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Craig C, Johnston J, Goodley P, Bishop P, Al-Najjar H, Brown L, Gallagher J, Sundar R, Upperton S, Callister M, Meek D, Succony L, Parvez W, Tufail M, Jayasekera G, Maclay J, Livesey A, Woolhouse I, Smith N, Bibby A, Evison M. What Is the Accuracy of Clinical Staging for Stage III-Single-station N2 NSCLC? A Multi-Centre UK Study. JTO Clin Res Rep 2024; 5:100694. [PMID: 39161961 PMCID: PMC11332836 DOI: 10.1016/j.jtocrr.2024.100694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 05/19/2024] [Accepted: 05/25/2024] [Indexed: 08/21/2024] Open
Abstract
Introduction Single-station N2 (ssN2) versus multi-station N2 has been used as a selection criterion for treatment recommendations between surgical versus non-surgical multimodality treatment in stage III-N2 NSCLC. We hypothesized that clinical staging would be susceptible to upstaging on pathologic staging and, therefore, challenge this practice. Methods A retrospective study of prospectively collected routine clinical data for patients with stage III-N2 NSCLC that had completed computed tomography (CT), positron emission tomography (PET), and staging endobronchial ultrasound (EBUS) and had been confirmed clinical stage III-ssN2 at multidisciplinary team discussion and went on to complete surgical resection as the first treatment to provide pathologic staging. The study was completed in two cohorts (A) across a single cancer alliance in England (Greater Manchester) January 1, 2015 to December 31, 2018 and (B) across five United Kingdom centers to validate the findings in part A January 1, 2016 to December 31, 2020. Results A total of 115 patients met the inclusion criteria across cohort A (56 patients) and cohort B (59 patients) across 15 United Kingdom hospitals. The proportion of cases in which clinical stage III-ssN2 was upstaged to pathologic stage III-multi-station N2 was 34% (19 of 56) in cohort A, 32% in cohort B (19 of 59), and 33% across the combined study cohort (38 of 115). Most patients had a single radiologically abnormal lymph node on CT and PET (88%, 105 of 115). In the majority, the reasons for missed N2 disease on staging EBUS were due to inaccessible (stations 5, 6, 8, 9) N2 nodes at EBUS (34%, 13 of 38) and accessible lymph nodes not sampled during staging EBUS as not meeting sampling threshold (40%, 15 of 38) rather than false-negative sampling during EBUS (26%, 10 of 38). Conclusions During multidisciplinary team discussions, clinicians must be aware that one-third of patients with stage III-ssN2 on the basis of CT, PET, and staging EBUS do not truly have ssN2 and this questions the use of this criterion to define treatment recommendations.
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Affiliation(s)
- Christopher Craig
- Lung Cancer & Thoracic Surgery Directorate, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Janet Johnston
- Lung Cancer & Thoracic Surgery Directorate, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Patrick Goodley
- Lung Cancer & Thoracic Surgery Directorate, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Paul Bishop
- Department of Thoracic Histopathology, Clinical Support Services, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Haider Al-Najjar
- Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Louise Brown
- North Manchester General Hospital, Manchester, United Kingdom
| | - Joanna Gallagher
- Macclesfield Hospital, East Cheshire NHS Trust, Macclesfield, United Kingdom
| | - Ramachandran Sundar
- Royal Albert Edward Infirmary, Wrightington, Wigan & Leigh NHS Foundation Trust, Wigan, United Kingdom
| | - Sara Upperton
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | | | - David Meek
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Laura Succony
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Wadood Parvez
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Muhammad Tufail
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Geeshath Jayasekera
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - John Maclay
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - Alana Livesey
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Ian Woolhouse
