Diagnostic performance of endobronchial ultrasound-guided mediastinal lymph node sampling in early stage non-small cell lung cancer: A prospective study

Invasive Nodal Staging via Endobronchial Ultrasound and Outcome in Patients Treated with Stereotactic Body Radiation Therapy for Early-Stage Non-Small Cell Lung Cancer - Results from a Single Institution Study

INTRODUCTION

Stereotactic body radiation therapy (SBRT) is an effective treatment for medically inoperable early-stage non-small cell lung cancer (NSCLC). The prognostic value of invasive nodal staging (INS) for patients undergoing SRBT has not been studied extensively. Herein, we report the impact of INS in addition to 18F-FDG-PET on treatment outcome for patients with NSCLC undergoing SBRT.

MATERIALS AND METHODS

Patients with stage I/ II NSCLC who underwent SBRT were included with IRB approval. Clinical, dosimetric, and radiological data were obtained. Overall survival (OS), regional recurrence free survival (RRFS), local recurrence free survival (LRFS), and distant recurrence free survival (DRFS) were analyzed using Kaplan Meyer method. Univariable analysis (UVA) and multivariable analysis (MVA) were performed to assess the relationship between the variables and the outcomes.

RESULTS

A total of 376 patients were included in the analysis. Median follow up was 43 months (IQ 32.6-45.8). Median OS, LRFS, RRFS, DRFS were 40, 32, 32, 33 months, respectively. The 5-year local, regional, and distant failure rates were 13.4%, 23.5% and 25.3%, respectively. The 1-year, 3-year and 5-year OS were 83.8%, 55.6%, and 36.3%, respectively. On MVA, INS was not a predictor of either improved overall or any recurrence free survival endpoints while larger tumor size, age, and adjusted Charleston co-morbidity index (aCCI) were significant for inferior LRFS, RRFS, and DRFS.

CONCLUSION

Invasive nodal staging did not improve overall or recurrence free survival among patients with early-stage NSCLC treated with SBRT whereas older age, aCCI, and larger tumor size were significant predictors of LRFS, RRFS, and DRFS.

An accurate prediction of negative lymph node metastasis with consideration of glucose metabolism in early-stage non-small cell lung cancer

OBJECTIVE

We aimed to identify risk factors in lymph node metastasis in early-stage non-small cell lung cancer (NSCLC) and predict lymph node metastasis.

METHODS

A total of 416 patients with clinical stage IA2-3 NSCLC who underwent lobectomy and lymph node dissection between July 2016 and December 2020 at National Cancer Center Hospital East were included. Multivariable logistic regression was performed to develop a model for predicting lymph node metastasis. Leave-one-out cross-validation was performed to evaluate the developing prediction model, and sensitivity, specificity, and concordance statistics were calculated to evaluate its diagnostic performance.

RESULTS

The formula for calculating the probability of pathological lymph node metastasis included SUVmax of the primary tumor and serum CEA level. The concordance statistics was 0.7452. When the cutoff value associated with the risk of incorrectly predicting pathological lymph node metastasis was 7.2%, the diagnostic sensitivity and specificity for predicting metastasis were 96.4% and 38.6%, respectively.

CONCLUSIONS

We created a prediction model for lymph node metastasis in NSCLC by combining the SUVmax of the primary tumor and serum CEA levels, which showed a particularly strong association. This model is clinically useful as it successfully predicts negative lymph node metastasis in patients with clinical stage IA2-3 NSCLC.

Meeting the New Commission on Cancer Operative Standards: Where Do We Stand Now?

INTRODUCTION

The 2020 Commission on Cancer accreditation standards 5.7 and 5.8 address total mesorectal excision for rectal cancer and lymph node sampling for lung cancer. The purpose of this review was to assess our institution's compliance with these operative standards, which will be required in 2022 and 2023, and provide recommendations to other military training facilities seeking to comply with these standards.

MATERIALS AND METHODS

A 2018-2020 single institution chart review was performed of operative and pathology reports. Identified deficits were addressed in meetings with colorectal and thoracic surgery leadership, and cases were followed to reassess compliance.

RESULTS

A total of 12 rectal and 48 lung cancer cases met the inclusion criteria and were examined. Pre-intervention compliance for standards 5.7 and 5.8 was 58% and 35%, respectively, because of inadequate synoptic reporting and lymph node sampling. After intervention, compliance was 100%.

CONCLUSIONS

Our institution requires changes to comply with new standards, including in areas of documentation and systematic pulmonary lymph node sampling. We provide lessons learned from our own institutional experience, including practical tips and recommendations to achieve compliance. All military training facilities performing lung and rectal oncologic resections should conduct an internal review of applicable cases in preparation for upcoming American College of Surgeons Commission on Cancer site visits.

Portrayal of video-assisted mediastinoscopic lymphadenectomy's range subsequent to its simultaneous use with uniportal VAT-lobectomy for left-sided NSCLC: a case-based perspective

BACKGROUND

Video-assisted mediastinoscopic lymphadenectomy (VAMLA) is the most precise approach combining staging and therapeutic interventions in non-small cell lung cancer (NSCLC). In the case of left-sided NSCLC, the likelihood of mediastinal lymph node metastases depends on the involvement of the left lung regional lymphatic network. As such, it appears obvious - at least for selected patients with mediastinal staging by either PET-CT or EBUS-TBNA ± EUS-FNA and with cN ≤ 2 - to merge VAMLA and left-sided video-assisted thoracoscopic (VAT) lobectomy for a single-stage therapeutical procedure.

CASE PRESENTATION

We present the clinical course of an 83-year-old patient following simultaneous VAMLA and VAT-lobectomy for invasive mucinous adenocarcinoma of the left upper lobe with a provisional cT3cN0cM0 stage. The patient developed a clinically relevant postoperative pneumothorax due to a persistent parenchymal air leak. CT scan revealed a substantial pneumomediastinum and showed the capability of VAMLAs range for mediastinal lymph node dissection in a unique way. Following the prompt insertion of a second chest tube, the situation was stabilized with an unremarkable further in-hospital stay. The patient remains free of tumor recurrence or distant metastases at a one-year follow-up.

