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Bin Essa N, Kaplar Z, Balaji N, Alduraibi A, Bomanji J, Groves AM, Lilburn DML, Navani N, Fraioli F. PET/CT in treatment response assessment in lung cancer. When should it be recommended? Nucl Med Commun 2023; 44:1059-1066. [PMID: 37706268 DOI: 10.1097/mnm.0000000000001757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Non-small cell lung cancer (NSCLC) is the most common type of lung cancer. Different treatment options are now possible both for surgical candidates and for those NSCLC patients deemed not suitable for surgery. Despite the treatments available, only a limited number of less advanced stages are potentially curable, with many patients suffering local recurrence or distant metastases. FDG-PET/CT is commonly used in many centers for post-treatment evaluation, follow-up, or surveillance; Nonetheless, there is no clear consensus regarding the indications in these cases. Based upon the results of a literature review and local expertise from a large lung cancer unit, we built clinical evidence-based recommendations for the use of FDG-PET/CT in response assessment. We found that in general this is not recommended earlier than 3 months from treatment; however, as described in detail the correct timing will also depend upon the type of treatment used. We also present a structured approach to assessing treatment changes when reporting FDG-PET/CT, using visual or quantitative approaches.
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Affiliation(s)
- Noora Bin Essa
- Nuclear Medicine Department, Kuwait Cancer Control Center, Kuwait City, Kuwait,
| | - Zoltan Kaplar
- Institute of Nuclear Medicine, University College Hospital, London, UK,
| | - Nikita Balaji
- Institute of Nuclear Medicine, University College Hospital, London, UK,
| | - Alaa Alduraibi
- Department of Radiology, College of Medicine, Qassim University, Saudi Arabia and
| | - Jamshed Bomanji
- Institute of Nuclear Medicine, University College Hospital, London, UK,
| | - Ashley M Groves
- Institute of Nuclear Medicine, University College Hospital, London, UK,
| | - David M L Lilburn
- Institute of Nuclear Medicine, University College Hospital, London, UK,
| | - Neal Navani
- Respiratory Medicine, University College Hospital, London, UK
| | - Francesco Fraioli
- Institute of Nuclear Medicine, University College Hospital, London, UK,
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Lee J, Lee J, Hong YS, Lee G, Kang D, Yun J, Jeon YJ, Shin S, Cho JH, Choi YS, Kim J, Zo JI, Shim YM, Guallar E, Cho J, Kim HK. Validation of the IASLC Residual Tumor Classification in Patients With Stage III-N2 Non-Small Cell Lung Cancer Undergoing Neoadjuvant Chemoradiotherapy Followed By Surgery. Ann Surg 2023; 277:e1355-e1363. [PMID: 35166266 DOI: 10.1097/sla.0000000000005414] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to validate the International Association for the Study of Lung Cancer (IASLC) residual tumor classification in patients with stage III-N2 non-small cell lung cancer (NSCLC) undergoing neoadjuvant concurrent chemoradiotherapy (nCCRT) followed by surgery. BACKGROUND As adequate nodal assessment is crucial for determining prognosis in patients with clinical N2 NSCLC undergoing nCCRT followed by surgery, the new classification may have better prognostic implications. METHODS Using a registry for thoracic cancer surgery at a tertiary hospital in Seoul, Korea, between 2003 and 2019, we analyzed 910 patients with stage III-N2 NSCLC who underwent nCCRT followed by surgery. We classified resections using IASLC criteria: complete (R0), uncertain (R[un]), and incomplete resection (R1/R2). Recurrence and mortality were compared using adjusted subdistribution hazard model and Cox-proportional hazards model, respectively. RESULTS Of the 96.3% (n = 876) patients who were R0 by Union for International Cancer Control (UICC) criteria, 34.5% (n = 3O2) remained R0 by IASLC criteria and 37.6% (n = 329) and 28% (n = 245) migrated to R(un) and R1, respectively. Most of the migration from UICC-R0 to lASLC-R(un) and IASLC-R1/R2 occurred due to inadequate nodal assessment (85.5%) and extracapsular nodal extension (77.6%), respectively. Compared to R0, the adjusted hazard ratios in R(un) and R1/R2 were 1.20 (95% confidence interval, 0.94-1.52), 1.50 (1.17-1.52) ( P fortrend = .001) for recurrence and 1.18 (0.93-1.51) and 1.51 (1.17-1.96) for death ( P for trend = .002). CONCLUSIONS The IASLC R classification has prognostic relevance in patients with stage III-N2 NSCLC undergoing nCCRT followed by surgery. The IASLC classification will improve the thoroughness of intraoperative nodal assessment and the completeness of resection.
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Affiliation(s)
- Junghee Lee
- Department of Thoracic and Cardiovascular Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
| | - Jin Lee
- Department of Thoracic and Cardiovascular Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
| | - Yun Soo Hong
- Departments of Epidemiology and Medicine, and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University Bloomberg School of Public Health. Baltimore, MD
| | - Genehee Lee
- Department of Clinical Research Design and Evaluation, SAIHST, Sung-kyunkwan University, Seoul, Korea
- Patient-Centered Outcomes Research institute, Samsung Medical Center, Seoul, Korea
| | - Danbee Kang
- Department of Clinical Research Design and Evaluation, SAIHST, Sung-kyunkwan University, Seoul, Korea
- Center for Clinical Epidemiology, Sungkyunkwan University, Samsung Medical Center, Seoul, Korea
| | - Jeonghee Yun
- Department of Thoracic and Cardiovascular Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
| | - Yeong Jeong Jeon
- Department of Thoracic and Cardiovascular Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
| | - Sumin Shin
- Department of Thoracic and Cardiovascular Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Jong Ho Cho
- Department of Thoracic and Cardiovascular Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
| | - Yong Soo Choi
- Department of Thoracic and Cardiovascular Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
| | - Jhingook Kim
- Department of Thoracic and Cardiovascular Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
| | - Jae Ill Zo
- Department of Thoracic and Cardiovascular Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
- Patient-Centered Outcomes Research institute, Samsung Medical Center, Seoul, Korea
| | - Eliseo Guallar
- Departments of Epidemiology and Medicine, and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University Bloomberg School of Public Health. Baltimore, MD
| | - Juhee Cho
- Department of Clinical Research Design and Evaluation, SAIHST, Sung-kyunkwan University, Seoul, Korea
- Center for Clinical Epidemiology, Sungkyunkwan University, Samsung Medical Center, Seoul, Korea
- Departments of Epidemiology and Medicine, and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University Bloomberg School of Public Health. Baltimore, MD
- Patient-Centered Outcomes Research institute, Samsung Medical Center, Seoul, Korea
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
- Patient-Centered Outcomes Research institute, Samsung Medical Center, Seoul, Korea
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PET imaging of lung and pleural cancer. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00206-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Mielgo-Rubio X, Montemuiño S, Jiménez U, Luna J, Cardeña A, Mezquita L, Martín M, Couñago F. Management of Resectable Stage III-N2 Non-Small-Cell Lung Cancer (NSCLC) in the Age of Immunotherapy. Cancers (Basel) 2021; 13:cancers13194811. [PMID: 34638296 PMCID: PMC8507745 DOI: 10.3390/cancers13194811] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/21/2021] [Accepted: 09/22/2021] [Indexed: 12/25/2022] Open
Abstract
Simple Summary The treatment of resectable stage III non-small-cell lung cancer with N2 lymph node involvement is usually multimodal and is generally based on neoadjuvant chemotherapy +/− radiotherapy followed by surgery, but the cure rate is still low. Immunotherapy based on anti-PD1/PD-L1 immune checkpoint inhibitors has improved survival in advanced and stage III non-resectable NSCLC patients and is being studied in earlier stages to improve the cure rate of lung cancer. In this article, we review all therapeutic approaches to stage III-N2 NSCLC, analysing both completed and ongoing studies that evaluate the addition of immunotherapy with or without chemotherapy and/or radiotherapy. Abstract Stage III non-small-cell lung cancer (NSCLC) with N2 lymph node involvement is a heterogeneous group with different potential therapeutic approaches. Patients with potentially resectable III-N2 NSCLC are those who are considered to be able to receive a multimodality treatment that includes tumour resection after neoadjuvant therapy. Current treatment for these patients is based on neoadjuvant chemotherapy +/− radiotherapy followed by surgery and subsequent assessment for adjuvant chemotherapy and/or radiotherapy. In addition, some selected III-N2 patients could receive upfront surgery or pathologic N2 incidental involvement can be found a posteriori during analysis of the surgical specimen. The standard treatment for these patients is adjuvant chemotherapy and evaluation for complementary radiotherapy. Despite being a locally advanced stage, the cure rate for these patients continues to be low, with a broad improvement margin. The most immediate hope for improving survival data and curing these patients relies on integrating immunotherapy into perioperative treatment. Immunotherapy based on anti-PD1/PD-L1 immune checkpoint inhibitors is already a standard treatment in stage III unresectable and advanced NSCLC. Data from the first phase II studies in monotherapy neoadjuvant therapy and, in particular, in combination with chemotherapy, are highly promising, with impressive improved and complete pathological response rates. Despite the lack of confirmatory data from phase III trials and long-term survival data, and in spite of various unresolved questions, immunotherapy will soon be incorporated into the armamentarium for treating stage III-N2 NSCLC. In this article, we review all therapeutic approaches to stage III-N2 NSCLC, analysing both completed and ongoing studies that evaluate the addition of immunotherapy with or without chemotherapy and/or radiotherapy.
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Affiliation(s)
- Xabier Mielgo-Rubio
- Department of Medical Oncology, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain;
- Correspondence:
| | - Sara Montemuiño
- Department of Radiation Oncology, Hospital Universitario Fuenlabrada, 28942 Madrid, Spain;
| | - Unai Jiménez
- Department of Thoracic Surgery, Hospital Universitario Cruces, 48903 Barakaldo, Bizkaia, Spain;
| | - Javier Luna
- Department of Radiation Oncology, Fundación Jiménez Díaz, 28040 Madrid, Spain;
| | - Ana Cardeña
- Department of Medical Oncology, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain;
| | - Laura Mezquita
- Department of Medical Oncology, Hospital Universitari Clínic Barcelona, 08036 Barcelona, Spain;
| | - Margarita Martín
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain;
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid, 28223 Madrid, Spain;
- Department of Radiation Oncology, Hospital La Luz, 28003 Madrid, Spain
- Medicine Department, School of Biomedical Siciences, Universidad Europea, 28670 Madrid, Spain
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Survival analysis of pathological complete response of locally advanced lung cancer after neoadjuvant treatment. Gen Thorac Cardiovasc Surg 2021; 69:1086-1095. [PMID: 33449266 DOI: 10.1007/s11748-020-01584-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 12/30/2020] [Indexed: 12/17/2022]
Abstract
AIM The first aim is to determine the clinical and pathological characteristics and factors affecting survival in patients with pathological complete response (pCR) after neoadjuvant therapy, and the secondary aim is to investigate the effect of adjuvant therapy on survival in these patients. METHODS Between 2003 and 2015, there was 372 patients who underwent lung resection after neoadjuvant therapy with a diagnosis of locally advanced lung cancer. Sixty-eight patients who had pCRwere retrospectively analyzed. The odds ratios (OR) were calculated in regards of recurrence. RESULTS Overall 5-year survival rate was 65.1%. Recurrence was the risk factor affecting survival (78.2% vs 19.3%, p = 0.001) while neoadjuvant treatment type (p = 0.766), the reason of neodjuvant treatment (p = 0.581), and the type of operation (p = 0.860) did not affect survival. Postoperative adjuvant treatment had a positive effect on survival (71.1% versus 62.7%), although this difference was not significant (p = 0.561). Local or distant recurrence was detected in 15 patients (22%). In multivariate analysis, the independent risk factors affecting the recurrence were the time from the end of the neoadjuvant therapy to the surgery being less than eight weeks (OR = 6.49, p = 0.03), the type of neoadjuvant treatment (OR = 0.203, p = 0.03). In patients with a squamous cell carcinoma, there was a decreased trend toward in terms of recurrence (p = 0.06). CONCLUSIONS pCR after neoadjuvant therapy positively affects survival. Better survival may be detected in patients receiving adjuvant therapy. Due to unexpected the high recurrence rate, patients should be followed in the postoperative period closely.