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | | | - Anna Bibby
- North Bristol NHS Trust, Bristol, United Kingdom
| | - Matthew Evison
- Lung Cancer & Thoracic Surgery Directorate, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Manchester Academic Health Science Centre (MAHSC), Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
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Ramos R, Moura CS, Costa M, Lamas NJ, Correia R, Garcez D, Pereira JM, Sousa C, Vale N. Enhancing Lung Cancer Care in Portugal: Bridging Gaps for Improved Patient Outcomes. J Pers Med 2024; 14:446. [PMID: 38793028 PMCID: PMC11121920 DOI: 10.3390/jpm14050446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/18/2024] [Accepted: 04/22/2024] [Indexed: 05/26/2024] Open
Abstract
Lung cancer has the highest incidence and cancer-related mortality worldwide. In Portugal, it ranks as the fourth most common cancer, with nearly 6000 new cases being diagnosed every year. Lung cancer is the main cause of cancer-related death among males and the third cause of cancer-related death in females. Despite the globally accepted guidelines and recommendations for what would be the ideal path for a lung cancer patient, several challenges occur in real clinical management across the world. The recommendations emphasize the importance of adequate screening of high-risk individuals, a precise tumour biopsy, and an accurate final diagnosis to confirm the neoplastic nature of the nodule. A detailed histological classification of the lung tumour type and a comprehensive molecular characterization are of utmost importance for the selection of an efficacious and patient-directed therapeutic approach. However, in the context of the Portuguese clinical organization and the national healthcare system, there are still several gaps in the ideal pathway for a lung cancer patient, involving aspects ranging from the absence of a national lung cancer screening programme through difficulties in histological diagnosis and molecular characterization to challenges in therapeutic approaches. In this manuscript, we address the most relevant weaknesses, presenting several proposals for potential solutions to improve the management of lung cancer patients, helping to decisively improve their overall survival and quality of life.
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Affiliation(s)
- Raquel Ramos
- PerMed Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal; (R.R.); (C.S.)
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
- Molecular Diagnostics Laboratory, Unilabs Portugal, Centro Empresarial Lionesa Porto, Rua Lionesa, 4465-671 Leça do Balio, Portugal; (M.C.); (N.J.L.)
| | - Conceição Souto Moura
- Pathology Laboratory, Unilabs Portugal, Rua Manuel Pinto de Azevedo 173, 4100-321 Porto, Portugal;
| | - Mariana Costa
- Molecular Diagnostics Laboratory, Unilabs Portugal, Centro Empresarial Lionesa Porto, Rua Lionesa, 4465-671 Leça do Balio, Portugal; (M.C.); (N.J.L.)
| | - Nuno Jorge Lamas
- Molecular Diagnostics Laboratory, Unilabs Portugal, Centro Empresarial Lionesa Porto, Rua Lionesa, 4465-671 Leça do Balio, Portugal; (M.C.); (N.J.L.)
- Anatomic Pathology Service, Pathology Department, Centro Hospitalar Universitário de Santo António (CHUdSA), Largo Professor Abel Salazar, 4099-001 Porto, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, Campus de Gualtar, University of Minho, Rua da Universidade, 4710-057 Braga, Portugal
| | - Renato Correia
- Technology & Innovation Department, Unilabs Portugal, Rua Manuel Pinto de Azevedo 173, 4100-321 Porto, Portugal; (R.C.); (D.G.)
| | - Diogo Garcez
- Technology & Innovation Department, Unilabs Portugal, Rua Manuel Pinto de Azevedo 173, 4100-321 Porto, Portugal; (R.C.); (D.G.)
| | - José Miguel Pereira
- Radiology Department, Unilabs Portugal, Rua de Diogo Botelho 485, 4150-255 Porto, Portugal;
| | - Carlos Sousa
- PerMed Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal; (R.R.); (C.S.)
- Molecular Diagnostics Laboratory, Unilabs Portugal, Centro Empresarial Lionesa Porto, Rua Lionesa, 4465-671 Leça do Balio, Portugal; (M.C.); (N.J.L.)
| | - Nuno Vale
- PerMed Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal; (R.R.); (C.S.)
