Remediastinoscopy after neoadjuvant therapy for non-small cell lung cancer

Comparative evaluation of staging algorithms proven N2 non-small cell lung cancer treated by lung resection after neoadjuvant therapy

Background

In this study, we aimed to compare the performances of clinical methods, minimally invasive methods, mediastinoscopy, and re-mediastinoscopy used in the restaging of patients receiving neoadjuvant therapy for pathologically proven N2. Our secondary objective was to determine the most optimal algorithm for initial staging and restaging after neoadjuvant therapy.

Methods

Between April 2003 and August 2017, a total of 105 patients (99 males, 6 females; mean age: 54.5±8.2 years; range, 27 to 73 years) who were diagnosed with pathologically proven Stage 3A-B N2 non-small cell lung cancer and received neoadjuvant therapy and subsequently lung resection were retrospectively analyzed. Staging algorithm groups (Group 1=first mediastinoscopy-second clinic, Group 2=first mediastinoscopy-second minimally invasive, Group 3=first mediastinoscopy-second re-mediastinoscopy, and Group 4=first minimally invasive-second mediastinoscopy) were created and compared.

Results

In the first stage, N2 diagnosis was made in 90 patients by mediastinoscopy and in 15 patients by minimally invasive method. In the second stage, 44 patients were restaged by the clinical method, 23 by the minimally invasive method, 23 by re-mediastinoscopy, and 15 by mediastinoscopy. The false negativity rates of Groups 1, 2, 3, and 4 were 27.2%, 26.1%, 21.8%, and 13.3%, respectively. The most reliable staging algorithm was found to be the minimally invasive method in the first step and mediastinoscopy in the second step. The mean overall five-year survival rate was 46.3±4.4%, and downstaging in lymph node involvement was found to have a favorable effect on survival (54.3% vs. 21.8%, respectively; p=0.003).

Conclusion

The staging method to be chosen before and after neoadjuvant therapy is critical in the treatment of Stage 3A-B N2 non-small cell lung cancer. In re-mediastinoscopy, the rate of false negativity increases due to technical difficulties and insufficient sampling. As the most optimal staging algorithm, the minimally invasive method is recommended in the first step and mediastinoscopy in the second step.

Recent developments in advanced diagnostic bronchoscopy

The field of bronchoscopy is advancing rapidly. Minimally invasive diagnostic approaches are replacing more aggressive surgical ones for the diagnosis and staging of lung cancer. Evolving diagnostic modalities allow early detection and serve as an adjunct to early treatment, ideally influencing patient outcomes. In this review, we will elaborate on recent bronchoscopic developments as well as some promising investigational tools and approaches in development. We aim to offer a concise overview of the significant advances in the field of advanced bronchoscopy and to put them into clinical context. We will also address potential complications and current diagnostic challenges associated with sampling central and peripheral lung lesions.

Endosonography with lymph node sampling for restaging the mediastinum in lung cancer: A systematic review and pooled data analysis

BACKGROUND

Mediastinal restaging after induction treatment is still a difficult and controversial issue. We aimed to investigate the diagnostic accuracy of endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound-guided fine-needle aspiration for restaging the mediastinum after induction treatment in patients with lung cancer.

METHODS

Embase and PubMed databases were searched from conception to March 2019. Data from relevant studies were analyzed to assess sensitivity and specificity of endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound-guided fine-needle aspiration, and to fit the hierarchical summary receiver operating characteristic curves.

RESULTS

A total of 10 studies consisting of 558 patients fulfilled the inclusion criteria. All patients were restaged by endobronchial ultrasound-guided transbronchial needle aspiration, endoscopic ultrasound-guided fine-needle aspiration, or both. Negative results were confirmed by subsequent surgical approaches. There were no complications reported during any endosonography approaches reviewed. The pooled sensitivities of endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound-guided fine-needle aspiration were 65% (95% confidence interval [CI], 52-76) and 73% (95% CI, 52-87), respectively, and specificities were 99% (95% CI, 78-100) and 99% (95% CI, 90-100), respectively. The area under the hierarchical summary receiver operating characteristic curves were 0.85 (95% CI, 0.81-0.88) for endobronchial ultrasound-guided transbronchial needle aspiration and 0.99 (95% CI, 0.98-1) for endoscopic ultrasound-guided fine-needle aspiration. Moreover, for patients who received chemotherapy alone, the pooled sensitivity of endosonography with lymph node sampling for restaging was 66% (95% CI, 56-75), and specificity was 100% (95% CI, 34-100); for patients who received chemoradiotherapy, the results seemed similar with a sensitivity of 77% (95% CI, 47-92) and specificity of 99% (95% CI, 48-100).

CONCLUSIONS

Endosonography with lymph node sampling is an accurate and safe technique for mediastinal restaging of lung cancer.

Prognosis of multi-level N2-positive non-small cell lung cancer according to lymph node staging using endobronchial ultrasound-transbronchial biopsy

Background

The optimal treatment for stage IIIA‐N2 non‐small cell lung cancer (NSCLC) remains controversial, and multidisciplinary team approaches are needed. Downstaging after induction therapy is a good prognostic factor in surgical patients; however, re‐evaluation of nodal status before surgery is challenging. The aim of this study was to evaluate the prognosis of patients with multi‐level N2 NSCLC who received surgery or chemoradiation therapy (CRT) according to restaging using endobronchial ultrasound‐transbronchial aspiration (EBUS‐TBNA).