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Computed Tomography Radiomics for Residual Positron Emission Tomography-Computed Tomography Uptake in Lymph Nodes after Treatment. Cancers (Basel) 2020; 12:cancers12123564. [PMID: 33260608 PMCID: PMC7761511 DOI: 10.3390/cancers12123564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/17/2020] [Accepted: 11/26/2020] [Indexed: 11/16/2022] Open
Abstract
Simple Summary In this study we explored the predictive ability of radiomics in non-small cell lung cancer patients, and reported the complementary role of radiomics in predicting the treatment response of the lymph nodes. Radiomics analysis is a cutting-edge technology for the noninvasive assessment of tumor biology, which converts medical images into mineable high-dimensional data. Our method is cost-effective with no need for additional studies, and moreover, we used an easily reproducible study method that can be applicable in further studies using radiomics in oncology. Abstract Although a substantial decrease in 2-[fluorine-18]fluoro-2-deoxy-d-glucose (FDG) uptake on positron emission tomography-computed tomography (PET-CT) indicates a promising metabolic response to treatment, predicting the pathologic status of lymph nodes (LN) remains challenging. We investigated the potential of a CT radiomics approach to predict the pathologic complete response of LNs showing residual uptake after neoadjuvant concurrent chemoradiotherapy (NeoCCRT) in patients with non-small cell lung cancer (NSCLC). Two hundred and thirty-seven patients who underwent NeoCCRT for stage IIIa NSCLC were included. Two hundred fifty-two CT radiomics features were extracted from LNs showing remaining positive FDG uptake upon restaging PET-CT. A multivariable logistic regression analysis of radiomics features and clinicopathologic characteristics was used to develop a prediction model. Of the 237 patients, 135 patients (185 nodes) met our inclusion criteria. Eighty-seven LNs were proven to be malignant (47.0%, 87/185). Upon multivariable analysis, metastatic LNs were significantly prevalent in females and patients with adenocarcinoma (odds ratio (OR) = 2.02, 95% confidence interval (CI) = 0.88–4.62 and OR = 0.39, 95% CI = 0.19–0.77 each). Metastatic LNs also had a larger maximal 3D diameter and higher cluster tendency (OR = 9.92, 95% CI = 3.15–31.17 and OR = 2.36, 95% CI = 1.22–4.55 each). The predictive model for metastasis showed a discrimination performance with an area under the receiver operating characteristic curve of 0.728 (95% CI = 0.654–0.801, p value < 0.001). The radiomics approach allows for the noninvasive detection of metastases in LNs with residual FDG uptake after the treatment of NSCLC patients.
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Filice A, Casali M, Ciammella P, Galaverni M, Fioroni F, Iotti C, Versari A. Radiotherapy Planning and Molecular Imaging in Lung Cancer. Curr Radiopharm 2020; 13:204-217. [PMID: 32186275 PMCID: PMC8206193 DOI: 10.2174/1874471013666200318144154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/11/2019] [Accepted: 11/11/2019] [Indexed: 12/24/2022]
Abstract
INTRODUCTION In patients suitable for radical chemoradiotherapy for lung cancer, 18F-FDGPET/ CT is a proposed management to improve the accuracy of high dose radiotherapy. However, there is a high rate of locoregional failure in patients with locally advanced non-small cell lung cancer (NSCLC), probably due to the fact that standard dosing may not be effective in all patients. The aim of the present review was to address some criticisms associated with the radiotherapy image-guided in NSCLC. MATERIALS AND METHODS A systematic literature search was conducted. Only published articles that met the following criteria were included: articles, only original papers, radiopharmaceutical ([18F]FDG and any tracer other than [18F]FDG), target, only specific for lung cancer radiotherapy planning, and experimental design (eventually "in vitro" studies were excluded). Peer-reviewed indexed journals, regardless of publication status (published, ahead of print, in press, etc.) were included. Reviews, case reports, abstracts, editorials, poster presentations, and publications in languages other than English were excluded. The decision to include or exclude an article was made by consensus and any disagreement was resolved through discussion. RESULTS Hundred eligible full-text articles were assessed. Diverse information is now available in the literature about the role of FDG and new alternative radiopharmaceuticals for the planning of radiotherapy in NSCLC. In particular, the role of alternative technologies for the segmentation of FDG uptake is essential, although indeterminate for RT planning. The pros and cons of the available techniques have been extensively reported. CONCLUSION PET/CT has a central place in the planning of radiotherapy for lung cancer and, in particular, for NSCLC assuming a substantial role in the delineation of tumor volume. The development of new radiopharmaceuticals can help overcome the problems related to the disadvantage of FDG to accumulate also in activated inflammatory cells, thus improving tumor characterization and providing new prognostic biomarkers.
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Affiliation(s)
- Angelina Filice
- Address correspondence to this author at the Nuclear Medicine Unit, Azienda Unità Sanitaria Locale, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy; E-mail:
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Romero-Vielva L, Viteri S, Moya-Horno I, Toscas JI, Maestre-Alcácer JA, Ramón Y Cajal S, Rosell R. Salvage surgery after definitive chemo-radiotherapy for patients with Non-Small Cell Lung Cancer. Lung Cancer 2019; 133:117-122. [PMID: 31200817 DOI: 10.1016/j.lungcan.2019.05.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 04/26/2019] [Accepted: 05/09/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Despite all treatment advances, lung cancer is still the main cause of death worldwide. Treatment for resectable stage IIIA remains controversial including definitive chemoradiotherapy and induction treatment followed by surgery. After definitive chemoradiation up to 35% of patients will relapse locally. Experience with salvage resection after definitive chemoradiotherapy in lung cancer is limited. We present our experience in 27 patients who underwent surgical resection after definitive treatment. PATIENTS AND METHODS Between January 2007 and December 2016, 27 patients were evaluated in our department for surgical resection after receiving definitive chemoradiation treatment in different institutions. We conducted a retrospective study gathering the following data: age, gender, clinical and pathologic stage, histology, chemotherapy treatment regimen, radiotherapy dosage, surgical procedure and complications. Time between surgical resection and last follow-up was used to calculate Overall Survival (OS). Disease-Free Survival (DFS) was calculated from surgical resection to diagnosis of relapse. RESULTS Most of the patients were men with a median age of 56.09 years. Median follow-up time was 46.94 months. All patients received platinum-based chemotherapy regimen and high-dose radiotherapy, except for one patient who received 45 Gy. Lobectomy and bilobectomy was performed in 7 patients each, and pneumonectomy in 13. Complications appeared in 5 patients. Bronchopleural fistula appeared in two patients, and only one death in the early postoperative period. The analysis showed an OS of 75.56 months, with 1-year, 3-year and 5-year survival of 74.1%, 57.8% and 53.3% respectively. CONCLUSION Salvage surgery in selected patients is technically feasible, with low morbidity and mortality rates and good long-term outcomes.
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Affiliation(s)
- Laura Romero-Vielva
- Thoracic Surgery Department, University Hospital General de Catalunya, C/ Pedro i Pons, 1., 08195, Sant Cugat del Vallès, Spain.
| | - Santiago Viteri
- Medical Oncology Department, Rosell Oncology Institute (IOR), Dexeus University Hospital, Quironsalud Group, C/ Sabino Arana 5-19, 08028, Barcelona, Spain
| | - Irene Moya-Horno
- Medical Oncology Department Instituto Oncológico Dr Rosell (IOR), University Hospital General de Catalunya, C/ Pedro i Pons, 1., 08195, Sant Cugat del Vallès, Spain
| | - José Ignacio Toscas
- Radio-oncology Department, Institut Oncològic Teknon (IOT), Carrer de Vilana, 12, 08022, Barcelona, Spain
| | - José Antonio Maestre-Alcácer
- Thoracic Surgery Department, University Hospital General de Catalunya, C/ Pedro i Pons, 1., 08195, Sant Cugat del Vallès, Spain
| | - Santiago Ramón Y Cajal
- Pathology Department, Vall d'Hebron Institute of Research, Vall d'Hebron University Hospital, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Rafael Rosell
- Medical Oncology Department, Rosell Oncology Institute (IOR), Dexeus University Hospital, Quironsalud Group, C/ Sabino Arana 5-19, 08028, Barcelona, Spain
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Induction Therapies Plus Surgery Versus Exclusive Radiochemotherapy in Stage IIIA/N2 Non-Small Cell Lung Cancer (NSCLC). Am J Clin Oncol 2019; 41:267-273. [PMID: 29116951 DOI: 10.1097/coc.0000000000000416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In spite of the growing body of data from prospective randomized clinical trials (PRCTs) and meta-analyses, the optimal treatment approach in patients with stage IIIA non-small cell lung cancer remains unknown. This review focuses on the available data directly confronting induction chemotherapy or induction radiochemotherapy (RT-CHT) when followed by surgery with exclusive RT-CHT. Seven PRCTs and 4 meta-analyses investigated this issue. In addition, numerous retrospective studies attempted to identify potential predictors and/or prognosticators that may have influenced the decision to offer surgery in a particular patient subgroup. Several retrospective studies also evaluated exclusive RT-CHT in this setting. There is not a single piece of the highest level of evidence (PRCT or MA) showing any advantage of induction therapies followed by surgery over exclusive RT-CHT with the former treatment option leading to significantly more morbidity and mortality. Although several studies attempted to identify patient subgroups favoring induction therapies followed by surgery, they have invariably been retrospective in nature, and their results have never been reproduced even in other retrospective setting. Furthermore, no PRCT investigated potential pretreatment patient and/or tumor-related predictors of surgical multimodality success. Exclusive RT-CHT achieves similar results to induction therapies followed by surgery but with less morbidity and mortality. This is accompanied with the finding that no pretreatment predictor exists to enable identification of even a subgroup of stage IIIA/pN2 patients benefiting from any surgical approach.
