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Thoracoscopic lobectomy versus open lobectomy in stage I non-small cell lung cancer: a meta-analysis. PLoS One 2013; 8:e82366. [PMID: 24391716 PMCID: PMC3877005 DOI: 10.1371/journal.pone.0082366] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 10/24/2013] [Indexed: 11/28/2022] Open
Abstract
The objective of the present meta-analysis was to evaluate the survival, recurrence rate, and complications in patients with stage I non-small cell lung cancer (NSCLC) who received video-assisted thoracoscopic surgery (VATS) or open lobectomy. A literature search was conducted on June 31, 2012 using combinations of the search terms video-assisted thoracic surgery, open thoracotomy, lobectomy, and non-small-cell lung cancer (NSCLC). Inclusion criteria were: 1) Compared video-assisted thoracic surgery (VATS) lobectomy with open lobectomy. 2) Stage I NSCLC. 2) No previous treatment for lung cancer. 4) Outcome data included 5-year survival rate, complication, and recurrence rate. Tests of heterogeneity, sensitivity, and publication bias were performed. A total of 23 studies (21 retrospective and 2 prospective) met the inclusion criteria. VATS was associated with a longer 5-year survival (odds ratio [OR] = 1.622, 95% confidence interval [CI] 1.272 to 2.069; P<0.001), higher local recurrence rate (OR = 2.152, 95% CI 1.349 to 3.434; P = 0.001), similar distant recurrence rate (OR = 0.91, 95% CI 0.33 to 2.48; P = 0.8560), and lower total complication rate (OR = 0.45, 95% CI 0.24 to 0.84; P = 0.013) compared to open lobectomy. VATS was also associated with lower rates arrhythmias, prolonged air leakage, and pneumonia but it did not show any statistical significance. Patients with stage I NSCLC undergoing VATS lobectomy had longer survival and fewer complications than those who received open lobectomy.
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Vyas KS, Davenport DL, Ferraris VA, Saha SP. Mediastinoscopy: trends and practice patterns in the United States. South Med J 2013; 106:539-44. [PMID: 24096946 DOI: 10.1097/smj.0000000000000000] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Historically, mediastinoscopy has been the gold standard for the staging of lung cancer. A practice gap exists as the result of a variation in knowledge concerning current trends and practice patterns of mediastinoscopy usage. In addition, there are regional variations in practice-based learning and patient care. Lessons learned during surgeries performed on patients with lung cancer and other advances such as positron emission tomography and endobronchial ultrasound could be universally applied to improve surgeons' management of patient care. The purpose of this study was to assess contemporary practices in the staging of lung cancer. METHODS We queried the Society of Thoracic Surgeons National Database for data regarding mediastinoscopy usage, yield, and variation, both by year and region. RESULTS Cases with mediastinoscopy, as a percentage of all cases performed in the database, have significantly decreased from 14.6% in 2006 to 11.4% in 2010 (P < 0.001). The 5-year median rate of mediastinoscopy in lung cancer patients at 163 centers was 15.3% (interquartile range 5.2%-31.7%), indicating significant variation among centers. The overall median center rate also decreased over time from 21.4% (2006) to 10.0% (2010). CONCLUSIONS With advances in minimally invasive procedures and imaging, mediastinoscopy usage has declined significantly. Our findings are likely to be relevant to both clinical practice and practice guidelines.
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Affiliation(s)
- Krishna S Vyas
- From the College of Medicine, and the Department of Surgery, University of Kentucky, Lexington
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Patel VK, Naik SK, Naidich DP, Travis WD, Weingarten JA, Lazzaro R, Gutterman DD, Wentowski C, Grosu HB, Raoof S. A practical algorithmic approach to the diagnosis and management of solitary pulmonary nodules: part 1: radiologic characteristics and imaging modalities. Chest 2013; 143:825-839. [PMID: 23460160 DOI: 10.1378/chest.12-0960] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The solitary pulmonary nodule (SPN) is frequently encountered on chest imaging and poses an important diagnostic challenge to clinicians. The differential diagnosis is broad, ranging from benign granulomata and infectious processes to malignancy. Important concepts in the evaluation of SPNs include the definition, morphologic characteristics via appropriate imaging modalities, and the calculation of pretest probability of malignancy. Morphologic differentiation of SPN into solid or subsolid types is important in the choice of follow-up and further management. In this first part of a two-part series, we describe the morphologic characteristics and various imaging modalities available to further characterize SPN. In Part 2, we will describe the determination of pretest probability of malignancy and an algorithmic approach to the diagnosis of SPN.
