonary sites of involvement are discussed. TNM combinations are grouped according to prognosis, with patient-level, tumor-level, and environment-level factors also influencing survival outcomes. Although the staging system does not include molecular and immunologic information, anatomic staging remains the common language for communicating extent of disease.
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Affiliation(s)
- Lynn T Tanoue
- Yale School of Medicine, 333 Cedar Street, PO Box 208057, New Haven, CT 06520, USA.
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Pluyter JR, Jacobs I, Langereis S, Cobben D, Williams S, Curfs J, van den Borne B. Looking through the eyes of the multidisciplinary team: the design and clinical evaluation of a decision support system for lung cancer care. Transl Lung Cancer Res 2020; 9:1422-1432. [PMID: 32953514 PMCID: PMC7481580 DOI: 10.21037/tlcr-19-441] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Decision-making in lung cancer is complex due to a rapidly increasing amount of diagnostic data and treatment options. The need for timely and accurate diagnosis and delivery of care demands high-quality multidisciplinary team (MDT) collaboration and coordination. Clinical decision support systems (CDSSs) can potentially support MDTs in constructing a shared mental model of a patient case. This enables the team to assess the strength and completeness of collected diagnostic data, stratification for the right personalized therapy driven by clinical stage and other treatment-influencing factors, and adapt care management strategies when needed. Current CDSSs often have a suboptimal fit into the decision-making workflow, which hampers their impact in clinical practice. Methods A CDSS for multidisciplinary decision-making in lung cancer was designed to support the abovementioned goals through presentation of relevant clinical data in line with existing mental model structures of the MDT members. The CDSS was tested in a simulated multidisciplinary tumor board meeting for primary diagnosis and treatment selection, based on de-identified primary lung cancer cases (n=8). Decision course analysis, eye-tracking data and questionnaires were used to assess the impact of the CDSS on constructing shared mental models to improve the decision-making process and outcome. Results The CDSS supported the team in their self-correcting capacity for accurate diagnosis and TNM classification. It enabled cross-validation of diagnostic findings, surfaced discordance between diagnostic tests and facilitated cancer staging according the diagnostic evidence, as well as spotting contra-indications for personalized treatment selection. Conclusions This study shows the potential of CDSS on clinical decision making, when these systems are properly designed in line with clinical thinking. The presented setup enables assessment of the impact of CDSS design on clinical decision making and optimization of CDSSs to maximize their effect on decision quality and confidence.
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Affiliation(s)
- Jon R Pluyter
- Philips Experience Design, High Tech Campus 33, Eindhoven, The Netherlands
| | - Igor Jacobs
- Department of Oncology Solutions, Philips Research Europe, High Tech Campus 34, Eindhoven, The Netherlands
| | - Sander Langereis
- Department of Oncology Solutions, Philips Research Europe, High Tech Campus 34, Eindhoven, The Netherlands
| | - David Cobben
- Department of Radiotherapy Related Research, University of Manchester-The Christie National Health Trust, Manchester, UK
| | - Sharon Williams
- Philips Experience Design, High Tech Campus 33, Eindhoven, The Netherlands
| | - Jeannine Curfs
- Department of Pulmonary Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Ben van den Borne
- Department of Pulmonary Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
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Contrera KJ, Hair BB, Prendes B, Reddy CA, Zimmer DI, Burkey BB, Tassone P. Clinical Versus Pathologic Laryngeal Cancer Staging and the Impact of Stage Change on Outcomes. Laryngoscope 2020; 131:559-565. [PMID: 32692866 DOI: 10.1002/lary.28924] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/02/2020] [Accepted: 06/18/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVES/HYPOTHESIS Evaluate the impact and accuracy of clinical laryngeal cancer staging. STUDY DESIGN Retrospective cohort study. METHODS Two hundred sixty-five consecutive patients with laryngeal squamous cell carcinoma who underwent total laryngectomy from 2001 to 2017 were studied. Clinical versus pathologic tumor (T) and nodal (N) categories were compared. Logistic regression and Cox proportional hazards analyzed the association of stage change with perioperative factors and outcomes. RESULTS Forty-seven patients (17.7%, accuracy = 0.969 ± 0.010 [standard error]) changed between T1-2 and T3-4. Sixty-four patients (24.1%, accuracy = 0.866 ± 0.020) had inaccurate N category. Salvage patients were less likely to have stage change (downstage: odds ratio [OR] = 0.20, 95% confidence interval [CI]: 0.08-0.50, P < .001; upstage: OR = 0.41, 95% CI: 0.23-0.74, P = .003), but more likely to have inaccurate nodal category (39.8% vs. 11.7%, P < .001). Patients with stage change tended to have greater odds of positive/close margins (upstage: OR = 1.78, 95% CI: 0.91-3.5, P = .092) and chemotherapy (downstage: OR = 2.21, 95% CI: 0.80-6.14, P = .128; upstage: OR = 1.87, 95% CI: 0.85-4.11, P = .119). Stage change was associated with recurrence (P = .047) with downstaged patients less likely to recur (hazard ratio = 0.26, 95% CI: 0.08-0.82, P = .021). Stage change was not associated with positron emission tomography scan, subsite, time to surgery, or mortality. CONCLUSIONS A third of laryngeal cancer patients were downstaged or upstaged after laryngectomy with 18% and 24% of clinical T and N categories inaccurate, respectively. Stage change was less common for salvage patients and associated with risk of recurrence. LEVEL OF EVIDENCE 3 Laryngoscope, 131:559-565, 2021.
