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Call S, Reig-Oussedik N, Obiols C, Sanz-Santos J, Ochoa-Alba JM, Cabanillas LR, Serra-Mitjans M, Rami-Porta R. Video-assisted mediastinoscopic lymphadenectomy (VAMLA): Mature results for staging non-small cell lung cancer with normal mediastinum. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00098-9. [PMID: 38311066 DOI: 10.1016/j.jtcvs.2024.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 01/20/2024] [Accepted: 01/28/2024] [Indexed: 02/06/2024]
Abstract
OBJECTIVES The aim of this study is to analyze the accuracy of video-assisted mediastinoscopic lymphadenectomy (VAMLA) and the unsuspected (u) N2/3 rates in patients with non-small cell lung cancer (NSCLC) and normal mediastinum by integrated positron emission tomography-computed tomography. METHODS Prospective observational single-center study of 603 consecutive VAMLAs from 2010 to 2022. EXCLUSION CRITERIA other indications (n = 32), tumors different from NSCLC (n = 91), and clinical (c) N2/3 tumors by positron emission tomography-computed tomography (n = 46). Systematic nodal dissection was the gold standard to validate negative VAMLAs. Those patients with negative VAMLA and missing reference standard test were excluded. uN2/3 rates were analyzed in the global series and in the subgroups of tumors according to their clinical nodal and tumor categories. Pathologic findings were reviewed, and staging values were calculated. RESULTS Three hundred eighty-three patients with cN0/1 NSCLC underwent VAMLA. Staging values of VAMLA were: sensitivity, 0.98 (95% CI, 0.92-0.99); negative predictive value, 0.99 (95% CI, 0.98-1); and diagnostic accuracy, 0.99 (95% CI, 0.98-1). The uN2/3 rate for the whole series (N = 383) was 18.8%. The uN2/3 rates according to presurgical nodal and tumor categories determined by positron emission tomography computed tomography were: 3.6% (4 out of 111) in cT1N0; 16.3% (18 out of 110) in cT2N0; 10.25% (4 out of 39) in cT3N0; and 32% (7 out of 22) in cT4N0. Forty-two percent (39 out of 93) in cN1; complication rate was 7%. CONCLUSIONS This series of NSCLC with normal mediastinum staged by VAMLA demonstrates a high accuracy of this technique and a high rate of uN2/3 disease (specially in cN1 and cT4N0). VAMLA could be considered the reference staging procedure for staging cN0/1 NSCLC.
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Affiliation(s)
- Sergi Call
- Department of Thoracic Surgery, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Spain; Department of Morphological Sciences, Medical School, Autonomous University of Barcelona, Bellaterra, Spain.
| | - Nina Reig-Oussedik
- Department of Thoracic Surgery, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Spain
| | - Carme Obiols
- Department of Thoracic Surgery, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Spain
| | - José Sanz-Santos
- Department Pulmonology, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Spain
| | - Juan Manuel Ochoa-Alba
- Department of Thoracic Surgery, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Spain
| | - Lucía Reyes Cabanillas
- Department of Thoracic Surgery, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Spain
| | - Mireia Serra-Mitjans
- Department of Thoracic Surgery, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Spain
| | - Ramón Rami-Porta
- Department of Thoracic Surgery, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Spain; Network of Centers of Biomedical Research in Respiratory Diseases, Lung Cancer Group, Terrassa, Spain
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Serra Mitjà P, García-Cabo B, Garcia-Olivé I, Radua J, Rami-Porta R, Esteban L, Barreiro B, Call S, Centeno C, Andreo F, Obiols C, Ochoa JM, Martínez-Palau M, Reig N, Serra M, Sanz-Santos J. EBUS-TBNA for mediastinal staging of centrally located T1N0M0 non-small cell lung cancer clinically staged with PET/CT. Respirology 2024; 29:158-165. [PMID: 37885329 DOI: 10.1111/resp.14613] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 10/11/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND AND OBJECTIVE To evaluate the diagnostic accuracy and clinical usefulness of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging of centrally located T1N0M0 non-small cell lung cancer (NSCLC) clinically staged with positron emission tomography/computed tomography (PET/CT). METHODS We conducted a study that included patients with centrally located T1N0M0 NSCLC, clinically staged with PET/CT who underwent EBUS-TBNA for mediastinal staging. Patients with negative EBUS-TBNA underwent mediastinoscopy, video-assisted mediastinoscopic lymphadenectomy (VAMLA) and/or lung resection with systematic nodal dissection, that were considered the gold standard. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), overall accuracy of EBUS-TBNA for diagnosing mediastinal metastases (N2 disease) and the number needed to treat (NNT: number of patients needed to undergo EBUS-TBNA to avoid a case of pathologic N2 disease after resection) were calculated. RESULTS One-hundred eighteen patients were included. EBUS-TBNA proved N2 disease in four patients. In the remaining 114 patients who underwent mediastinoscopy, VAMLA and/or resection there were two cases of N2 (N2 prevalence 5.1%). The sensitivity, specificity, NPV, PPV and overall accuracy for diagnosing mediastinal metastases (N2 disease) were of 66%, 100%, 98%, 100% and 98%, respectively. The NNT was 31 (95% CI: 15-119). CONCLUSION EBUS-TBNA in patients with central clinically staged T1N0M0 NSCLC presents a good diagnostic accuracy for mediastinal staging, even in a population with low prevalence of N2 disease. Therefore, its indication should be considered in the management of even these early lung cancers.