Methods

This was a single center, prospective study that included 16 patients with biopsy‐proven multi‐level N2 disease on initial EBUS‐TBNA that was restaged using EBUS‐TBNA after induction therapy. Cases downstaged after rebiopsy were treated surgically. Three‐year progression‐free survival (PFS) and locoregional PFS were determined using Kaplan–Meier analysis.

Results

Of the 16 patients (median age 58 years, male 63%), eight had persistent N2 disease and eight showed N2 clearance on restaging using EBUS‐TBNA. Ten patients underwent surgery, including two patients without N2 clearance. Recurrence and locoregional recurrence occurred in eight and five patients, respectively. The three‐year PFS was longer in patients with N2 clearance than in those with N2 persistent disease (57.1% vs. 37.5%). Patients with N2 clearance also had longer three‐year locoregional PFS than those with N2 persistent disease (71.4% vs. 62.5%).

Conclusions

EBUS‐TBNA could be an effective diagnostic method for restaging in multi‐level N2 NSCLC patients after induction CRT. As this was a pilot study, further large‐scale randomized studies are needed.

Comparison of mediastinal lymph node status and relapse pattern in clinical stage IIIA non-small cell lung cancer patients treated with neoadjuvant chemotherapy versus upfront surgery: A single center experience

Background

In spite of the progress made in neoadjuvant therapy for operable non small‐cell lung cancer (NSCLC), many issues remain unsolved, especially in locally advanced stage IIIA.

Methods

Retrospective data of 163 patients diagnosed with stage IIIA NSCLC after surgery was analyzed. The patients were divided into two groups: a preoperative chemotherapy group including 59 patients who received platinum‐etoposide doublet treatment before surgery, and an upfront surgery group including 104 patients for whom surgical resection was the first treatment step. Adjuvant chemotherapy or/and radiotherapy was administered to 139 patients (85.3%), while 24 patients (14.7%) were followed‐up only.

Results

The rate of N2 disease was significantly higher in the upfront surgery group (P < 0.001). The one‐year relapse rate was 49.5% in the preoperative chemotherapy group compared to 65.4% in the upfront surgery group. There was a significant difference in relapse rate in relation to adjuvant chemotheraphy treatment (P = 0.007). The probability of relapse was equal whether radiotherapy was applied or not (P = 0.142). There was no statistically significant difference in two‐year mortality (P = 0.577). The median survival duration after two years of follow‐up was 19.6 months in the preoperative chemotherapy group versus 18.8 months in the upfront surgery group (P = 0.608 > 0.05).

Conclusion

There was significant difference in preoperative chemotherapy group regarding relapse rate and treatment outcomes related to the lymph node status comparing to the upfront surgery group. Neoadjuvant/adjuvant chemo‐therapy is a part of treatment for patients with stage IIIA NSCLC, but further investigation is required to determine optimal treatment.

Molecular imaging to identify tumor recurrence following chemoradiation in a hostile surgical environment

Surgical biopsy of potential tumor recurrence is a common challenge facing oncologists, surgeons, and cancer patients. Imaging modalities have limited ability to accurately detect recurrent cancer in fields affected by previous surgery, chemotherapy, or radiation. However, definitive tissue diagnosis is often needed to initiate treatment and to direct therapy. We sought to determine if a targeted fluorescent intraoperative molecular imaging technique could be applied in a clinical setting to assist a surgical biopsy in a "hostile" field. We describe the use of a folate-fluorescein conjugate to direct the biopsy of a suspected recurrent lung adenocarcinoma invading the mediastinum that had been previously treated with chemoradiation. We found that intraoperative imaging allowed the identification of small viable tumor deposits that were otherwise indistinguishable from scar and necrosis. Our operative observations were confirmed by histology, fluorescence microscopy, and immunohistochemistry. Our results demonstrate one possible application and clinical value of intraoperative molecular imaging.

Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

Correctly staging lung cancer is important because the treatment options and prognosis differ significantly by stage. Several noninvasive imaging studies and invasive tests are available. Understanding the accuracy, advantages, and disadvantages of the available methods for staging non-small cell lung cancer is critical to decision-making.

METHODS

Test accuracies for the available staging studies were updated from the second iteration of the American College of Chest Physicians Lung Cancer Guidelines. Systematic searches of the MEDLINE database were performed up to June 2012 with the inclusion of selected meta-analyses, practice guidelines, and reviews. Study designs and results are summarized in evidence tables.