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Muthu V, Sehgal IS, Dhooria S, Aggarwal AN, Agarwal R. Efficacy of Endosonographic Procedures in Mediastinal Restaging of Lung Cancer After Neoadjuvant Therapy. Chest 2018; 154:99-109. [DOI: 10.1016/j.chest.2018.04.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 03/10/2018] [Accepted: 04/02/2018] [Indexed: 01/04/2023] Open
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SEOM-SERAM-SEMNIM guidelines on the use of functional and molecular imaging techniques in advanced non-small-cell lung cancer. RADIOLOGIA 2018; 60:332-346. [PMID: 29807678 DOI: 10.1016/j.rx.2018.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 01/18/2018] [Indexed: 12/11/2022]
Abstract
Imaging in oncology is an essential tool for patient management but its potential is being profoundly underutilized. Each of the techniques used in the diagnostic process also conveys functional information that can be relevant in treatment decision making. New imaging algorithms and techniques enhance our knowledge about the phenotype of the tumor and its potential response to different therapies. Functional imaging can be defined as the one that provides information beyond the purely morphological data, and include all the techniques that make it possible to measure specific physiological functions of the tumor, whereas molecular imaging would include techniques that allow us to measure metabolic changes. Functional and molecular techniques included in this document are based on multi-detector computed tomography (CT), 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET), magnetic resonance imaging (MRI), and hybrid equipments, integrating PET with CT (PET/CT) or MRI (PET-MRI). Lung cancer is one of the most frequent and deadly tumors although survival is increasing thanks to advances in diagnostic methods and new treatments. This increased survival poises challenges in terms of proper follow-up and definitions of response and progression, as exemplified by immune therapy-related pseudoprogression. In this consensus document, the use of functional and molecular imaging techniques will be addressed to exploit their current potential and explore future applications in the diagnosis, evaluation of response and detection of recurrence of advanced NSCLC.
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Schreiner W, Gavrychenkova S, Dudek W, Rieker RJ, Lettmaier S, Fietkau R, Sirbu H. Pathologic complete response after induction therapy-the role of surgery in stage IIIA/B locally advanced non-small cell lung cancer. J Thorac Dis 2018; 10:2795-2803. [PMID: 29997942 DOI: 10.21037/jtd.2018.05.68] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Pathologic complete response (pCR) is dominant prognostic factor determining favorable outcome in locally advanced non-small cell lung cancer (NSCLC) after induction therapy (IT). There is no non-operative diagnostics that adequately estimates the pCR. Aim of this retrospective study was to assess the correlation between clinical and pathological factors in patients with pCR. Methods Twenty-five patients with pCR after curative lung resection following IT were assessed using univariate and multivariate Cox regression and descriptive analysis. The survival rate was estimated by Kaplan-Meier method. Results The IT included chemoradiation with median doses of 50.4 Gy (range, 45-59.4 Gy) combined with platinum-based chemotherapy in 23 patients (92%) and induction platinum-based chemotherapy in 2 patients (8%). Clinical tumor stage before IT was IIIA in 21, IIIB in 4 patients. Mean interval between IT and surgery was 8.1±3.0 weeks. Perioperative morbidity and 30-day mortality was 32% and 4%, respectively. There was no significant correlation of pCR and different clinical and pathological factors. The estimated 5-year long-term survival (LTS) and progressive-free survival (PFS) was 57% and 54%, respectively. The median LTS and PFS was not reached. Conclusions pCR in patients with locally advanced NSCLC following IT is an independent prognostic factor, without correlation with pathological and clinical factors. Non-operative accurate assessment of pCR is currently impossible. Surgical resection enables secure identification of pCR and might improve the patient stratification for additive therapy.
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Affiliation(s)
- Waldemar Schreiner
- Division of Thoracic Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Sofiya Gavrychenkova
- Division of Thoracic Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Wojciech Dudek
- Division of Thoracic Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Ralf Joachim Rieker
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Sebastian Lettmaier
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Horia Sirbu
- Division of Thoracic Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
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Yoon HY, Lee JC, Kim SW, Kim HR, Kim YH, Choi SH, Kim SS, Song SY, Choi EK, Jang SJ, Choi CM. Prognosis of multi-level N2-positive non-small cell lung cancer according to lymph node staging using endobronchial ultrasound-transbronchial biopsy. Thorac Cancer 2018; 9:684-692. [PMID: 29607613 PMCID: PMC5983197 DOI: 10.1111/1759-7714.12629] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 02/20/2018] [Accepted: 02/20/2018] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Hee-Young Yoon
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jae Cheol Lee
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sang-We Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hyeong Ryul Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yong-Hee Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Se Hoon Choi
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Su San Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Si Yeol Song
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Eun Kyung Choi
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Se Jin Jang
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Chang-Min Choi
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.,Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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SEOM-SERAM-SEMNIM guidelines on the use of functional and molecular imaging techniques in advanced non-small-cell lung cancer. Clin Transl Oncol 2017; 20:837-852. [PMID: 29256154 PMCID: PMC5996017 DOI: 10.1007/s12094-017-1795-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 11/04/2017] [Indexed: 12/17/2022]
Abstract
Imaging in oncology is an essential tool for patient management but its potential is being profoundly underutilized. Each of the techniques used in the diagnostic process also conveys functional information that can be relevant in treatment decision-making. New imaging algorithms and techniques enhance our knowledge about the phenotype of the tumor and its potential response to different therapies. Functional imaging can be defined as the one that provides information beyond the purely morphological data, and include all the techniques that make it possible to measure specific physiological functions of the tumor, whereas molecular imaging would include techniques that allow us to measure metabolic changes. Functional and molecular techniques included in this document are based on multi-detector computed tomography (CT), 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET), magnetic resonance imaging (MRI), and hybrid equipments, integrating PET with CT (PET/CT) or MRI (PET-MRI). Lung cancer is one of the most frequent and deadly tumors although survival is increasing thanks to advances in diagnostic methods and new treatments. This increased survival poises challenges in terms of proper follow-up and definitions of response and progression, as exemplified by immune therapy-related pseudoprogression. In this consensus document, the use of functional and molecular imaging techniques will be addressed to exploit their current potential and explore future applications in the diagnosis, evaluation of response and detection of recurrence of advanced NSCLC.
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Arnett AL, Packard AT, Mara K, Mansfield AS, Wigle DA, Haddock MG, Park SS, Olivier KR, Garces YI, Merrell KW. FDG-PET parameters as predictors of pathologic response and nodal clearance in patients with stage III non-small cell lung cancer receiving neoadjuvant chemoradiation and surgery. Pract Radiat Oncol 2017; 7:e531-e541. [DOI: 10.1016/j.prro.2017.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 04/13/2017] [Accepted: 04/17/2017] [Indexed: 01/21/2023]
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16
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Cata JP, Lasala J, Mena GE, Mehran JR. Anesthetic Considerations for Mediastinal Staging Procedures for Lung Cancer. J Cardiothorac Vasc Anesth 2017; 32:893-900. [PMID: 29174661 DOI: 10.1053/j.jvca.2017.08.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Indexed: 12/25/2022]
Abstract
Tumor staging is critical for the treatment of lung malignancies. Invasive techniques of lung tumor staging can be accomplished via mediastinoscopy, endobronchial ultrasound, and video-assisted thoracoscopy. Anesthesiologists taking care of patients undergoing mediastinal staging procedures might face different challenges. In this narrative review, the authors summarize the literature on the anesthetic considerations for mediastinal staging procedures.
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Affiliation(s)
- J P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Texas, USA.
| | - J Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Texas, USA; Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Texas, USA
| | - G E Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Texas, USA
| | - J R Mehran
- Anesthesiology and Surgical Oncology Research Group, Houston, Texas, USA
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17
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Yendamuri S, Battoo A, Dy G, Chen H, Gomez J, Singh AK, Hennon M, Nwogu CE, Dexter EU, Huang M, Picone A, Demmy TL. Transcervical Extended Mediastinal Lymphadenectomy: Experience From a North American Cancer Center. Ann Thorac Surg 2017; 104:1644-1649. [PMID: 28942077 DOI: 10.1016/j.athoracsur.2017.05.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 04/30/2017] [Accepted: 05/08/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Accurate staging of the mediastinum is a critical element of therapeutic decision making in non-small cell lung cancer. We sought to determine the utility of transcervical extended mediastinal lymphadenectomy (TEMLA) in staging non-small cell lung cancer for large central tumors and after induction therapy. METHODS A retrospective record review was performed of all patients who underwent TEMLA at our institution from 2010 to 2015. Clinical stage as assessed by positron emission tomography integrated with computed tomography (PET-CT), stage as assessed by TEMLA, final pathologic stage, lymph node yield, and clinical characteristics of tumors were assessed along with TEMLA-related perioperative morbidity. Accuracy of staging by TEMLA for restaging the mediastinum after neoadjuvant therapy was compared with that of PET-CT. RESULTS Of 164 patients who underwent TEMLA, 157 (95.7%) were completed successfully. Combined surgical resection along with TEMLA was performed in 138 of these patients, with 131 (94.2%) undergoing a video-assisted thoracoscopic resection. The recurrent laryngeal nerve injury rate was 6.7%. TEMLA was performed in 118 of 164 patients for restaging after neoadjuvant therapy, and 101 of these patients were also restaged by PET-CT. Based on TEMLA, 7 patients did not go on to have resection. Of the 101 patients who did have a resection, TEMLA was more accurate than PET-CT in staging the mediastinum (95% vs 73%, p < 0.0001). However, the pneumonia rate in this subgroup of patients was 13%. CONCLUSIONS TEMLA is a safe procedure and superior to PET-CT for restaging of the mediastinum after neoadjuvant therapy for non-small cell lung cancer. However, this increased accuracy comes with a high postoperative pneumonia rate.
