Invasive mediastinal staging for resected non-small cell lung cancer in a population-based cohort

The American Cancer Society National Lung Cancer Roundtable strategic plan: Promoting guideline-concordant lung cancer staging

Accurate staging improves lung cancer survival by increasing the chances of delivering stage-appropriate therapy. However, there is underutilization of, and variability in, the use of guideline-recommended diagnostic tests used to stage lung cancer. Consequently, the American Cancer Society National Lung Cancer Roundtable (ACS NLCRT) convened the Triage for Appropriate Treatment Task Group-a multidisciplinary expert and stakeholder panel-to identify knowledge and/or resource gaps contributing to guideline-discordant staging and make recommendations to overcome these gaps. The task group determined the following: Gap 1: facilitators of and barriers to guideline-concordant staging are incompletely understood; Recommendation 1: identify facilitators of and barriers to guideline-concordant lung cancer staging; Gap 2: the level of evidence supporting staging algorithms is low-to-moderate; Recommendation 2: prioritize comparative-effectiveness studies evaluating lung cancer staging; Gap 3: guideline recommendations vary across professional societies; Recommendation 3: harmonize guideline recommendations across professional societies; Gap 4: existing databases do not contain sufficient information to measure guideline-concordant staging; Recommendation 4: augment existing databases with the information required to measure guideline-concordant staging; Gap 5: health systems do not have a performance feedback mechanism for lung cancer staging; Recommendation 5: develop and implement a performance feedback mechanism for lung cancer staging; Gap 6: patients rarely self-advocate for guideline-concordant staging; Recommendation 6: increase opportunities for patient self-advocacy for guideline-concordant staging; and Gap 7: current health policies do not motivate guideline-concordant lung cancer staging; Recommendation 7: organize a representative working group under the ACS NLCRT that promotes policies that motivate guideline-concordant lung cancer staging. PLAIN LANGUAGE SUMMARY: Staging-determining the degree of cancer spread-is important because it helps clinicians choose the best cancer treatment. Receiving the best cancer treatment leads to the best possible patient outcomes. Practice guidelines are intended to help clinicians stage patients with lung cancer. However, lung cancer staging in the United States often varies from practice guideline recommendations. This report identifies seven opportunities to improve lung cancer staging.

Rapid Advances in Resectable Non-Small Cell Lung Cancer: A Narrative Review

Importance

A series of high-profile clinical trials for patients with resectable early-stage non-small cell lung cancer (NSCLC) have recently changed the standard of care in this setting. Specifically, studies have demonstrated statistically and clinically significant improvements in efficacy with the targeted therapy for adjuvant osimertinib in patients with resected NSCLC harboring an epidermal growth factor receptor (EGFR) genomic abnormality (GA), whereas trials with chemotherapy combined with nivolumab in the neoadjuvant setting and others testing atezolizumab or pembrolizumab as adjuvant therapy have all demonstrated improvements in event-free survival (EFS) (for neoadjuvant therapy) or disease-free survival (DFS) (for adjuvant therapy). These trials introduce many open questions about how to apply these findings in clinical practice.

Observations

Treatment with adjuvant osimertinib for 3 years was associated with significant improvement in both DFS and overall survival (OS), but the erosion of the DFS benefit after the duration of treatment ends suggests a potential value for more longitudinal treatment. The potential value of highly effective targeted therapies as adjuvant therapy for other GAs has a compelling rationale but no data at this time. Adjuvant atezolizumab or pembrolizumab, generally administered for 1 year after postoperative chemotherapy, are appropriate considerations, but only atezolizumab for patients with tumor programmed death-ligand 1 (PD-L1) levels of 50% has demonstrated a benefit in OS. Neoadjuvant chemotherapy with nivolumab offers a strong EFS benefit, a shorter interval of treatment, and radiographic and pathologic feedback for patients with resectable stage IB to IIIA NSCLC, although very recent randomized clinical trials of perioperative immunotherapy both combined with chemotherapy preoperatively and administered postoperatively highlight the debatable value of adjuvant immunotherapy after prior chemoimmunotherapy. Improved tumor shrinkage rates with neoadjuvant chemoimmunotherapy suggest the possibility that criteria for resectability may potentially be redefined in anticipation of a good response to neoadjuvant chemoimmunotherapy.