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Affiliation(s)
- Kevin J Contrera
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Bryan B Hair
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, U.S.A
| | - Brandon Prendes
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Chandana A Reddy
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - David I Zimmer
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Brian B Burkey
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Patrick Tassone
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri, Columbia, Missouri, U.S.A
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DiBardino DM, Navani N. Hitting a HOMER: Epidemiology to the Bedside when Evaluating for Stereotactic Ablative Radiotherapy. Am J Respir Crit Care Med 2020; 201:136-138. [PMID: 31658428 PMCID: PMC6961734 DOI: 10.1164/rccm.201910-1933ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- David M DiBardino
- Division of Pulmonary, Allergy and Critical Care MedicineUniversity of PennsylvaniaPhiladelphia, Pennsylvania
| | - Neal Navani
- University College London Respiratoryand.,Department of Thoracic MedicineUniversity College London HospitalLondon, England
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Bade BC, Silvestri GA. Setting the Stage for Success in Lung Cancer: The Importance of Remembering Your (Guide)Lines. Chest 2019; 155:456-457. [PMID: 30846061 DOI: 10.1016/j.chest.2018.11.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 11/20/2018] [Accepted: 11/20/2018] [Indexed: 12/25/2022] Open
Affiliation(s)
- Brett C Bade
- Department of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, CT
| | - Gerard A Silvestri
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC.
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Taylor SA, Mallett S, Miles A, Morris S, Quinn L, Clarke CS, Beare S, Bridgewater J, Goh V, Janes S, Koh DM, Morton A, Navani N, Oliver A, Padhani A, Punwani S, Rockall A, Halligan S. Whole-body MRI compared with standard pathways for staging metastatic disease in lung and colorectal cancer: the Streamline diagnostic accuracy studies. Health Technol Assess 2019; 23:1-270. [PMID: 31855148 PMCID: PMC6936168 DOI: 10.3310/hta23660] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Whole-body magnetic resonance imaging is advocated as an alternative to standard pathways for staging cancer. OBJECTIVES The objectives were to compare diagnostic accuracy, efficiency, patient acceptability, observer variability and cost-effectiveness of whole-body magnetic resonance imaging and standard pathways in staging newly diagnosed non-small-cell lung cancer (Streamline L) and colorectal cancer (Streamline C). DESIGN The design was a prospective multicentre cohort study. SETTING The setting was 16 NHS hospitals. PARTICIPANTS Consecutive patients aged ≥ 18 years with histologically proven or suspected colorectal (Streamline C) or non-small-cell lung cancer (Streamline L). INTERVENTIONS Whole-body magnetic resonance imaging. Standard staging investigations (e.g. computed tomography and positron emission tomography-computed tomography). REFERENCE STANDARD Consensus panel decision using 12-month follow-up data. MAIN OUTCOME MEASURES The primary outcome was per-patient sensitivity difference between whole-body magnetic resonance imaging and standard staging pathways for metastasis. Secondary outcomes included differences in specificity, the nature of the first major treatment decision, time and number of tests to complete staging, patient experience and cost-effectiveness. RESULTS Streamline C - 299 participants were included. Per-patient sensitivity for metastatic disease was 67% (95% confidence interval 56% to 78%) and 63% (95% confidence interval 51% to 74%) for whole-body magnetic resonance imaging and standard pathways, respectively, a difference in sensitivity of 4% (95% confidence interval -5% to 13%; p = 0.51). Specificity was 95% (95% confidence interval 92% to 97%) and 93% (95% confidence interval 90% to 96%) respectively, a difference of 2% (95% confidence interval -2% to 6%). Pathway treatment decisions agreed with the multidisciplinary team treatment decision in 96% and 95% of cases, respectively, a difference of 1% (95% confidence interval -2% to 4%). Time for staging was 8 days (95% confidence interval 6 to 9 days) and 13 days (95% confidence interval 11 to 15 days) for whole-body magnetic resonance imaging and standard pathways, respectively, a difference of 5 days (95% confidence interval 3 to 7 days). The whole-body magnetic resonance imaging pathway was cheaper than the standard