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Affiliation(s)
- Pere Serra Mitjà
- Pulmonology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Bruno García-Cabo
- Pulmonology Department, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Barcelona, Spain
- Departament de Medicina, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Catalonia, Barcelona, Spain
| | - Ignasi Garcia-Olivé
- Pulmonology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Joaquim Radua
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Biomedical Network Research Centre on Mental Health (CIBERSAM), Instituto de Salud Carlos III, University of Barcelona, Barcelona, Spain
| | - Ramón Rami-Porta
- Thoracic Surgery Department, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Barcelona, Spain
- Network of Centres for Biomedical Research on Respiratory Diseases (CIBERES), Lung Cancer Group, Terrassa, Barcelona, Spain
| | - Lluís Esteban
- Pulmonology Department, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Barcelona, Spain
| | - Bienvenido Barreiro
- Pulmonology Department, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Barcelona, Spain
| | - Sergi Call
- Thoracic Surgery Department, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Barcelona, Spain
- Department of Morphological Sciences, Medical School, Autonomous University of Barcelona, Bellaterra, Barcelona, Spain
| | - Carmen Centeno
- Pulmonology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Felipe Andreo
- Pulmonology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Carme Obiols
- Thoracic Surgery Department, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Barcelona, Spain
| | - Juan Manuel Ochoa
- Thoracic Surgery Department, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Barcelona, Spain
| | - Mireia Martínez-Palau
- Pulmonology Department, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Barcelona, Spain
| | - Nina Reig
- Thoracic Surgery Department, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Barcelona, Spain
| | - Mireia Serra
- Thoracic Surgery Department, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Barcelona, Spain
| | - José Sanz-Santos
- Pulmonology Department, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Barcelona, Spain
- Departament de Medicina, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Catalonia, Barcelona, Spain
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Lucena CM, Martin-Deleon R, Boada M, Marrades RM, Sánchez D, Sánchez M, Vollmer I, Martínez D, Fontana A, Reguart N, Molins L, Agustí C. Integral mediastinal staging in patients with NON-SMALL cell lung cancer and risk factors for occult N2 disease. Respir Med 2023; 208:107132. [PMID: 36720323 DOI: 10.1016/j.rmed.2023.107132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023]
Abstract
BACKGROUND In patients with non-small cell lung cancer (NSCLC), the presence of abnormal hiliar lymph nodes (clinical N1; cN1), central tumor location and/or tumor size (diameter >3 cm) increases the risk of occult mediastinal metastasis (OMM). This study investigates prospectively the diagnostic value of an integral mediastinal staging (IMS) strategy that combines EndoBronchial Ultrasound-TransBronchial Needle Aspiration (EBUS-TBNA) and Video-Assisted Mediastinoscopy (VAM) in patients with NSCLC at risk of OMM. METHODS Patients with NSCLC and radiologically normal mediastinum assessed non-invasively by positron emission tomography and computed tomography of the chest (PET-CT), and OMM risk factors (cN1, central tumor and/or >3 cm) underwent EBUS-TBNA followed by VAM if the former was negative. Those with negative IMS underwent resection surgery of the tumor. RESULTS EBUS-TBNA identified OMM in 2 out of the 49 patients evaluated (4%) and VAM in 1 of the 47 patients with negative EBUS (2%). Two patients with a negative IMS had OMM at surgery. Overall, the prevalence of OMM was 10%. EBUS-TBNA has a sensitivity of 40%, a negative predictive value (NPV) of 93.6%, and negative likelihood ratio of 0.60 (95%CI:0.30-1.16). The risk of not diagnosing OMM after EBUS was 6% and after IMS was 4.4%. CONCLUSION Integral mediastinal staging in patients with NSCLC and clinical risk factors for OMM, does not seem to provide added diagnostic value to that of EBUS-TBNA, except perhaps in patients with cN1 disease who deserve further research.