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Marty-Ané CH, Canaud L, Solovei L, Alric P, Berthet JP. Video-assisted thoracoscopic lobectomy: an unavoidable trend? A retrospective single-institution series of 410 cases. Interact Cardiovasc Thorac Surg 2013; 17:36-43. [PMID: 23592725 DOI: 10.1093/icvts/ivt146] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Evaluation of the feasibility, safety and oncological validity of video-assisted thoracic lobectomy (VATS). The VATS study exclusion criteria included T3 or T4 tumours, central hilar tumours, tumours visible on bronchoscopy requiring sleeve resection, hilar lymphadenopathy, N2 disease, history of neoadjuvant chemotherapy or radiation, previous thoracic surgery or pleurodesis. METHODS A retrospective study of 410 patients (143 women, mean age 61.5 ± 13.1 years (84-15) treated by VATS lobectomy between 1996 and 2011 was performed at our institution. VATS lobectomy was performed for lung cancer (n = 364, 88.9%), pulmonary metastasis (n = 25, 5.8%) and non-neoplastic diseases (n = 21, 5.1%). In lung cancer, a systematic radical lymph node dissection was performed. RESULTS There was no intraoperative death. The conversion rate was 6.1% (n = 25): bleeding (n = 4), extended pleural adhesion (n = 6, 1.4%), technical difficulty (n = 6, 1.4%), tumour extension to the fissure or mediastinum or adenopathy (n = 7, 1.7%) and intolerance to one-lung ventilation (n = 2, 0.4%). The postoperative mortality rate was 1.2% (n = 5). Major complications occurred in 21 patients (5.1%). The mean number of mediastinal nodes removed was 14.6 (5-44) and 42 patients (10.2%) presented N2 disease at the definitive staging. The mean operating time was 152 (85-315) min. The mean drainage duration was 3.2 days (1-15). Mean postoperative length of hospital stay before return at home was 6.8 days (3-75) and 5.5 days in patients without major complications. There was no port site recurrence. Kaplan-Meier 3-year survival rates were 76.5% for Stage I and 87.3% for Stage IA, 58% for Stage II and 61% for Stage III. CONCLUSIONS VATS lobectomy is an acceptable alternative and seems equivalent to open lobectomy in terms of complications and oncological value. Our experience prompts us to consider VATS lobectomy for early stage NSCLC as the first surgical approach in view of the improvement in outcome, provided that the procedure is performed by a surgeon with adequate experience with this approach.
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Affiliation(s)
- Charles-Henri Marty-Ané
- Department of Thoracic, Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.
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Lee SM, Park CM, Paeng JC, Im HJ, Goo JM, Lee HJ, Kang CH, Kim YW, Kim JI. Accuracy and predictive features of FDG-PET/CT and CT for diagnosis of lymph node metastasis of T1 non-small-cell lung cancer manifesting as a subsolid nodule. Eur Radiol 2012; 22:1556-63. [PMID: 22358427 DOI: 10.1007/s00330-012-2395-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Revised: 12/13/2011] [Accepted: 12/21/2011] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To retrospectively evaluate the diagnostic accuracy and predictive features of F-18 fluorodeoxyglucose positron emission tomography/ computed tomography (FDG-PET/CT) and CT in lymph node (LN) staging of T1 non-small-cell lung cancers (NSCLCs) manifesting as subsolid nodules. METHODS From January 2005 to May 2011, 160 patients with pathologically proven T1 subsolid NSCLCs with LN staging were included in this study. Diagnostic accuracies of FDG-PET/CT and CT for LN staging were evaluated. Maximum standardised uptake value (SUVmax) and CT features of primary tumours were evaluated to investigate predictive factors for LN metastasis. RESULTS LN metastases were found in nine of the 160 patients (5.6%). No LN metastasis was present in patients with a solid proportion ≤50%. Sensitivity, specificity and accuracy of FDG-PET/CT for LN staging on a per-patient basis were 11.1%, 86.1% and 81.9%; those of CT were 11.1%, 96.7% and 91.9%. Among patients with a solid proportion >50%, there were significant differences in SUVmax, solid portion size, solid proportion and lesion location between patients with and without LN metastasis. Multivariate analysis revealed that higher SUVmax, a larger solid proportion and central location were independent predictors of LN metastasis. CONCLUSIONS FDG-PET/CT adds little value to CT in the lymph node staging of T1 subsolid NSCLCs. KEY POINTS Lymph node (LN) metastases are important in non-small-cell lung cancer (NSCLC). • Positron emission tomography (PET) helps to stage solid NSCLCs. • FDG-PET/CT adds little to the LN staging of T1 subsolid NSCLCs. • No LN metastasis in patients with a solid proportion ≤50%. • LN metastasis is more common in solid and/or centrally sited tumours.