staging pathway: £216 (95% confidence interval £211 to £221) versus £285 (95% confidence interval £260 to £310). Streamline L - 187 participants were included. Per-patient sensitivity for metastatic disease was 50% (95% confidence interval 37% to 63%) and 54% (95% confidence interval 41% to 67%) for whole-body magnetic resonance imaging and standard pathways, respectively, a difference in sensitivity of 4% (95% confidence interval -7% to 15%; p = 0.73). Specificity was 93% (95% confidence interval 88% to 96%) and 95% (95% confidence interval 91% to 98%), respectively, a difference of 2% (95% confidence interval -2% to 7%). Pathway treatment decisions agreed with the multidisciplinary team treatment decision in 98% and 99% of cases, respectively, a difference of 1% (95% confidence interval -2% to 4%). Time for staging was 13 days (95% confidence interval 12 to 14 days) and 19 days (95% confidence interval 17 to 21 days) for whole-body magnetic resonance imaging and standard pathways, respectively, a difference of 6 days (95% confidence interval 4 to 8 days). The whole-body magnetic resonance imaging pathway was cheaper than the standard staging pathway: £317 (95% confidence interval £273 to £361) versus £620 (95% confidence interval £574 to £666). Participants generally found whole-body magnetic resonance imaging more burdensome than standard imaging but most participants preferred the whole-body magnetic resonance imaging staging pathway if it reduced time to staging and/or number of tests. LIMITATIONS Whole-body magnetic resonance imaging was interpreted by practitioners blinded to other clinical data, which may not fully reflect how it is used in clinical practice. CONCLUSIONS In colorectal and non-small-cell lung cancer, the whole-body magnetic resonance imaging staging pathway has similar accuracy to standard staging pathways, is generally preferred by patients, improves staging efficiency and has lower staging costs. Future work should address the utility of whole-body magnetic resonance imaging for treatment response assessment. TRIAL REGISTRATION Current Controlled Trials ISRCTN43958015 and ISRCTN50436483. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 66. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Susan Mallett
- Institute of Applied Health Research, NIHR Birmingham Biomedical Research Centre, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Anne Miles
- Department of Psychological Sciences, Birkbeck, University of London, London, UK
| | - Stephen Morris
- Applied Health Research, University College London, London, UK
| | - Laura Quinn
- Institute of Applied Health Research, NIHR Birmingham Biomedical Research Centre, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Caroline S Clarke
- Research Department of Primary Care and Population Health, and Priment Clinical Trials Unit, University College London, London, UK
| | - Sandy Beare
- Cancer Research UK & UCL Cancer Trials Centre, University College London, London, UK
| | | | - Vicky Goh
- Department of Cancer Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Sam Janes
- Lungs for Living Research Centre, UCL Respiratory, University College London, London, UK
| | - Dow-Mu Koh
- Department of Radiology, The Royal Marsden Hospital, Sutton, UK
| | - Alison Morton
- c/o Centre for Medical Imaging, University College London, London, UK
| | - Neal Navani
- Lungs for Living Research Centre, UCL Respiratory, University College London, London, UK
| | - Alfred Oliver
- c/o Centre for Medical Imaging, University College London, London, UK
| | - Anwar Padhani
- Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, UK
| | - Shonit Punwani
- Centre for Medical Imaging, University College London, London, UK
| | - Andrea Rockall
- Imaging Department, Imperial College Healthcare NHS Trust, London, UK
| | - Steve Halligan
- Centre for Medical Imaging, University College London, London, UK
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Response. Chest 2019; 156:634-635. [PMID: 31511157 DOI: 10.1016/j.chest.2019.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 05/11/2019] [Indexed: 11/21/2022] Open
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Gard G, Voskoboynik M. Setting the Stage: Delay to Surgery May Upstage Patients With Non-Small Cell Lung Cancer. Chest 2019; 156:633-634. [PMID: 31511156 DOI: 10.1016/j.chest.2019.04.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 04/11/2019] [Indexed: 11/16/2022] Open
Affiliation(s)
- Grace Gard
- Medical Oncology, Alfred Health, Melbourne, VIC, Australia; Central Clinical School, Monash University, Melbourne, VIC, Australia.