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Affiliation(s)
- Carmen M Lucena
- Pulmonary Service, Thoracic Oncology Unit, Hospital Clínic, Barcelona, Spain
| | | | - Marc Boada
- Thoracic Surgery Service, Thoracic Oncology Unit, Hospital Clínic, Barcelona, Spain
| | - Ramon M Marrades
- Pulmonary Service, Thoracic Oncology Unit, Hospital Clínic, Barcelona, Spain
| | - David Sánchez
- Thoracic Surgery Service, Thoracic Oncology Unit, Hospital Clínic, Barcelona, Spain
| | - Marcelo Sánchez
- Radiology Service, Thoracic Oncology Unit, Hospital Clínic, Barcelona, Spain
| | - Ivan Vollmer
- Radiology Service, Thoracic Oncology Unit, Hospital Clínic, Barcelona, Spain
| | - Daniel Martínez
- Pathology Service, Thoracic Oncology Unit, Hospital Clínic, Barcelona, Spain
| | - Ainhoa Fontana
- Pulmonary Service, Thoracic Oncology Unit, Hospital Clínic, Barcelona, Spain
| | - Noemi Reguart
- Medical Oncology Service, Thoracic Oncology Unit, Hospital Clínic, Barcelona, Spain; Translational Genomics and Targeted Therapeutics in Solid Tumors, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain
| | - Laureano Molins
- Thoracic Surgery Service, Thoracic Oncology Unit, Hospital Clínic, Barcelona, Spain
| | - Carlos Agustí
- Pulmonary Service, Thoracic Oncology Unit, Hospital Clínic, Barcelona, Spain.
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Gorodetski B, Becker PH, Baur ADJ, Hartenstein A, Rogasch JMM, Furth C, Amthauer H, Hamm B, Makowski M, Penzkofer T. Inferring FDG-PET-positivity of lymph node metastases in proven lung cancer from contrast-enhanced CT using radiomics and machine learning. Eur Radiol Exp 2022; 6:44. [PMID: 36104467 PMCID: PMC9474782 DOI: 10.1186/s41747-022-00296-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 07/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background We evaluated the role of radiomics applied to contrast-enhanced computed tomography (CT) in the detection of lymph node (LN) metastases in patients with known lung cancer compared to 18F-fluorodeoxyglucose positron emission tomography (PET)/CT as a reference. Methods This retrospective analysis included 381 patients with 1,799 lymph nodes (450 malignant, 1,349 negative). The data set was divided into a training and validation set. A radiomics analysis with 4 filters and 6 algorithms resulting in 24 different radiomics signatures and a bootstrap algorithm (Bagging) with 30 bootstrap iterations was performed. A decision curve analysis was applied to generate a net benefit to compare the radiomics signature to two expert radiologists as one-by-one and as a prescreening tool in combination with the respective radiologist and only the radiologists. Results All 24 modeling methods showed good and reliable discrimination for malignant/benign LNs (area under the curve 0.75−0.87). The decision curve analysis showed a net benefit for the least absolute shrinkage and selection operator (LASSO) classifier for the entire probability range and outperformed the expert radiologists except for the high probability range. Using the radiomics signature as a prescreening tool for the radiologists did not improve net benefit. Conclusions Radiomics showed good discrimination power irrespective of the modeling technique in detecting LN metastases in patients with known lung cancer. The LASSO classifier was a suitable diagnostic tool and even outperformed the expert radiologists, except for high probabilities. Radiomics failed to improve clinical benefit as a prescreening tool. Supplementary Information The online version contains supplementary material available at 10.1186/s41747-022-00296-8.
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Ashok A, Jiwnani SS, Karimundackal G, Bhaskar M, Shetty NS, Tiwari VK, Niyogi DM, Pramesh CS. Controversies in Mediastinal Staging for Nonsmall Cell Lung Cancer. Indian J Med Paediatr Oncol 2021. [DOI: 10.1055/s-0041-1739345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
AbstractMediastinal lymph nodal involvement in nonsmall cell lung cancer plays a crucial role in deciding treatment strategy. Survival falls markedly with increasing involvement of mediastinal nodal stations. Hence, accurate staging of the mediastinum with lowest morbidity is of utmost importance. A wide array of invasive and noninvasive modalities that complement each other in assessing the nodes are available at our disposal. Guidelines recommend noninvasive imaging as the initial step in the staging algorithm for all tumors, followed by invasive staging. No single modality has proven to be the ideal method to stage the mediastinum when used alone. In the present decade, minimally invasive endobronchial ultrasound (EBUS) has challenged the position of surgical mediastinoscopy, which has been the gold standard, historically. However, a negative EBUS needs to be confirmed by surgical mediastinoscopy. Video-assisted mediastinoscopic lymphadenectomy has also come to the forefront in last two decades and has shown exceptional results, when performed in experienced centers. This review details the various modalities of mediastinal staging and the controversies surrounding the optimal method of staging, restaging after neoadjuvant therapy, and the most cost-effective strategy.