CONCLUSION

Presenting this aperçu, we encourage reviving the debate on (1) precise mediastinal staging in general and (2) VAMLA's important role as a diagnostic and therapeutic tool.

Artificial intelligence-based radiomics for the prediction of nodal metastasis in early-stage lung cancer

We aimed to investigate the value of computed tomography (CT)-based radiomics with artificial intelligence (AI) in predicting pathological lymph node metastasis (pN) in patients with clinical stage 0-IA non-small cell lung cancer (c-stage 0-IA NSCLC). This study enrolled 720 patients who underwent complete surgical resection for c-stage 0-IA NSCLC, and were assigned to the derivation and validation cohorts. Using the AI software Beta Version (Fujifilm Corporation, Japan), 39 AI imaging factors, including 17 factors from the AI ground-glass nodule analysis and 22 radiomics features from nodule characterization analysis, were extracted to identify factors associated with pN. Multivariate analysis showed that clinical stage IA3 (p = 0.028), solid-part size (p < 0.001), and average solid CT value (p = 0.033) were independently associated with pN. The receiver operating characteristic analysis showed that the area under the curve and optimal cut-off values of the average solid CT value relevant to pN were 0.761 and -103 Hounsfield units, and the threshold provided sensitivity, specificity, and negative predictive values of 69%, 65%, and 94% in the entire cohort, respectively. Measuring the average solid-CT value of tumors for pN may have broad applications such as guiding individualized surgical approaches and postoperative treatment.

Systematic endoscopic staging of mediastinum to determine impact on radiotherapy for locally advanced lung cancer (SEISMIC): protocol for a prospective single arm multicentre interventional study

Background

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is established as the preferred method of mediastinal lymph node (LN) staging in non-small cell lung cancer (NSCLC). Selective (targeted) LN sampling is most commonly performed however studies in early stage NSCLC and locally advanced NSCLC confirm systematic EBUS-TBNA evaluation improves accuracy of mediastinal staging. This study aims to establish the rate of detection of positron emission tomography (PET)-occult LN metastases following systematic LN staging by EBUS-TBNA, and to determine the utility of systematic mediastinal staging for accurate delineation of radiation treatment fields in patients with locally advanced NSCLC.

Methods

Consecutive patients undergoing EBUS-TBNA for diagnosis/staging of locally advanced NSCLC will be enrolled in this international multi-centre single arm study. Systematic mediastinal LN evaluation will be performed, with all LN exceeding 6 mm to be sampled by TBNA. Where feasible, endoscopic ultrasound staging (EUS-B) may also be performed. Results of minimally invasive staging will be compared to FDG-PET. The primary end-point is proportion of patients in whom systematic LN staging identified PET-occult NSCLC metastases. Secondary outcome measures include (i) rate of nodal upstaging, (ii) false positive rate of PET for mediastinal LN assessment, (iii) analysis of clinicoradiologic risk factors for presence of PET-occult LN metastases, (iv) impact of systematic LN staging in patients with discrepant findings on PET and EBUS-TBNA on target coverage and dose to organs at risk (OAR) in patients undergoing radiotherapy.

Discussion

With specificity of PET of 90%, guidelines recommend tissue confirmation of positive mediastinal LN to ensure potentially early stage patients are not erroneously denied potentially curative resection. However, while confirmation of pathologic LN is routinely sought, the exact extent of mediastinal LN involvement in NSCLC in patient with Stage III NSCLC is rarely established. Studies examining systematic LN staging in early stage NSCLC report a significant discordance between PET and EBUS-TBNA. In patients with locally advanced disease this has significant implications for radiation field planning, with risk of geographic miss in the event of PET-occult mediastinal LN metastases. The SEISMIC study will examine both diagnostic outcomes following systematic LN staging with EBUS-TBNA, and impact on radiation treatment planning.

Trial registration

ACTRN12617000333314, ANZCTR, Registered on 3 March 2017.

Mediastinal Staging with Endobronchial Ultrasound in Early-Stage Non-Small Cell Lung Cancer: Is It Necessary?

Herein we examine the need for minimally invasive mediastinal staging for patients with early-stage non-small cell lung cancer (NSCLC) using endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Early NSCLC, stages 1 and 2, has a 5-year survival rate between 53 and 92%, whereas stages 3 and 4 have a 5-year survival of 36% and below. With more favorable outcomes in earlier stages, greater emphasis has been placed on identifying lung cancer earlier in its disease process. Accurate staging is crucial as it dictates both prognosis and therapy. Inaccurate staging can adversely impact surgical candidacy (if falsely "over-staged") or lead to inadequate treatment (if "under-staged"). Clinical staging utilizes noninvasive methods to evaluate the anatomic extent of disease; however, it remains controversial whether mediastinal staging of early NSCLC with radiological exams alone is sufficient. EBUS-TBNA has altered the landscape of invasive mediastinal staging and is a crucial component to improving confidence in lung cancer staging, specifically in early NSCLC. Radiographic occult lymph node metastasis identified upon review of surgical resection specimens of early NSCLC may support the argument to perform EBUS-TBNA in all cases of early-stage disease. Other data suggest that EBUS-TBNA could be spared in cases of peripheral cT1aN0 and cT1bN0 for which surgical resection with lymph node dissection is planned. By reviewing reported EBUS-TBNA outcomes in patients with early NSCLC, we aim to emphasize the necessity of staging with EBUS in this population.

A narrative review of deep learning applications in lung cancer research: from screening to prognostication

Background and Objective

Deep learning (DL) algorithms have been developed for various tasks, including lung nodule detection on chest radiographs or lung cancer computed tomography screening, potential candidate selection in lung cancer screening, malignancy prediction for indeterminate pulmonary nodules, lung cancer staging, treatment response prediction, prognostication, and prediction of genetic mutations in lung cancer. Furthermore, these DL algorithms have been applied in various clinical settings in order for them to be generalized in real-world clinical practice. Multiple DL algorithms have been corroborated to be on par with experts or current clinical prediction models for several specific tasks. However, no article has yet comprehensively reviewed DL algorithms dedicated to lung cancer research. This narrative review presents an overview of the literature dealing with DL techniques applied in lung cancer research and briefly summarizes the results according to the DL algorithms’ clinical use cases.