RESULTS

The sensitivity and specificity of CT scanning for identifying mediastinal lymph node metastasis were approximately 55% and 81%, respectively, confirming that CT scanning has limited ability either to rule in or exclude mediastinal metastasis. For PET scanning, estimates of sensitivity and specificity for identifying mediastinal metastasis were approximately 77% and 86%, respectively. These findings demonstrate that PET scanning is more accurate than CT scanning, but tissue biopsy is still required to confirm PET scan findings. The needle techniques endobronchial ultrasound-needle aspiration, endoscopic ultrasound-needle aspiration, and combined endobronchial ultrasound/endoscopic ultrasound-needle aspiration have sensitivities of approximately 89%, 89%, and 91%, respectively. In direct comparison with surgical staging, needle techniques have emerged as the best first diagnostic tools to obtain tissue. Based on randomized controlled trials, PET or PET-CT scanning is recommended for staging and to detect unsuspected metastatic disease and avoid noncurative resections.

CONCLUSIONS

Since the last iteration of the staging guidelines, PET scanning has assumed a more prominent role both in its use prior to surgery and when evaluating for metastatic disease. Minimally invasive needle techniques to stage the mediastinum have become increasingly accepted and are the tests of first choice to confirm mediastinal disease in accessible lymph node stations. If negative, these needle techniques should be followed by surgical biopsy. All abnormal scans should be confirmed by tissue biopsy (by whatever method is available) to ensure accurate staging. Evidence suggests that more complete staging improves patient outcomes.

Restaging after induction therapy for non-small-cell lung cancer

SUMMARY Select patients with stage IIIa-N2 non-small-cell lung cancer will benefit from treatment with induction chemoradiotherapy followed by surgical resection. The identification of patients with residual N2 disease may allow for selection of those patients most likely to benefit from resection. The optimal strategy for restaging of mediastinal lymph nodes following induction therapy is controversial. Noninvasive, imaging-based strategies are largely ineffective. Minimally invasive approaches such as endobronchial ultrasound-transbronchial needle aspiration and endoscopic ultrasound-guided fine needle aspiration may identify residual nodal disease, but require surgical confirmation of negative results. Repeat mediastinoscopy may be effective at centers that specialize in this technique, but in the authors opinion its use cannot be broadly recommended. A thoughtful and minimally invasive approach to initial staging of N2 nodes is recommended, reserving mediastinoscopy for restaging whenever possible.

Invasive staging of mediastinal lymph nodes: mediastinoscopy and remediastinoscopy

Nodal status in lung cancer is essential for planning therapy and assessing prognosis. The involvement of ipsilateral and contralateral mediastinal lymph nodes is associated with poor prognosis and usually excludes patients from upfront surgical treatment. Mediastinoscopy is a time-honored procedure that allows the surgeon to access the upper mediastinal lymph nodes for either biopsy or removal. Remediastinoscopy is mainly indicated to assess objective tumor response in mediastinal lymph nodes after induction therapy for locally advanced lung cancer and to indicate further therapy.

Prognostic factors of resected node-positive lung cancer: location, extent of nodal metastases, and multimodal treatment

Objective: To investigate the prognostic significance of location and extent of lymph node metastasis in resected non-small cell lung cancer (NSCLC), and to weigh up the influence of treatment modalities on survival.

Patients and method: On exploratory analysis, patients were grouped according to location and time of diagnosis of nodal metastasis: group I, pN2-disease in the aortopulmonary region (N=14); group II, pN2-disease at other level (N=30); group III, cN2-disease with response to induction treatment (ypN0; N=21); group IV, cN2-disease without response to induction treatment (ypN1-2; N=27); group V, pN1-disease (N=66).

Results: From 1999 to 2005, 158 patients (median age: 64 years) with node-positive NSCLC were treated at our institution either by neoadjuvant chemo-radiotherapy plus surgery or by surgery plus adjuvant therapy (chemotherapy, radiotherapy, or both). Operative mortality and major morbidity rates were 2% and 15%. Five-year survival rates were 19% for group I, 12% for group II, 66% for group III, 15% for group IV, and 29% for group V (P<.05). On multivariate analysis, time of N+-diagnosis, extent of nodal involvement and therapy approach were significantly linked to prognosis.

Conclusion: The survival of patients with node-positive NSCLC does not depend on anatomical location of nodal disease, but strongly correlates to extent of nodal metastases and treatment modality. Combined therapy approaches including chemotherapy and surgery may improve long-term survival.

Significance of a new fluorodeoxyglucose-positive lesion on restaging positron emission tomography/computed tomography after induction therapy for non-small-cell lung cancer

OBJECTIVES

Restaging of patients with locally advanced non-small-cell lung cancer (NSCLC) is of paramount importance, since only patients with down-staging after induction therapy will benefit from surgery. In this study, we assessed the aetiology of new (18)fluoro-2-deoxy-d-glucose (FDG)-positive focal abnormalities on restaging positron emission tomography/computed tomography (PET/CT) in patients with a good response after induction chemotherapy in the primary tumour and lymph nodes.

METHODS

Between 2004 and 2008, 31 patients with histological proven stage III NSCLC had a PET/CT prior and after induction chemotherapy. Their medical charts were retrospectively reviewed.