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Affiliation(s)
- Sai Yendamuri
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York; Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York.
| | - Athar Battoo
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York
| | - Grace Dy
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | - Hongbin Chen
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | - Jorge Gomez
- Department of Radiation Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Anurag K Singh
- Department of Radiation Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Mark Hennon
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York; Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Chukwumere E Nwogu
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York; Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Elisabeth U Dexter
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York; Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Miriam Huang
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York; Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Anthony Picone
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York
| | - Todd L Demmy
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York; Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
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Martin LW, Mehran RJ. Perspectives on the effect of nodal downstaging and its implication of the role of surgery in stage IIIA (N2) non-small cell lung cancer. J Thorac Dis 2017; 9:E646-E652. [PMID: 28840035 DOI: 10.21037/jtd.2017.06.24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Linda W Martin
- Department of Thoracic Cardiovascular Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Reza J Mehran
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Van Schil PE, Yogeswaran K, Hendriks JM, Lauwers P, Faivre-Finn C. Advances in the use of surgery and multimodality treatment for N2 non-small cell lung cancer. Expert Rev Anticancer Ther 2017; 17:555-561. [PMID: 28403675 DOI: 10.1080/14737140.2017.1319766] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Stage IIIA-N2 non-small cell lung cancer (NSCLC) represents a heterogeneous group of bronchogenic carcinomas with locoregional involvement. Different categories of N2 disease exist, ranging from unexpectedly encountered N2 involvement after detailed preoperative staging or 'surprise' N2, to potentially resectable disease treated within a combined modality setting, and finally, bulky N2 involvement treated by chemoradiation. Areas covered: Large randomised controlled trials and meta-analyses on stage IIIA-N2 NSCLC have been published but their implications for treatment remain a matter of debate. No definite recommendations can be provided as diagnostic and therapeutic algorithms vary according to local, national or international guidelines. Expert commentary: From the literature, it is clear that patients with stage IIIA-N2 NSCLC should be treated by combined modality therapy including chemotherapy, radiotherapy and surgery. The relative contribution of each modality has not been firmly established. For patients undergoing induction therapy, adequate restaging is important as only down-staged patients will clearly benefit from surgical resection. Each patient should be discussed within a multidisciplinary team to determine the best diagnostic and therapeutic approach according to the specific local expertise. In the near future, it might be expected that targeted therapies and immunotherapy will be incorporated as possible therapeutic options.
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Affiliation(s)
- Paul E Van Schil
- a Department of Thoracic and Vascular Surgery , Antwerp University Hospital , Edegem (Antwerp) , Belgium
| | - Krishan Yogeswaran
- a Department of Thoracic and Vascular Surgery , Antwerp University Hospital , Edegem (Antwerp) , Belgium
| | - Jeroen M Hendriks
- a Department of Thoracic and Vascular Surgery , Antwerp University Hospital , Edegem (Antwerp) , Belgium
| | - Patrick Lauwers
- a Department of Thoracic and Vascular Surgery , Antwerp University Hospital , Edegem (Antwerp) , Belgium
| | - Corinne Faivre-Finn
- b Division of Molecular and Clinical Cancer Sciences , University of Manchester , Manchester , UK
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20
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Czarnecka-Kujawa K, Yasufuku K. The role of endobronchial ultrasound versus mediastinoscopy for non-small cell lung cancer. J Thorac Dis 2017; 9:S83-S97. [PMID: 28446970 DOI: 10.21037/jtd.2017.03.102] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This review provides an update on the current role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and mediastinoscopy (Med) in assessment of patients with non-small cell lung cancer (NSCLC). Invasive mediastinal lymph node (LN) staging is the major application for both of these techniques. Up until recently, Med was the gold standard for invasive mediastinal LN staging in NSCLC. However, EBUS-TBNA has shown to be equivalent, and in some studies better than Med for invasive staging of lung cancer. EBUS-TBNA offers access to N1 LNs and development of the thin convex probe EBUS (TCP-EBUS) will expand EBUS-TBNA access from the paratracheal region and central airways to more distal parabronchial regions allowing for more extensive N1 LN assessment and sampling more distal lung tumors. EBUS-TBNA is more cost-effective than Med and it is currently recommended as the test of first choice for invasive mediastinal LN staging in lung cancer. Confirmatory Med should be performed selectively in patients with high pretest probability of metastatic disease. Addition of esophageal ultrasound fine needle aspiration (EUS-FNA) may increase diagnostic yield of EBUS-TBNA mediastinal staging. Both Med and EBUS-TBNA can be used in primary lung cancer diagnosis, restaging of the mediastinum following neoadjuvant therapy and in diagnosis of lung cancer recurrence. In the future, a combination of EBUS-TBNA with or without EUS-FNA and Med is most likely going to provide the most optimal invasive assessment of the mediastinum in patients with lung cancer. The decision on test choice and sequence should be made on a case-by-case basis and factoring in local resources and expertise.
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Affiliation(s)
- Katarzyna Czarnecka-Kujawa
- Division of Respirology, University Health Network, Canada University of Toronto, Toronto, Canada.,Division of Thoracic Surgery, University Health Network, Canada University of Toronto, Toronto, Canada
| | - Kazuhiro Yasufuku
- Division of Thoracic Surgery, University Health Network, Canada University of Toronto, Toronto, Canada
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Sheikhbahaei S, Mena E, Yanamadala A, Reddy S, Solnes LB, Wachsmann J, Subramaniam RM. The Value of FDG PET/CT in Treatment Response Assessment, Follow-Up, and Surveillance of Lung Cancer. AJR Am J Roentgenol 2017; 208:420-433. [PMID: 27726427 DOI: 10.2214/ajr.16.16532] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The purpose of this article is to summarize the evidence regarding the role of FDG PET/CT in treatment response assessment and surveillance of lung cancer and to provide suggested best practices. CONCLUSION FDG PET/CT is a valuable imaging tool for assessing treatment response for patients with lung cancer, though evidence for its comparative effectiveness with chest CT is still evolving. FDG PET/CT is most useful when there is clinical suspicion or other evidence for disease recurrence or metastases. The sequencing, cost analysis, and comparative effectiveness of FDG PET/CT and conventional imaging modalities in the follow-up setting need to be investigated.
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Affiliation(s)
- Sara Sheikhbahaei
- 1 Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD
| | - Esther Mena
- 1 Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD
| | - Anusha Yanamadala
- 1 Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD
| | - Siddaling Reddy
- 1 Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD
| | - Lilja B Solnes
- 1 Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD
| | - Jason Wachsmann
- 2 Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| | - Rathan M Subramaniam
- 1 Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD
- 2 Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
- 3 Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, TX
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Clinical Predictors of Persistent Mediastinal Nodal Disease After Induction Therapy for Stage IIIA N2 Non-Small Cell Lung Cancer. Ann Thorac Surg 2017; 103:281-286. [DOI: 10.1016/j.athoracsur.2016.06.061] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/13/2016] [Accepted: 06/20/2016] [Indexed: 11/19/2022]
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Cetinkaya E, Usluer O, Yılmaz A, Tutar N, Çam E, Özgül MA, Demirci NY. Is endobronchial ultrasound-guided transbronchial needle aspiration an effective diagnostic procedure in restaging of non-small cell lung cancer patients? Endosc Ultrasound 2017. [PMID: 28621292 PMCID: PMC5488518 DOI: 10.4103/eus.eus_3_17] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background and Objectives: Selecting the diagnostic procedure for mediastinal restaging after chemotherapy and/or radiotherapy in Stage IIIA-N2 non-small cell lung cancer (NSCLC) patients remains a problem. The aim of the study was to determine the efficacy of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for the evaluation of mediastinal lymph nodes in the restaging of NSCLC patients. Materials and Methods: The present multicentric study retrospectively analyzed the results of Stage IIIA-N2 NSCLC patients who had undergone EBUS for mediastinal restaging after preoperative chemotherapy or radiotherapy or both. Results: In 44 patients with 73 N2 nodes, malignant cells were identified in EBUS-TBNA from 23 patients (57.5%) and 25 lymph nodes (34.2%). Twenty-one patients (42.5%) and 48 lymph nodes (65.8%) were negative for nodal metastasis. All of these patients with negative results subsequently underwent mediastinoscopy or surgery (n = 9 and n = 12, respectively). Metastasis was detected in 5 (23.8%) of 21 patients and 6 (12.5%) of 48 lymph nodes. The diagnostic sensitivity, specificity, positive predictive value, negative predicted value and accuracy of EBUS-TBNA based on number of patients were 82.1%, 100%, 100%, 76.2%, and 88.6%, respectively. Conclusions: EBUS-TBNA should be done before invasive procedures in restaging of the mediastinum in patients previously treated with neoadjuvant therapy because of high diagnostic accuracy rate. However, negative results should be confirmed with invasive procedures such as mediastinoscopy and thoracoscopy.
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Affiliation(s)
- Erdoğan Cetinkaya
- Department of Pulmonary Medicine, Yedikule Chest Disease and Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ozan Usluer
- Department of Pulmonary Medicine, Izmir Suat Seren Chest Disease and Surgery Training and Research Hospital, Izmir, Turkey
| | - Aydın Yılmaz
- Department of Pulmonary Medicine, Atatürk Chest Disease and Surgery Training and Research Hospital, Ankara, Turkey
| | - Nuri Tutar
- Department of Pulmonary Medicine, Erciyes University School of Medicine, Kayseri, Turkey
| | - Ertan Çam
- Department of Pulmonary Medicine, Yedikule Chest Disease and Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Akif Özgül
- Department of Pulmonary Medicine, Yedikule Chest Disease and Surgery Training and Research Hospital, Istanbul, Turkey
| | - Nilgün Yılmaz Demirci
- Department of Pulmonary Medicine, Atatürk Chest Disease and Surgery Training and Research Hospital, Ankara, Turkey
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Awan M, Sharma N, Towe CW, Efird JT, Machtay M, Biswas T. Optimum treatment for mediastinal lymph node positive (N2) resectable non-small cell lung cancer: what is the role for surgery? Expert Rev Anticancer Ther 2016; 16:1131-1144. [PMID: 27654059 DOI: 10.1080/14737140.2016.1240039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION A third of patients with Non-Small Cell Lung Cancer (NSCLC) present with Stage III disease with mediastinal (N2) nodal involvement representing an extremely heterogeneous population with a generally poor prognosis. Areas covered: This article describes the complexity of Stage III-N2 patients reviewing the outcomes of key clinical trials while highlighting the trial designs and subtleties that have created controversy in management. Both bimodality approaches combining chemotherapy with either surgery or radiation and trimodality approaches combining chemotherapy with both local therapies are reviewed. Finally, prognostic factors and future directions are explored for the management of this population. Expert commentary: Upfront surgery is not recommended for patients with Stage III-N2 NSCLC. Neoadjuvant approaches with both chemotherapy and chemoradiation are acceptable in a multidisciplinary setting if appropriate surgery is performed by a dedicated thoracic surgeon. Non-operative candidates should receive definitive concurrent chemoradiation. Innovative approaches are necessary to improve outcomes in this population.