Methods

we performed a narrative review by searching the Embase and OVID-MEDLINE databases for articles published in English from October, 2016 until September, 2021 and reviewing the bibliographies of key references to identify important literature related to DL in lung cancer research. The background, development, results, and clinical implications of each DL algorithm are briefly discussed. Lastly, we end this review article by highlighting future directions in lung cancer research using DL techniques.

Key Content and Findings

DL algorithms have been introduced to show comparable or higher performance than human experts in various clinical settings. Specifically, they have been actively applied to detect lung nodules in chest radiographs or computed tomography (CT) examinations, optimize candidate selection for lung cancer screening (LCS), predict the malignancy of lung nodules, stage lung cancer, and predict treatment response, patients’ prognoses, and genetic mutations in lung cancers.

Conclusions

DL algorithms have corroborated their potential value for various tasks, ranging from lung cancer screening to prognostication of lung cancer patients. Future research is warranted for the clinical application of these algorithms in daily clinical practice and verification of their real-world clinical usefulness.

Mediastinal Nodal Staging Performance of Combined Endobronchial and Esophageal Endosonography in Lung Cancer Cases: A Systematic Review and Meta-Analysis

By searching lliteratures till January 5, 2022, we evaluated the role of the mediastinal nodal staging of endobronchial ultrasound-guided fine-needle aspiration (EBUS) and endoscopic ultrasound-guided fine-needle aspiration (EUS) in lung cancer. A total of 20 studies with 2,961 patients were included in this study. The pooled sensitivity, specificity, PLR, and NLR for EBUS were 0.79, 0.97, 27.29, and 0.25, respectively. EUS showed staging performance similar to EBUS. The staging performance was significantly improved when combining EBUS + EUS.

Endoscopic nodal staging in oligometastatic non-small cell lung cancer (NSCLC) being treated with stereotactic ablative radiotherapy (ENDO-SABR)

Background

Research in treatment of non-small cell lung cancer (NSCLC) has shown promising results with stereotactic ablative radiotherapy (SABR) of oligometastatic disease, wherein distant disease may be limited to one or a few distant organs by host factors. Traditionally, PET/CT has been used in detecting metastatic disease and avoiding futile surgical intervention, however, sensitivity and specificity is limited to only 81 and 79%, respectively. Mediastinal staging still identifies occult nodal disease in up to 20% of NSCLC patients initially thought to be operative candidates. Endobronchial ultrasound and transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive tool for the staging and diagnosis of thoracic malignancy. When EBUS is combined with endoscopic ultrasound using the same bronchoscope (EUS-B), the diagnostic sensitivity and negative predictive value increase to 84 and 97%, respectively. Endoscopic staging in patients with advanced disease has never been studied, but may inform treatment if a curative SABR approach is being taken.

Methods

This is a multi-centre, prospective, cohort study with two-stage design. In the first stage, 10 patients with oligometastatic NSCLC (lung tumour ± hilar/mediastinal lymphadenopathy) with up to 5 synchronous metastases will be enrolled An additional 19 patients will be enrolled in the second stage if rate of treatment change is greater than 10% in the first stage. Patients will be subject to EBUS or combined modality EBUS/EUS-B to assess bilateral lymph node stations using a N3 to N2 to N1 progression. Primary endpoint is defined as the rate of change to treatment plan including change from SABR to conventional dose radiation, change in mediastinal radiation field, and change from curative to palliative intent treatment.

Discussion

If a curative approach with SABR for oligometastatic disease is being explored, invasive mediastinal staging may guide treatment and prognosis. This study will provide insight into the use of endoscopic mediastinal staging in determining changes in treatment plan of NSCLC. Results will inform the design of future phase II trials.

Trial registration

Clinicaltrials.gov identifier NCT04852588. Date of registration: April 19, 2021. Protocol version: 1.1 on December 9, 2021.

Confirmatory Mediastinoscopy after Negative EBUS-TBNA for Mediastinal Staging of Lung Cancer: Systematic Review and Meta-analysis

RATIONALE

Current guidelines of non-small cell lung cancer (NSCLC) mediastinal staging recommend starting invasive staging with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). However, the indication to confirm a negative result of EBUS-TBNA by means of video-assisted mediastinoscopy (VAM) prior to resection differs in every guideline.

OBJECTIVE

Our aim was to evaluate the current evidence regarding the added value of confirmatory VAM after a negative EBUS-TBNA for mediastinal staging in patients with NSCLC.

METHODS

Systematic searches of studies on EBUS-TBNA for NSCLC mediastinal staging with or without confirmatory VAM but with surgical confirmation of negative results were conducted in accordance with PRISMA statement in PubMed, SCOPUS, Cochrane and Guidelines from 2005 through November 2021. In the meta-analysis the sensitivity of confirmatory VAM after a negative EBUS-TBNA, the sensitivity and negative predictive value (NPV) of the combination EBUS-TBNA plus confirmatory VAM, alongside the number of confirmatory VAM required to detect additional N2/3 disease (number needed to treat [NNT]), in patients with a previous negative EBUS-TBNA were estimated.

RESULTS

5412 articles were found, of which 29 studies were included. Random effects meta-analysis showed a sensitivity of 66.9% (95% CI: 55.8%-77.1%) for confirmatory VAM, and 96.7% (95% CI: 95.1%- 98%) for the combination EBUS-TBNA plus confirmatory VAM. NPV in studies with confirmatory VAM increased of 79.2% (95% CI: 71.4%-86.1%) for EBUS-TBNA alone to 91.8% (95% CI: 87.1%-95.5%) for EBUS-TBNA plus confirmatory VAM. The NNT of confirmatory VAM in patients with a previous negative EBUS-TBNA was 23.8 (95% CI: 19.3-31.2) CONCLUSIONS: Confirmatory VAM after negative EBUS-TBNA reduces the rate of unforeseen N2/3 disease, but with a high NNT, and should be recommended only to certain cases yet to be defined.