Conclusions and Relevance

Developments in resectable NSCLC have arrived so rapidly that they have also created practical challenges of identifying optimal patients and prioritizing options among these new competing standards. In some cases, practical management requires clinical judgment and discussion with the patient to cover the gaps in prospective data. Caution should be exerted when extrapolating beyond the available data.

Analysis of predictive factors of unforeseen nodal metastases in resected clinical stage I NSCLC

Background

Despite notable advances made in preoperative staging, unexpected nodal metastases after surgery are still significantly detected. In this study we aim to analyze the upstaging rate in patients with clinical stage I NSCLC without evidence of nodal disease in the preoperative staging who underwent lobectomy and radical lymphadenectomy.

Methods

Patients who underwent lobectomy and systematic lymphadenectomy for clinical stage I NSCLC were evaluated. Exclusion criteria included the neoadjuvant treatment, incomplete resection and no adherence to preoperative guidelines.

Results

A total of 297 patients were included in the study. 159 patients were female, and the median age was 68 (61 - 73). The variables that showed a significant correlation with the upstaging rate at the univariate analysis were the number of resected lymph nodes and micropapillar/solid adenocar-cinoma subtype. This result was confirmed in the multivariate analysis with a OR= 2.545 (95%CI 1.136-5.701; p=0.02) for the number of resected lymph nodes and a OR=2.717 (95%CI 1.256-5.875; p=0.01) for the high-grade pattern of adenocarcinoma.

Conclusion

Our results showed that in a homogeneous cohort of patients with clinical stage I NSCLC, the number of resected lymph nodes and the histological subtype of adenocarcinoma can significantly be associated with nodal metastasis.

Surgeon Quality and Patient Survival After Resection for Non-Small-Cell Lung Cancer

PURPOSE

The quality and outcomes of curative-intent lung cancer surgery vary in populations. Surgeons are key drivers of surgical quality. We examined the association between surgeon-level intermediate outcomes differences, patient survival differences, and potential mitigation by processes of care.

PATIENTS AND METHODS

Using a baseline population-based surgical resection cohort, we derived surgeon-level cut points for rates of positive margins, nonexamination of lymph nodes, nonexamination of mediastinal lymph nodes, and wedge resections. Applying the baseline cut points to a subsequent cohort from the same population-based data set, we assign surgeons into three performance categories in reference to each metric: 1 (<25th percentile), 2 (25th-75th percentile), and 3 (>75th percentile). The sum of performance scores created three surgeon quality tiers: 1 (4-6, low), 2 (7-9, intermediate), and 3 (10-12, high). We used chi-squared, Wilcoxon-Mann-Whitney, and Kruskal-Wallis tests to compare patient characteristics between the baseline and subsequent cohorts and across surgeon tiers. We applied Cox proportional hazards models to examine the association between patient survival and surgeon performance tier, sequentially adjusting for clinical stage, patient characteristics, and four specific processes.

RESULTS

From 2009 to 2021, 39 surgeons performed 4,082 resections across the baseline and subsequent cohorts. Among 31 subsequent cohort surgeons, five were tier 1, five were tier 2, and 21 were tier 3. Tier 1 and 2 surgeons had significantly worse outcomes than tier 3 surgeons (hazard ratio [HR], 1.37; 95% CI, 1.10 to 1.72 and 1.19; 95% CI, 1.00 to 1.43, respectively). Adjustment for specific processes mitigated the surgeon-tiered survival differences, with adjusted HRs of 1.02 (95% CI, 0.8 to 1.3) and 0.93 (95% CI, 0.7 to 1.25), respectively.

CONCLUSION

Readily accessible intermediate outcomes metrics can be used to stratify surgeon performance for targeted process improvement, potentially reducing patient survival disparities.

Prospective Comparative Effectiveness Trial of Multidisciplinary Lung Cancer Care Within a Community-Based Health Care System

PURPOSE

Multidisciplinary lung cancer care is assumed to improve care delivery by increasing transparency, objectivity, and shared decision making; however, there is a lack of high-level evidence demonstrating its benefits, especially in community-based health care systems. We used implementation and team science principles to establish a colocated multidisciplinary lung cancer clinic in a large community-based health care system and evaluated patient experience and outcomes within and outside this clinic.