| | - Mark Voskoboynik
- Central Clinical School, Monash University, Melbourne, VIC, Australia
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Navani N. Accurate staging of non-small cell lung cancer-tissue is the issue. J Thorac Dis 2019; 11:E141-E143. [PMID: 31559087 DOI: 10.21037/jtd.2019.07.62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Neal Navani
- Thoracic Medicine, University College London Hospital, London, UK.,Lungs for Living Research Centre, University College London, London, UK
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Kim H, Goo JM, Paeng JC, Kim YT, Park CM. Evaluation of maximum standardized uptake value at fluorine-18 fluorodeoxyglucose positron emission tomography as a complementary T factor in the eighth edition of lung cancer stage classification. Lung Cancer 2019; 134:151-157. [DOI: 10.1016/j.lungcan.2019.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/28/2019] [Accepted: 06/12/2019] [Indexed: 12/25/2022]
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40
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Taylor SA, Mallett S, Ball S, Beare S, Bhatnagar G, Bhowmik A, Boavida P, Bridgewater J, Clarke CS, Duggan M, Ellis S, Glynne-Jones R, Goh V, Groves AM, Hameeduddin A, Janes SM, Johnston EW, Koh DM, Lock S, Miles A, Morris S, Morton A, Navani N, Oliver A, O'Shaughnessy T, Padhani AR, Prezzi D, Punwani S, Quinn L, Rafiee H, Reczko K, Rockall AG, Russell P, Sidhu HS, Strickland N, Tarver K, Teague J, Halligan S. Diagnostic accuracy of whole-body MRI versus standard imaging pathways for metastatic disease in newly diagnosed non-small-cell lung cancer: the prospective Streamline L trial. THE LANCET. RESPIRATORY MEDICINE 2019; 7:523-532. [PMID: 31080129 PMCID: PMC6529610 DOI: 10.1016/s2213-2600(19)30090-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 02/11/2019] [Accepted: 02/12/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Whole-body magnetic resonance imaging (WB-MRI) could be an alternative to multi-modality staging of non-small-cell lung cancer (NSCLC), but its diagnostic accuracy, effect on staging times, number of tests needed, cost, and effect on treatment decisions are unknown. We aimed to prospectively compare the diagnostic accuracy and efficiency of WB-MRI-based staging pathways with standard pathways in NSCLC. METHODS The Streamline L trial was a prospective, multicentre trial done in 16 hospitals in England. Eligible patients were 18 years or older, with newly diagnosed NSCLC that was potentially radically treatable on diagnostic chest CT (defined as stage IIIb or less). Exclusion criteria were severe systemic disease, pregnancy, contraindications to MRI, or histologies other than NSCLC. Patients underwent WB-MRI, the result of which was withheld until standard staging investigations were complete and the first treatment decision made. The multidisciplinary team recorded its treatment decision based on standard investigations, then on the WB-MRI staging pathway (WB-MRI plus additional tests generated), and finally on all tests. The primary outcome was difference in per-patient sensitivity for metastases between standard and WB-MRI staging pathways against a consensus reference standard at 12 months, in the per-protocol population. Secondary outcomes were difference in per-patient specificity for metastatic disease detection between standard and WB-MRI staging pathways, differences in treatment decisions, staging efficiency (time taken, test number, and costs) and per-organ sensitivity and specificity for metastases and per-patient agreement for local T and N stage. This trial is registered with the International Standard Randomised Controlled Trial registry, number ISRCTN50436483, and is complete. FINDINGS Between Feb 26, 2013, and Sept 5, 2016, 976 patients were screened for eligibility. 353 patients were recruited, 187 of whom completed the trial; 52 (28%) had metastasis at baseline. Pathway sensitivity was 50% (95% CI 37-63) for WB-MRI and 54% (41-67) for standard pathways, a difference of 4% (-7 to 15, p=0·73). No adverse events related to imaging were reported. Specificity did not differ between WB-MRI (93% [88-96]) and standard pathways (95% [91-98], p=0·45). Agreement with the multidisciplinary team's final treatment decision was 98% for WB-MRI and 99% for the standard pathway. Time to complete staging was shorter for WB-MRI (13 days [12-14]) than for the standard pathway (19 days [17-21]); a 6-day (4-8) difference. The number of tests required was similar WB-MRI (one [1-1]) and standard pathways (one [1-2]). Mean per-patient costs were £317 (273-361) for WBI-MRI and £620 (574-666) for standard pathways. INTERPRETATION WB-MRI staging pathways have similar accuracy to standard pathways, and reduce the staging time and costs. FUNDING UK National Institute for Health Research.