Predicting pathological lymph node status in clinical stage IA peripheral lung adenocarcinoma

OBJECTIVES

Even with current diagnostic technology, it is difficult to accurately predict pathological lymph node status (PLNS). This study aimed to develop a prediction model of PLNS in peripheral adenocarcinoma with a dominant solid component, based on clinical and radiological factors on thin-section computed tomography, to identify patients to whom wedge resection or other local therapies could be applied.

METHODS

Of 811 patients enrolled in a prospective multi-institutional study (JCOG0201), 420 patients with clinical stage IA peripheral lung adenocarcinoma having a dominant solid component were included. Multivariable logistic regression was performed to develop a model based on clinical and centrally reviewed radiological factors. Leave-one-out cross-validation and external validation analyses were performed, using independent data from 221 patients. Sensitivity, specificity and concordance statistics were calculated to evaluate diagnostic performance.

RESULTS

The formula for calculating the probability of pathological lymph node metastasis included the following variables: tumour diameter (including ground-glass opacity), consolidation-to-tumour ratio and density of solid component. The concordance statistic was 0.8041. When the cut-off value associated with the risk of incorrectly predicting negative pathological lymph node metastasis (pN-) was 4.9%, diagnostic sensitivity and specificity in predicting PLNS were 95.7% and 46.0%, respectively. The concordance statistic for the external validation set was 0.7972, and diagnostic sensitivity and specificity in predicting PLNS were 95.4% and 40.5%, respectively.

CONCLUSIONS

The proposed model is clinically useful and successfully predicts pN- in patients with clinical stage IA peripheral lung adenocarcinoma with a dominant solid component.

Training in interventional pulmonology: the European and US perspective

As the breadth of interventional pulmonology continues to expand, training in this discipline gains further importance. Interventional pulmonology training in the USA and Europe has common roots and similar concepts; however, there are variations in its delivery. We discuss the similarities, differences, challenges and goals of interventional pulmonology training in both continents. Collaboration and exchange of experiences between the USA and Europe are fundamental to entering the new era of competency/mastery training to implement a multidimensional approach to procedure-related education.

Occult lymph node metastasis in radiologic stage I non-small cell lung cancer: The role of endobronchial ultrasound

RATIONALE

The use of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is currently recommended for staging non-small cell lung cancer (NSCLC) in centrally located tumors, tumors >3 cm, or with radiologic evidence of lymph node (LN) metastasis. Current guidelines do not recommend staging EBUS-TBNA in patients with stage I NSCLC who do not have any of the aforementioned conditions.

OBJECTIVE

We hypothesize that using EBUS-TBNA is useful for detecting occult metastasis in radiologic stage I NSCLC.

METHODS

In this single-center, retrospective study, charts of patients ≥18 years old who underwent staging EBUS-TBNA from January 2005 to May 2019 were reviewed. Only patients with combined positron-emission tomography and computed tomography (PET/CT) scans consistent with radiologic stage I NSCLC were included. Identified variables included: age, gender, personal history of any cancer, smoking history, tumor location, tumor centrality, tumor size, tumor PET activity, histopathologic type of NSCLC, and LN biopsy results. Patients whose LN samples showed a diagnosis other than NSCLC were excluded. The association between LN positivity, and each of the variables was assessed using Pearson's correlation for categorical variables, and logistic regression analysis for continuous variables.

RESULTS

From the 2,892 initially screened patients, 188 were included. Of those, 13 (6.9%; 95% CI, 4%-11%) had a malignancy-positive LN biopsy. The number needed to test (NNT) in order to detect one case of any occult metastasis was 15. Among the included variables, a significant association was found between LN positivity and tumor centrality, with central tumors found in 61.5% of patients with positive LN (n = 8) (p < 0.01). This association stayed significant after adjusting for age, gender, smoking history, tumor size, tumor location, and PET activity (p = 0.015). Among patients with malignancy-positive LN biopsies, five (38.5%; 95% CI, 17.6%-64.6%) were upstaged to N1, and eight (61.5%; 95% CI, 35.4%-82.4%) were upstaged to N2, with NNT of 23 to detect one case of occult N2 metastasis. Subgroup analysis comparing LN-positive patients based on their N stage did not show statistically significant association with any of the variables.

CONCLUSION

Based on our results and along with the existing evidence, EBUS-TBNA should be recommended as part of the routine staging in all patients with radiologic stage I NSCLC.

A PET/CT nomogram incorporating SUVmax and CT radiomics for preoperative nodal staging in non-small cell lung cancer

Objectives

To develop and validate a PET/CT nomogram for preoperative estimation of lymph node (LN) staging in patients with non-small cell lung cancer (NSCLC).

Methods

A total of 263 pathologically confirmed LNs from 124 patients with NCSLC were retrospectively analyzed. Positron-emission tomography/computed tomography (PET/CT) examination was performed before treatment according to the clinical schedule. In the training cohort (N = 185), malignancy-related features, such as SUVmax, short-axis diameter (SAD), and CT radiomics features, were extracted from the regions of LN based on the PET/CT scan. The Minimum-Redundancy Maximum-Relevance (mRMR) algorithm and the Least Absolute Shrinkage and Selection Operator (LASSO) regression model were used for feature selection and radiomics score building. The radiomics score (Rad-Score) and SUVmax were incorporated in a PET/CT nomogram using the multivariable logistic regression analysis. The performance of the proposed model was evaluated with discrimination, calibration, and clinical application in an independent testing cohort (N = 78).

Results

The radiomics scores consisting of 14 selected features were significantly associated with LN status for both training cohort with AUC of 0.849 (95% confidence interval (CI), 0.796–0.903) and testing cohort with AUC of 0.828 (95% CI, 0.782–0.919). The PET/CT nomogram incorporating radiomics score and SUVmax showed moderate improvement of the efficiency with AUC of 0.881 (95% CI, 0.834–0.928) in the training cohort and AUC of 0.872 (95% CI, 0.797–0.946) in the testing cohort. The decision curve analysis indicated that the PET/CT nomogram was clinically useful.

Conclusion

The PET/CT nomogram, which incorporates Rad-Score and SUVmax, can improve the diagnostic performance of LN metastasis.

Key Points

• The PET/CT nomogram (Int-Score) based on lymph node (LN) PET/CT images can reliably predict LN status in NSCLC.