METHODS

We conducted a prospective frequency-matched comparative effectiveness study (ClinicalTrials.gov identifier: NCT02123797) evaluating the thoroughness of lung cancer staging, receipt of stage-appropriate treatment, and survival between patients receiving care in the multidisciplinary clinic and those receiving usual serial care. Target enrollment was 150 patients on the multidisciplinary arm and 300 on the serial care arm. We frequency-matched patients by clinical stage, performance status, insurance type, race, and age.

RESULTS

A total of 526 patients were enrolled: 178 on the multidisciplinary arm and 348 on the serial care arm. After adjusting for other factors, multidisciplinary patients had significantly higher odds (odds ratio [OR]: 2.3 [95% CI, 1.5 to 3.4]) of trimodality staging compared with serial care. Patients on the multidisciplinary arm also had higher odds of receiving invasive stage confirmation (OR: 2.0 [95% CI, 1.4 to 3.1]) and mediastinal stage confirmation (OR: 1.9 [95% CI, 1.3 to 2.8]). Additionally, patients receiving multidisciplinary care were significantly more likely to receive stage-appropriate treatment (OR: 1.8 [95% CI, 1.1 to 3.0]). We found no significant difference in overall or progression-free survival between study arms.

CONCLUSION

The multidisciplinary clinic delivered significant improvements in evidence-based quality care on multiple levels. Even in the absence of a demonstrable survival benefit, these findings provide a strong rationale for recommending this model of care.

Predicting Malignant Lymph Nodes Using a Novel Scoring System Based on Multi-Endobronchial Ultrasound Features

Endobronchial ultrasound (EBUS) features with B-, power/color Doppler, and elastography modes help differentiate between benign and malignant lymph nodes (MLNs) during transbronchial needle aspiration (TBNA); however, only few studies have assessed them simultaneously. We evaluated the diagnostic accuracy of each EBUS feature and aimed to establish a scoring system to predict MLNs. EBUS features of consecutive patients and final diagnosis per lymph node (LN) were examined retrospectively. In total, 594 LNs from 301 patients were analyzed. Univariable analyses revealed that EBUS features, except for round shape, could differentiate MLNs from benign LNs. Multivariable analysis revealed that short axis (>1 cm), heterogeneous echogenicity, absence of central hilar structure, presence of coagulation necrosis sign, and blue-dominant elastographic images were independent predictors of MLNs. At three or more EBUS features predicting MLNs, our scoring system had high sensitivity (77.9%) and specificity (91.8%). The area under the receiver operating curve (AUC) was 0.894 (95% confidence interval (CI): 0.868−0.920), which was higher than that of B-mode features alone (AUC: 0.840 (95% CI: 0.807−0.873)). The novel scoring system could predict MLNs more accurately than B-mode features alone. Multi-EBUS features may increase EBUS-TBNA efficiency for LN evaluation.

Rates of Guideline-Concordant Surgery and Adjuvant Chemotherapy Among Patients With Early-Stage Lung Cancer in the US ALCHEMIST Study (Alliance A151216)

Importance

Standard treatment for resectable non-small cell lung cancer (NSCLC) includes anatomic resection with adequate lymph node dissection and adjuvant chemotherapy for appropriate patients. Historically, many patients with early-stage NSCLC have not received such treatment, which may affect the interpretation of the results of adjuvant therapy trials.

Objective

To ascertain patterns of guideline-concordant treatment among patients enrolled in a US-wide screening protocol for adjuvant treatment trials for resected NSCLC.

Design, Setting, and Participants

This retrospective cohort study included 2833 patients with stage IB to IIIA NSCLC (per American Joint Committee on Cancer 7th edition criteria) who enrolled in the Adjuvant Lung Cancer Enrichment Marker Identification and Sequencing Trial (ALCHEMIST) screening study (Alliance for Clinical Trials in Oncology A151216) from August 18, 2014, to April 1, 2019, and who did not enroll in a therapeutic adjuvant clinical trial; patients had tumors of at least 4 cm and/or with positive lymph nodes. Statistical analysis was conducted from June 1, 2020, through October 1, 2021.

Exposures

Care patterns were ascertained overall and by sociodemographic and clinical factors, including age, sex, race and ethnicity, educational level, marital status, geography, histologic characteristics, stage, genomic variant status, smoking history, and comorbidities.

Main Outcomes and Measures

Five outcomes are reported: whether patients (1) had anatomic surgical resection, (2) had adequate lymph node dissection (≥1 N1 nodal station plus ≥3 N2 nodal stations), (3) received any adjuvant chemotherapy, (4) received any cisplatin-based adjuvant chemotherapy, and (5) received at least 4 cycles of adjuvant chemotherapy.