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Affiliation(s)
- Musaddiq Awan
- a Department of Radiation Oncology , Case Western Reserve University , Cleveland , OH , USA
| | - Neelesh Sharma
- b Department of Medical Oncology , Case Western Reserve University , Cleveland , OH , USA
| | - Christopher W Towe
- c Department of Surgery, Division of Thoracic and Esophageal Surgery , University Hospitals Case Medical Center , Cleveland , OH , USA
| | - Jimmy T Efird
- d Center for Health Disparities, Brody School of Medicine and Office of Research, College of Nursing , East Carolina University , Greenville , NC , USA
| | - Mitchell Machtay
- a Department of Radiation Oncology , Case Western Reserve University , Cleveland , OH , USA
| | - Tithi Biswas
- a Department of Radiation Oncology , Case Western Reserve University , Cleveland , OH , USA
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Friedman EL, Kruklitis RJ, Patson BJ, Sopka DM, Weiss MJ. Effectiveness of a thoracic multidisciplinary clinic in the treatment of stage III non-small-cell lung cancer. J Multidiscip Healthc 2016; 9:267-74. [PMID: 27358568 PMCID: PMC4912343 DOI: 10.2147/jmdh.s98345] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction The Institute of Medicine, the American Society of Clinical Oncology, and the European Society of Medical Oncology promote a multidisciplinary approach for the treatment of cancer. Stage III non-small-cell lung cancer (NSCLC) represents a heterogeneous group of diseases necessitating coordination of care among medical, radiation, and surgical oncology. The optimal care of stage III NSCLC underscores the need for a multidisciplinary approach. Methods From tumor registry data, we identified all cases of stage III NSCLC seen at Lehigh Valley Health Network between March 2010 and March 2013. The care received by patients when seen in the thoracic multidisciplinary clinic (MDC) was compared with the care received when not seen in the thoracic MDC. Results All patients seen in the MDC, compared to <50% of patients seen outside the MDC, were evaluated by more than one physician prior to beginning the treatment. Time to initiate treatment was shorter in MDC patients than in non-MDC patients. Patients seen in the MDC had a greater concordance with clinical pathways. A greater percentage of patients seen in the thoracic MDC had pathologic staging of their mediastinum. Patients seen in the MDC were more likely to receive all of their care at Lehigh Valley Health Network. Conclusion Multidisciplinary care is essential in the treatment of patients with stage III NSCLC. Greater utilization of MDCs for this complex group of patients will result in more efficient coordination of care, pretreatment evaluation, and therapy, which in turn should translate to improve patients’ outcomes.
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Affiliation(s)
- Eliot L Friedman
- Division of Hematology-Medical Oncology, Lehigh Valley Health Network, Allentown, PA, USA
| | - Robert J Kruklitis
- Division of Pulmonary and Critical Care Medicine, Lehigh Valley Health Network, Allentown, PA, USA
| | - Brian J Patson
- Division of Hematology-Medical Oncology, Lehigh Valley Health Network, Allentown, PA, USA
| | - Dennis M Sopka
- Department of Radiation Oncology, Lehigh Valley Health Network, Allentown, PA, USA
| | - Michael J Weiss
- Health Systems Research and Innovation, Lehigh Valley Health Network, Allentown, PA, USA
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Sindoni A, Minutoli F, Pontoriero A, Iatì G, Baldari S, Pergolizzi S. Usefulness of four dimensional (4D) PET/CT imaging in the evaluation of thoracic lesions and in radiotherapy planning: Review of the literature. Lung Cancer 2016; 96:78-86. [DOI: 10.1016/j.lungcan.2016.03.019] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 03/31/2016] [Indexed: 11/30/2022]
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27
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Pöttgen C, Gauler T, Bellendorf A, Guberina M, Bockisch A, Schwenzer N, Heinzelmann F, Cordes S, Schuler MH, Welter S, Stamatis G, Friedel G, Darwiche K, Jöckel KH, Eberhardt W, Stuschke M. Standardized Uptake Decrease on [18F]-Fluorodeoxyglucose Positron Emission Tomography After Neoadjuvant Chemotherapy Is a Prognostic Classifier for Long-Term Outcome After Multimodality Treatment: Secondary Analysis of a Randomized Trial for Resectable Stage IIIA/B Non-Small-Cell Lung Cancer. J Clin Oncol 2016; 34:2526-33. [PMID: 27247220 DOI: 10.1200/jco.2015.65.5167] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE A confirmatory analysis was performed to determine the prognostic value of metabolic response during induction chemotherapy followed by bimodality/trimodality treatment of patients with operable locally advanced non-small-cell lung cancer. PATIENTS AND METHODS Patients with potentially operable stage IIIA(N2) or selected stage IIIB non-small-cell lung cancer received three cycles of cisplatin/paclitaxel (induction chemotherapy) followed by neoadjuvant radiochemotherapy (RCT) to 45 Gy (1.5 Gy twice per day concurrent cisplatin/vinorelbine) within the ESPATUE (Phase III Study of Surgery Versus Definitive Concurrent Chemoradiotherapy Boost in Patients With Resectable Stage IIIA[N2] and Selected IIIB Non-Small-Cell Lung Cancer After Induction Chemotherapy and Concurrent Chemoradiotherapy) trial. Positron emission tomography scans were recommended before (t0) and after (t2) induction chemotherapy. Patients who were eligible for surgery after neoadjuvant RCT were randomly assigned to definitive RCT or surgery. The prognostic value of percentage of maximum standardized uptake value (%SUVmax) remaining in the primary tumor after induction chemotherapy-%SUVremaining = SUVmax(t2)/SUVmax(t0)-was assessed by proportional hazard analysis and receiver operating characteristic analysis. RESULTS Overall, 161 patients were randomly assigned (155 from the Essen and Tübingen centers), and 124 of these received positron emission tomography scans at t0 and t2. %SUVremaining as a continuous variable was prognostic for the three end points of overall survival, progression-free survival, and freedom from extracerebral progression in univariable and multivariable analysis (P < .016). The respective hazard ratios per 50% increase in %SUVremaining from multivariable analysis were 2.3 (95% CI, 1.5 to 3.4; P < .001), 1.8 (95% CI, 1.3 to 2.5; P < .001), and 1.8 (95% CI, 1.2 to 2.7; P = .006) for the three end points. %SUVremaining dichotomized at a cut point of maximum sum of sensitivity and specificity from receiver operating characteristic analysis at 36 months was also prognostic. Exploratory analysis revealed that %SUVremaining was likewise prognostic for overall survival in both treatment arms and was more closely associated with extracerebral distant metastases (P = .016) than with isolated locoregional relapses (P = .97). CONCLUSION %SUVremaining is a predictor for survival and other end points after multimodality treatment and can serve as a parameter for treatment stratification after induction chemotherapy or for evaluation of adjuvant new systemic treatment options for high-risk patients.
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Affiliation(s)
- Christoph Pöttgen
- Christoph Pöttgen, Thomas Gauler, Alexander Bellendorf, Maja Guberina, Andreas Bockisch, Sebastian Cordes, Martin H. Schuler, Karl-Heinz Jöckel, Wilfried Eberhardt, and Martin Stuschke, University Hospital Essen; University of Duisburg-Essen; Stefan Welter, Georgios Stamatis, and Kaid Darwiche, Ruhrlandklinik, Essen; Nina Schwenzer and Frank Heinzelmann, University Hospital Tübingen; University of Tübingen, Tübingen; and Godehard Friedel, Robert-Bosch-Krankenhaus; Klinikum Schillerhöhe, Gerlingen, Germany
| | - Thomas Gauler
- Christoph Pöttgen, Thomas Gauler, Alexander Bellendorf, Maja Guberina, Andreas Bockisch, Sebastian Cordes, Martin H. Schuler, Karl-Heinz Jöckel, Wilfried Eberhardt, and Martin Stuschke, University Hospital Essen; University of Duisburg-Essen; Stefan Welter, Georgios Stamatis, and Kaid Darwiche, Ruhrlandklinik, Essen; Nina Schwenzer and Frank Heinzelmann, University Hospital Tübingen; University of Tübingen, Tübingen; and Godehard Friedel, Robert-Bosch-Krankenhaus; Klinikum Schillerhöhe, Gerlingen, Germany
| | - Alexander Bellendorf
- Christoph Pöttgen, Thomas Gauler, Alexander Bellendorf, Maja Guberina, Andreas Bockisch, Sebastian Cordes, Martin H. Schuler, Karl-Heinz Jöckel, Wilfried Eberhardt, and Martin Stuschke, University Hospital Essen; University of Duisburg-Essen; Stefan Welter, Georgios Stamatis, and Kaid Darwiche, Ruhrlandklinik, Essen; Nina Schwenzer and Frank Heinzelmann, University Hospital Tübingen; University of Tübingen, Tübingen; and Godehard Friedel, Robert-Bosch-Krankenhaus; Klinikum Schillerhöhe, Gerlingen, Germany
| | - Maja Guberina
- Christoph Pöttgen, Thomas Gauler, Alexander Bellendorf, Maja Guberina, Andreas Bockisch, Sebastian Cordes, Martin H. Schuler, Karl-Heinz Jöckel, Wilfried Eberhardt, and Martin Stuschke, University Hospital Essen; University of Duisburg-Essen; Stefan Welter, Georgios Stamatis, and Kaid Darwiche, Ruhrlandklinik, Essen; Nina Schwenzer and Frank Heinzelmann, University Hospital Tübingen; University of Tübingen, Tübingen; and Godehard Friedel, Robert-Bosch-Krankenhaus; Klinikum Schillerhöhe, Gerlingen, Germany
| | - Andreas Bockisch
- Christoph Pöttgen, Thomas Gauler, Alexander Bellendorf, Maja Guberina, Andreas Bockisch, Sebastian Cordes, Martin H. Schuler, Karl-Heinz Jöckel, Wilfried Eberhardt, and Martin Stuschke, University Hospital Essen; University of Duisburg-Essen; Stefan Welter, Georgios Stamatis, and Kaid Darwiche, Ruhrlandklinik, Essen; Nina Schwenzer and Frank Heinzelmann, University Hospital Tübingen; University of Tübingen, Tübingen; and Godehard Friedel, Robert-Bosch-Krankenhaus; Klinikum Schillerhöhe, Gerlingen, Germany
| | - Nina Schwenzer
- Christoph Pöttgen, Thomas Gauler, Alexander Bellendorf, Maja Guberina, Andreas Bockisch, Sebastian Cordes, Martin H. Schuler, Karl-Heinz Jöckel, Wilfried Eberhardt, and Martin Stuschke, University Hospital Essen; University of Duisburg-Essen; Stefan Welter, Georgios Stamatis, and Kaid Darwiche, Ruhrlandklinik, Essen; Nina Schwenzer and Frank Heinzelmann, University Hospital Tübingen; University of Tübingen, Tübingen; and Godehard Friedel, Robert-Bosch-Krankenhaus; Klinikum Schillerhöhe, Gerlingen, Germany
| | - Frank Heinzelmann
- Christoph Pöttgen, Thomas Gauler, Alexander Bellendorf, Maja Guberina, Andreas Bockisch, Sebastian Cordes, Martin H. Schuler, Karl-Heinz Jöckel, Wilfried Eberhardt, and Martin Stuschke, University Hospital Essen; University of Duisburg-Essen; Stefan Welter, Georgios Stamatis, and Kaid Darwiche, Ruhrlandklinik, Essen; Nina Schwenzer and Frank Heinzelmann, University Hospital Tübingen; University of Tübingen, Tübingen; and Godehard Friedel, Robert-Bosch-Krankenhaus; Klinikum Schillerhöhe, Gerlingen, Germany