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Affiliation(s)
- Sang Min Lee
- Department of Radiology, Seoul National University College of Medicine, 101, Daehangno, Jongno-gu, Seoul, 110-744, Korea
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Kasai T, Motoori K, Horikoshi T, Uchiyama K, Yasufuku K, Takiguchi Y, Takahashi F, Kuniyasu Y, Ito H. Dual-time point scanning of integrated FDG PET/CT for the evaluation of mediastinal and hilar lymph nodes in non-small cell lung cancer diagnosed as operable by contrast-enhanced CT. Eur J Radiol 2010; 75:143-6. [DOI: 10.1016/j.ejrad.2009.04.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Accepted: 04/14/2009] [Indexed: 10/20/2022]
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Herth FJ, Eberhardt R, Krasnik M, Ernst A. Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration of Lymph Nodes in the Radiologically and Positron Emission Tomography-Normal Mediastinum in Patients With Lung Cancer. Chest 2008; 133:887-91. [DOI: 10.1378/chest.07-2535] [Citation(s) in RCA: 276] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Yi CA, Lee KS, Kim BT, Shim SS, Chung MJ, Sung YM, Jeong SY. Efficacy of Helical Dynamic CT Versus Integrated PET/CT for Detection of Mediastinal Nodal Metastasis in Non-Small Cell Lung Cancer. AJR Am J Roentgenol 2007; 188:318-25. [PMID: 17242237 DOI: 10.2214/ajr.05.2081] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of our study was to compare the diagnostic efficacies of helical dynamic CT and integrated PET/CT for the prediction of mediastinal nodal metastasis in stage T1 non-small cell lung cancer (NSCLC). MATERIALS AND METHODS One hundred forty-three patients with stage T1 NSCLC underwent both helical dynamic CT and integrated PET/CT followed by surgical nodal staging. In helical dynamic CT, patients were regarded to have stage N2 disease when a nodule showed a peak enhancement > or = 110 H or a net enhancement > or = 60 H. In integrated PET/CT, nodes were regarded as positive for malignancy when they showed > or = 3.5 in maximum standardized uptake value with a discrete margin and more 18F-FDG uptake than mediastinal structures. Sensitivities, specificities, and accuracies for mediastinal nodal metastasis detection were compared for helical dynamic CT and integrated PET/CT using the McNemar test. RESULTS Of the 143 patients, 34 (24%) had positive mediastinal nodes. The sensitivity, specificity, and accuracy for mediastinal nodal metastasis prediction on helical dynamic CT were 65% (22 of 34 patients), 89% (97 of 109), and 83% (119 of 143), respectively, whereas those on integrated PET/CT were 56% (19 of 34), 100% (109 of 109), and 90% (128 of 143). The p values were 0.664, < 0.001, and 0.015. CONCLUSION In stage T1 NSCLC, contrast-enhanced helical dynamic CT better predicts, but not significantly so, mediastinal nodal metastasis than PET/CT, whereas PET/CT shows perfect specificity and higher accuracy than helical dynamic CT.
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Affiliation(s)
- Chin A Yi
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, Ilwon-Dong, Kangnam-Ku, Seoul 135-710, Korea
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Kim BT, Lee KS, Shim SS, Choi JY, Kwon OJ, Kim H, Shim YM, Kim J, Kim S. Stage T1 non-small cell lung cancer: preoperative mediastinal nodal staging with integrated FDG PET/CT--a prospective study. Radiology 2006; 241:501-9. [PMID: 16966480 DOI: 10.1148/radiol.2412051173] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To prospectively evaluate the sensitivity and specificity of integrated fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) and computed tomography (CT) (PET/CT) for the preoperative diagnosis of mediastinal nodal metastasis in stage T1 non-small cell lung cancer (NSCLC), with surgical and histologic results as reference standards. MATERIALS AND METHODS Institutional review board approval and informed consent were obtained. From June 2003 to February 2005, 150 patients (89 men and 61 women; mean age, 59 years) with stage T1 NSCLC at stand-alone CT underwent integrated PET/CT and surgical staging. Two observers (one radiologist and one nuclear medicine physician) evaluated prospectively and in consensus the mediastinal nodes by analyzing both PET (functional) and CT (anatomic) images. Nodal stages were determined by using the American Joint Committee on Cancer staging system and surgical and histologic findings as the reference standard. Statistical evaluation of malignant lymph nodes was performed on per-nodal-station and per-person bases. RESULTS A total of 568 mediastinal nodal stations were evaluated. Nodes were positive for malignancy in 34 (23%) of 150 patients and 55 (10%) of 568 nodal stations. For depiction of malignant nodes, the respective sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of integrated PET/CT were 42% (23 of 55), 100% (513 of 513), 100% (23 of 23), 94% (513 of 545), and 94% (536 of 568) on per-nodal-station basis and 47% (16 of 34), 100% (116 of 116), 100% (16 of 16), 87% (116 of 134), and 88% (132 of 150) on a per-patient basis. CONCLUSION Integrated FDG PET/CT provides high specificity and positive predictive value of mediastinal nodal staging in stage T1 NSCLC, although the sensitivity is low.