Results

Of the 2833 patients (1505 women [53%]; mean [SD] age, 66.5 [9.2] years) included in this analysis, 2697 (95%) had anatomic surgical resection, 1513 (53%) had adequate lymph node dissection, 1617 (57%) received any adjuvant chemotherapy, 1237 (44%) received at least 4 cycles of adjuvant platinum-based chemotherapy, and 965 (34%) received any cisplatin-based adjuvant chemotherapy. Rates were similar across race and ethnicity.

Conclusions and Relevance

This cohort study found that among participants in a screening protocol for adjuvant clinical trials for resected early-stage NSCLC, just 53% underwent adequate lymph node dissection, and 57% received adjuvant chemotherapy, despite indications for such treatment. These results may affect the interpretation of adjuvant trials. Efforts are needed to optimize the use of proven therapies for early-stage NSCLC.

Trial Registration

ClinicalTrials.gov Identifier: NCT02194738.

Pretreatment Invasive Nodal Staging in Lung Cancer: Knowledge, Attitudes, and Beliefs Among Academic and Community Physicians

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.

Controversies in Mediastinal Staging for Nonsmall Cell Lung Cancer

Mediastinal lymph nodal involvement in nonsmall cell lung cancer plays a crucial role in deciding treatment strategy. Survival falls markedly with increasing involvement of mediastinal nodal stations. Hence, accurate staging of the mediastinum with lowest morbidity is of utmost importance. A wide array of invasive and noninvasive modalities that complement each other in assessing the nodes are available at our disposal. Guidelines recommend noninvasive imaging as the initial step in the staging algorithm for all tumors, followed by invasive staging. No single modality has proven to be the ideal method to stage the mediastinum when used alone. In the present decade, minimally invasive endobronchial ultrasound (EBUS) has challenged the position of surgical mediastinoscopy, which has been the gold standard, historically. However, a negative EBUS needs to be confirmed by surgical mediastinoscopy. Video-assisted mediastinoscopic lymphadenectomy has also come to the forefront in last two decades and has shown exceptional results, when performed in experienced centers. This review details the various modalities of mediastinal staging and the controversies surrounding the optimal method of staging, restaging after neoadjuvant therapy, and the most cost-effective strategy.

How We Do It: Mediastinal Staging for Lung Cancer

Mediastinal lymph node staging in the setting of known or suspected lung cancer is supported by multiple professional societies as standard for high-quality care, yet proper mediastinal staging often is lacking. Neglecting pathologic lymph node sampling can understage or overstage the patient and lead to inappropriate treatment. Although some cases of nodal disease are radiographically obvious, others are not as apparent, and both situations require pathologic proof to allow for appropriate treatment selection. This article discusses the nuances of mediastinal staging and emphasizes the usefulness of a multidisciplinary approach and dialog to address lung cancer staging and treatment. We summarize the relevant guidelines and literature and provide a case scenario to illustrate the approach to mediastinal staging from our viewpoints as a thoracic surgeon and pulmonologist.

Trends in mediastinal nodal staging and its impact on unforeseen N2 and survival in lung cancer

INTRODUCTION

Guidelines for invasive mediastinal nodal staging in resectable nonsmall cell lung cancer (NSCLC) have changed over the years. The aims of this study were to describe trends in invasive staging and unforeseen N2 (uN2) and to assess a potential effect on overall survival.

METHODS

A nationwide Dutch cohort study included all clinical stage IA-IIIB NSCLC patients primarily treated by surgical resection between 2005 and 2017 (n=22 555). We assessed trends in invasive nodal staging (mediastinoscopy 2005-2017; endosonography 2011-2017), uN2 and overall survival and compared outcomes in the entire group and in clinical nodal stage (cN)1-3 patients with or without invasive staging.

RESULTS

An overall increase in invasive nodal staging from 26% in 2005 to 40% in 2017 was found (p<0.01). Endosonography increased from 19% in 2011 to 32% in 2017 (p<0.01), while mediastinoscopy decreased from 24% in 2011 to 21% in 2017 (p=0.08). Despite these changes, uN2 was stable over the years at 8.7%. 5-year overall survival rate was 41% for pN1 compared to 37% in single node uN2 (p=0.18) and 26% with more than one node uN2 (p<0.01). 5-year overall survival rate of patients with cN1-3 with invasive staging was 44% versus 39% in patients without invasive staging (p=0.12).