• Int-Score is a relatively objective diagnostic method, which can play an auxiliary role in the process of clinicians making treatment decisions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-020-07624-9.

Predictors of mediastinal staging and usefulness of pet in patients with stage IIIA (N2) or IIIB (N3) lung cancer

OBJECTIVE

To analyze which factors predict mediastinal N2/N3 lymph node staging and diagnostic accuracy of PET and CT to determine it.

PATIENTS AND METHODS

We analyzed data collected prospectively in a database that included patients with non-small cell lung cancer (NSCLC) who underwent EBUS-TBNA. Prior to EBUS-TBNA, CT and PET were used to define the radiographic N stage and lymph nodes with short axis ≥ 1 cm by CT or with ratio between maximum standardized uptake value (maxSUV), by PET, of lymph node and primary tumor greater than 0.56, were considered pathological. Definitive lymph node staging was established through EBUS-TBNA, mediastinoscopy or surgical lymph node dissection.

RESULTS

One hundred and thirty four patients were included, in 88 of whom (65.6%), definitive lymph node staging was N2 or N3. Primary tumor of central location, lymph node size, maxSUV of lymph node and radiographic N stage by CT or PET were associated with N2/N3 in univariate analysis, but in logistic regression model it was only independently related with N stage by CT or PET. Negative predictive value and positive predictive value of CT were 0.81 and 0.74, respectively, and for PET 0.78 and 0.68.

CONCLUSION

In NSCLC, in locoregional disease radiographic staging by CT or PET predict the existence of N2/N3 mediastinal disease, but negative and positive predictive values of both imaging techniques are not adequate, so EBUS-TBNA samples should be taken in all lymph nodes with a diameter greater than 5 mm, regardless of PET findings.

Occult lymph node metastases in clinical N0/N1 NSCLC; A single center in-depth analysis

OBJECTIVES

Lymph node staging in patients with non-small cell lung cancer is crucial for determining prognosis and treatment. Our objective was to evaluate the clinical- to pathological agreement of guideline-concordant nodal staging in patients with resectable NSCLC and assess occurrence and distribution of occult lymph node metastases (OLM).

MATERIALS AND METHODS

In a retrospective single center cohort study (n = 390), we analyzed all surgically treated NSCLC patients from January 2015 until April 2019. Patients were classified into sub-groups (1) mediastinal staging by PET-CT/CT-scan (IMAGE-group) or (2) invasive staging by endobronchial ultrasound and mediastinoscopy (INVAS-group). Agreement between final clinical (cN) and pathological nodal stage (pN) and the presence and location of OLM are analyzed.

RESULTS

Agreement between cN- and pN-stage was 86.3 % in the IMAGE-group (n = 117) and 50.9 % in the INVAS-group (n = 167). Occult N1 disease was found in 33 patients (16.6 % in cN0) of which 52 % occurred in LN-regions 12-14. Occult N2 disease was found in 20 cases (6.5 % in cN0 and 12.7 % in cN1). Combined, 23.1 % of all pre-operatively cN0-staged patients (n = 46/199) had OLM (pN+), of which 12.1 % (24/199) had metastases in regions 5-6 and/or 12-14. Of all patients with OLM, 50.0 % (23/46) had primary tumors ≤30 mm.

CONCLUSION

OLM are frequently identified in clinically N0/N1 NSCLC, also in tumors <3 cm, and often in regions beyond reach of current staging techniques. These findings should be addressed when non-surgical treatment or sub-lobar resections are considered for early stage lung cancer.

Endobronchial ultrasound- guided transbronchial needle aspiration for mediastinal lymph node staging in patients with typical pulmonary carcinoids

BACKGROUND

Pulmonary carcinoids, which are well-differentiated lung neuroendocrine carcinomas, account for only 1-2 % of primary lung malignancies. Although fluorodeoxyglucose positron-emission tomography/computed tomography performs poorly in the identification of mediastinal lymph node metastases, particularly for pulmonary carcinoids, endobronchial ultrasound-guided (EBUS) transbronchial needle aspiration (TBNA) may be a useful means of preoperative nodal assessment in patients with these conditions. However, the diagnostic performance of EBUS TBNA is unknown. This study was designed to determine the sensitivity of EBUS for mediastinal staging in patients with typical carcinoid.

STUDY DESIGN AND METHODS

A retrospective review of all patients with carcinoids who underwent EBUS TBNA and/or surgical resection with lymphadenectomy at The University of Texas MD Anderson Cancer Center was performed. The sensitivity of EBUS -TBNA in diagnosis of mediastinal lymph node metastases was determined.

RESULTS

Of the 212 patients with pulmonary carcinoids we identified, 137 had surgery with no preoperative EBUS TBNA, 68 had EBUS TBNA followed by surgery, and 7 had EBUS TBNA only. The sensitivity rate for EBUS TBNA in diagnosis of mediastinal lymph node metastases was 77.78 % overall (95 % CI, 57.7-91.3%) and it was 87.5 % (95 % CI, 67.6-97.3%) when we considered only patients with EBUS TBNA-accessible lymph nodes.

DISCUSSION

The sensitivity of EBUS TBNA for diagnosis of mediastinal lymph node metastases of pulmonary carcinoids was slightly lower than that reported previously for non-small cell lung cancer. Preoperative EBUS TBNA identified nodal metastases not previously identified by imaging.

Recent Advances in Interventional Pulmonology

The field of interventional pulmonology has grown rapidly since first being defined as a subspecialty of pulmonary and critical care medicine in 2001. The interventional pulmonologist has expertise in minimally invasive diagnostic and therapeutic procedures involving airways, lungs, and pleura. In this review, we describe recent advances in the field as well as up-and-coming developments, chiefly from the perspective of medical practice in the United States. Recent advances include standardization of formalized training, new tools for the diagnosis and potential treatment of peripheral lung nodules (including but not limited to robotic bronchoscopy), increasingly well-defined bronchoscopic approaches to management of obstructive lung diseases, and minimally invasive techniques for maximizing patient-centered outcomes for those with malignant pleural effusion.