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Affiliation(s)
- Byung-Tae Kim
- Department of Nuclear Medicine, Division of Pulmonary and Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-Dong, Kangnam-Ku, Seoul 135-710, Korea
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Fang LC, Komaki R, Allen P, Guerrero T, Mohan R, Cox JD. Comparison of outcomes for patients with medically inoperable Stage I non–small-cell lung cancer treated with two-dimensional vs. three-dimensional radiotherapy. Int J Radiat Oncol Biol Phys 2006; 66:108-16. [PMID: 16904517 DOI: 10.1016/j.ijrobp.2006.04.015] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2005] [Revised: 03/30/2006] [Accepted: 04/17/2006] [Indexed: 12/25/2022]
Abstract
PURPOSE This retrospective analysis was performed to assess the outcomes of three-dimensional (3D) conformal radiotherapy and two-dimensional (2D) planning. METHODS AND MATERIALS Between 1978 and 2003, 200 patients with Stage I non-small-cell lung cancer (NSCLC) were treated with radiotherapy alone at M.D. Anderson Cancer Center. Eighty-five patients were treated with 3D conformal radiotherapy. For the 3D group, median age, radiation dose, and follow-up was 73 (range, 50-92), 66 Gy (range, 45-90.3 Gy), and 19 months (range, 3-77 months), respectively; and for the 2D group, 69 (range, 44-88), 64 Gy (range, 20-74 Gy), 20 months (range, 1-173 months), respectively. Overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), locoregional control (LRC), and distant metastasis-free survival (DMFS) rates were analyzed. RESULTS There was no statistically significant difference in patient and tumor characteristics between 2D and 3D groups, except the 3D patients were older (p = 0.006). The OS, DSS, and LRC rates were significantly higher in patients who were treated by 3D conformal radiotherapy. Two- and 5-year OS for the 3D group were 68% and 36%, respectively, and 47% and 10% in the 2D group (p = 0.001). DSS at 2 and 5 years for the 3D group were 83% and 68%, respectively, vs. 62% and 29% in the 2D group (p < 0.001). LRC rates at 2 and 5 years for patients in the 3D group were 77% and 70% and 53% and 34% in the 2D group (p < 0.001). On univariate analysis elective, nodal irradiation was associated with decreased OS, DSS, and LRC. On multivariate analysis, 3D conformal radiotherapy was associated with increased OS and DSS. Male sex, age > or =70, weight loss > or =5%, and tumor size > or =4 cm were associated with decreased OS and DSS. CONCLUSIONS This study demonstrates that 3D conformal radiotherapy improves outcomes in patients with medically inoperable Stage I NSCLC compared with 2D treatment and is an acceptable treatment for this group of patients.
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Affiliation(s)
- L Christine Fang
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA
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Shim SS, Lee KS, Chung MJ, Kim H, Kwon OJ, Kim S. Do Hemodynamic Studies of Stage T1 Lung Cancer Enable the Prediction of Hilar or Mediastinal Nodal Metastasis? AJR Am J Roentgenol 2006; 186:981-8. [PMID: 16554567 DOI: 10.2214/ajr.04.1858] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We aimed to identify CT enhancement characteristics that predict hilar or mediastinal nodal metastasis in patients with stage T1 lung cancer. SUBJECTS AND METHODS Eighty-four patients (50 men and 34 women; age range, 39-80 years; mean age, 61 years) with stage T1 lung cancer underwent a hemodynamic and a conventional morphologic CT study before curative surgical resection. Peak enhancement (maximum attenuation over the entire time course), net enhancement (peak enhancement minus preenhancement attenuation), maximum enhancement ratio (MER), time to peak enhancement, slope of enhancement on dynamic studies, nodule size, presence of tumor necrosis or thickening of bronchovascular bundles, and marginal characteristics on morphologic studies were analyzed and correlated with the presence of histologically determined mediastinal or hilar nodal metastasis. RESULTS Mediastinal or hilar nodal metastases were found at surgery in 26 (31%) of 84 patients: mediastinal nodes in 13 (15%) and hilar nodes in 19 (23%). Six (7%) had both mediastinal and hilar nodal metastasis. Peak enhancement, net enhancement, and MER were significantly associated (p = 0.001, 0.002, and 0.008, respectively) with the presence of mediastinal or hilar nodal metastasis. A peak attenuation of 110 H or greater and a net enhancement of 60 H or greater predicted nodal metastasis with accuracies of 73% (61/84 nodules) and 73% (61/84 nodules) and odd ratios of 4.98 and 5.94, respectively. CONCLUSION Stage T1 lung cancers showing peak enhancement of 110 H or greater or net enhancement of 60 H or greater on dynamic CT indicate a high likelihood of hilar or mediastinal nodal metastasis.