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Affiliation(s)
- Apurva Ashok
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Sabita S. Jiwnani
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - George Karimundackal
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Maheema Bhaskar
- Department of Pulmonology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Nitin S. Shetty
- Division of Interventional Radiology, Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Virendra Kumar Tiwari
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Devayani M. Niyogi
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - C. S. Pramesh
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
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Preoperative 18F-FDG SUVmax >6.3 or Size >2.3 cm of primary lesions predict lymph nodes metastasis with higher negative predictive value in peripheral cT1 non-small-cell lung cancer. Nucl Med Commun 2021; 42:1328-1335. [PMID: 34284441 DOI: 10.1097/mnm.0000000000001462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Sublobar resection is suitable for peripheral cT1N0M0 non-small-cell lung cancer (NSCLC). The traditional PET-CT criterion (lymph node size ≥1.0 cm or SUVmax ≥2.5) for predicting lymph nodes metastasis (LNM) has unsatisfactory performance. OBJECTIVE We explore the clinical role of preoperative SUVmax and the size of the primary lesions for predicting peripheral cT1 NSCLC LNM. METHODS We retrospectively analyzed 174 peripheral cT1 NSCLC patients underwent preoperative 18F-FDG PET-CT and divided into the LNM and non-LNM group by pathology. We compared the differences of primary lesions' baseline characteristics between the two groups. The risk factors of LNM were determined by univariate and multivariate analysis, and we assessed the diagnostic efficacy with the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive predictive value and negative predictive value (NPV). RESULTS Of the enrolled cases, the incidence of LNM was 24.7%. The preoperative SUVmax >6.3 or size >2.3 cm of the primary lesions were independent risk factors of peripheral cT1 NSCLC LNM (ORs, 95% CIs were 6.18 (2.40-15.92) and 3.03 (1.35-6.81). The sensitivity, NPV of SUVmax >6.3 or size >2.3 cm of the primary lesions were higher than the traditional PET-CT criterion for predicting LNM (100.0 vs. 86.0%, 100.0 vs. 89.7%). A Hosmer-Lemeshow test showed a goodness-of-fit (P = 0.479). CONCLUSIONS The excellent sensitivity and NPV of preoperative of the SUVmax >6.3 or size >2.3 cm of the primary lesions based on 18F-FDG PET-CT might identify the patients at low-risk LNM in peripheral cT1 NSCLC.
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Cordovilla R, López-Zubizarreta M, Velasco A, Álvarez A, Rodríguez M, Gómez A, Hernández-Mezquita MÁ, Iglesias M. The Value of a Systematic Protocol Using Endobronchial Ultrasound and Endoscopic Ultrasound in Staging of Lung Cancer for Patients with Imaging iN0–N1 Disease. Biomed Hub 2021; 6:92-101. [PMID: 34950670 PMCID: PMC8613614 DOI: 10.1159/000519034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/04/2021] [Indexed: 11/19/2022] Open
Abstract
<b><i>Introduction:</i></b> We hypothesize that systematic, combined, and multidisciplinary study of the mediastinum (endobronchial ultrasound [EBUS] and endoscopic ultrasound [EUS]) in patients with NSCLC with radiologically normal mediastinum improves the results of mediastinal staging obtained with EBUS alone. <b><i>Material and Methods:</i></b> A retrospective study of the prospective database collected on the patients with NSCLC with a radiologically normal mediastinum and an indication for systematic staging with EBUS and EUS. EBUS staging was followed by EUS in patients in which the results from the pathological analysis of EBUS were negative. <b><i>Results:</i></b> Forty-five patients were included in the analysis. The combination of EBUS followed by EUS provided better results than EBUS alone: sensitivity (S) 95% versus 80%, negative predictive value (NPV) 96.15% versus 86.21%, negative likelihood ratio 0.05 versus 0.20, and post-test probability 3.8% versus 13.8%. This represents an increase in S (15%), the validity index (6.6%), and NPV (9.9%) compared to EBUS alone. There were 4 false negatives (FNs) (8.8%) with the EBUS test alone. After adding EUS, 3 more cases were positive (6.6%) and only 1 FN (2.2%). <b><i>Conclusions:</i></b> In patients with NSCLC and a radiographically normal mediastinum, a systematic and combined staging with EBUS and EUS show higher sensitivity in the detection of mediastinal metastasis than with the use of EBUS alone. The high accuracy of the test means that the use of mediastinoscopy is not necessary to confirm the results in these patients. Since the availability of EUS is low, it may be advisable for the interventional pulmonologist to receive training in EUS-b.