An International Survey of Mediastinal Staging Practices amongst Interventional Bronchoscopists

INTRODUCTION

In potentially curable non-small-cell lung cancer, different practice guidelines recommend invasive me-diastinal staging in tumors larger than 3 cm, central, or hy-permetabolic N1 lymph nodes. There is no consensus concerning the use of an endosonographic procedure or a mediastinoscopy in the first line in patients with a radiologically normal mediastinum, while in case of a mediastinal involvement, the latest European guidelines recommend the combination of endobronchial ultrasound (EBUS) and endoscopic ultrasound/endoscopic ultrasound with EBUS endoscope (EUS/EUS-B), using a systematic endosonographic procedure. This international survey was conducted to describe current medical practices in endoscopic mediastinal staging amongst interventional bronchoscopists.

METHODS

A survey was developed and sent to all members of different interventional pulmonology societies, with the purpose to describe who, when and how an endoscopic mediastinal staging was performed.

RESULTS

One hundred and fifty-three bronchoscopists responded to the survey. Most of them practiced in Europe (n = 84, 55%) and North America (n = 52, 34%). In the first line, EBUS alone was the most widely used endoscopic procedure for mediastinal staging. Half of the responders performed a systematic endoscopic staging procedure, including a systematic examination of all accessible nodal stations and a sampling of all lymph nodes >5 mm in the short axis at each station. A higher proportion of bronchoscopists who have completed a dedicated fellowship program performed systematic endoscopic mediastinal staging. Few endoscopists routinely perform combined EBUS/EUS(-B) for mediastinal staging and use the combination only in selected cases.

CONCLUSION

There are several areas of divergence between published guidelines and current practices reported by interventional bronchoscopists. EBUS alone is the most widely used endoscopic procedure for mediastinal staging in lung cancer, and a combined endoscopic approach is frequently omitted by the responders. A fellowship program appears to be associated with a higher rate of systematic endoscopic staging procedures.

Application of CT images in the diagnosis of lung cancer based on finite mixed model

Investigating the application of CT images when diagnosing lung cancer based on finite mixture model is the objective. Method: 120 clean healthy rats were taken as the research objects to establish lung cancer rat model and carry out lung CT image examination. After the successful CT image data preprocessing, the image is segmented by different methods, which include lung nodule segmentation on the basis of Adaptive Particle Swarm Optimization – Gaussian mixture model (APSO-GMM), lung nodule segmentation on the basis of Adaptive Particle Swarm Optimization – gamma mixture model (APSO-GaMM), lung nodule segmentation based on statistical information and self-selected mixed distribution model, and lung nodule segmentation based on neighborhood information and self-selected mixed distribution model. The segmentation effect is evaluated. Results: Compared with the results of lung nodule segmentation based on statistical information and self-selected mixed distribution model, the Dice coefficient of lung nodule segmentation based on neighborhood information and self-selected mixed distribution model is higher, the relative final measurement accuracy is smaller, the segmentation is more accurate, but the running time is longer. Compared with APSO-GMM and APSO-GaMM, the dice value of self-selected mixed distribution model segmentation method is larger, and the final measurement accuracy is smaller. Conclusion: Among the five methods, the dice value of the self-selected mixed distribution model based on neighborhood information is the largest, and the relative accuracy of the final measurement is the smallest, indicating that the segmentation effect of the self-selected mixed distribution model based on neighborhood information is the best.

Application of computed tomography, positron emission tomography-computed tomography, magnetic resonance imaging, endobronchial ultrasound, and mediastinoscopy in the diagnosis of mediastinal lymph node staging of non-small-cell lung cancer: A protocol for a systematic review

BACKGROUND

Ruling out distant metastases, non-small cell lung cancer (NSCLC)treatment depends on the results of mediastinal node staging (N staging). Several diagnostic methods play central roles in mediastinal N staging. This study is intended to evaluate the existing diagnostic methods and report quality, and to search for the best method for staging mediastinal lymph nodes.

METHODS

We searched PubMed, Embase, and the Cochrane Library to identify relevant studies, including randomized controlled trials and retrospective studies. These studies report the application of computed tomography, positron emission tomography-computed tomography, magnetic resonance imaging, endobronchial ultrasound, and mediastinoscopy in the diagnosis of mediastinal lymph node staging of NSCLC. The quality of the literature was assessed using the Quality Assessment of Diagnostic Accuracy Study 2. The true positive, false positive, true negative, and false negative of each study was extracted. The corresponding sensitivity, specificity, and other indicators were calculated and the Summary Receiver Operating curve was established. Then, head-to-head and indirect comparison meta-analyses will be conducted.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSION

This study will provide basis for mediastinal lymph node staging of non-small cell lung cancer.

PROSPERO REGISTRATION NUMBER

CRD42019145667.

A Prediction Model to Help with Oncologic Mediastinal Evaluation for Radiation: HOMER

Rationale: When stereotactic ablative radiotherapy is an option for patients with non-small cell lung cancer (NSCLC), distinguishing between N0, N1, and N2 or N3 (N2|3) disease is important.Objectives: To develop a prediction model for estimating the probability of N0, N1, and N2|3 disease.Methods: Consecutive patients with clinical-radiographic stage T1 to T3, N0 to N3, and M0 NSCLC who underwent endobronchial ultrasound-guided staging from a single center were included. Multivariate ordinal logistic regression analysis was used to predict the presence of N0, N1, or N2|3 disease. Temporal validation used consecutive patients from 3 years later at the same center. External validation used three other hospitals.Measurements and Main Results: In the model development cohort (n = 633), younger age, central location, adenocarcinoma, and higher positron emission tomography-computed tomography nodal stage were associated with a higher probability of having advanced nodal disease. Areas under the receiver operating characteristic curve (AUCs) were 0.84 and 0.86 for predicting N1 or higher (vs. N0) disease and N2|3 (vs. N0 or N1) disease, respectively. Model fit was acceptable (Hosmer-Lemeshow, P = 0.960; Brier score, 0.36). In the temporal validation cohort (n = 473), AUCs were 0.86 and 0.88. Model fit was acceptable (Hosmer-Lemeshow, P = 0.172; Brier score, 0.30). In the external validation cohort (n = 722), AUCs were 0.86 and 0.88 but required calibration (Hosmer-Lemeshow, P < 0.001; Brier score, 0.38). Calibration using the general calibration method resulted in acceptable model fit (Hosmer-Lemeshow, P = 0.094; Brier score, 0.34).Conclusions: This prediction model can estimate the probability of N0, N1, and N2|3 disease in patients with NSCLC. The model has the potential to facilitate decision-making in patients with NSCLC when stereotactic ablative radiotherapy is an option.