CONCLUSION

A significant increase in invasive mediastinal nodal staging in patients with resectable NSCLC was found between 2011 and 2017 in the Netherlands. Increasing use of less invasive endosonography prior to (or as a substitute for) surgical staging did not lead to more cases of uN2. Performance of invasive staging indicated a possible overall survival benefit in patients with cN1-3 disease.

Institutional-Level Differences in Quality and Outcomes of Lung Cancer Resections in the United States

BACKGROUND

Institutional-level disparities in non-small cell lung cancer (NSCLC) survival may be driven by reversible differences in care-delivery processes. We quantified the impact of differences in readily identifiable quality metrics on long-term survival disparities in resected NSCLC.

RESEARCH QUESTION

How do reversible differences in oncologic quality of care contribute to institutional-level disparities in early-stage NSCLC survival?

STUDY DESIGN AND METHODS

We retrospectively analyzed patients in the National Cancer Data Base who underwent NSCLC resection from 2004 through 2015 within institutions categorized as Community, Comprehensive Community, Integrated Network, Academic, and National Cancer Institute (NCI)-Designated Cancer Programs. We estimated percentages and adjusted ORs for six potentially avoidable poor-quality markers: incomplete resection, nonexamination of lymph nodes, nonanatomic resection, non-evidence-based use of adjuvant chemotherapy, non-evidence-based use of adjuvant radiation therapy, and 60-day postoperative mortality. By sequentially eliminating patients with poor-quality markers and calculating adjusted hazard ratios, we quantified their overall survival impact.

RESULTS

Of 169,775 patients, 7%, 46%, 10%, 24%, and 12% underwent surgery at Community, Comprehensive Community, Integrated Network, Academic, and NCI-Designated Cancer Programs, with 5-year overall survival rates of 52%, 56%, 58%, 60% and 66%, respectively. After the sequential elimination process, using NCI-Designated Cancer Centers as a reference, the adjusted hazard ratio for 5-year overall survival changed from 1.47 (95% CI, 1.41-1.53), 1.29 (95% CI, 1.25-1.33), 1.18 (95% CI, 1.14-1.23), and 1.20 (95% CI, 1.16-1.24) for Community, Comprehensive Community, Integrated Networks, and Academic Cancer Programs to 1.35 (95% CI, 1.28-1.42), 1.22 (95% CI, 1.17-1.26), 1.16 (95% CI, 1.11-1.22), and 1.17 (95% CI, 1.12-1.21), respectively (P < .001 for all comparisons with NCI-designated programs). Differences in quality of surgical resection and postoperative care accounted for 11% to 26% of the interinstitutional survival disparities.

INTERPRETATION

Targeting six readily identified poor-quality markers narrowed, but did not eliminate, institutional survival disparities. The greatest impact was in community programs. Residual factors driving persistent institution-level long-term NSCLC survival disparities must be characterized to eliminate them.

Mediastinal staging for non-small cell lung cancer

The staging of mediastinal lymph nodes for lung cancer is crucial for planning treatments or reinterventions. In potentially curable patients the aim of mediastinal staging is to exclude the presence of malignancy in mediastinal lymph nodes with a high level of accuracy while also considering clinical factors and the balance of the benefits and risks of tissue sampling techniques. Mediastinal staging is based on computed tomography (CT) and positron emission tomography (PET) and can be sufficient when no mediastinal abnormalities are present and the probability of unforeseen N2 disease is low. In the case of bulky lymph nodes with a high probability of malignancy in PET-CT, tissue confirmation is not normally required. If mediastinal sampling is needed it can be achieved by endosonographic techniques, including endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) or a combination of the two. Positive results do not need further confirmation. In the case of negative results, surgical techniques still play a role in the selected cases discussed by multidisciplinary lung cancer committees. New mediastinal surgical techniques including video-assisted cervical mediastinoscopy (VACM), video-assisted mediastinoscopic lymphadenectomy (VAMLA), and transcervical extended mediastinal lymphadenectomy (TEMLA) have been shown to be useful in selected patients. Final pathological staging is based on lymph node removal during surgery and can be achieved by taking one of two approaches: lymph node sampling or systematic lymph node sampling. The accuracy of PET-CT and mediastinal endosonography is lower for mediastinal restaging than it is for surgical techniques; their false positive and false negative (FN) rate is high and so, they require histological confirmation. Here we explain and revise the results from the most recent studies and current international guidelines.