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Affiliation(s)
- Rosa Cordovilla
- Interventional Pulmonology Unit, Pulmonary Department, Salamanca University Hospital, Salamanca, Spain
- *Rosa Cordovilla,
| | - Marco López-Zubizarreta
- Interventional Pulmonology Unit, Pulmonary Department, Salamanca University Hospital, Salamanca, Spain
| | - Antonio Velasco
- Gastroenterologist Department, Salamanca University Hospital, Salamanca, Spain
| | - Alberto Álvarez
- Gastroenterologist Department, Salamanca University Hospital, Salamanca, Spain
| | - Marta Rodríguez
- Cytopathology Unit, Pathology Department, Salamanca University Hospital, Salamanca, Spain
| | - Asunción Gómez
- Cytopathology Unit, Pathology Department, Salamanca University Hospital, Salamanca, Spain
| | | | - Miguel Iglesias
- Interventional Pulmonology Unit, Pulmonary Department, Salamanca University Hospital, Salamanca, Spain
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Guinde J, Bourdages-Pageau E, Collin-Castonguay MM, Laflamme L, Lévesque-Laplante A, Marcoux S, Roy P, Ugalde PA, Lacasse Y, Fortin M. A Prediction Model to Optimize Invasive Mediastinal Staging Procedures for Non-Small Cell Lung Cancer in Patients With a Radiologically Normal Mediastinum: The Quebec Prediction Model. Chest 2021; 160:2283-2292. [PMID: 34119514 DOI: 10.1016/j.chest.2021.05.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/04/2021] [Accepted: 05/23/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Current guideline-recommended criteria for invasive mediastinal staging in patients with a radiologically normal mediastinum fail to identify a significant proportion of patients with occult mediastinal disease (OMD), despite it leading to a large number of invasive staging procedures. RESEARCH QUESTION Which variables available before surgery predict the probability of OMD in patients with a radiologically normal mediastinum? STUDY DESIGN AND METHODS We identified all cTxN0/N1M0 non-small cell lung cancer tumors staged by CT imaging and PET with CT imaging in our institution between 2014 and 2018 who underwent gold standard surgical lymph node dissection or were demonstrated to have OMD before surgery by invasive mediastinal staging techniques and divided them into a derivation and an independent validation cohort to create the Quebec Prediction Model (QPM), which allows calculation of the probability of OMD. RESULTS Eight hundred three patients were identified (development set, n = 502; validation set, n = 301) with a prevalence of OMD of 9.1%. The developed prediction model included largest mediastinal lymph node size (P < .001), tumor centrality (P = .23), presence of cN1 disease (P = .29), and lesion standardized uptake value (P = .09). Using a calculated probability of more than 10% as a threshold to identify OMD, this model had a sensitivity, specificity, positive predictive value, and negative predictive value in the derivation cohort of 73.9% (95% CI, 58.9%-85.7%), 81.1% (95% CI, 77.2%-84.6%), 28.3% (95% CI, 23.4%-33.8%), and 96.8% (95% CI, 95.0%-98.1%), respectively. It performed similarly in the validation cohort (P = .77, Hosmer-Lemeshow test; P = .5163, Pearson χ2 and unweighted sum-of-squares statistics; and P = .0750, Stukel score test) and outperformed current guideline-recommended criteria in identifying patients with OMD (area under the receiver operating characteristic curve [AUC] for American College of Chest Physicians guidelines criteria, 0.65 [95% CI, 0.59-0.71]; AUC for European Society of Thoracic Surgeons guidelines criteria, 0.60 [95% CI, 0.54-0.67]; and AUC for the QPM, 0.85 [95% CI, 0.80-0.90]). INTERPRETATION The QPM allows the clinician to integrate available information from CT and PET imaging to minimize invasive staging procedures that will not modify management, while also minimizing the risk of unforeseen mediastinal disease found at surgery.
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Affiliation(s)
- Julien Guinde
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, QC, Canada; Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, North University Hospital, Marseille, France
| | - Etienne Bourdages-Pageau
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, QC, Canada
| | - Marie-May Collin-Castonguay
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, QC, Canada
| | - Laurie Laflamme
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, QC, Canada
| | - Alexandra Lévesque-Laplante
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, QC, Canada
| | - Sabrina Marcoux
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, QC, Canada
| | - Pascalin Roy
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, QC, Canada
| | - Paula Antonia Ugalde
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, QC, Canada
| | - Yves Lacasse
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, QC, Canada
| | - Marc Fortin
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, QC, Canada.
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Martínez-Palau M, Trujillo-Reyes JC, Jaen À, Call S, Martínez-Hernández NJ, Provencio M, Vollmer I, Rami-Porta R, Sanz-Santos J. How do we Classify a Central Tumor? Results of a Multidisciplinary Survey from the SEPAR Thoracic Oncology Area. Arch Bronconeumol 2021; 57:359-365. [PMID: 32828588 DOI: 10.1016/j.arbres.2020.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/27/2020] [Accepted: 06/15/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION In patients with non-small cell lung cancer (NSCLC) and normal mediastinal imaging tests, centrally located tumors have greater occult mediastinal involvement. Clinical guidelines, therefore, recommend invasive mediastinal staging in this situation. However, definitions of centrality in the different guidelines are inconsistent. The SEPAR Thoracic Oncology area aimed to evaluate the degree of familiarity with various concepts related to tumor site among professionals who see patients with NSCLC in Spain. METHODS A questionnaire was distributed to members of Spanish medical societies involved in the management of NSCLC, structured according to the 3 aspects to be evaluated: 1) uniformity in the definition of central tumor location; 2) uniformity in the classification of lesions that extend beyond dividing lines; and 3) ability to delineate lesions in the absence of dividing lines. RESULTS A total of 430 participants responded. The most voted definition of centrality was «lesions in contact with hilar structures» (49.7%). The lines most often chosen to delimit the hemitorax were concentric hilar lines (89%). Most participants (92.8%) classified tumors according to the side of the dividing line that contained most of their volume. Overall, 78.6% were able to correctly classify a central lesion in the absence of dividing lines. CONCLUSIONS In our survey, the most widely accepted definition of centrality is not one of the proposals specified in the clinical guidelines. The results reflect wide variability in the classification of tumor lesions.