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Affiliation(s)
- Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK.
| | - Sue Mallett
- Institute of Applied Health Research, NIHR Birmingham Biomedical Research Centre, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Simon Ball
- Barking, Havering, and Redbridge NHS Trust, Romford, UK
| | - Sandy Beare
- Cancer Research UK & UCL Cancer Trials Centre, University College London, London, UK
| | | | - Angshu Bhowmik
- Department of Respiratory Medicine, Homerton University Hospital, London, UK
| | - Peter Boavida
- Department of Radiology, Homerton University Hospital, London, UK
| | | | - Caroline S Clarke
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Marian Duggan
- Cancer Research UK & UCL Cancer Trials Centre, University College London, London, UK
| | - Steve Ellis
- Department of Radiology, Barts Health NHS Trust, London, UK
| | - Robert Glynne-Jones
- Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, UK
| | - Vicky Goh
- Department of Cancer Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, King's Health Partners, London, UK
| | - Ashley M Groves
- Institute of Nuclear Medicine, University College London, London, UK
| | | | - Sam M Janes
- Lungs for Living Research Centre, UCL Respiratory, University College London, London, UK; Department of Thoracic Medicine, University College London Hospitals, UK
| | | | - Dow-Mu Koh
- Department of Radiology, Royal Marsden Hospital, Sutton, Surrey, UK
| | - Sara Lock
- Department of Respiratory Medicine, Whittington Hospital, London, UK
| | - Anne Miles
- Department of Psychological Sciences, Birkbeck University of London, London, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Alison Morton
- Centre for Medical Imaging, University College London, London, UK
| | - Neal Navani
- Lungs for Living Research Centre, UCL Respiratory, University College London, London, UK; Department of Thoracic Medicine, University College London Hospitals, UK
| | - Alfred Oliver
- Centre for Medical Imaging, University College London, London, UK
| | | | - Anwar R Padhani
- Paul Strickland Scanner Centre, Mount Vernon Cancer Centre, Northwood, UK
| | - David Prezzi
- Department of Cancer Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, King's Health Partners, London, UK; Department of Radiology, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Shonit Punwani
- Centre for Medical Imaging, University College London, London, UK
| | - Laura Quinn
- Institute of Applied Health Research, NIHR Birmingham Biomedical Research Centre, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Hameed Rafiee
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Krystyna Reczko
- Cancer Research UK & UCL Cancer Trials Centre, University College London, London, UK
| | - Andrea G Rockall
- Department of Imaging, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK; Department of Cancer and Surgery, Imperial College London, London, UK
| | - Peter Russell
- Department of Respiratory Medicine, Princess Alexandra Hospital NHS Trust, Harlow, UK
| | - Harbir S Sidhu
- Centre for Medical Imaging, University College London, London, UK
| | - Nicola Strickland
- Department of Imaging, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | - Jonathan Teague
- Cancer Research UK & UCL Cancer Trials Centre, University College London, London, UK
| | - Steve Halligan
- Centre for Medical Imaging, University College London, London, UK
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41
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Affiliation(s)
- Michael A Jantz
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, Gainesville, FL, USA
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