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
- Department of Community Medicine, Health Information and Decision (MEDCIDS), Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
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Steinfort DP, Evison M, Witt A, Tsaknis G, Kheir F, Manners D, Madan K, Sidhu C, Fantin A, Korevaar DA, Van Der Heijden EHFM. Proposed quality indicators and recommended standard reporting items in performance of EBUS bronchoscopy: An official World Association for Bronchology and Interventional Pulmonology Expert Panel consensus statement. Respirology 2023; 28:722-743. [PMID: 37463832 DOI: 10.1111/resp.14549] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/28/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Since their introduction, both linear and radial endobronchial ultrasound (EBUS) have become an integral component of the practice of Pulmonology and Thoracic Oncology. The quality of health care can be measured by comparing the performance of an individual or a health service with an ideal threshold or benchmark. The taskforce sought to evaluate quality indicators in EBUS bronchoscopy based on clinical relevance/importance and on the basis that observed significant variation in outcomes indicates potential for improvement in health care outcomes. METHODS A comprehensive literature review informed the composition of a comprehensive list of candidate quality indicators in EBUS. A multiple-round modified Delphi consensus process was subsequently performed with the aim of reaching consensus over a final list of quality indicators and performance targets for these indicators. Standard reporting items were developed, with a strong preference for items where evidence demonstrates a relationship with quality indicator outcomes. RESULTS Twelve quality Indicators are proposed, with performance targets supported by evidence from the literature. Standardized reporting items for both radial and linear EBUS are recommended, with evidence supporting their utility in assessing procedural outcomes presented. CONCLUSION This statement is intended to provide a framework for individual proceduralists to assess the quality of EBUS they provide their patients through the identification of clinically relevant, feasible quality measures. Emphasis is placed on outcome measures, with a preference for consistent terminology to allow communication and benchmarking between centres.
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Affiliation(s)
- Daniel P Steinfort
- Department of Medicine, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Parkville, Victoria, Australia
- Department of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Matthew Evison
- Lung Cancer & Thoracic Surgery Directorate, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Ashleigh Witt
- Department of Medicine, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Parkville, Victoria, Australia
- Department of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Georgios Tsaknis
- Department of Respiratory Sciences, College of Life Sciences, University of Leicester, Leicester, UK
- Department of Respiratory Medicine, Kettering General Hospital, UK
| | - Fayez Kheir
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David Manners
- St John of God Midland Public and Private Hospitals, Midland, Western Australia, Australia
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
| | - Karan Madan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Calvin Sidhu
- School of Health Sciences, Edith Cowan University, Perth, Western Australia, Australia
| | - Alberto Fantin
- Department of Pulmonology, University Hospital of Udine (ASUFC), Udine, Italy
| | - Daniel A Korevaar
- Department of Respiratory Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- University of Amsterdam, Amsterdam, The Netherlands
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Evison M, Shackley D, Galligan-Dawson L. Regional single-queue scheduling platform for specialist diagnostics in the lung cancer pathway: accelerating cancer recovery from the COVID-19 pandemic. BMJ Open Respir Res 2022; 9:9/1/e001321. [PMID: 35902134 PMCID: PMC9340577 DOI: 10.1136/bmjresp-2022-001321] [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: 06/03/2022] [Accepted: 07/24/2022] [Indexed: 11/03/2022] Open
Abstract
Lung cancer is the single biggest cause of cancer death. The diagnostic pathway can be complex, including specialist cancer diagnostics that are not performed at every hospital. One such example is endobronchial ultrasound (EBUS), a day-case bronchoscopic procedure used for nodal staging and tissue diagnosis. In this proof-of-concept pilot in Greater Manchester, we tested a novel digital EBUS booking platform. This platform was accessible across multiple acute care trusts and provided visibility of all available EBUS appointments, allowing referring teams to book directly into the appropriate slot. During a 6-month pilot, 193 EBUS procedures were booked through this new single-queue platform. The median waiting times reduced by 2 days from 9 to 7 days (22% reduction and saving approximately 386 days in total) and reduced variation in waiting times by 1 day from 5 to 4 days (20% reduction). 98% of patients who completed an experience of care survey felt the process was 'very well' or 'well' organised and 77% felt the most important factor in deciding where to have their EBUS was the earliest possible appointment regardless of travel. This proof-of-concept pilot has shown improvements in cancer waiting times with significant future potential in delivering specialist cancer diagnostics.