RESULTS

Restaging PET/CT revealed a new FDG-positive lesion in 6 of 31 (20%) patients. The initial clinical stage of the disease was IIIA N2 in four and IIIB T4 in two patients. The maximal standard uptake value in the primary tumour (P = 0.043) and in the initially involved mediastinal nodes (P = 0.068) decreased after induction treatment in all patients. The new PET/CT findings were located in an ipsilateral cervical lymph node in two patients, a contralateral mediastinal in one patient and an ipsilateral mammary internal lymph node in one patient. Two other patients had a lesion on the contralateral lung. Malignant lymph node infiltrations were excluded following fine-needle puncture, intraoperative biopsy or follow-up PET/CT. Contralateral pulmonary lesions were diagnosed as benign following mini thoracotomy and pulmonary wedge resection.

CONCLUSIONS

New solitary FDG-positive lesions on restaging PET/CT after induction chemotherapy for NSCLC are not rare in good responders to chemotherapy. In our experience, all these lesions were not associated with malignancy.

SEPAR guidelines for lung cancer staging

The latest tumour, lymph node and metastasis (TNM) classification by the International Association for the Study of Lung Cancer (IASLC), based on the analysis of patients from all over the world, has incorporated changes in the descriptors, especially those regarding tumor size, while proposing new group staging. A new lymph node map has also been developed with the intention of facilitating the classification of the "N" component. SEPAR recommends using this new classification. As for the procedures recommended for staging, in addition to the generalized use of computed tomography (CT), it points to the role of positron emission tomography (PET) or image fusion methods (PET/CT), which provide a better evaluation of the mediastinum and extrathoracic metastases. Endobronchial ultrasound (EBUS) and esophageal ultrasound (EUS) for obtaining cytohistological samples have been incorporated in the staging algorithm, and it emphasizes the importance of precise re-staging after induction treatment in order to make new therapeutic decisions. Comment is made on the foreseeable incorporation in the near future of molecular staging, and systematic lymph node dissection is recommended with the intention of making a more exact surgical-pathological classification.

[New endoscopic ultrasound (EUS) applications in lung cancer: evaluation of patients with negative mediastinal CT and re-staging after neoadjuvant treatment]

The main purpose of staging in non-small cell lung cancer (NSCLC) is to assess mediastinal lymph node involvement, with thoracic CT being the main non-invasive test for this. However, given that up to 15% of patients who show no mediastinal lymph node involvement in the CT have lymph node metastasis during surgery, other examinations are required. Endoscopic ultrasonography guided fine-needle aspiration (EUS-FNA) has shown to be able to detect advanced disease (metastatic mediastinal lymph nodes, adrenal metastasis, mediastinal invasion by the tumour) in approximately 25% of patients with a CT that suggested a non-advanced disease. Another situation in which CT has a very limited value is in the evaluation of the response to induction therapy, with its most limiting factor being its intrinsic inability to distinguish between a tumour and necrosis. In this context, EUS-FNA has shown to have a good performance, with a sensitivity, negative predictive value and precision of 75%, 67% and 83%, respectively. In conclusion, EUS-FNA may be considered a good alternative in the pre-operative staging of patients with NSCLC, with and without diseased mediastinal lymph nodes in CT, and could play an important role in the mediastinal re-staging of these patients by identifying a patient sub-group who might benefit from additional surgical treatment.

[Utility of PET/CT for mediastinal staging of non-small cell lung cancer in stage III (N2)]

PURPOSE

To evaluate the accuracy of integrated positron emission tomography with (18)F-fluoro-2-deoxy-D-glucose (FDG) and computed tomography (PET/CT) in mediastinal lymph node staging in patients with potentially operable (N2) non-small cell lung cancer (NSCLC) and to ascertain the role of invasive staging in verifying positron emission tomography (PET)/computed tomography (CT) results.

MATERIAL AND METHODS

A retrospective study of consecutive patients with pathologically-proven NSCLC and N2 staging by enhanced CT was performed. A PET/CT scan was performed for all the patients. Lymph node staging was pathologically confirmed when it was possible or by consensus in the Thoracic Cancer Committee. Sensitivity, specificity, negative predictive value and positive predictive value of PET/CT in N2 cases were determined.

RESULTS

A total of 34 patients with N2 by CT were evaluated. PET/CT showed N2 in 30 patients. Discrepancies were found in four patients, two patients were classified as N1 in PET/CT and two patients as N0. Lymph node staging was pathologically confirmed in 20 patients. No false positives were found in PET/CT study. Sensitivity was 94.7%, specificity and positive predictive values were 100% and negative predictive value was 50%.

CONCLUSIONS

Our data show that integrated PET/CT provides high sensitivity and positive predictive value in mediastinal nodal staging of NSCLC patients. Therefore, in patients with potentially resectable lung cancer, neoadjuvant chemotherapy candidate, mediastinoscopy could be reserved for restaging after induction therapy.

Endobronchial ultrasound-guided transbronchial needle aspiration

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive mediastinal staging tool for lung cancer but also a diagnostic tool for mediastinal lesions near the airway. After a brief historic rationale, this article reviews the indications for EBUS-TBNA, provides an overview of practical, training and financial issues; reviews the evidence comparing the mediastinal staging tools and briefly discusses potential future applications. EBUS-TBNA is most commonly used for staging non-small cell lung cancer (NSCLC), but is also used for diagnosis of unexplained mediastinal lymphadenopathy of other causes. For staging before radical treatment, many centres still perform mediastinoscopy and this should be done to confirm negative EBUS-TBNA results in this setting and when the pre-test clinical probability of lung cancer is high. EBUS-TBNA may be used in the future for staging when the mediastinal nodes are normal according to radiological staging and also in re-staging. EBUS-TBNA can be learned with appropriate training and mentorship; it offers numerous advantages over mediastinoscopy; and it is less invasive and can reduce costs by avoiding unnecessary mediastinoscopies in many cases.