Extended resections and other special cases in lung cancer surgery: Real-world population-based outcomes

Background

Lung cancer invading outside a lobe centrally or peripherally, or presenting with synchronous or metachronous tumors, requires a special approach. Here, we aimed to evaluate the rate and outcomes of surgery of these patients in a medium‐volume practice using real‐world, population‐based data.

Methods

All patients (n = 269) on whom lung cancer surgery was performed in Central Finland and Ostrobothnia between January 2013 and December 2019 were included. A total of 40 patients with sleeve (n = 18) or other extended resections (n = 9), multifocal diseases (n = 14), and other operated synchronous cancers (n = 3) required an extended or otherwise special surgical approach (extended group). Short‐ and long‐term outcomes were compared to high‐risk (n = 72) and normal patient groups (n = 157).

Results

The rate of extended resection was 14.9%. The rates of PET‐CT (95%), invasive staging (35%), and brain imaging (42.5%) were highest in extended group compared to other groups. Extended group had larger and higher rate of stage III tumors than high‐risk and normal groups. All extended group patients underwent anatomic lung resection with better lymph node yield than the other two groups, with a neoadjuvant and/or adjuvant treatment rate of 70.0%. Major complications occurred in 7.5% in the extended group, 19.4% in the high‐risk group, and 6.4% in the normal group; at one year, alive and living at home rates were 88.2%, 83.3%, and 97.8%, and overall five‐year survival rates 75.6%, 62.4%, and 63.9% (P = 0.287), respectively.

Conclusions

After guideline‐based evaluation, a significant rate of these special cases can be resected with a low complication rate and good long‐term survival in real‐world practice.

Key points

Significant findings of the study

Extended resections for lung cancer include tumors spreading outside the lung

The rate of extended resection was 14.9% in a population‐based setting

Major complications occurred in 7.5% and five‐year survival was 75.6%

What this study adds

Complication rate and long‐term outcome were similar compared to normal patients

Guideline‐based evaluation results with excellent outcome in real‐world practice

Quantitative analysis of endobronchial ultrasound elastography in computed tomography-negative mediastinal and hilar lymph nodes

Background

Endobronchial ultrasound (EBUS) elastography assists in the differentiation of benign and malignant lymph nodes (LNs) during transbronchial needle aspiration (TBNA). However, previous studies have not compared B‐mode sonographic images (BSIs) and EBUS elastography images (EEIs) with final pathological diagnoses in radiologically normal‐sized (computed tomography [CT]‐negative) LNs.

Methods

Consecutive patients with CT‐negative LNs, who received EBUS‐TBNA, were retrospectively reviewed. Images of BSIs and EEIs of each LN were stored and independently evaluated. EEIs were assessed by calculating the stiffness area ratio (SAR, blue/overall areas). The receiver operating characteristic curve was used to calculate the cutoff value for the SAR. Diagnostic test parameters were evaluated for each EBUS finding.

Results

A total of 132 patients (149 LNs) were enrolled, and the median SAR of malignant LNs was significantly higher than that of benign LNs (0.58 vs. 0.32, P < 0.001). At the SAR cutoff of 0.41, the sensitivity, specificity, positive predictive value, negative predictive value (NPV), and diagnostic accuracy rate (DAR) of elastography were 88.2%, 80.2%, 78.9%, 89.0%, and 83.9%, respectively. The logistic regression analysis showed that elastography was the strongest predictor of malignancy (odds ratio, 18.5; 95% confidence interval [CI]: 6.48–52.6; P < 0.001). The highest NPV (96.6%) was achieved with a combination of BSIs and EEIs.

Conclusions

EBUS elastography predicted malignant LNs with a high DAR and NPV in CT‐negative LNs. The NPV was highest when EEIs were combined with BSIs. Therefore, the combined evaluation of CT‐negative LNs using EEIs and BSIs may help bronchoscopists perform EBUS‐TBNA more efficiently.

Key points

Significant findings of the study

Endobronchial ultrasound elastography accurately predicted malignancy with a high diagnostic accuracy rate and negative predictive value in radiologically normal‐sized lymph nodes. The additional use of B‐mode sonographic features resulted in a higher negative predictive value.