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Affiliation(s)
- Matthew Evison
- Lung Cancer & Thoracic Surgery Directorate, Manchester University NHS Foundation Trust, Manchester, UK .,Greater Manchester Cancer Alliance, Manchester, UK
| | - David Shackley
- Greater Manchester Cancer Alliance, Greater Manchester Strategic Health Authority, Manchester, UK
| | - Lisa Galligan-Dawson
- Greater Manchester Cancer Alliance, Greater Manchester Strategic Health Authority, Manchester, UK
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Taylor M, Evison M, Clayton B, Grant SW, Martin GP, Shah R, Krysiak P, Rammohan K, Fontaine E, Joshi V, Granato F. Adequacy of Mediastinal Lymph Node Sampling in Patients With Lung Cancer Undergoing Lung Resection. J Surg Res 2021; 270:271-278. [PMID: 34715539 DOI: 10.1016/j.jss.2021.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 08/06/2021] [Accepted: 09/01/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intraoperative mediastinal lymph node sampling (MLNS) is a crucial component of lung cancer surgery. Whilst several sampling strategies have been clearly defined in guidelines from international organizations, reports of adherence to these guidelines are lacking. We aimed to assess our center's adherence to guidelines and determine whether adequacy of sampling is associated with survival. MATERIALS AND METHODS A single-center retrospective review of consecutive patients undergoing lung resection for primary lung cancer between January 2013 and December 2018 was undertaken. Sampling adequacy was assessed against standards outlined in the International Association for the Study of Lung Cancer 2009 guidelines. Multivariable logistic and Cox proportional hazards regression analyses were used to assess the impact of specific variables on adequacy and of specific variables on overall survival, respectively. RESULTS A total of 2380 patients were included in the study. Overall adequacy was 72.1% (n= 1717). Adherence improved from 44.8% in 2013 to 85.0% in 2018 (P< 0.001). Undergoing a right-sided resection increased the odds of adequate MLNS on multivariable logistic regression (odds ratio 1.666, 95% confidence interval [CI]: 1.385-2.003, P< 0.001). Inadequate MLNS was not significantly associated with reduced overall survival on log rank analysis (P= 0.340) or after adjustment with multivariable Cox proportional hazards (hazard ratio 0.839, 95% CI 0.643-1.093). CONCLUSIONS Adherence to standards improved significantly over time and was significantly higher for right-sided resections. We found no evidence of an association between adequate MLNS and overall survival in this cohort. A pressing need remains for the introduction of national guidelines defining acceptable performance.
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Affiliation(s)
- Marcus Taylor
- Department of Cardiothoracic Surgery, Manchester University Hospital Foundation Trust, Wythenshawe Hospital, Manchester, UK.
| | - Matthew Evison
- Department of Respiratory Medicine, Manchester University Hospital Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Bethan Clayton
- Department of Cardiothoracic Surgery, Manchester University Hospital Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Stuart W Grant
- Division of Cardiovascular Sciences, University of Manchester, ERC, Manchester University Hospital Foundation Trust, Manchester, UK
| | - Glen P Martin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, Manchester Academic Heath Science Centre, University of Manchester, Manchester, UK
| | - Rajesh Shah
- Department of Cardiothoracic Surgery, Manchester University Hospital Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Piotr Krysiak
- Department of Cardiothoracic Surgery, Manchester University Hospital Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Kandadai Rammohan
- Department of Cardiothoracic Surgery, Manchester University Hospital Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Eustace Fontaine
- Department of Cardiothoracic Surgery, Manchester University Hospital Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Vijay Joshi
- Department of Cardiothoracic Surgery, Manchester University Hospital Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Felice Granato
- Department of Cardiothoracic Surgery, Manchester University Hospital Foundation Trust, Wythenshawe Hospital, Manchester, UK
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Punjabi A, Al-Najjar H, Teng B, Borrill Z, Brown L, Nagarajan T, Gallagher J, Grundy S, Sundar R, Higgins C, Shackley D, Sinnott N, Balata H, Lyons J, Martin J, Brocklesby C, Crosbie P, Booton R, Evison M. Performance monitoring of EBUS for the staging and diagnosis of lung cancer: auditing the Greater Manchester EBUS service against new national standards. BMJ Open Respir Res 2021; 8:8/1/e000777. [PMID: 34172527 PMCID: PMC8237730 DOI: 10.1136/bmjresp-2020-000777] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 04/16/2021] [Indexed: 12/25/2022] Open
Abstract
