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Confirmatory Mediastinoscopy after Negative EBUS-TBNA for Mediastinal Staging of Lung Cancer: Systematic Review and Meta-analysis. Ann Am Thorac Soc 2022; 19:1581-1590. [PMID: 35348446 DOI: 10.1513/annalsats.202111-1302oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Current guidelines of non-small cell lung cancer (NSCLC) mediastinal staging recommend starting invasive staging with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). However, the indication to confirm a negative result of EBUS-TBNA by means of video-assisted mediastinoscopy (VAM) prior to resection differs in every guideline. OBJECTIVE Our aim was to evaluate the current evidence regarding the added value of confirmatory VAM after a negative EBUS-TBNA for mediastinal staging in patients with NSCLC. METHODS Systematic searches of studies on EBUS-TBNA for NSCLC mediastinal staging with or without confirmatory VAM but with surgical confirmation of negative results were conducted in accordance with PRISMA statement in PubMed, SCOPUS, Cochrane and Guidelines from 2005 through November 2021. In the meta-analysis the sensitivity of confirmatory VAM after a negative EBUS-TBNA, the sensitivity and negative predictive value (NPV) of the combination EBUS-TBNA plus confirmatory VAM, alongside the number of confirmatory VAM required to detect additional N2/3 disease (number needed to treat [NNT]), in patients with a previous negative EBUS-TBNA were estimated. RESULTS 5412 articles were found, of which 29 studies were included. Random effects meta-analysis showed a sensitivity of 66.9% (95% CI: 55.8%-77.1%) for confirmatory VAM, and 96.7% (95% CI: 95.1%- 98%) for the combination EBUS-TBNA plus confirmatory VAM. NPV in studies with confirmatory VAM increased of 79.2% (95% CI: 71.4%-86.1%) for EBUS-TBNA alone to 91.8% (95% CI: 87.1%-95.5%) for EBUS-TBNA plus confirmatory VAM. The NNT of confirmatory VAM in patients with a previous negative EBUS-TBNA was 23.8 (95% CI: 19.3-31.2) CONCLUSIONS: Confirmatory VAM after negative EBUS-TBNA reduces the rate of unforeseen N2/3 disease, but with a high NNT, and should be recommended only to certain cases yet to be defined.
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Hwangbo B, Park EY, Yang B, Lee GK, Kim TS, Kim HY, Kim MS, Lee JM. Long-Term Survival According to N Stage Diagnosed by Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Non-Small Cell Lung Cancer. Chest 2021; 161:1382-1392. [PMID: 34896095 DOI: 10.1016/j.chest.2021.11.032] [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: 02/22/2021] [Revised: 11/22/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the main procedure for mediastinal staging. However, long-term survival analyses according to cN stage diagnosed by EBUS-TBNA (abbreviated to eN stage) have not been reported. The value of EBUS-TBNA has not been assessed through an analysis of survival in false-negative EBUS-TBNA cases. RESEARCH QUESTIONS What is the prognostic impact of eN stage in non-small cell lung cancer (NSCLC)? What is the survival rate in false-negative EBUS-TBNA cases? STUDY DESIGN AND METHODS We retrospectively (January 2006-December 2011) reviewed the medical records of NSCLC patients who underwent EBUS-TBNA (± transesophageal approach) for initial staging (n=1,089). Mediastinoscopy was not performed for EBUS-TBNA negative cases. We performed 5-year survival analyses according to eN stage and treatment modality. Survival in false-negative EBUS cases was compared with that in pN0-1 patients, including 941 non-EBUS cases, during the same period. RESULTS Among 1,089 EBUS patients (eN0-1=681, eN2=314, eN3=94), we observed significant differences in survival between the eN stages [eN0-1 vs eN2; p <0.0001, eN2 vs eN3; p=0.0118, estimated 5-year overall survival (5YOS) rate: eN0-1=57.4%, eN2=23.2%, eN3=12.8%]. Surgery cases had better survival than non-surgery cases among eN0-1 and eN2 patients (eN0-1/surgery vs. eN0-1/no surgery; p<0.0001, eN2/surgery vs. eN2/no surgery; p<0.0001). Among eN0-1 patients, there were 55 false-negative cases (eN0-1/pN2-3, pN2=54, pN3=1). The 5YOS rates of pN0, pN1, and eN0-1/pN2-3 patients were 76.4%, 56.0% and 56.4%, respectively. eN0-1/pN2-3 patients had worse survival than pN0 patients (p=0.0061), whereas there was no significant difference compared with pN1 patients (p=0.9191). INTERPRETATIONS Long-term survival significantly differed according to eN stage in NSCLC, highlighting the importance of EBUS-TBNA in NSCLC staging. False-negative EBUS-TBNA cases had favorable survival which was similar to that of pN1 patients, which may provide a rationale for performing surgery after negative EBUS-TBNA results.