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Affiliation(s)
- Sung Shine Shim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, Ilwon-Dong, Kangnam-Ku, Seoul 135-710, Korea
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Abstract
Computed tomography (CT) is still the cornerstone of imaging studies in the preoperative staging and post- therapeutic evaluation of lung cancer. The most recent developments in multidetector technology have dramatically improved the temporal and spatial resolution of CT. In the mean time, magnetic resonance imaging (MRI) has not become a routine examination in lung imaging and is today only used as a problem-solving tool in patients in whom CT remains equivocal. This article will describe the current tools developed in the multidetector CT era for evaluating the lung, and state-of-the-art MR examination of the chest. Then, the role of CT and MRI in nodule detection, the distinction between benign and malignant nodules, and the benefit of CT and MRI in the staging and post-therapeutic evaluation of lung cancer will be covered.
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Affiliation(s)
- François Laurent
- Laboratoire de Physiologie Cellulaire Respiratoire, Université Bordeaux 2, and INSERM E356, Bordeaux.
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Munden RF, Swisher SS, Stevens CW, Stewart DJ. Imaging of the Patient with Non–Small Cell Lung Cancer. Radiology 2005; 237:803-18. [PMID: 16251391 DOI: 10.1148/radiol.2373040966] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Lung cancer is the most common type of cancer and is the leading cause of cancer deaths in the United States for both men and women. Even though the 5-year survival rate of patients with lung cancer remains dismal at 14% for all cancer stages, treatments are improving and newer agents for lung cancer appear promising. Therefore, an accurate assessment of the extent of disease is critical to determine whether the patient is treated with surgical resection, radiation therapy, chemotherapy, or a combination of these modalities. Radiologic imaging plays an important role in the staging evaluation of the patient; however, radiologists need to be aware that there are also important differences in what each specialist needs from imaging to provide appropriate treatment. This article reviews the role of imaging in patients with non-small cell lung cancer, with an emphasis on the radiologic imaging findings relevant for each specialty.
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Affiliation(s)
- Reginald F Munden
- Division of Diagnostic Imaging, Department of Diagnostic Radiology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA.
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Abstract
Radiologic evaluation is an important component of the clinical staging evaluation of lung cancer and can greatly influence whether the patient is treated with surgical resection, radiation therapy, chemotherapy, or a combination of these modalities. In addition to staging, the radiologic evaluation of the patient undergoing treatment and subsequent follow-up is important to the clinician for assessing treatment effects and complications. This article discusses the imaging of patients with non-small cell lung cancer and its use in management of these patients.
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Affiliation(s)
- Reginald F Munden
- Division of Diagnostic Imaging, Department of Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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Martín de Nicolás J, Gómez-Caro Andrés A, Moradiellos Díez F, Díaz-Hellín V, Gigirey Castro O, Larrú Cabrero E, Pérez Antón J, Marrón Fernández C. Importancia de la estadificación mediastínica, sistemática en mujeres con carcinoma broncogénico, no microcítico. Arch Bronconeumol 2005. [DOI: 10.1157/13071582] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Martín de Nicolás J, Gómez-Caro Andrés A, Moradiellos Díez FJ, Díaz-Hellín V, Gigirey Castro O, Larrú Cabrero E, Pérez Antón JA, Marrón Fernández C. Importance of Routine Mediastinal Staging in Women With Nonsmall Cell Lung Cancer. ACTA ACUST UNITED AC 2005; 41:125-9. [PMID: 15766464 DOI: 10.1016/s1579-2129(06)60412-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To study the specific importance of mediastinal staging in women with nonsmall cell lung cancer. PATIENTS AND METHODS Between July 1981 and September 2003 we surgically staged 2172 patients with nonsmall cell lung cancer who met the inclusion criteria for resectability and operability. A subgroup of 108 women was studied. Cervical mediastinoscopy was performed in all cases, with the addition of anterior mediastinotomy in cases with left upper lobe involvement. All patients underwent a preoperative computed tomography chest scan. RESULTS Cervical mediastinoscopy was performed on all 108 patients, 26 of whom also underwent anterior mediastinotomy. Positive findings were recorded in 44 (40.7%) of the 108 cases: 39 of the 108 mediastinoscopies (36.1%), 9 of the 26 mediastinotomies (34.6%), and in 5 cases (19.2%) both mediastinoscopy and mediastinotomy. Nodal involvement was found in 13% of cases in clinical stage IA and 30.8% of cases in clinical stage IB. The percentage of positive findings was significantly higher for cases with adenocarcinoma or large cell carcinoma (P<.05). We performed 67 thoracotomies: 46 patients underwent lobectomy (42.6% of the 108), 7 bilobectomy (6.5%), 9 pneumonectomy (8.3%), and 5 exploratory thoracotomy (4.6%). The agreement between clinical staging after mediastinoscopy and pathological staging after thoracotomy was 47% (stage IA) and 57% (stage IB). CONCLUSIONS Routine mediastinoscopy is indicated for all women with nonsmall cell lung cancer, regardless of clinical stage.