Introduction Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a pivotal test in lung cancer staging and diagnosis, mandating robust audit and performance monitoring of EBUS services. We present the first regional cancer alliance EBUS performance audit against the new National EBUS specification. Methods Across the five EBUS centres in the Greater Manchester Cancer Alliance, data are recorded at the point of procedure, when pathological results are available and at 6 months postprocedure to review any further pathological sampling (eg, at surgical resection) and the outcome of clinical–radiological follow-up. Outcomes across all five centres were compared with national standards for all lung cancer EBUS procedures from 01 January 2017 to 31 December 2018. Results 1899 lung cancer staging or diagnostic EBUS procedures were performed across the five centres during the study period; 1309 staging EBUS procedures and 590 diagnostic EBUS procedures. Major complications were seen in six cases (<1%). All five trusts demonstrated performance above that set national standards in key metrics for both staging and diagnostic EBUS, however the provision of adequate tissue for predictive marker testing was below national standards at one trust. Across Greater Manchester, 72% and 64% of patients had their EBUS procedure performed within 7 days of referral in 2017 and 2018, respectively. Only one out of five trusts met the national targets of >85% of procedures performed within 7 days of referral. Conclusion The National EBUS service specification is an important framework to drive the quality of EBUS services across the UK. Our data provide assurance of appropriate performance and safety while also highlighting specific areas for attention that can be addressed with the support of the cancer alliance.
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Affiliation(s)
| | - Haider Al-Najjar
- Respiratory, Manchester University NHS Foundation Trust, Manchester, UK
| | - Benjamin Teng
- Respiratory Medicine, Manchester Royal Infirmary, Manchester, UK
| | - Zoe Borrill
- Respiratory Medicine, North Manchester General Hospital, Manchester, UK
| | - Louise Brown
- Respiratory Medicine, Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Thapas Nagarajan
- Respiratory Medicine, Macclesfield Hospital, East Cheshire NHS Trust, Macclesfield, UK
| | - Joanna Gallagher
- Respiratory Medicine, Macclesfield Hospital, East Cheshire NHS Trust, Macclesfield, UK
| | - Seamus Grundy
- Respiratory Medicine, Royal Albert Edward Infirmary, Wrightington, Wigan & Leigh NHS Foundation Trust, Wigan, UK
| | - Ram Sundar
- Department of Respiratory Medicine, Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Coral Higgins
- Manchester Health & Care Commisioning, South Manchester Clinical Commissiong Group & Macmillan Cancer Improvement Partnership, Manchester, UK
| | | | - Nicola Sinnott
- Respiratory Medicine, Wythenshawe Hospital, Manchester Foundation Trust, Mnachester, UK
| | - Haval Balata
- Respiratory Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Judith Lyons
- Respiratory Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Julie Martin
- Respiratory Medicine, Wythenshawe Hospital, Manchester Foundation Trust, Mnachester, UK
| | | | - Phil Crosbie
- Respiratory Medicine, Wythenshawe Hospital, Manchester, Greater Manchester, UK
| | - Richard Booton
- Respiratory Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Matthew Evison
- Respiratory Medicine, Manchester University NHS Foundation Trust, Manchester, UK
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Leong P, Deshpande S, Irving LB, Bardin PG, Farmer MW, Jennings BR, Steinfort DP. Endoscopic ultrasound fine-needle aspiration by experienced pulmonologists: a cusum analysis. Eur Respir J 2017; 50:50/5/1701102. [PMID: 29097432 DOI: 10.1183/13993003.01102-2017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 08/01/2017] [Indexed: 11/05/2022]
Abstract
Endobronchial ultrasound transbronchial needle aspiration (EBUS TBNA) is an established, minimally invasive way to sample intrathoracic abnormalities. The EBUS scope can be passed into the oesophagus to perform endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA). In cases of suspected lung cancer, a combination of the two techniques is now recommended by consensus guidelines. EBUS TBNA is usually performed by pulmonologists; however, the learning curve for EUS-B-FNA, which may be performed during the same procedure, has not been described.A multicentre, observational Australian study, using prospectively collected data from three experienced pulmonologists was conducted. Cumulative sum (cusum) analysis was used to generate visual learning curves.A total of 152 target lesions were sampled in 137 patients, with an overall sensitivity for malignancy of 94.8%. The sensitivity for malignant lesions outside of the 2009 International Association for the Study of Lung Cancer lymph node map (largely intraparenchymal lesions) was 92.9%. All three operators were competent by conventional cusum criteria. There was one case of pneumothorax, and no episodes of mediastinitis or oesophageal perforation were observed.Our data suggest that experienced pulmonologists can safely and accurately perform EUS-B-FNA, with a high diagnostic sensitivity for both lymph node and non-nodal lesions.