Is it necessary to sample the contralateral nodal stations by EBUS-TBNA in patients with lung cancer and clinical N0 / N1 on PET-CT?

OBJECTIVES

Systematic mediastinal staging (sampling all visible nodes measuring ≥ 5 mm from N3 station to N1, regardless of PET/CT (positron emission tomography/computed tomography) by endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a decisive step in patients with non-small cell lung cancer (NSCLC). We analyzed the prevalence of N3 disease and the utility of systematic staging in the subgroup of patients who underwent EBUS-TBNA staging without showing mediastinal lesions on the PET/CT (N0/N1).

MATERIAL AND METHODS

We conducted a retrospective analysis of a prospectively collected database that included 174 patients with a final diagnosis of NSCLC, with N0/N1 disease on PET/CT who underwent a systematic EBUS-TBNA staging.

RESULTS

174 consecutive patients were included. Systematic EBUS-TBNA detected N2 mediastinal involvement in 21 (12 %) cases, and no cases of N3 disease were detected (neither hilar nor mediastinal). Of the remaining 153 patients N0/N1 EBUS-TBNA, 122 underwent lung resection that revealed 4 cases of N2 disease while 117 were confirmed to be N0/N1. Thirty-three patients with N0/1 disease after EBUS-TBNA did not undergo surgery and were excluded for the NPV calculation. Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and overall accuracy of systematic EBUS was 84 %, 100 %, 96.7 %, 100 % and 97 % respectively.

CONCLUSION

Systematic EBUS-TBNA is a very accurate method for lymph node staging in patients with NSCLC without mediastinal involvement on PET/CT. Pending more studies, the absence of contralateral hilar nodal involvement in our series, questions the need for a contralateral hilar sampling in this subgroup of patients.

Computed Tomography Histogram Approach to Predict Lymph Node Metastasis in Patients With Clinical Stage IA Lung Cancer

BACKGROUND

Quantitative computed tomography (CT) histogram analysis of tumors is reported to help distinguish between invasive and less invasive lung cancers. This study aimed to clarify whether CT histogram analysis of tumors can be used to classify patients with clinical stage 0 to IA non-small cell lung cancer according to pathologic lymph node (pN) status.

METHODS

Predictive factors associated with pN metastasis were identified from the derivation dataset including 629 patients with clinical stage 0 to IA non-small cell lung cancer who underwent complete resection with lymph node dissection (surgeries between 2008 and 2013). The validation dataset including 238 patients (surgeries between 2014 and 2015) were subsequently reevaluated. Clinicosurgical factors, including CT histogram analysis of tumors (CT value percentiles 2.5, 25, 50, 75, and 97.5, skewness, and kurtosis) were assessed.

RESULTS

Seventy-three patients (12%) in the derivation cohort and 35 patients (15%) in the validation cohort had positive nodes. The pN status significantly affected survival in the entire population: 5-year overall survival of 93.1% vs 71.1% and 5-year disease-free survival of 85.9% vs 43.1% for negative vs positive (both P < .001). On multivariate analysis in the derivation cohort, the 75th percentile CT value (P < .001), age (P = .003), and comorbidities (P = .006) were significantly associated with pN metastasis. The area under the curve and the cutoff level of the 75th percentile CT value relevant to pN metastasis were 0.729 and 1.5 HU, respectively, and the threshold value provided accuracy of 71% for the validation cohort.

CONCLUSIONS

Histogram analysis of CT imaging metrics of tumors contributes to noninvasive prediction of pN metastasis in patients with clinical stage 0 to IA non-small cell lung cancer.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Diagnosis and Staging of Lung Cancer

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS TBNA) is fundamental to the diagnosis of lung cancer, as many patients present with more advanced stages of lung cancer, with enlarged hilar and mediastinal lymph nodes. It also represents a way to sample pulmonary masses directly to make the diagnosis, whereby no other accessible tissue is present and the mass sits adjacent to a large central airway. Very importantly also, EBUS TBNA is the widely accepted first procedure in lung cancer staging. A combined procedure of EUS TBNA can be performed to improve diagnostic accuracy.

18F-fluorodeoxyglucose positron emission tomography/computed tomography in the evaluation of clinically node-negative non-small cell lung cancer

One in four non-small cell lung cancer (NSCLC) patients are diagnosed at an early-stage. Following the results of the National Lung Screening Trial that demonstrated a survival benefit for low-dose computed tomography screening in high-risk patients, the incidence of early-stage NSCLC is expected to increase. Use of 18F-fluorodeoxyglucose positron emission tomography/computed tomography during initial diagnosis of these early-stage lesions has been increasing. Traditionally, positron emission tomography/computed tomography scans have been utilized for mediastinal nodal staging and to rule out distant metastases in suspected early-stage NSCLC. In clinically node-negative NSCLC, the use of sublobar resection and selective lymph node dissection has been increasing as a therapeutic option. The higher rate of locoregional recurrences after limited resection and the significant incidence of occult lymph node metastases underscores the need to further stratify clinically node-negative NSCLC in order to select patients for limited resection versus lobectomy with complete mediastinal lymph node dissection. In this report, we review the published data, and discuss the significance and potential role of 18F-fluorodeoxyglucose positron emission tomography/computed tomography evaluation for clinically node-negative NSCLC. Consequently, the literature review demonstrates that maximum standardized uptake value is a predictive factor for occult nodal metastasis with an accuracy of 55-77%. In addition, maximum standardized uptake value is a predictor for worse overall, as well as disease-free, survival.