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Affiliation(s)
- Jl Martín de Nicolás
- Servicio de Cirugía Torácica, Hospital Universitario 12 de Octubre, Madrid, España
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Smulders SA, Smeenk FWJM, Janssen-Heijnen MLG, Wielders PLML, de Munck DRAJ, Postmus PE. Surgical mediastinal staging in daily practice. Lung Cancer 2005; 47:243-51. [PMID: 15639723 DOI: 10.1016/j.lungcan.2004.06.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2004] [Revised: 06/17/2004] [Accepted: 06/21/2004] [Indexed: 01/03/2023]
Abstract
STUDY OBJECTIVES An adequately staged mediastinum remains obligatory in patients with NSCLC prior to surgery. In this study, we investigated the accuracy of preoperative surgical mediastinal staging procedures in four hospitals. SETTING Non-university teaching hospital and three surrounding community hospitals in Eindhoven, The Netherlands. PATIENTS, MEASUREMENTS AND RESULTS Patients with NSCLC who underwent mediastinoscopy and/or thoracotomy, between 1993 and 1999. Adherence to guidelines for indicating and performing mediastinoscopy were investigated and compared in four hospitals. Guidelines for indicating mediastinoscopy were adequately followed in two-thirds of cases. Mediastinoscopy was performed according to gold standards in 40% of cases. The hospital with the smallest number of evaluated patients scored the worst. Postoperatively, 17% of patients appeared to have "unforeseen N2-3 disease". In approximately 18% of these "upstaged" patients, thoracotomy could have been prevented, if guidelines had been followed adequately. CONCLUSIONS In clinical practice the adherence to staging guidelines with respect to mediastinoscopy is insufficient in one-third of patients. Furthermore, mediastinoscopy was performed according to gold standards in 40% of patients.
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Affiliation(s)
- Sietske A Smulders
- Department of Pulmonary Diseases, Catharina Hospital, Eindhoven, PO Box 1350, 5602 ZA Eindhoven, The Netherlands.
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Pass HI, Altorki NK. Computerized Tomographic Nodule Heterogeneity: Present and Future Impact on Indications for Sublobar Resections. Clin Lung Cancer 2004; 6:20-7. [PMID: 15310413 DOI: 10.3816/clc.2004.n.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
With the advent of lung cancer screening, many nodules are being detected that are subsequently proven to be lung cancer. These nodules have different radiographic appearances and different biologic characteristics regarding their invasiveness and propensity for metastasis. These solid and part-solid nodules are now having surgeons reassess issues of lung sparing for early-stage lung cancer by not only considering smaller nodules as potentially appropriate for wedge resection or segmentectomies, but are also requiring surgeons to stratify these lesions by radiographic appearance. Data that argue for considering lesser resection of selected early-stage lung cancers, as well as the need for more prospectively accumulated facts that arise from trial designs like the original randomized Lung Cancer Study Group Trial, are discussed.
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Affiliation(s)
- Harvey I Pass
- Department of Surgery and Oncology, Wayne State University and Karmanos Cancer Institute, Detroit, MI 48201, USA.
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Kelly RF, Tran T, Holmstrom A, Murar J, Segurola RJ. Accuracy and Cost-Effectiveness of [18F]-2-Fluoro-Deoxy-D-Glucose-Positron Emission Tomography Scan in Potentially Resectable Non-small Cell Lung Cancer. Chest 2004; 125:1413-23. [PMID: 15078754 DOI: 10.1378/chest.125.4.1413] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES This retrospective study of patients who were referred for surgical resection of non-small cell lung cancer (NSCLC) assessed the accuracy and cost-effectiveness of positron emission tomography (PET) with radiolabeled [18F]-2-fluoro-deoxy-D-glucose (FDG) in staging mediastinal lymph nodes (MLNs). DESIGN From January 2001 to September 2002, 90 patients with suspected or proven NSCLC who had been referred for curative resection were retrospectively reviewed. All patients were without evidence of metastatic disease. Sixty-nine of the 90 patients had undergone thoracic FDG-PET imaging as part of their evaluation and are the focus of this study. Sensitivity, specificity, accuracy, and positive and negative predictive values for metastasis to the MLN were calculated for CT scanning vs FDG-PET scanning. Four algorithms for staging MLN with mediastinoscopy and/or FDG-PET scan were compared. MEASUREMENTS AND RESULTS Sixty-nine patients underwent preoperative CT and FDG-PET scans, and 32 of 69 patients underwent mediastinoscopy. Fifty-seven patients underwent thoracotomy with complete mediastinal lymphadenectomy. Sensitivity, specificity, accuracy, and positive and negative predictive values for CT scans and FDG-PET scans were 46%, 86%, 78%, 43%, and 87%, and 62%, 98%, 91%, 89% and 92%, respectively. Mediastinoscopy was accurate in 32 of 32 patients (100%). Routine mediastinoscopy remains the most economically reasonable strategy with excellent sensitivity. Selective FDG-PET imaging improved the sensitivity of noninvasive staging for patients with normal MLNs on CT scans. CONCLUSIONS Selective use of FDG-PET imaging improves staging accuracy compared to CT scanning alone and makes it a cost-effective adjunct to the preoperative staging of NSCLC. However, in patients with adenocarcinoma and MLNs of < 1 cm, FDG-PET scanning cannot yet replace mediastinoscopy.