Endobronchial and endoscopic ultrasound-guided fine-needle aspiration: a must for thoracic surgeons

A thoracic surgeon facile in endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA) and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) can accurately sample mediastinal lymph nodes (MLNs) for histologic assessment of mediastinal adenopathy and for thoracic malignancy staging. Although mediastinoscopy is the gold standard for histologic MLN assessment, EBUS-FNA and EUS-FNA have emerged as useful, less-invasive sampling techniques that offer access to a wider range of MLN stations than mediastinoscopy and can be used to biopsy suspicious lesions within (ie, peribronchial masses) and outside the mediastinum (ie, left adrenal gland masses, liver lesions, and enlarged celiac lymph nodes). The negative predictive value of EBUS-TBNA and EUS-FNA in patients with malignancy is somewhat lower than the negative predictive value of mediastinoscopy. Therefore, we recommend that nonmalignant EBUS or EUS cytologic findings should be confirmed with a surgical MLN biopsy (ie, mediastinoscopy or thoracoscopy) if the pretest probability of malignancy is high.

Advances in diagnostic bronchoscopy

Diagnostic bronchoscopy has undergone two major paradigm shifts in the last 40 years. First, the advent of flexible bronchoscopy gave chest physicians improved access to the tracheobronchial tree with a rapid learning curve and greater patient comfort compared with rigid bronchoscopy. The second paradigm shift has evolved over the last 5 years with the proliferation of new technologies that have significantly enhanced the diagnostic capabilities of flexible bronchoscopy compared with traditional methods. At the forefront of these new technologies is endobronchial ultrasound. In its various forms, endobronchial ultrasound has improved diagnostic yield for pulmonary masses, nodules, intrathoracic adenopathy, and disease extent, thereby reducing the need for more invasive surgical interventions. Various navigational bronchoscopy systems have become available to increase flexible bronchoscope access to small peripheral pulmonary lesions. Furthermore, various modalities of airway assessment, including optical microscopic imaging technologies, may play significant roles in the diagnosis of a variety of pulmonary diseases in the future. Finally, the combination of new diagnostic bronchoscopy technologies and novel approaches in molecular analysis and biomarker assessment hold promise for enhanced diagnosis and personalized management of many pulmonary disorders. In this review, we provide a contemporary review of diagnostic bronchoscopy developments over the past decade.

Endobronchial ultrasound-guided transbronchial needle aspiration cytology: a state of the art review

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a recently developed, accurate, safe and cost-effective technique that allows sampling of mediastinal lymph nodes and peribronchial lesions including pulmonary and mediastinal lesions. Its major indications are the nodal staging of non-small cell carcinomas of the lung, their restaging after chemotherapy and/or radiation, the diagnosis of sarcoidosis and of metastases from extrathoracic malignancies, and the diagnosis of mediastinal lymphadenopathy and masses of unknown aetiology. From our experience at the University of Minnesota and a comprehensive review of the literature, we discuss technical aspects of the procedure, its advantages and limitations in comparison with other methods of sampling mediastinal lymph nodes, focusing on the role of the cytopathologist in ensuring the effectiveness of the procedure. An algorithmic approach to the cytological diagnosis, starting with the determination of the adequacy of the sample, is also presented.

Mediastinal staging procedures in lung cancer: EBUS, TBNA and mediastinoscopy

PURPOSE OF REVIEW

There is increasing awareness of minimally invasive endoscopic techniques for mediastinal staging in lung cancer. Traditionally, cervical mediastinoscopy has been utilized. Endobronchial ultrasound-guided fine needle aspiration (EBUS) has recently emerged as a potential alternative.

RECENT FINDINGS

EBUS has sensitivity for lung cancer which is at least equivalent (if not superior) to cervical mediastinoscopy. However, cervical mediastinoscopy remains superior to EBUS and other techniques in its high negative predictive value. More recent data suggest EBUS may have a role in presurgical staging of radiologically normal subcentimetre nodes and its negative predictive value may be equivalent to surgical staging. Ongoing comparative studies between EBUS and cervical mediastinoscopy may well clarify relative performance and cost analyses.

SUMMARY

Currently, insufficient data are present to recommend replacing cervical mediastinoscopy with EBUS for lung cancer staging; the negative predictive value of EBUS requires validation. However, EBUS can be recommended for initial staging as a minimally invasive option provided negative results are followed by cervical mediastinoscopy. This would also allow cervical mediastinoscopy to be reserved for re-staging. Conventional transbronchial needle aspiration has a limited role only as a first-line staging procedure but may aid diagnosis. In the future, EBUS may have a role in presurgical staging of the radiologically normal mediastinum and re-staging if prior staging is done by cervical mediastinoscopy.