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Affiliation(s)
- Bin Hwangbo
- Division of Pulmonology, Center for Lung Cancer, National Cancer Center, Goyang, Korea.
| | - Eun Young Park
- Biostatistics Collaboration Team, Research Core Center, National Cancer Center, Goyang, Korea
| | - Bumhee Yang
- Division of Pulmonology, Center for Lung Cancer, National Cancer Center, Goyang, Korea; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Geon Kook Lee
- Department of Pathology, National Cancer Center, Goyang, Korea
| | - Tae Sung Kim
- Department of Nuclear Medicine, National Cancer Center, Goyang, Korea
| | - Hyae Young Kim
- Department of Radiology, Center for Lung Cancer, National Cancer Center, Goyang, Korea
| | - Moon Soo Kim
- Department of Thoracic Surgery, Center for Lung Cancer, National Cancer Center, Goyang, Korea
| | - Jong Mog Lee
- Department of Thoracic Surgery, Center for Lung Cancer, National Cancer Center, Goyang, Korea
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Joosten PJM, Damhuis RAM, van Diessen JNA, de Langen JA, Belderbos JSA, Smit EF, Klomp HM, Veenhof AAFA, Hartemink KJ. Results of neoadjuvant chemo(radio)therapy and resection for stage IIIA non-small cell lung cancer in The Netherlands. Acta Oncol 2020; 59:748-752. [PMID: 32347142 DOI: 10.1080/0284186x.2020.1757150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction: Concurrent chemoradiotherapy remains the main treatment strategy for patients with stage IIIA non-small cell lung cancer (NSCLC); stage cT3N1 or cT4N0-1 may be eligible for surgery and potentially resectable stage IIIA (N2) NSCLC for neoadjuvant therapy followed by resection. We evaluated treatment patterns and outcomes of patients with stage IIIA NSCLC in The Netherlands.Material and Methods: Primary treatment data of patients with clinically staged IIIA NSCLC between 2010 and 2016 were extracted from The Netherlands Cancer Registry. Patient characteristics were tabulated and 5-year overall survival (OS) was calculated and reported.Results: In total, 9,591 patients were diagnosed with stage IIIA NSCLC. Of these patients, 41.3% were treated with chemoradiotherapy, 11.6% by upfront surgery and 428 patients (4.5%) received neoadjuvant treatment followed by resection. The 5-year OS was 26% after chemoradiotherapy, 40% after upfront surgery and 54% after neoadjuvant treatment followed by resection. Clinical over staging was seen in 42.3% of the patients that were operated without neoadjuvant therapy.Conclusion: In The Netherlands, between 2010 and 2016, 4.5% of patients with stage IIIA NSCLC were selected for treatment with neoadjuvant therapy followed by resection. The 5-year OS in these patients exceeded 50%. However, the outcome might be overestimated due to clinical over staging.
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Affiliation(s)
- Pieter J. M. Joosten
- Department of Surgery, Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Ronald A. M. Damhuis
- Department of Research, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
| | - Judi N. A. van Diessen
- Department of Radiation Oncology, Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Joop A. de Langen
- Department of Thoracic Oncology, Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Jose S. A. Belderbos
- Department of Radiation Oncology, Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Egbert F. Smit
- Department of Thoracic Oncology, Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Houke M. Klomp
- Department of Surgery, Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Alexander A. F. A. Veenhof
- Department of Surgery, Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Koen J. Hartemink
- Department of Surgery, Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Unforeseen N2 Disease after Negative Endosonography Findings with or without Confirmatory Mediastinoscopy in Resectable Non–Small Cell Lung Cancer: A Systematic Review and Meta-Analysis. J Thorac Oncol 2019; 14:979-992. [DOI: 10.1016/j.jtho.2019.02.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 02/10/2019] [Accepted: 02/22/2019] [Indexed: 02/06/2023]
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Kim S, Shin B, Lee H, Ha JH, Lee K, Um SW, Kim H, Jeong BH. Are there differences among operators in false-negative rates of endosonography with needle aspiration for mediastinal nodal staging of non-small cell lung cancer? BMC Pulm Med 2019; 19:14. [PMID: 30642321 PMCID: PMC6332520 DOI: 10.1186/s12890-018-0774-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 12/28/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Endosonography with needle aspiration (EBUS/EUS-NA) is recommended as the first choice for mediastinal nodal assessment in non-small cell lung cancer (NSCLC). It is important to maintain adequate negative predictive value of the procedure to avoid unnecessary additional surgical staging, but there are few studies on the influence of operator-related factors including competency on false negative results. This study aims to compare the false negative rate of individual operators and whether it changes according to accumulation of experience. METHODS This is a retrospective study of NSCLC patients who were N0/N1 by EBUS/EUS-NA and confirmed by pathologic staging upon mediastinal lymph node dissection (n = 705). Patients were divided into a false negative group (finally confirmed as pN2/N3) and a true negative group (pN0/N1). False negative rates of six operators and whether these changed according to accumulated experience were analyzed. RESULTS There were 111 (15.7%) false negative cases. False negative rates among six operators ranged from 8.3 to 21.4%; however, there were no statistical differences before and after adjustment for patient characteristics and procedure-related factors (P = 0.346 and P = 0.494, respectively). In addition, false negative rates did not change as each operator accumulated experience (P for trend = 0.632). CONCLUSIONS Our data suggest that there would be no difference in false negative rates regardless of which operator performs the procedure assuming that the operators have completed a certain period of observation and have performed procedures under the guidance of an expert.