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Massone PPB, Lequaglie C, Magnani B, Ferro F, Cataldo I. The real impact and usefulness of video-assisted thoracoscopic surgery in the diagnosis and therapy of clinical lymphadenopathies of the mediastinum. Ann Surg Oncol 2004; 10:1197-202. [PMID: 14654477 DOI: 10.1245/aso.2003.03.538] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the impact of video-assisted thoracoscopic surgery (VATS) in the diagnosis and therapy of clinical mediastinal lymphadenopathies. METHODS In our Institute, from 1995 to 2001, 85 patients underwent VATS biopsy: 55 subjects (group 1) for suspected lung cancer (65%) and 30 (group 2) for unknown nodes enlargement (35%). Lymphonodes were considered suspected if > 1 cm by radiological imaging. We performed 83 thoracoscopic biopsies: 33 in level 5 (39%), 24 in level 6 (29%), 19 in level 7 (22%), and 7 in level 8 (8%). RESULTS A histological analysis of frozen sections was made in every case. Twenty subjects underwent lung resection in one-time (24%). Histology in group 1 was adenocarcinoma in 28 cases, epidermoid carcinoma in 14, microcytoma in 9, and giant-cell carcinoma in 4. Ten patients were at stage I, 10 at stage II, 33 at stage III, and two at stage IV. Histology of group 2 was lymphoma in 18 cases, sarcoidosis in eight, and focal aspecific hyperplasia in four. CONCLUSION The usefulness of VATS allowed the pathological assessment of the presumed involved mediastinal lymph nodes in every patient and thus permitted to assure in all the cases the indicated therapeutic treatment.
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Affiliation(s)
- Alexander Spira
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD 21231-1000, USA
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Bradley JD, Wahab S, Lockett MA, Perez CA, Purdy JA. Elective nodal failures are uncommon in medically inoperable patients with Stage I non-small-cell lung carcinoma treated with limited radiotherapy fields. Int J Radiat Oncol Biol Phys 2003; 56:342-7. [PMID: 12738307 DOI: 10.1016/s0360-3016(02)04614-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE To review the outcome for 56 Stage I non-small-cell lung cancer treated definitively with three-dimensional conformal radiotherapy (3D-CRT) and to investigate the value of elective nodal irradiation in this patient population. METHODS AND MATERIALS Between 1992 and 2001, 56 patients were treated with 3D-CRT for inoperable Stage I histologically confirmed non-small-cell lung cancer; 31 with T1N0 and 25 with T2N0 disease. All patients were treated with 3D-CRT to a median isocenter dose of 70 Gy (range 59.94-83.85) given in daily doses of 1.8 or 2 Gy. Prognostic factors were analyzed with respect to their impact on overall survival. Twenty-two patients received radiotherapy (RT) directed to elective regional lymphatics to doses of 45-50 Gy. The remaining 33 patients were treated to limited fields confined to the primary lung cancer with a margin. The patterns of failure were reviewed. RESULTS The median follow-up was 20 months (range 6 months to 6 years). The actuarial local control rate was 88%, 69%, and 63%, at 1, 2, and 3 years, respectively. The actuarial cause-specific survival rate was 82%, 67%, and 51% at 1, 2, and 3 years, respectively. The actuarial overall survival rate was 73%, 51%, and 34% at 1, 2, and 3 years, respectively. The actuarial metastasis-free survival rate was 90%, 85%, and 81% at 1, 2, and 3 years, respectively. The RT dose was the only factor predictive of overall survival in our analysis. No statistically significant difference was noted in cause-specific or overall survival according to whether patients received elective nodal irradiation. Two of 33 patients treated with limited fields had regional nodal failure. CONCLUSION Many patients with medically inoperable Stage I lung cancer die of intercurrent causes. The omission of the elective nodal regions from the RT portals did not compromise either the cause-specific or overall survival rate. Elective nodal failures were uncommon in the group treated with limited RT fields. A radiation dose 70 Gy was predictive of better survival in our population. We await the results of prospective trials evaluating high-dose RT in patients treated with RT alone for Stage I lung cancer.