Endobronchial ultrasound-guided transbronchial needle aspiration for mediastinal lymph node staging in non-small cell lung cancer

Mediastinoscopy is the gold standard for mediastinal lymph node (MLN) staging for non-small cell lung cancer patients; however, mediastinoscopy is invasive and allows access to a limited number of American Thoracic Society MLN stations (1, 2, 3, 4, and 7). Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is emerging as a useful, less invasive staging technique that offers access to a wider range of MLN stations (2, 3, 4, 7, 10, and 11). Although EBUS-TBNA has excellent sensitivity and diagnostic accuracy, an alternative MLN biopsy technique (i.e., mediastinoscopy or thoracoscopy) is required to confirm negative cytology findings, especially after induction therapy. Additionally, an experienced cytopathologist is critical to establishing an effective EBUS-TBNA program.

Positron emission tomography in lung cancer

Recent advances in positron emission tomography (PET) with 2-deoxy-2-fluoro [F-18]-D: -glucose (FDG) has enabled not only the diagnosis and staging of lung cancer but also the prediction of its malignancy grade. However, FDG-PET has been known to have several pitfalls for imaging of lung cancer. For the effective clinical use of FDG-PET in lung cancer, we reviewed the pitfalls of using FDG-PET in the diagnosis of pulmonary nodules, semiquantitative analysis of FDG-uptake, N-staging, prediction of tumor aggressiveness, prognostic significance, and prediction of pathological response after chemoradiotherapy.

[Role of mediastinoscopy and repeat mediastinoscopy today]

For patients with lung cancer preoperative evaluation of the mediastinal lymph nodes is important to estimate local operability and/or to consider the necessity of neoadjuvant treatment. Cervical mediastinoscopy is generally accepted as a safe and highly accurate procedure in the staging of lung cancer. Nodes accessible to CM are the levels of the superior (level 2R and 2L) and inferior (level 4R and 4L) paratracheal and subcarinal (level 7) nodal stations. Additionally extended CM and left parasternal mediastinotomy allow the exploration of the aortopulmonary window (level 5) and anterior mediastinal nodes (level 6). In locally advanced lung cancer repeat mediastinoscopy was used after induction chemotherapy or chemoradiation to reexplore the upper mediastinum in order to select patients with a higher probability to undergo complete resection. Operative mortality of both investigations is less than 0.5%; the preoperative complication rate is very low (less than 4%). Because of the higher sensitivity, specificity, and accuracy, mediastinoscopy and repeat mediastinoscopy are superior to new methods like FDG-PET, FDG-PET/CT, EBUS-FNA, and EUS-FNA.

Endobronchial ultrasound with transbronchial needle aspiration for restaging the mediastinum in lung cancer

PURPOSE

To investigate the sensitivity and accuracy of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for restaging the mediastinum after induction chemotherapy in patients with non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

One hundred twenty-four consecutive patients with tissue-proven stage IIIA-N2 disease who were treated with induction chemotherapy and who had undergone mediastinal restaging by EBUS-TBNA were reviewed. On the basis of computed tomography, 58 patients were classified as having stable disease and 66 were judged to have had a partial response. All patients subsequently underwent thoracotomy with attempted curative resection and a lymph node dissection regardless of EBUS-TBNA findings.

RESULTS

Persistent nodal metastases were detected by using EBUS-TBNA in 89 patients (72%). Of the 35 patients in whom no metastases were assessed by EBUS-TBNA, 28 were found to have residual stage IIIA-N2 disease at thoracotomy. The majority (91%) of these false negative results were due to nodal sampling error rather than detection error. Overall sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of EBUS-TBNA for mediastinal restaging after induction chemotherapy were 76%, 100%, 100%, 20%, and 77%, respectively.

CONCLUSION

EBUS-TBNA is a sensitive, specific, accurate, and minimally invasive test for mediastinal restaging of patients with NSCLC. However, because of the low negative predictive value, tumor-negative findings should be confirmed by surgical staging before thoracotomy.

Induction chemotherapy with cisplatin, vinorelbine, and mitomycin-C followed by surgery for patients with pathologic N2 non-small-cell lung cancer

PURPOSE

The treatment strategy for patients with non-small-cell lung cancer (NSCLC) involving ipsilateral mediastinal lymph nodes is still controversial. We performed a phase II feasibility study of induction chemotherapy followed by surgery for patients with pathologic N2 NSCLC.

PATIENTS AND METHODS

Patients with mediastinoscopy- positive stage IIIA N2 NSCLC received 2 cycles of cisplatin 80 mg/m2, vinorelbine 25 mg/m2, and mitomycin-C 8 mg/m2. Patients without progressive disease underwent thoracotomy and lobectomy with lymph node dissections 2-4 weeks later.

RESULTS

From January 2000 to July 2004, 24 eligible patients (15 men, 9 women) were enrolled. Induction chemotherapy was completed as planned in 23 patients (95.8%). Hematological toxicity was the primary grade 3/4 toxicity. Twelve (50%) patients achieved a partial response. Twenty-three patients underwent surgical resection, and complete resection was achieved in 22 patients (95.7%). There were no surgery-related deaths. Pathologic complete response in metastatic lymph nodes was achieved in 5 patients. With a median follow-up of 5.4 years (range, 2.88-7.7 years), the estimated 5-year survival was 51.8% (95% CI, 41.3-62.3) and progression-free survival was 46.6% (95% CI, 36-57.2).