What this study adds

Endobronchial ultrasound elastography can guide the accurate collection of specimens with transbronchial needle aspiration, even in radiologically normal‐sized lymph nodes. It can also readily distinguish benign and malignant lymph nodes, thus avoiding unnecessary punctures.

Survival After Mediastinal Node Dissection, Systematic Sampling, or Neither for Early Stage NSCLC

INTRODUCTION

The American College of Surgeons Oncology Group Z0030 found no survival difference between patients with early stage NSCLC who had mediastinal nodal dissection or systematic sampling. However, a meta-analysis of 1980 patients in five randomized controlled trials from 1989 to 2007 associated better survival with nodal dissection. We tested the survival impact of the extent of nodal dissection in curative-intent resections for early stage NSCLC in a population-based observational cohort.

METHODS

Resections for clinical T1 or T2, N0 or nonhilar N1, M0 NSCLC in four contiguous United States Hospital Referral Regions from 2009 to 2019 were categorized into mediastinal nodal dissection, systematic sampling, and "neither" on the basis of of the evaluation of lymph node stations. We compared demographic and clinical characteristics, perioperative complication rates, and survival after assessing statistical interactions and confounding.

RESULTS

Of the 1942 eligible patients, 18% had nodal dissection, 6% had systematic sampling, and 75% had an intraoperative nodal evaluation that met neither standard. In teaching hospitals, nodal dissection was associated with a lower hazard of death than "neither" resections (0.57 [95% confidence interval: 0.41-0.79]) but not systematic sampling (0.74 [0.40-1.37]) after adjusting for multiple comparisons. There was no significant difference in hazard ratios at nonteaching institutions (p > 0.3 for all comparisons). Perioperative complication rates were not significantly worse after mediastinal nodal dissection or systematic sampling, compared with "neither," (p > 0.1 for all comparisons).

CONCLUSIONS

In teaching institutions, mediastinal nodal dissection was associated with superior survival over less-comprehensive pathologic nodal staging. There was no survival difference between teaching and nonteaching institutions, a finding that warrants further investigation.

Rurality, Stage-Stratified Use of Treatment Modalities, and Survival of Non-small Cell Lung Cancer

BACKGROUND

To eliminate them, non-small cell lung cancer (NSCLC) care and outcome disparities need to be better understood.

RESEARCH QUESTION

How does rurality interact with NSCLC care and outcome disparities?

STUDY DESIGN AND METHODS

We examined guideline-concordant use of active treatment for NSCLC across five institutions in one community-based health care system spanning 44% of the Delta Regional Authority catchment area from 2011 to 2017. Institution- and patient-level rurality were based on Rural-Urban Commuting Area codes. Chi-squared, F-tests, and logistic regressions were used to analyze differences across institutions and rurality; survival was examined using log-rank tests and Cox regression.

RESULTS

Of 6,259 patients, 47% resided in rural areas; two of five institutions were rurally located and provided care for 20% of patients. Compared with rural residents at rural institutions, urban and rural residents attending urban institutions were more likely to receive stage-preferred treatment: OR 1.68 (95%CI, 1.44-1.96), and 1.33 (1.11-1.61), respectively, after adjusting for insurance, age, and clinical stage. Urban and rural residents attending urban institutions had a lower hazard of death compared with rural residents attending rural institutions: hazard ratio (HR) 0.69 (0.64-0.75) and 0.61 (0.55-0.67), respectively. Among recipients of stage-preferred treatment, care at urban institutions remained less hazardous: HR 0.7 (0.63-0.79). When further stratified by stage, care for late-stage patients at urban institutions remained less hazardous: HR 0.8 (0.71-0.91).

INTERPRETATION

Rurality-associated treatment and survival disparities were present at the patient and institution levels, but the institution-level disparity was greater. Rural residents receiving care at urban institutions had similar outcomes to urban residents receiving care at urban hospitals. To overcome rurality-associated NSCLC survival disparity, interventions should preferentially target the institution level, including expanding access to higher-quality guideline-concordant care.

Real-world guideline-based treatment of lung cancer improves short- and long-term outcomes and resection rate: A population-based study

OBJECTIVES

Recent guidelines for the treatment of lung cancer include comprehensive lists of recommendations for pre-operative risk evaluation, staging, and surgery. Our aim was to evaluate whether the implementation of these in a population-based real-world setting would improve outcomes.