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Affiliation(s)
- Jeffrey D Bradley
- Department of Radiation Oncology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA.
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Lardinois D, Schallberger A, Betticher D, Ris HB. Postinduction video-mediastinoscopy is as accurate and safe as video-mediastinoscopy in patients without pretreatment for potentially operable non-small cell lung cancer. Ann Thorac Surg 2003; 75:1102-6. [PMID: 12683545 DOI: 10.1016/s0003-4975(02)04714-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Prospective assessment of accuracy and safety of video-mediastinoscopy (VMS) in patients without pretreatment and those after induction therapy for potentially operable non-small cell lung cancer. METHODS Between 1996 and 1999, 219 patients underwent VMS at our institution: 195 patients without pretreatment and 24 after completion of induction therapy. Mediastinal lymph nodes were dissected and biopsied according to the American Thoracic Society (ATS) lymph node mapping system using a video-assisted approach. The accuracy of VMS was assessed for each patient according to the results obtained from mediastinal lymph node dissection (MLND) performed during lung resection. RESULTS Video-mediastinoscopy in patients without pretreatment revealed a sensitivity, specificity, and accuracy as compared with MLND of 87%, 100%, and 95.6%, respectively, and a procedure-related complication rate of 4% (8/195 patients). Video-mediastinoscopy in patients after induction therapy revealed a sensitivity, specificity, and accuracy of 81%, 100%, and 91% as compared with MLND, without apparent complications. CONCLUSIONS Video-mediastinoscopy performed after induction therapy for non-small cell lung cancer is as accurate as mediastinoscopy in patients without pretreatment and did not confer additional morbidity.
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Affiliation(s)
- Didier Lardinois
- Division of Thoracic Surgery and Institute of Medical Oncology, Inselspital Bern, Bern, Switzerland.
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Abstract
BACKGROUND The aim of this study was to investigate the significance of mediastinoscopy for clinical stage I non-small cell lung cancer. METHODS We reviewed 291 patients who underwent mediastinoscopy from January 1995 to December 2001 for clinical stage I non-small cell lung cancer. The patients who presented tumor-negative lymph nodes on mediastinoscopy underwent thoracotomy for pulmonary resection and mediastinal lymph node dissection in the same operative session. Mediastinoscopy-positive patients were referred for neoadjuvant therapy. RESULTS Of the 291 patients, 20 patients (6.9%) were found with N2 or N3 disease on mediastinoscopy. Among 271 mediastinoscopy-negative patients, thoracotomy-proven N0 was found in 201 patients (74.2%), N1 in 44 patients (16.2%), and N2 in 25 patients (9.2%). Seventeen of 25 patients with unforeseen N2 disease had positive lymph nodes in the station that could be approached by mediastinoscopy only. The positive rate of mediastinoscopy was significantly higher in the patients with nonbronchioloalveolar-type adenocarcinoma than in squamous cell carcinoma (11.5% vs 3.3%, p = 0.013). However, there was no difference in the mediastinoscopy-positive rate between clinical T1 and T2 status. CONCLUSIONS Though there are still controversies about routine mediastinoscopy in patients without mediastinal nodal enlargement on chest computed tomography scan, this study demonstrates that routine mediastinoscopy is necessary, especially for nonbronchioloalveolar-type adenocarcinoma patients.
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Affiliation(s)
- Yong Soo Choi
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
Carcinoma of the lung is one of the most frequent malignancies and a major cause of mortality. The use of positron emission tomography (PET) has been extensively investigated in patients with carcinoma of the lung and has established clinical utility and cost-effectiveness in characterization of solitary pulmonary nodules and preoperative staging of carcinoma of the lung. Evolving applications in carcinoma of the lung include detection of recurrence, assessment of treatment response, radiotherapy planning, and prognosis. In addition, there is developing interest in combined anatomic/metabolic imaging and new tracer techniques, in particular gene expression imaging. This review aims to present existing data supporting the use of PET in carcinoma of the lung and to explore the evolving indications and future prospects of PET and lung cancer.
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Affiliation(s)
- I Ho Shon
- Clinical PET Centre, Lambeth Wing, St Thomas' Hospital, London, UK
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Abstract
Accurate staging of lung cancer is essential for proper treatment and management of the disease, and allows predictions for patient survival. Several different invasive and noninvasive modalities exist for staging, and the determination of the best approach of one or a combination of those methods depends on the clinical situation and the clinician's assessment of the most appropriate means of staging evaluation. This review discusses the elements and framework of lung cancer staging, with particular emphasis on those newer modalities, especially positron emission tomography and endoscopic ultrasound needle biopsy, which will be expected to be used increasingly more common in clinical practice.
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Affiliation(s)
- John M Barker
- Medical University of South Carolina, Division of Pulmonary and Critical Care Medicine, Charleston, South Carolina 29425, USA
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