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Affiliation(s)
- Paul Leong
- Monash Lung and Sleep, Monash Health, Clayton, Australia .,Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia.,Dept of Respiratory Medicine, Melbourne Health, Parkville, Australia
| | | | - Louis B Irving
- Dept of Respiratory Medicine, Melbourne Health, Parkville, Australia
| | - Philip G Bardin
- Monash Lung and Sleep, Monash Health, Clayton, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
| | - Michael W Farmer
- Monash Lung and Sleep, Monash Health, Clayton, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
| | | | - Daniel P Steinfort
- Dept of Respiratory Medicine, Melbourne Health, Parkville, Australia.,Dept of Medicine, University of Melbourne, Melbourne, Australia
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Edwards T, Balata H, Elshafi M, Foden P, Bishop P, Fontaine E, Jones M, Krysiak P, Rammohan K, Shah R, Crosbie P, Booton R, Evison M. Adequacy of Intraoperative Nodal Staging during Surgical Resection of NSCLC: Influencing Factors and Its Relationship to Survival. J Thorac Oncol 2017; 12:1845-1850. [PMID: 28782727 DOI: 10.1016/j.jtho.2017.07.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 06/29/2017] [Accepted: 07/12/2017] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Adequate intraoperative lymph node sampling is a fundamental part of lung cancer surgery, but adherence to standards is not well known. This study sought to measure the adequacy of intraoperative lymph node sampling at a regional Thoracic Surgery Centre and a tertiary lung cancer center in the United Kingdom. METHODS This retrospective study analyzed the pathological reports from NSCLC resections over the 4-year period 2011-2014. Adequacy of sampling was assessed against International Association for the Study of Lung Cancer recommendations of at least three mediastinal lymph node stations: station 7 in all patients, station 5 or 6 in left upper lobe tumors, and station 9 in lower lobe tumors. The influence of clinical variables (age, tumor T stage, type of surgery, and laterality) on adequacy of sampling and the effect of adequacy on overall survival were also assessed. RESULTS A total of 1301 NSCLC resections were performed from January 11, 2011, to December 31, 2014. Adequate intraoperative lymph node sampling increased significantly from 14% (22 of 160) in 2011 to 53% (206 of 390) in 2014 (p = 0.001). Secondary analysis of clinical variables also revealed that patients with T1a or T4 tumors, those undergoing sublobar resections, those undergoing video-assisted thoracic surgery resections, and those undergoing left-sided resections have significantly higher rates of inadequate lymph node sampling. Overall, there was no statistically significant difference in survival between patients with adequate versus inadequate intraoperative lymph node sampling or when survival was stratified according to overall stage. There was worse survival in inadequate sampling for patients with pN2 disease than for patients with pN2 disease and adequate sampling. CONCLUSION This study provides a much-needed benchmark of current thoracic surgical practice in lung cancer in the United Kingdom and important granularity to facilitate changes to improve adequacy of staging.