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Affiliation(s)
- Mireia Martínez-Palau
- Servicio de Neumología, Hospital Universitari Mútua Terrassa, Barcelona, España; Departament de Medicina, Facultat de Medicina, Universitat de Barcelona, Barcelona, España
| | - Juan Carlos Trujillo-Reyes
- Servicio de Cirugía Torácica, Hospital de la Santa Creu i Sant Pau, Barcelona, España; Departament de Cirurgia, Universitat Autonoma de Barcelona, Barcelona, España; Sociedad Española de Neumología y Cirugía Torácica, Área de Oncología Torácica, Barcelona, España
| | - Àngels Jaen
- Fundació Mútua Terrassa per a la Recerca Biomèdica i Social, Barcelona, España
| | - Sergi Call
- Servicio de Cirugía Torácica. Hospital Universitari Mútua Terrassa, Barcelona, España; Departament de Ciències Morfològiques, Àrea d'anatomia i embriologia humana, Universitat Autònoma de Barcelona, Barcelona, España
| | - Néstor J Martínez-Hernández
- Servicio de Cirugía Torácica. Hospital Universitari de la Ribera, Valencia, España; Sociedad Española de Cirugía Torácica, Comité Científico, Madrid, España
| | - Mariano Provencio
- Servicio de Oncología Médica, Hospital Universitario Puerta de Hierro, Madrid, España; Facultad de Medicina, Universidad Autónoma de Madrid, España; Grupo Español de Cáncer de Pulmón, Barcelona, España
| | - Iván Vollmer
- Servicio de Radiologia, Centre Diagnòstic per la Imatge (CDI), Hospital Clínic, Barcelona, España; Sociedad Española de Imagen Cardiotorácica, Valencia, España
| | - Ramón Rami-Porta
- Servicio de Cirugía Torácica. Hospital Universitari Mútua Terrassa, Barcelona, España
| | - José Sanz-Santos
- Servicio de Neumología, Hospital Universitari Mútua Terrassa, Barcelona, España; Departament de Medicina, Facultat de Medicina, Universitat de Barcelona, Barcelona, España.
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10
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Gullón JA, Villanueva MA, Sánchez-Antuña AA, Rodríguez MR, Álvarez-Navascues F, Allende J, Martínez-Muñiz MA, García-García JM. Predictors of mediastinal staging and usefulness of pet in patients with stage IIIA (N2) or IIIB (N3) lung cancer. CLINICAL RESPIRATORY JOURNAL 2021; 15:42-47. [PMID: 33448698 DOI: 10.1111/crj.13267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 08/08/2020] [Accepted: 08/12/2020] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | - Jesús Allende
- Pneumology Department, University Hospital San Agustín, Avilés, Spain
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11
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Guinde J, Bourdages-Pageau E, Ugalde PA, Fortin M. Central location and risk of imaging occult mediastinal lymph node involvement in cN0T2-4 non-small cell lung cancer. J Thorac Dis 2020; 12:7156-7163. [PMID: 33447404 PMCID: PMC7797819 DOI: 10.21037/jtd-20-1565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Appropriate pre-operative staging is a cornerstone in the treatment of non-small cell lung cancer (NSCLC). Central location and size greater than 3 cm are amongst indications for pre-operative invasive mediastinal staging but the quality of the evidence behind this recommendation is low. Methods We retrospectively reviewed all cases of cT2-4N0M0 NSCLCL after CT and TEP-CT which underwent surgical resection with lymph node dissection or had a positive invasive pre-operative mediastinal staging in our institution from 2014 to 2018. Results Three hundred and ten patients met inclusion criteria, 79 (25.5%) central and 231 (74.5%) peripheral tumors. Central tumor location was associated with a higher prevalence of pN2-3 disease (17.7% vs. 6.1%, P<0.001). In a multivariate analysis, central tumor location remained the only factor statistically associated with imaging occult mediastinal disease (OR 3.23, 95% CI: 1.45–7.18). NPV of PET-CT for occult mediastinal disease was 0.83 (95% CI: 0.72–0.90) in central and 0.94 (95% CI: 0.90–0.97) in peripheral tumor. Central location was also associated with a higher prevalence of occult N1 to N3 disease (43.0% vs. 15.2%, P<0.001). Conclusions This study suggests that invasive mediastinal staging is required in central cT2-4N0 NSCLC but can be questioned in peripheral one, especially in cT2N2 subgroup if the patient is a candidate for lobar resection.