CONCLUSION

Induction chemotherapy followed by surgery for patients with pathologic N2 NSCLC was feasible and associated with high response to lymph node metastasis and good survival.

Remediastinoscopy in restaging of lung cancer after induction therapy

OBJECTIVES

The aim of the present study was to evaluate the feasibility and diagnostic value of repeat mediastinoscopy as part of the response-evaluation protocol of 2 phase II multimodality studies for either stage IIIA/B non-small cell lung cancer or small cell lung cancer.

METHODS

From January 1991 through December 1998, 104 patients (79 men and 25 women) with stage IIIA/B non-small cell lung cancer (84 patients) or small cell lung cancer (17 patients) were enrolled in 2 different multimodality trials and underwent remediastinoscopy after induction chemoradiotherapy. The median age was 56 years (range, 34-72 years). Sensitivity, specificity, accuracy, and predictive values of remediastinoscopy were calculated by using standard definitions.

RESULTS

Remediastinoscopy was feasible in 98% of cases. Mortality was nil, and morbidity very low (1.9%). Lymph node downstaging (N0) was observed in 84 patients, persisting N2 disease was observed in 15 patients, and N3 disease was observed in 5 patients. Sensitivity was 61%, specificity was 100%, and accuracy was 88%. Positive predictive and negative predictive values reached 100% and 85%, respectively. According to the results of remediastinoscopy, 81 patients underwent surgical intervention, 3 refused the operation, and an unnecessary thoracotomy could be avoided in the remaining 20.

CONCLUSIONS

Remediastinoscopy provides a histologic proof of mediastinal downstaging with high diagnostic accuracy, is technically feasible with low morbidity, and still remains a valuable tool, even in an era of highly sophisticated imaging and endoscopic procedures. Persisting nodal disease at repeat mediastinoscopy carries a poor survival in the majority of cases because of occult metastases, so that indication for surgical intervention in such an unfavorable group of patients should be evaluated very carefully.

Endobronchial ultrasound and value of PET for prediction of pathological results of mediastinal hot spots in lung cancer patients

SUMMARY

In the staging of lung cancer with positron emission tomography (PET) positive mediastinal lymph nodes, tissue sampling is required. The performance of transbronchial needle aspiration (TBNA) using linear endobronchial ultrasound (real-time EBUS-TBNA) under local anaesthesia and the value of PET for prediction of pathological results were assessed in that setting. The number of eluded surgical procedures was evaluated. All consecutive patients with suspected/proven lung cancers and FDG-PET positive mediastinal adenopathy were included. If no diagnosis was reached, further surgical sampling was required. Lymph node SUVmax (maximum standardized uptake value) was assessed in patients whose PET was performed in the leading centre. One hundred and six patients were included. The average number of TBNA samples per patient was 4.9+/-1.1. The prevalence of lymph node metastasis was 58%. Sensitivity, accuracy and negative predictive value of EBUS-TBNA in the staging of mediastinal hot spots were 95, 97 and 91%. Patients without malignant lymph node involvement showed lower SUVmax (respective median values of 3.7 and 10.0; p<0.0001). Surgical procedures were eluded in 56% of the patients. Real-time EBUS-TBNA should be preferred over mediastinoscopy as the first step procedure in the staging of PET mediastinal hot spots in lung cancer patients. In case of negative EBUS, surgical staging procedure should be undertaken. The addition of SUVmax cut-off may allow further refinement but needs validation.

Invasive mediastinal staging of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition)

BACKGROUND

The treatment of non-small cell lung cancer (NSCLC) is determined by accurate definition of the stage. If there are no distant metastases, the status of the mediastinal lymph nodes is critical. Although imaging studies can provide some guidance, in many situations invasive staging is necessary. Many different complementary techniques are available.

METHODS

The current guidelines and medical literature that are applicable to this issue were identified by computerized search and were evaluated using standardized methods. Recommendations were framed using the approach described by the Health and Science Policy Committee of the American College of Chest Physicians.

RESULTS

Performance characteristics of invasive staging interventions are defined. However, a direct comparison of these results is not warranted because the patients selected for these procedures have been different. It is crucial to define patient groups, and to define the need for an invasive test and selection of the best test based on this.

CONCLUSIONS

In patients with extensive mediastinal infiltration, invasive staging is not needed. In patients with discrete node enlargement, staging by CT or positron emission tomography (PET) scanning is not sufficiently accurate. The sensitivity of various techniques is similar in this setting, although the false-negative (FN) rate of needle techniques is higher than that for mediastinoscopy. In patients with a stage II or a central tumor, invasive staging of the mediastinal nodes is necessary. Mediastinoscopy is generally preferable because of the higher FN rates of needle techniques in the setting of normal-sized lymph nodes. Patients with a peripheral clinical stage I NSCLC do not usually need invasive confirmation of mediastinal nodes unless a PET scan finding is positive in the nodes. The staging of patients with left upper lobe tumors should include an assessment of the aortopulmonary window lymph nodes.