| | - Sebastian Cordes
- Christoph Pöttgen, Thomas Gauler, Alexander Bellendorf, Maja Guberina, Andreas Bockisch, Sebastian Cordes, Martin H. Schuler, Karl-Heinz Jöckel, Wilfried Eberhardt, and Martin Stuschke, University Hospital Essen; University of Duisburg-Essen; Stefan Welter, Georgios Stamatis, and Kaid Darwiche, Ruhrlandklinik, Essen; Nina Schwenzer and Frank Heinzelmann, University Hospital Tübingen; University of Tübingen, Tübingen; and Godehard Friedel, Robert-Bosch-Krankenhaus; Klinikum Schillerhöhe, Gerlingen, Germany
| | - Martin H Schuler
- Christoph Pöttgen, Thomas Gauler, Alexander Bellendorf, Maja Guberina, Andreas Bockisch, Sebastian Cordes, Martin H. Schuler, Karl-Heinz Jöckel, Wilfried Eberhardt, and Martin Stuschke, University Hospital Essen; University of Duisburg-Essen; Stefan Welter, Georgios Stamatis, and Kaid Darwiche, Ruhrlandklinik, Essen; Nina Schwenzer and Frank Heinzelmann, University Hospital Tübingen; University of Tübingen, Tübingen; and Godehard Friedel, Robert-Bosch-Krankenhaus; Klinikum Schillerhöhe, Gerlingen, Germany
| | - Stefan Welter
- Christoph Pöttgen, Thomas Gauler, Alexander Bellendorf, Maja Guberina, Andreas Bockisch, Sebastian Cordes, Martin H. Schuler, Karl-Heinz Jöckel, Wilfried Eberhardt, and Martin Stuschke, University Hospital Essen; University of Duisburg-Essen; Stefan Welter, Georgios Stamatis, and Kaid Darwiche, Ruhrlandklinik, Essen; Nina Schwenzer and Frank Heinzelmann, University Hospital Tübingen; University of Tübingen, Tübingen; and Godehard Friedel, Robert-Bosch-Krankenhaus; Klinikum Schillerhöhe, Gerlingen, Germany
| | - Georgios Stamatis
- Christoph Pöttgen, Thomas Gauler, Alexander Bellendorf, Maja Guberina, Andreas Bockisch, Sebastian Cordes, Martin H. Schuler, Karl-Heinz Jöckel, Wilfried Eberhardt, and Martin Stuschke, University Hospital Essen; University of Duisburg-Essen; Stefan Welter, Georgios Stamatis, and Kaid Darwiche, Ruhrlandklinik, Essen; Nina Schwenzer and Frank Heinzelmann, University Hospital Tübingen; University of Tübingen, Tübingen; and Godehard Friedel, Robert-Bosch-Krankenhaus; Klinikum Schillerhöhe, Gerlingen, Germany
| | - Godehard Friedel
- Christoph Pöttgen, Thomas Gauler, Alexander Bellendorf, Maja Guberina, Andreas Bockisch, Sebastian Cordes, Martin H. Schuler, Karl-Heinz Jöckel, Wilfried Eberhardt, and Martin Stuschke, University Hospital Essen; University of Duisburg-Essen; Stefan Welter, Georgios Stamatis, and Kaid Darwiche, Ruhrlandklinik, Essen; Nina Schwenzer and Frank Heinzelmann, University Hospital Tübingen; University of Tübingen, Tübingen; and Godehard Friedel, Robert-Bosch-Krankenhaus; Klinikum Schillerhöhe, Gerlingen, Germany
| | - Kaid Darwiche
- Christoph Pöttgen, Thomas Gauler, Alexander Bellendorf, Maja Guberina, Andreas Bockisch, Sebastian Cordes, Martin H. Schuler, Karl-Heinz Jöckel, Wilfried Eberhardt, and Martin Stuschke, University Hospital Essen; University of Duisburg-Essen; Stefan Welter, Georgios Stamatis, and Kaid Darwiche, Ruhrlandklinik, Essen; Nina Schwenzer and Frank Heinzelmann, University Hospital Tübingen; University of Tübingen, Tübingen; and Godehard Friedel, Robert-Bosch-Krankenhaus; Klinikum Schillerhöhe, Gerlingen, Germany
| | - Karl-Heinz Jöckel
- Christoph Pöttgen, Thomas Gauler, Alexander Bellendorf, Maja Guberina, Andreas Bockisch, Sebastian Cordes, Martin H. Schuler, Karl-Heinz Jöckel, Wilfried Eberhardt, and Martin Stuschke, University Hospital Essen; University of Duisburg-Essen; Stefan Welter, Georgios Stamatis, and Kaid Darwiche, Ruhrlandklinik, Essen; Nina Schwenzer and Frank Heinzelmann, University Hospital Tübingen; University of Tübingen, Tübingen; and Godehard Friedel, Robert-Bosch-Krankenhaus; Klinikum Schillerhöhe, Gerlingen, Germany
| | - Wilfried Eberhardt
- Christoph Pöttgen, Thomas Gauler, Alexander Bellendorf, Maja Guberina, Andreas Bockisch, Sebastian Cordes, Martin H. Schuler, Karl-Heinz Jöckel, Wilfried Eberhardt, and Martin Stuschke, University Hospital Essen; University of Duisburg-Essen; Stefan Welter, Georgios Stamatis, and Kaid Darwiche, Ruhrlandklinik, Essen; Nina Schwenzer and Frank Heinzelmann, University Hospital Tübingen; University of Tübingen, Tübingen; and Godehard Friedel, Robert-Bosch-Krankenhaus; Klinikum Schillerhöhe, Gerlingen, Germany
| | - Martin Stuschke
- Christoph Pöttgen, Thomas Gauler, Alexander Bellendorf, Maja Guberina, Andreas Bockisch, Sebastian Cordes, Martin H. Schuler, Karl-Heinz Jöckel, Wilfried Eberhardt, and Martin Stuschke, University Hospital Essen; University of Duisburg-Essen; Stefan Welter, Georgios Stamatis, and Kaid Darwiche, Ruhrlandklinik, Essen; Nina Schwenzer and Frank Heinzelmann, University Hospital Tübingen; University of Tübingen, Tübingen; and Godehard Friedel, Robert-Bosch-Krankenhaus; Klinikum Schillerhöhe, Gerlingen, Germany.
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Nason KS. Is there a role for postinduction positron emission tomography and computed tomography with fludeoxyglucose F 18? A call for standardization. J Thorac Cardiovasc Surg 2016; 151:980-1. [PMID: 26872447 DOI: 10.1016/j.jtcvs.2016.01.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 01/15/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Katie S Nason
- Division of Thoracic and Foregut, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa.
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Postinduction positron emission tomography assessment of N2 nodes is not associated with ypN2 disease or overall survival in stage IIIA non-small cell lung cancer. J Thorac Cardiovasc Surg 2015; 151:969-77, 979.e1-3. [PMID: 26614420 DOI: 10.1016/j.jtcvs.2015.09.127] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 09/11/2015] [Accepted: 09/23/2015] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Induction therapy is often recommended for patients with clinical stage IIIA-N2 (cIIIA/pN2) lung cancer. We examined whether postinduction positron emission tomography (PET) scans were associated with ypN2 disease and survival of patients with cIIIA/pN2 disease. METHODS We performed a retrospective review of a prospectively maintained database to identify patients with cIIIA/pN2 non-small cell lung cancer treated with induction chemotherapy followed by surgery between January 2007 and December 2012. The primary aim was the association between postinduction PET avidity and ypN2 status; the secondary aims were overall survival, disease-free survival, and recurrence. RESULTS Persistent pathologic N2 disease was present in 61% of patients (61 out of 100). PET N2-negative disease increased from 7% (6 out of 92) before induction therapy to 47% (36 out of 77) afterward. The sensitivity, specificity, and accuracy of postinduction PET for identification of ypN2 disease were 59%, 55%, and 57%, respectively. Logistic regression analysis indicated that postinduction PET N2 status was not associated with ypN2 disease. Of the 39 patients with both pre- and postinduction PET N2-avidity, 25 (64%) had ypN2 disease. The 5-year overall survival was 40% for ypN2 disease versus 38% for N2-persistent disease (P = .936); the 5-year overall survival was 43% for postinduction PET N2-negative disease versus 39% for N2-avid disease (P = .251). The 5-year disease-free survival was 34% for ypN2-negative disease versus 9% for N2-persistent disease (P = .079). CONCLUSIONS Postinduction PET avidity for N2 nodes is not associated with ypN2 disease, overall survival, or disease-free survival in patients undergoing induction chemotherapy for stage IIIA/pN2 disease.
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Van Schil PE, De Waele M, Hendriks JM, Lauwers PR. Approaches in patients with locally advanced NSCLC: a surgeon's perspective. Lung Cancer 2015. [DOI: 10.1183/2312508x.10010414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Van Schil PE, Balduyck B, De Waele M, Hendriks JM, Hertoghs M, Lauwers P. Surgical treatment of early-stage non-small-cell lung cancer. EJC Suppl 2015. [PMID: 26217120 PMCID: PMC4041566 DOI: 10.1016/j.ejcsup.2013.07.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Surgical resection remains the standard of care for functionally operable early-stage non-small-cell lung cancer (NSCLC) and resectable stage IIIA disease. The role of invasive staging and restaging techniques is currently being debated, but they provide the largest biopsy samples which allow for precise mediastinal staging. Different types of operative procedures are currently available to the thoracic surgeon, and some of these interventions can be performed by video-assisted thoracic surgery (VATS) with the same oncological results as those by open thoracotomy. The principal aim of surgical treatment for NSCLC is to obtain a complete resection which has been precisely defined by a working group of the International Association for the Study of Lung Cancer (IASLC). Intraoperative staging of lung cancer is of utmost importance to decide on the extent of resection according to the intraoperative tumour (T) and nodal (N) status. Systematic nodal dissection is generally advocated to evaluate the hilar and mediastinal lymph nodes which are subdivided into seven zones according to the most recent 7th tumour-node-metastasis (TNM) classification. Lymph-node involvement not only determines prognosis but also the administration of adjuvant therapy. In 2011, a new multidisciplinary adenocarcinoma classification was published introducing the concepts of adenocarcinoma in situ and minimally invasive adenocarcinoma. This classification has profound surgical implications. The role of limited or sublobar resection, comprising anatomical segmentectomy and wide wedge resection, is reconsidered for early-stage lesions which are more frequently encountered with the recently introduced large screening programmes. Numerous retrospective non-randomised studies suggest that sublobar resection may be an acceptable surgical treatment for early lung cancers, also when performed by VATS. More tailored, personalised therapy has recently been introduced. Quality-of-life parameters and surgical quality indicators become increasingly important to determine the short-term and long-term impact of a surgical procedure. International databases currently collect extensive surgical data, allowing more precise calculation of mortality and morbidity according to predefined risk factors. Centralisation of care has been shown to improve results. Evidence-based guidelines should be further developed to provide optimal staging and therapeutic algorithms.