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Affiliation(s)
- Tim Edwards
- Manchester Thoracic Oncology Centre, University Hospital of South Manchester National Health Service Foundation Trust, Manchester, United Kingdom
| | - Haval Balata
- Manchester Thoracic Oncology Centre, University Hospital of South Manchester National Health Service Foundation Trust, Manchester, United Kingdom; The Institute of Inflammation and Repair, The University of Manchester, Manchester, United Kingdom
| | - Mohamed Elshafi
- Manchester Thoracic Oncology Centre, University Hospital of South Manchester National Health Service Foundation Trust, Manchester, United Kingdom
| | - Philip Foden
- Department of Medical Statistics, University Hospital of South Manchester, Manchester, United Kingdom
| | - Paul Bishop
- Department of Histopathology, University Hospital of South Manchester, Manchester, United Kingdom
| | - Eustace Fontaine
- Department of Thoracic Surgery, University Hospital South Manchester, Southmoor Road, Manchester, United Kingdom
| | - Mark Jones
- Department of Thoracic Surgery, University Hospital South Manchester, Southmoor Road, Manchester, United Kingdom
| | - Piotr Krysiak
- Department of Thoracic Surgery, University Hospital South Manchester, Southmoor Road, Manchester, United Kingdom
| | - Kandadai Rammohan
- Department of Thoracic Surgery, University Hospital South Manchester, Southmoor Road, Manchester, United Kingdom
| | - Rajesh Shah
- Department of Thoracic Surgery, University Hospital South Manchester, Southmoor Road, Manchester, United Kingdom
| | - Philip Crosbie
- Manchester Thoracic Oncology Centre, University Hospital of South Manchester National Health Service Foundation Trust, Manchester, United Kingdom; The Institute of Inflammation and Repair, The University of Manchester, Manchester, United Kingdom
| | - Richard Booton
- Manchester Thoracic Oncology Centre, University Hospital of South Manchester National Health Service Foundation Trust, Manchester, United Kingdom; The Institute of Inflammation and Repair, The University of Manchester, Manchester, United Kingdom
| | - Matthew Evison
- Manchester Thoracic Oncology Centre, University Hospital of South Manchester National Health Service Foundation Trust, Manchester, United Kingdom; The Institute of Inflammation and Repair, The University of Manchester, Manchester, United Kingdom.
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Nardecchia E, Cattoni M, Dominioni L. Endobronchial ultrasound-transbronchial needle aspiration for mediastinal staging of non-small cell lung cancer: variability of results and perspectives. J Thorac Dis 2017; 9:S418-S424. [PMID: 28603655 DOI: 10.21037/jtd.2017.04.12] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The remarkable value of endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging of non-small cell lung cancer (NSCLC) is recognized worldwide. Reports from different centers however show considerable variation of EBUS-TBNA performance in terms of diagnostic yield, sensitivity and negative predictive value (NPV). Interpretation of EBUS-TBNA diagnostic efficacy requires clarifying whether the technique is used for purely diagnostic purpose or mediastinal staging, recognizing that different study groups may be inherently heterogeneous and that numerous factors may impact on the procedure outcomes. Review of these factors indicates that the prevalence of N2/N3 disease, the thoroughness of mediastinal sampling and >3 needle passes per target lymph node (LN) [in the absence of rapid on-site evaluation (ROSE)] influence the procedure outcomes, while many details in the sample preparation technique are unlikely to impact on the results and should be left to the proceduralists' preference. Generalized use of a standardized database for prospective collection of relevant EBUS-TBNA data would allow reporting institutional results by sub-groups of N2/N3 disease prevalence and thoroughness of staging, and would help establishing quality standards for the procedure.
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Affiliation(s)
- Elisa Nardecchia
- Center for Thoracic Surgery, Department of Medicine and Surgery, University of Insubria, Ospedale di Circolo, Varese, Italy
| | - Maria Cattoni
- Center for Thoracic Surgery, Department of Medicine and Surgery, University of Insubria, Ospedale di Circolo, Varese, Italy
| | - Lorenzo Dominioni
- Center for Thoracic Surgery, Department of Medicine and Surgery, University of Insubria, Ospedale di Circolo, Varese, Italy
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