The Importance of Accurate Lymph Node Staging in Early and Locally Advanced Non-small Cell Lung Cancer: An Update on Available Techniques

Medical oncologists are faced with multiple factors to consider when staging a patient with suspected or confirmed non-small cell lung cancer (NSCLC). Identifying pathological nodal (N2) disease is, however, of great importance because its presence significantly affects outcomes and potential treatment strategies. Recent data supporting the use of adjuvant or neoadjuvant therapies in these patients suggests that every reasonable effort should be made to assess the lymph node status accurately in patients with clinical early stage disease as well as in those with clinically staged N2 disease who have undergone preoperative treatments. Newer procedures such as integrated positron emission tomography computed tomography and esophageal or endobronchial endoscopic ultrasound with fine needle aspiration are minimally invasive techniques that may enhance the accuracy of mediastinal staging, traditionally devoted to mediastinoscopy. As their availability widens, they are likely to become an important part of staging and treatment paradigms. Intraoperatively, a growing body of evidence suggests that lymph node dissection can be performed safely, and should replace sampling as a more effective means of identifying unsuspected N2 disease. This paper will review the current literature on staging NSCLC with regard to the detection of nodal disease through preoperative staging of the mediastinum, the use of intraoperative lymph node sampling or dissection at the time of resection, and procedures for use in restaging patients with clinical stage IIIA N2 disease who have undergone preoperative chemotherapy (with or without radiotherapy).

European Trends in Preoperative and Intraoperative Nodal Staging: ESTS Guidelines

Preoperative and intraoperative lymph node (LN) staging is of paramount importance for patients with non-small cell lung cancer. The Council of the European Society of Thoracic Surgery took the initiative to organize workshops on intraoperative and preoperative mediastinal LN staging. This resulted in specific guidelines. Relevant peer-reviewed publications on these subjects, the experience of the participants, and the opinion of the European Society of Thoracic Surgery members contributing online were used to reach a consensus. For primary staging, mediastinoscopy remains the gold standard for the superior mediastinal LNs. Invasive procedures can be omitted in patients with peripheral tumors and negative mediastinal and hilar nodes on positron emission tomography scan. Positron emission tomography-positive mediastinal findings should always be cytohistologically confirmed. New minimally invasive techniques that provide cytohistological diagnosis became available. Their specificity is high, but the negative predictive value is low. If they yield negative results, an invasive surgical technique remains indicated. For restaging, invasive techniques providing cytohistological information are advisable. Systematic nodal dissection is recommended in all cases to ensure complete resection. Lobe-specific systematic nodal dissection is acceptable for peripheral squamous T1 tumors if hilar and interlobar nodes are negative on frozen section studies. The report from the pathologist should describe the number of LNs removed and studied, the overall number of metastatic LNs in each station, and the status of the LN capsule. We hope that the adherence to these guidelines will standardize and improve preoperative and intraoperative LN staging and pathologic evaluation of non-small cell lung cancer.

Remediastinoscopy

Indications for remediastinoscopy include recurrent and second primary lung cancer, an inadequate first procedure, lung cancer occurring after an unrelated disease such as lymphoma, and restaging after induction therapy. Nowadays, restaging is the most frequent indication for remediastinoscopy. Only patients with proven mediastinal downstaging will benefit from a subsequent surgical resection. In contrast to imaging or functional studies, remediastinoscopy provides pathologic evidence of response after induction therapy. Although technically more challenging than a first procedure, remediastinoscopy can select patients for subsequent thoracotomy and provides prognostic information. In most recent series, sensitivity of remediastinoscopy is higher than 70% with an accuracy of approximately 85%. Survival also depends on the findings at remediastinoscopy, with patients with persisting mediastinal involvement having a poor prognosis. An alternative approach consists of the use of minimally invasive staging procedures as endobronchial or endoscopic esophageal ultrasonography to obtain initial proof of mediastinal nodal involvement. Mediastinoscopy is subsequently performed after induction therapy to evaluate response. In this way, a technically more difficult remediastinoscopy can be avoided.

Staging and diagnosis of non-small cell lung cancer: Invasive modalities

During the staging process of lung cancer, accurate mediastinal lymph node staging is one of the more important factors that affects patient outcome. Several different invasive and non-invasive modalities exist for mediastinal staging. Invasive tests include mediastinoscopy, thoracoscopy, transbronchial needle aspiration, transthoracic needle aspiration, endoscopic ultrasound-guided fine-needle aspiration and endobronchial ultrasound-guided transbronchial needle aspiration. Each of the invasive tests has limitations for particular locations, has particular risks and requires specific skills. Invasive tests are often used to confirm the staging of lung cancer, but are also used to obtain a diagnosis. The best approach depends upon the clinician's assessment of the patient. This review discusses the invasive staging tests that are available, with particular emphasis on newer modalities, especially endobronchial ultrasound-guided transbronchial needle aspiration. In addition, the current advances in diagnostic bronchoscopy for lung cancer will be reviewed.