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Affiliation(s)
- Paul E Van Schil
- Antwerp University Hospital, Department of Thoracic and Vascular Surgery, Edegem, Antwerp, Belgium
| | - Bram Balduyck
- Antwerp University Hospital, Department of Thoracic and Vascular Surgery, Edegem, Antwerp, Belgium
| | - Michèle De Waele
- Antwerp University Hospital, Department of Thoracic and Vascular Surgery, Edegem, Antwerp, Belgium
| | - Jeroen M Hendriks
- Antwerp University Hospital, Department of Thoracic and Vascular Surgery, Edegem, Antwerp, Belgium
| | - Marjan Hertoghs
- Antwerp University Hospital, Department of Thoracic and Vascular Surgery, Edegem, Antwerp, Belgium
| | - Patrick Lauwers
- Antwerp University Hospital, Department of Thoracic and Vascular Surgery, Edegem, Antwerp, Belgium
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Marquez-Medina D, Martin-Marco A, Popat S. Watch the weathercock: changes in re-staging 18F-FDG PET/CT scan predict the probability of relapse in locally advanced non-small cell lung cancer. Clin Transl Oncol 2015. [PMID: 26203801 DOI: 10.1007/s12094-015-1349-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Induction treatment is be coming the gold standard for locally advanced non-small cell lung cancers (LA-NSCLC). In contrast to baseline positron emission/computed tomography scan (PET/CT scan), re-staging PET/CT scan has been poorly studied in LA-NSCLC. MATERIALS AND METHODS We retrospectively explored the efficacy of re-staging PET/CT scan to diagnose response and to predict disease-free survival (DFS) in 55 induction-treated LA-NSCLC further treated with curative surgery or radiation but not with adjuvant therapy. RESULTS Re-staging N status by PET/CT scan significantly correlated with pathological N status. Radiological or metabolic response in the re-staging PET/CT scan was associated with a significantly better DFS, which decreased from 25.8 to 19.3, to 11.2, and to 9.4 months in cN0, cN1, cN2, and cN3 patients, respectively. CONCLUSION Re-staging PET/CT scan helps to define response and consolidation treatment in induction-treated LA-NSCLC and predicts DFS. Further extended studies should confirm our results.
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Affiliation(s)
- D Marquez-Medina
- Medical Oncology Department, Arnau de Vilanova University Hospital of Lleida, Avda. Rovira Roure, 80, 25198, Lleida, Spain.
| | - A Martin-Marco
- Medical Oncology Department, Arnau de Vilanova University Hospital of Lleida, Avda. Rovira Roure, 80, 25198, Lleida, Spain
| | - S Popat
- Lung Unit, Royal Marsden Hospital, London, UK
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Vilmann P, Frost Clementsen P, Colella S, Siemsen M, De Leyn P, Dumonceau JM, Herth FJ, Larghi A, Vazquez-Sequeiros E, Hassan C, Crombag L, Korevaar DA, Konge L, Annema JT. Combined endobronchial and esophageal endosonography for the diagnosis and staging of lung cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline, in cooperation with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg 2015; 48:1-15. [DOI: 10.1093/ejcts/ezv194] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Vilmann P, Clementsen PF, Colella S, Siemsen M, De Leyn P, Dumonceau JM, Herth FJ, Larghi A, Vazquez-Sequeiros E, Hassan C, Crombag L, Korevaar DA, Konge L, Annema JT. Combined endobronchial and oesophageal endosonography for the diagnosis and staging of lung cancer. Eur Respir J 2015; 46:40-60. [DOI: 10.1183/09031936.00064515] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 04/27/2015] [Indexed: 12/25/2022]
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Stamatis G. Staging of lung cancer: the role of noninvasive, minimally invasive and invasive techniques. Eur Respir J 2015; 46:521-31. [PMID: 25976686 DOI: 10.1183/09031936.00126714] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 04/07/2015] [Indexed: 12/25/2022]
Abstract
Accurate staging and restaging of primary tumour and mediastinal nodes in patients with lung cancer is of significant importance. For primary tumours, computed tomography (CT) scans of the chest are recommended. Positron emission tomography (PET) imaging should be used in patients with curative intent treatment to evaluate metastatic disease. Diagnosis of the primary tumour should be performed using bronchoscopy or CT-guided transthoracic needle aspiration. In patients with enlarged mediastinal nodes and no distant metastasis, invasive staging of the mediastinum is required. For suspicious N2 or N3 disease, endoscopic needle techniques, such as endobronchial ultrasound and transbronchial needle aspiration, oesophageal ultrasound and fine needle aspiration, or a combination of both, are preferred to any surgical staging technique. In cases of suspicious nodes and negative results using needle aspiration techniques, invasive surgical staging using mediastinoscopy or video-assisted thoracic surgery should be performed. In central tumours or N1 nodes, preoperative invasive staging is indicated.Restaging after induction therapy remains a controversial topic. Today, neither CT, PET nor PET/CT scans are accurate enough to make final further therapeutic decisions for mediastinal nodal involvement. An invasive technique providing cytohistological information is still recommended.
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Affiliation(s)
- Georgios Stamatis
- Dept of Thoracic Surgery and Endoscopy, Ruhrlandklinik, West German Lung Center of the University Duisburg Essen, Essen, Germany
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Lim HJ, Lee HY, Lee KS, Han J, Kwon OJ, Park K, Ahn YC, Kim BT, Shim YM. Predictive factors for survival in stage IIIA N2 NSCLC patients treated with neoadjuvant CCRT followed by surgery. Cancer Chemother Pharmacol 2014; 75:77-85. [PMID: 25374409 DOI: 10.1007/s00280-014-2619-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 10/26/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE To assess the impact of imaging, surgical, histopathologic and patient-related factors on the risks of recurrence and overall survival (OS) in stage IIIA-N2 non-small cell lung cancer (NSCLC) patients undergoing definitive resection after neoadjuvant concurrent chemoradiotherapy (CCRT). METHODS We retrospectively examined 104 consecutive patients with stage IIIA-N2 NSCLC who received neoadjuvant CCRT followed by surgery between 2008 and 2011. While reviewing the clinical and surgical data, we also assessed histopathologic and imaging (CT and PET/CT) factors. Disease-free survival (DFS) and OS were estimated with predictors for recurrence and survival. RESULTS The 3-year OS for patients with and without recurrence was 37.1 and 63.3 %, respectively (p < 0.001). Size decrease of target lesion(s) ≥36 % on post-neoadjuvant CCRT CT (p = 0.048) and viable tumor size on surgical specimen <9.4 mm (p = 0.035) were related to longer OS. Regarding shorter DFS, tumor size on post-neoadjuvant CCRT CT (p = 0.046), SUV(max) of the primary tumor (p = 0.011), male gender (p = 0.023), total tumor size on surgical specimen (p = 0.041) and viable tumor size on surgical specimen (p = 0.043) were the significant predictors. CONCLUSIONS OS is prolonged with greater extent of size decrease of target lesion(s) on post-neoadjuvant CCRT CT and smaller viable tumor size on surgical specimen. Larger tumor size on post-neoadjuvant CCRT CT, higher SUV(max), male gender, larger total tumor size and larger viable tumor size on surgical specimen may herald the higher probability of recurrence and the necessity of more attention.
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Affiliation(s)
- Hyun-ju Lim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, Ilwon-Dong, Kangnam-Ku, Seoul, 135-710, Korea
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Inage T, Nakajima T, Yoshino I. Staging lung cancer: role of endobronchial ultrasound. LUNG CANCER (AUCKLAND, N.Z.) 2014; 5:67-72. [PMID: 28210144 PMCID: PMC5217511 DOI: 10.2147/lctt.s46195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Accurate staging is the first step in the management of lung cancer. Nodal staging is quite important for physicians to be able to judge the primary operability of patients harboring no distant metastasis. For many years, mediastinoscopy has been considered a "gold standard" modality for nodal staging. Mediastinoscopy is known to be a highly sensitive procedure for mediastinal staging and has been performed worldwide, but is invasive. Because of this, clinicians have sought a less invasive modality for nodal staging. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive modality for diagnosis and staging of lung cancer. EBUS-TBNA is a needle biopsy procedure that has accessibility compatible with the reach of the convex-probe EBUS scope, so N1 nodes are also assessable. The diagnostic yield is similar to that of mediastinoscopy, and the core obtained by the dedicated needle biopsy can be used for histological assessment to determine the subtypes of lung cancer. The samples can also be used to test for various biomarkers using immunohistochemistry, polymerase chain reaction for DNA/complementary DNA, and in situ hybridization, and the technique is useful for selecting candidates for specific molecular-targeted therapeutic agents. According to the newly published American College of Chest Physicians guideline, EBUS-TBNA is now considered "the best first test" for nodal staging in patients with radiologically suspicious nodes. Appropriate training and thorough clinical experience is required to be able to perform correct nodal staging using this procedure.
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Affiliation(s)
- Terunaga Inage
- Department of General Thoracic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takahiro Nakajima
- Department of General Thoracic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Ichiro Yoshino
- Department of General Thoracic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
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Abstract
Proponents of the endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) propose that in this era of EBUS-TBNA, training for conventional transbronchial needle aspiration (C-TBNA) should be abandoned. The authors of this editorial provide the opposing view. C-TBNA has a short and a steep learning curve and adds to the diagnostic yield of flexible bronchoscopy in a cost-effective fashion. Considering its simplicity, availability, affordability, safety, and several unique indications, C-TBNA continues to contribute to the welfare of patients worldwide. It should remain as an integral part of pulmonary fellowship training programs.
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Yamamoto T, Sakairi Y, Nakajima T, Suzuki H, Tagawa T, Iwata T, Mizobuchi T, Yoshida S, Nakatani Y, Yoshino I. Comparison between endobronchial ultrasound-guided transbronchial needle aspiration and 18F-fluorodeoxyglucose positron emission tomography in the diagnosis of postoperative nodal recurrence in patients with lung cancer. Eur J Cardiothorac Surg 2014; 47:234-8. [DOI: 10.1093/ejcts/ezu214] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Cho HJ, Kim SR, Kim HR, Han JO, Kim YH, Kim DK, Park SI. Modern outcome and risk analysis of surgically resected occult N2 non-small cell lung cancer. Ann Thorac Surg 2014; 97:1920-5. [PMID: 24768044 DOI: 10.1016/j.athoracsur.2014.03.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 03/03/2014] [Accepted: 03/04/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND This study was performed to assess the incidence, survival, and risk factors associated with unsuspected pathologic N2 disease in patients with resectable clinical N0-1 non-small cell lung cancer. METHODS Between January 2002 and December 2010, 1,821 patients with clinical N0-1 non-small cell lung cancer underwent pulmonary resection and mediastinal lymph node dissection. Clinical outcomes and risk factors for pathologic N2 disease were retrospectively analyzed for this cohort. RESULTS Unsuspected pathologic N2 disease was identified in 196 patients (10.8%). The most common type of resection was lobectomy (81.6%). Adjuvant therapy was administered in 177 patients (90.3%). The median follow-up time was 28 months (range, 1 to 101 months). N2 involvement was single-station in 121 (66.8%) and multiple-station in 65 (33.2%). The 5-year overall and disease-free survival rates were 56.1% and 35.0%, respectively. The 5-year survival rates of single-station and multiple-station N2 were 66.6% and 36.4%, respectively (p < 0.001). Adenocarcinoma, clinical N1, tumor size (>3 cm), and a right middle lobe tumor were identified as independent risk factors for unsuspected multiple-station N2 disease by multivariate analysis. Incidence of unsuspected multiple-station N2 disease in low-risk classes (aggregate score, 0 to ≤2) was only 5.5%. CONCLUSIONS The incidence of unsuspected N2 disease in our cohort was similar to that of previous reports. Survival outcomes were favorable for unsuspected single-station N2 disease but were poor for unsuspected multiple-station N2 disease. Clinical N0-1 non-small cell lung cancer patients with risk class of low score for unsuspected multiple-station N2 disease can be exempted from aggressive mediastinal staging.