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Affiliation(s)
- Julien Guinde
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, Canada.,Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Marseille, France
| | - Etienne Bourdages-Pageau
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, Canada
| | - Paula Antonia Ugalde
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, Canada
| | - Marc Fortin
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, Canada
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12
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van der Woude L, Wouters MWJM, Hartemink KJ, Heineman DJ, Verhagen AFTM. Completeness of lymph node dissection in patients undergoing minimally invasive- or open surgery for non-small cell lung cancer: A nationwide study. Eur J Surg Oncol 2020; 47:1784-1790. [PMID: 33223414 DOI: 10.1016/j.ejso.2020.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/23/2020] [Accepted: 11/08/2020] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE In patients with NSCLC, lymph node metastases are an important prognostic factor. Despite an accurate pre-operative work up, for optimal staging an intrapulmonary- and mediastinal lymph node dissection (LND) as part of the operation is mandatory. The aim of this study is to assess the completeness of LND in patients undergoing an intended curative resection for NSCLC in the Netherlands and to compare performance between open surgery and minimally invasive surgery (MIS). MATERIALS AND METHODS The intraoperative LND was evaluated in 7460 patients who had undergone a lobectomy for clinically staged N0-1 NSCLC (2013-2018). The LND was considered complete, when three mediastinal (N2) lymph node stations, including station 7, were sampled or dissected, in addition to the lymph nodes from station 10 and 11. A comparison was made between open surgery and MIS. RESULTS Of 5154 patients, who had MIS, a sufficient intrapulmonary LND was performed in 47.9% and a sufficient mediastinal LND in 58.6%. A complete LND was performed in 31.6%. For 2306 patients who had an open resection, these numbers were 45.0%, 59.0%, and 30.6%, respectively. The overall between-hospital variation in a complete LND ranged between 0 and 72.5%. CONCLUSION In the Netherlands, a complete LND of both intrapulmonary- and mediastinal lymph nodes is performed only in a minority of patients with clinically staged N0-1 NSCLC, with substantial between-hospital variation. No differences were seen between open surgery and MIS. Because of poor performance, completeness of lymph node dissection will be recorded as a mandatory performance indicator in our national audit, to improve the quality of resection.
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Affiliation(s)
- Lisa van der Woude
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Cardiothoracic Surgery, Postbus 9101, 6500, HB Nijmegen, the Netherlands; Dutch Institute for Clinical Auditing, Rijnsburgerweg 10, 2333, AA Leiden, the Netherlands.
| | - Michel W J M Wouters
- Dutch Institute for Clinical Auditing, Rijnsburgerweg 10, 2333, AA Leiden, the Netherlands; Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Department of Surgery, Plesmanlaan 121, 1066, CX Amsterdam, the Netherlands.
| | - Koen J Hartemink
- Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Department of Surgery, Plesmanlaan 121, 1066, CX Amsterdam, the Netherlands.
| | - David J Heineman
- Amsterdam University Medical Center, Department of Surgery, Postbus 7057, 1008 MB Amsterdam, the Netherlands; Amsterdam University Medical Center, Department of Cardiothoracic Surgery, Postbus 7057, 1008, MB Amsterdam, the Netherlands.
| | - Ad F T M Verhagen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Cardiothoracic Surgery, Postbus 9101, 6500, HB Nijmegen, the Netherlands.
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13
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Nasralla A, Lee J, Dang J, Turner S. Elevated preoperative CEA is associated with subclinical nodal involvement and worse survival in stage I non-small cell lung cancer: a systematic review and meta-analysis. J Cardiothorac Surg 2020; 15:318. [PMID: 33059696 PMCID: PMC7565320 DOI: 10.1186/s13019-020-01353-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/28/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The standard for clinical staging of lung cancer is the use of CT and PET scans, however, these may underestimate the burden of the disease. The use of serum tumor markers might aid in the detection of subclinical advanced disease. The aim of this study is to review the predictive value of tumor markers in patients with clinical stage I NSCLC. METHODS A comprehensive search was performed using the Medline, EMBASE, Scopus data bases. Abstracts included based on the following inclusion criteria: 1) adult ≥18 years old, 2) clinical stage I NSCLC, 3) Tumor markers (CEA, SCC, CYFRA 21-1), 4) further imaging or procedure, 5) > 5 patients, 6) articles in English language. The primary outcome of interest was utility of tumour markers for predicting nodal involvement and oncologic outcomes in patients with clinical stage I NSCLC. Secondary outcomes included sub-type of lung cancer, procedure performed, and follow-up duration. RESULTS Two hundred seventy articles were screened, 86 studies received full-text assessment for eligibility. Of those, 12 studies were included. Total of 4666 patients were involved. All studies had used CEA, while less than 50% used CYFRA 21-1 or SCC. The most common tumor sub-type was adenocarcinoma, and the most frequently performed procedure was lobectomy. Meta-analysis revealed that higher CEA level is associated with higher rates of lymph node involvement and higher mortality. CONCLUSION There is significant correlation between the CEA level and both nodal involvement and survival. Higher serum CEA is associated with advanced stage, and poor prognosis. Measuring preoperative CEA in patient with early stage NSCLC might help to identify patients with more advanced disease which is not detected by CT scans, and potentially identify candidates for invasive mediastinal lymph node staging, helping to select the most effective therapy for patients with potentially subclinical nodal disease. Further prospective studies are needed to standardize the use of CEA as an adjunct for NSCLC staging.