MATERIALS AND METHODS

All patients diagnosed with primary lung cancer in Central Finland and Ostrobothnia between January 1, 2006, and December 31, 2017, were identified from registry data (N = 2116), including patients who underwent surgical resection (n = 303). Data were divided into two periods, old and modern, according to which international guidelines were followed.

RESULTS

Between surgical patients of the old and modern periods, significant changes occurred in the rate of pre-operative stair climbing tests (3.7 % vs. 68.6 %, p < 0.001), the use of positron emission computed tomography (18.7 % vs. 75.7 %, p < 0.001), and invasive staging (3.7 % vs. 26.0 %, p < 0.001). In surgery, the rate of VATS (2.2 % vs. 81.1 %, p < 0.001), segmentectomy (1.5 % vs. 27.2 %, p < 0.001), and extended resections (5.2 % vs. 13.6 %, p = 0.015) increased. However, between these periods, the rate of pneumonectomy decreased from 7.5 % to 1.2 % (p = 0.005) and bilobectomy from 9.0%-1.8% (p = 0.004). The overall resection rate increased from 10.5%-19.7 %, mainly due to a higher number of high-risk patients (12.7 % vs. 34.3 %, p < 0.001). Patients faced fewer major complications (21.6 % vs. 8.9 %, p = 0.002) and had shorter hospital stays (9 days, IQR 7-11 vs. 5 days, IQR 3-7; p < 0.001). In the modern period, patients underwent adjuvant therapy less often than in the old period (35.1 % vs. 22.5 %, p = 0.015). Recurrence-free 5-year survival rate improved, however, from 64.0%-76.8% (p < 0.001).

CONCLUSIONS

The introduction of guideline-based modern patient evaluation and treatment was associated with improved short- and long-term outcomes of lung cancer surgery.

Mediastinal staging: when and how?

Mediastinal staging for lung cancer includes both the assessment of mediastinal lymph nodes status before treatment and the postoperative pathological staging obtained by lymph-node removal performed during surgery. In patients with early stage NSCLC, the aim is to exclude with the highest certainty and the lowest morbidity the presence of mediastinal node involvement. Before treatment, mediastinal staging is based on imaging techniques, endoscopic techniques, and surgical procedures. Final pathological staging is based on lymph-node removal performed with lung resection according with different modalities (sampling, systematic dissection, etc.) and various approaches (thoracotomy, VATS, robotic). Data and indications from literature evidences are reported and discussed.

Safety and Costs of Endobronchial Ultrasound-Guided Nodal Aspiration and Mediastinoscopy

BACKGROUND

There remains debate over the best invasive diagnostic modality for mediastinal nodal evaluation. Prior studies have limited generalizability and insufficient power to detect differences in rare adverse events. We compared the risks and costs of endobronchial ultrasound (EBUS)-guided nodal aspiration and mediastinoscopy performed for any indication in a large national cohort.

METHODS

We conducted a retrospective study (2007-2015) with MarketScan, a claims database of individuals with employer-provided insurance in the United States. Patients who underwent multimodality mediastinal evaluation (n = 1,396) or same-day pulmonary resection (n = 2,130) were excluded. Regression models were used to evaluate associations between diagnostic modalities and risks and costs while adjusting for patient characteristics, year, concomitant bronchoscopic procedures, and lung cancer diagnosis.

RESULTS

Among 30,570 patients, 49% underwent EBUS. Severe adverse events-pneumothorax, hemothorax, airway/vascular injuries, or death-were rare and invariant between EBUS and mediastinoscopy (0.3% vs 0.4%; P = .189). The rate of vocal cord paralysis was lower for EBUS (1.4% vs 2.2%; P < .001). EBUS was associated with a lower adjusted risk of severe adverse events (OR, 0.42; 95% CI, 0.32-0.55) and vocal cord paralysis (OR, 0.57; 95% CI, 0.54-0.60). The mean cost of EBUS was $2,211 less than mediastinoscopy ($6,816 vs $9,023; P < .001). After adjustment this difference decreased to $1,650 (95% CI, $1,525-$1,776).

CONCLUSIONS

When performed as isolated procedures, EBUS is associated with lower risks and costs compared with mediastinoscopy. Future studies comparing the effectiveness of EBUS vs mediastinoscopy in the community at large will help determine which procedure is superior or if trade-offs exist.