Mediastinal staging by videomediastinoscopy in clinical N1 non-small cell lung cancer

Lung cancer is the number one cause of death due to cancer worldwide. According to the World Health Organization, it accounted for 1.69 million new cases in 2015, whereas in Europe, 20.8% of all deaths due to cancer (>266 000 cases) were attributable to lung cancer in 2011 [1, 2].

VAM(LA) has adequate sensitivity to be considered as the approach of choice for preoperative mediastinal staging in the subgroup of early-stage operable NSCLC patientshttp://ow.ly/42Wn30m78Zw

Prospective comparison of 18F-FDG PET/MRI and 18F-FDG PET/CT for thoracic staging of non-small cell lung cancer

OBJECTIVES

To compare the diagnostic performance of ¹⁸F-FDG PET/MRI and ¹⁸F-FDG PET/CT for primary and locoregional lymph node staging in non-small cell lung cancer (NSCLC).

METHODS

In this prospective study, a total of 84 patients (51 men, 33 women, mean age 62.5 ± 9.1 years) with histopathologically confirmed NSCLC underwent ¹⁸F-FDG PET/CT followed by ¹⁸F-FDG PET/MRI in a single injection protocol. Two readers independently assessed T and N staging in separate sessions according to the seventh edition of the American Joint Committee on Cancer staging manual for ¹⁸F-FDG PET/CT and ¹⁸F-FDG PET/MRI, respectively. Histopathology as a reference standard was available for N staging in all 84 patients and for T staging in 39 patients. Differences in staging accuracy were assessed by McNemars chi² test. The maximum standardized uptake value (SUV_max) and longitudinal diameters of primary tumors were correlated using Pearson's coefficients.

RESULTS

T stage was categorized concordantly in ¹⁸F-FDG PET/MRI and ¹⁸F-FDG PET/CT in 38 of 39 (97.4%) patients. Herein, ¹⁸F-FDG PET/CT and ¹⁸F-FDG PET/MRI correctly determined the T stage in 92.3 and 89.7% of patients, respectively. N stage was categorized concordantly in 83 of 84 patients (98.8%). ¹⁸F-FDG PET/CT correctly determined the N stage in 78 of 84 patients (92.9%), while ¹⁸F-FDG PET/MRI correctly determined the N stage in 77 of 84 patients (91.7%). Differences between ¹⁸F-FDG PET/CT and ¹⁸F-FDG PET/MRI in T and N staging accuracy were not statistically significant (p > 0.5, each). Tumor size and SUV_max measurements derived from both imaging modalities exhibited excellent correlation (r = 0.963 and r = 0.901, respectively).

CONCLUSION

¹⁸F-FDG PET/MRI and ¹⁸F-FDG PET/CT show an equivalently high diagnostic performance for T and N staging in patients suffering from NSCLC.

Present indications of surgical exploration of the mediastinum

Preoperative mediastinal staging is crucial in the management of patients with non-small cell lung cancer (NSCLC), especially to define prognosis and the most proper treatment. To obtain the highest certainty level before lung resection, the current American and European guidelines for preoperative mediastinal nodal staging for NSCLC recommend getting tissue confirmation of regional nodal spread in all cases except in patients with small (≤3 cm) peripheral carcinomas with no evidence of nodal involvement on computed tomography (CT) and positron emission tomography (PET). We have a wide variety of surgical methods for mediastinal staging that are well integrated in the current preoperative algorithms. Their main indication is the validation of negative results obtained by minimally invasive endoscopic techniques. However, recent studies have reported the superiority of mediastinoscopy over endosonography methods in terms of accuracy for those tumours classified as clinical (c) N0-1 by CT and PET or with intermediate risk of N2 disease (cN1 and central tumours). Apart from the exploration of the mediastinum, other surgical procedures [parasternal mediastinotomy, extended cervical mediastinoscopy (ECM) and video-assisted thoracoscopic surgery (VATS)] allow the completion of the staging process with the assessment of the primary tumour and metastasis, exploring the lung, pleural cavity, and pericardium when it is required. Transcervical lymphadenectomies represent the evolution of mediastinoscopy and they are already considered the most reliable method for mediastinal staging, mainly in the subgroup of patients in whom endosonography methods have a low sensitivity: tumours with normal mediastinum by CT and PET. In addition to their indication for staging, these procedures have also demonstrated to be feasible as preresectional lymphadenectomy in VATS lobectomy, improving the radicality of the number of lymph nodes and lymph node stations explored, mostly for left-sided tumours for which a complete mediastinal nodal dissection is not always possible by VATS approach.

Lung cancer staging: a concise update

Diagnosis and clinical staging of lung cancer are fundamental to planning therapy. The techniques for clinical staging, i.e anatomic and metabolic imaging, endoscopies and minimally invasive surgical procedures, should be performed sequentially and with an increasing degree of invasiveness. Intraoperative staging, assessing the magnitude of the primary tumour, the involved structures, and the loco-regional lymphatic spread by means of systematic nodal dissection, is essential in order to achieve a complete resection. In resected tumours, pathological staging, with the systematic study of the resected specimens, is the strongest prognostic indicator and is essential to make further decisions on therapy. In the present decade, the guidelines on lung cancer staging of the American College of Chest Physicians and the European Society of Thoracic Surgeons are based on the best available evidence and are widely followed. Recent advances in the classification of the adenocarcinoma of the lung, with the definition of adenocarcinoma in situ, minimally invasive adenocarcinoma and lepidic predominant adenocarcinoma, and the publication of the eighth edition of the tumour, node and metastasis classification of lung cancer, have to be integrated into the staging process. The present review complements the latest guidelines on lung cancer staging by providing an update of all these issues.

The role of positron emission tomography in the diagnosis, staging and response assessment of non-small cell lung cancer

Lung cancer is a common disease and the leading cause of cancer-related mortality, with non-small cell lung cancer (NSCLC) accounting for the majority of cases. Following diagnosis of lung cancer, accurate staging is essential to guide clinical management and inform prognosis. Positron emission tomography (PET) in conjunction with computed tomography (CT)-as PET-CT has developed as an important tool in the multi-disciplinary management of lung cancer. This article will review the current evidence for the role of ¹⁸F-fluorodeoxyglucose (FDG) PET-CT in NSCLC diagnosis, staging, response assessment and follow up.