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Affiliation(s)
- Sukyeon Kim
- Division of Pulmonary Medicine, Department of Internal medicine, Hangang Sacred Heart Hospital, Hallym University School of Medicine, Seoul, Republic of Korea
| | - Beomsu Shin
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Hyun Lee
- Division of Pulmonary Medicine and Allergy, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Jick Hwan Ha
- Division of Pulmonology, Critical Care and Sleep Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyungjong Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Irwon-ro 81, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Sang-Won Um
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Irwon-ro 81, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Hojoong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Irwon-ro 81, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Byeong-Ho Jeong
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Irwon-ro 81, Gangnam-gu, Seoul, 06351, Republic of Korea.
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Diagnostic Imaging and Newer Modalities for Thoracic Diseases: PET/Computed Tomographic Imaging and Endobronchial Ultrasound for Staging and Its Implication for Lung Cancer. PET Clin 2017; 13:113-126. [PMID: 29157382 DOI: 10.1016/j.cpet.2017.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Modalities to detect and characterize lung cancer are generally divided into those that are invasive [endobronchial ultrasound (EBUS), esophageal ultrasound (EUS), and electromagnetic navigational bronchoscopy (ENMB)] versus noninvasive [chest radiography (CXR), computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging (MRI)]. This chapter describes these modalities, the literature supporting their use, and delineates what tests to use to best evaluate the patient with lung cancer.
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Diagnostic Imaging and Newer Modalities for Thoracic Diseases: PET/Computed Tomographic Imaging and Endobronchial Ultrasound for Staging and Its Implication for Lung Cancer. Surg Clin North Am 2017; 97:733-750. [PMID: 28728712 DOI: 10.1016/j.suc.2017.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Modalities to detect and characterize lung cancer are generally divided into those that are invasive [endobronchial ultrasound (EBUS), esophageal ultrasound (EUS), and electromagnetic navigational bronchoscopy (ENMB)] versus noninvasive [chest radiography (CXR), computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging (MRI)]. This chapter describes these modalities, the literature supporting their use, and delineates what tests to use to best evaluate the patient with lung cancer.
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Gullón Blanco JA, Villanueva Montes MÁ, Rodríguez López J, Sánchez Antuña A. Negative Endobronchial Ultrasound in Lung Cancer Staging. Arch Bronconeumol 2017; 53:646-647. [PMID: 28438344 DOI: 10.1016/j.arbres.2017.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 03/07/2017] [Accepted: 03/08/2017] [Indexed: 11/30/2022]
Affiliation(s)
| | | | - Juan Rodríguez López
- Unidad de Gestión Clínica Neumología, Hospital Universitario San Agustín, Avilés, Asturias, España
| | - Andrés Sánchez Antuña
- Unidad de Gestión Clínica Neumología, Hospital Universitario San Agustín, Avilés, Asturias, España
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Linear endobronchial and endoesophageal ultrasound: a practice change in thoracic medicine. Curr Opin Pulm Med 2016; 22:281-8. [PMID: 26989819 DOI: 10.1097/mcp.0000000000000269] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Linear endosonography, including intrathoracic lymph nodal sampling by endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) and endoesophageal ultrasound fine-needle aspiration (EUS-FNA), has an important role in the diagnosing and staging of lung cancer. Furthermore, endosonography is applied in the mediastinal evaluation of sarcoidosis, lymphoma, cysts, and nodal metastases of extrathoracic malignancies. Endosonography-related complications as well as sedation and training strategies are discussed. The purpose of this review is to summarize current practice, recent advances, and future directions. RECENT FINDINGS Lung cancer guidelines recommend endosonography - above mediastinoscopy - as the initial test for mediastinal nodal tissue staging. By introducing the EBUS-scope into the esophagus (EUS-B) - following an EBUS procedure - the complete mediastinum and the left adrenal gland can be investigated in a single scope procedure by one operator. In patients with suspected stage I/II sarcoidosis, EBUS-TBNA/EUS-FNA is the test with the highest granuloma detection rate. Diagnosing (recurrent) lymphoma is an increasingly accepted indication for endosonography. Systematic surveys showed that endosonography has a low complication rate. Simulator-based training and assessment tools measuring competency are important instruments to provide standardized and optimal implementation. SUMMARY Endosonography is generally accepted as a powerful and safe diagnostic test for various diseases affecting the mediastinum. Large-scale implementation is needed.
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Annema JT, De Leyn P, Clementsen P, Siemsen M, Vilmann P. Mediastinoscopy after negative endoscopic mediastinal nodal staging: can it be omitted? Eur Respir J 2016; 46:1848-9. [PMID: 26621894 DOI: 10.1183/13993003.01472-2015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Jouke T Annema
- Academic Medical Center Amsterdam, Dept of Respiratory Medicine, Amsterdam, The Netherlands
| | - Paul De Leyn
- Thoracic Surgery, University Hospital Gasthuisberg, Leuven, Belgium
| | - Paul Clementsen
- Dept of Pulmonology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Peter Vilmann
- Hospital Herlev, Copenhagen University, Copenhagen, Denmark
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