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Affiliation(s)
- Hyun Jin Cho
- Department of Thoracic and Cardiovascular Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Sung Ryong Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyeong Ryul Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Jin-Ok Han
- Department of Preventive Medicine, Graduate School of Medicine, Gachon University, Incheon, Korea
| | - Yong-Hee Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Il Park
- Department of Thoracic and Cardiovascular Surgery, Seoul Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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41
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Pipkin M, Keshavjee S. Staging of the Mediastinum. Lung Cancer 2014. [DOI: 10.1002/9781118468791.ch12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Biswas T, Sharma N, Machtay M. Controversies in the management of stage III non-small-cell lung cancer. Expert Rev Anticancer Ther 2014; 14:333-47. [PMID: 24397773 DOI: 10.1586/14737140.2014.867809] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Lung cancer remains the leading cause of death in the USA and is the most common cancer both in incidence and in mortality globally (1.35 million deaths annually). Non-small-cell lung cancer accounts for >80% of all lung cancers [1] . About 35-45% of non-small-cell lung cancer patients present with locally advanced non-metastatic stage III disease. However, confirmed stage III disease represents a very heterogeneous group ranging from borderline surgical candidate with minimal mediastinal involvement to bulky mediastinal nodes or contralateral nodal involvement with significant controversy regarding optimal management in these various situations. This article specifically addresses the role of surgery, radiotherapy and chemotherapy in multimodal approach to treat stage III patients with N2/N3 involvement and controversies surrounding these recommendations.
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Affiliation(s)
- Tithi Biswas
- University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA
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Ramnath N, Dilling TJ, Harris LJ, Kim AW, Michaud GC, Balekian AA, Diekemper R, Detterbeck FC, Arenberg DA. Treatment of stage III non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e314S-e340S. [PMID: 23649445 DOI: 10.1378/chest.12-2360] [Citation(s) in RCA: 312] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Stage III non-small cell lung cancer (NSCLC) describes a heterogeneous population with disease presentation ranging from apparently resectable tumors with occult microscopic nodal metastases to unresectable, bulky nodal disease. This review updates the published clinical trials since the last American College of Chest Physicians guidelines to make treatment recommendations for this controversial subset of patients. METHODS Systematic searches were conducted through MEDLINE, Embase, and the Cochrane Database for Systematic Review up to December 2011, focusing primarily on randomized trials, selected meta-analyses, practice guidelines, and reviews. RESULTS For individuals with stage IIIA or IIIB disease, good performance scores, and minimal weight loss, treatment with combined chemoradiotherapy results in better survival than radiotherapy alone. Consolidation chemotherapy or targeted therapy following definitive chemoradiation for stage IIIA is not supported. Neoadjuvant therapy followed by surgery is neither clearly better nor clearly worse than definitive chemoradiation. Most of the arguments made regarding patient selection for neoadjuvant therapy and surgical resection provide evidence for better prognosis but not for a beneficial impact of this treatment strategy; however, weak comparative data suggest a possible role if only lobectomy is needed in a center with a low perioperative mortality rate. The evidence supports routine platinum-based adjuvant chemotherapy following complete resection of stage IIIA lung cancer encountered unexpectedly at surgery. Postoperative radiotherapy improves local control without improving survival. CONCLUSIONS Multimodality therapy is preferable in most subsets of patients with stage III lung cancer. Variability in the patients included in randomized trials limits the ability to combine results across studies and thus limits the strength of recommendations in many scenarios. Future trials are needed to investigate the roles of individualized chemotherapy, surgery in particular cohorts or settings, prophylactic cranial radiation, and adaptive radiation.
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Affiliation(s)
- Nithya Ramnath
- University of Michigan Comprehensive Cancer Center, Ann Arbor, MI
| | | | - Loren J Harris
- Thoracic Surgery, Maimonides Medical Center, Brooklyn, NY
| | | | | | | | | | | | - Douglas A Arenberg
- Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI.
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Ripley RT, Rusch VW. Role of induction therapy: surgical resection of non-small cell lung cancer after induction therapy. Thorac Surg Clin 2013; 23:273-85. [PMID: 23931012 DOI: 10.1016/j.thorsurg.2013.04.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Patients with Stage III non-small cell lung cancer are best managed by multimodality therapy. Patients with N2 disease can be treated with induction therapy (usually chemotherapy) followed by surgical resection. Patients whose medical comorbidities preclude surgery should be treated with definitive chemoradiotherapy. T3 or T4 tumors involving the superior sulcus or spine are best managed with induction chemoradiotherapy and surgical resection.
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Affiliation(s)
- R Taylor Ripley
- Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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Kuzmik GA, Detterbeck FC, Decker RH, Boffa DJ, Wang Z, Oliva IB, Kim AW. Pulmonary resections following prior definitive chemoradiation therapy are associated with acceptable survival. Eur J Cardiothorac Surg 2013; 44:e66-70. [PMID: 23557918 DOI: 10.1093/ejcts/ezt184] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The benefits of salvage resection for lung cancer recurrence following high-dose curative-intent chemoradiation therapy are unclear. We assessed survival after salvage lung resection following definitive chemoradiation. METHODS Medical records of patients undergoing lung cancer resections at our institution following definitive chemoradiation therapy were reviewed from June 2006 to August 2012. A multivariate Cox proportional model was used to assess the factors associated with improved survival. RESULTS Fourteen patients had chemoradiation therapy before lung resection (pneumonectomy, lobectomy or segmentectomy). Pretherapy cancer stage was Stage III in 11 patients, Stage IV in 2 and Stage II in 1. Postoperative 2-year survival was 49%. Patients had a median disease-free interval before resection of 33 months. No variables were found to be associated with improved post-chemoradiation survival from the time of definitive treatment or postoperative survival. Complications occurred in 6 (43%) patients, with 2 of those complications directly attributable to post-chemoradiation changes. There were no perioperative deaths within 90 days. CONCLUSIONS Salvage lung resection for recurrent lung cancer following definitive chemoradiation therapy is feasible and is associated with postoperative survival and complication rates that are reasonable.
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Lv C, Ma Y, Wu N, Yan S, Zheng Q, Sun Y, Li S, Fang J, Yang Y. A retrospective study: platinum-based induction chemotherapy combined with gemcitabine or paclitaxel for stage IIB-IIIA central non-small-cell lung cancer. World J Surg Oncol 2013; 11:76. [PMID: 23517534 PMCID: PMC3621287 DOI: 10.1186/1477-7819-11-76] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 02/23/2013] [Indexed: 12/25/2022] Open
Abstract
Background Several encouraging phase III clinical trials have evaluated platinum-based induction chemotherapy against stage IIB-IIIA non-small-cell lung cancer (NSCLC). Chemotherapy efficacy was assessed using common regimens in this retrospective analysis. Methods From 2007 to 2011, the clinical records of stage IIB-IIIA NSCLC patients undergoing surgery after neoadjuvant chemotherapy were reviewed. Gathered data were tested for significance and variables impacting survival were assessed by univariate and Cox regression analyses. Results Overall, 84% of patients were male and 93% had central disease. Platinum-based chemotherapy protocols with gemcitabine or paclitaxel gave an overall response rate of 55% (45/82) and 6.1% pathological complete response (5/82). Clinical response was unassociated with regimen or histology, while more pneumonectomies were performed in the stable compared to partial response disease group (P =0.040). Postoperative mortality was 1.2% (1/82), and complications, unassociated with regimen or histology, were atelectasis (26.8%) and supraventricular arrhythmias (13.4%). Right-sided procedures appeared to increase the incidence of bronchopleural fistula (P =0.073). The median disease-free survival time was 18 months and median overall survival time was not reached. Disease-free survival rates at one, two, and three years were 54%, 47%, and 33%, while the overall survival rate was 73%, 69%, and 59%, respectively. Disease-free survival predictors were radiographic response and mediastinal lymphadenopathy before chemotherapy (P =0.012 and 0.002, respectively). Conclusions Two cycles of platinum-based chemotherapy with gemcitabine or paclitaxel is efficacious for patients with stage IIB-IIIA central disease. Patients achieving clinical response had improved disease-free survival times, while those with mediastinal lymphadenopathy had a higher postoperative recurrence risk.
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Affiliation(s)
- Chao Lv
- Department of Thoracic Surgery II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Peking, China
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49
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Broderick SR, Patterson GA. Performance of integrated positron emission tomography/computed tomography for mediastinal nodal staging in non-small cell lung carcinoma. Thorac Surg Clin 2013; 23:193-8. [PMID: 23566971 DOI: 10.1016/j.thorsurg.2013.01.014] [Citation(s) in RCA: 14] [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
Integrated positron emission tomography (PET)/CT is routinely used for mediastinal nodal staging of non-small cell lung carcinoma in centers throughout the world. This modality is the most accurate noninvasive means by which to identify metastatic disease in mediastinal lymph nodes. This article reviews the evidence supporting the use of PET/CT and discusses the clinical applicability of this modality.
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Affiliation(s)
- Stephen R Broderick
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, 3108 Queeny Tower, One Barnes-Jewish Hospital Plaza, St Louis, MO 63110-1013, USA.
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50
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Abstract
It can be difficult to determine whether a patient with more than a single, "solid" lung nodule suspicious for malignancy is suffering from synchronous primary tumors or intrapulmonary metastasis. For this reason, if resection can be performed an aggressive approach is often warranted after demonstrating no mediastinal nodal disease. Increasing evidence suggests that the survival of a patient with a single, invasive lepidic-predominant adenocarcinoma depends on the stage of the invasive tumor, not on the presumed multiple in situ tumors. A suggested clinical approach to each of these types of multifocal tumors, solid and lepidic, is proposed in this article.
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Affiliation(s)
- Joseph B Shrager
- Division of Thoracic Surgery, VA Palo Alto Healthcare System, Stanford Medical Center, Stanford University School of Medicine, 300 Pasteur Drive, 2nd Floor, Falk Building, Stanford, CA 94305-5407, USA.
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