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Affiliation(s)
- Awrad Nasralla
- Division of General Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.
| | - Jeremy Lee
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Jerry Dang
- Division of General Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Simon Turner
- Division of Thoracic Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
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14
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Steunenberg BE, Beddows TPA, De Groot HGW, Ayez N, Van Der Leest C, Aerts JGJV, Veen EJ. Preoperative mediastinal staging in patients with cT1-3NxM0 non-small cell lung cancer. Thorac Cancer 2020; 11:3456-3462. [PMID: 33026177 PMCID: PMC7705925 DOI: 10.1111/1759-7714.13673] [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: 07/21/2020] [Revised: 09/05/2020] [Accepted: 09/07/2020] [Indexed: 11/29/2022] Open
Abstract
Background Endosonography is accepted as the initial procedure for mediastinal staging in patients with suspected non‐small cell lung cancer (NSCLC). However, the diagnostic value of different staging methods in specific subgroups is unclear. The purpose of this study was to assess the performance and outcome of mediastinal staging in lung cancer in a general teaching hospital. Methods The records of 870 consecutive patients with potentially resectable NSCLC (cT1‐3NxM0) were analyzed in a retrospective cohort study between January 2010 and December 2016. Patients were divided into four different groups according to ESTS guidelines. The primary endpoint was the rate of unforeseen mediastinal metastasis in these groups and the sensitivity of different staging methods. Results Mediastinal staging was performed in 336 patients of whom 112 (33%) underwent lobectomy. Unforeseen mediastinal metastasis was seen in 10 (9%) patients after negative mediastinal staging. Sensitivity after combined mediastinal staging (endosonography with mediastinoscopy) in the overall group was 94%. In patients without suspected mediastinal lymph nodes but with suspected hilar lymph nodes (N1), or a peripheral tumor >3 cm, sensitivity of endosonography was 33% and mediastinoscopy 75%. Biopsy of at least level 4L, 4R and 7 was taken in 18% of the endosonographies and 58% of the mediastinoscopies. Discussion Combined mediastinal staging (endosonography with mediastinoscopy) is reliable with a sensitivity of 94%. However, the diagnostic value of endosonography in patients with suspected hilar lymph nodes or a peripheral tumor >3 cm is questionable, and in these patients, performing direct mediastinoscopy should be considered. Key points Significant findings of this study The diagnostic value of endosonography in patients without suspected mediastinal lymph nodes but with potential risk factors (suspected N1 disease or peripheral tumor >3 cm) is questionable. Therefore, mediastinoscopy as the first choice should be considered in these patients. What this study adds? Accurate mediastinal nodal staging is essential in patients with suspected NSCLC to avoid unnecessary lobectomy. Detailed knowledge about sensitivity and specificity of mediastinal staging techniques in different patient groups can make a difference.
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Affiliation(s)
| | - Tom P A Beddows
- Department of Pulmonary Surgery, Amphia Hospital Breda, Breda, The Netherlands
| | - Hans G W De Groot
- Department of Pulmonary Surgery, Amphia Hospital Breda, Breda, The Netherlands
| | - Ninos Ayez
- Department of Pulmonary Surgery, Amphia Hospital Breda, Breda, The Netherlands
| | - Cor Van Der Leest
- Department of Pulmonary Medicine, Amphia Hospital Breda, Breda, The Netherlands
| | - Joachim G J V Aerts
- Department of Pulmonary Medicine, Amphia Hospital Breda, Breda, The Netherlands
| | - Eelco J Veen
- Department of Pulmonary Surgery, Amphia Hospital Breda, Breda, The Netherlands
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15
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Carretta A. Cost-effectiveness of endoscopic mediastinal staging. MEDIASTINUM (HONG KONG, CHINA) 2020; 4:18. [PMID: 35118286 PMCID: PMC8794317 DOI: 10.21037/med-20-27] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/15/2020] [Indexed: 12/25/2022]
Abstract
Lung cancer is the first cause of cancer-related mortality. Mediastinal staging has a main role in the definition of the therapeutic strategy in early-stage and locally-advanced non-small cell lung cancer (NSCLC). Non-invasive mediastinal staging with CT or PET imaging has relatively limited accuracy, and nodal biopsy may be required to reach adequate staging results. In the last two decades endoscopic techniques have been increasingly used in the field of mediastinal staging thanks to a reduced invasiveness and to the possibility of obtaining a more thorough assessment in comparison with surgical techniques. However, the ideal staging strategy is still a matter for debate, particularly considering the cost-effectiveness of the different approaches. Complication-rate, costs, impact on quality of life, time delay to treatment and survival of the different staging techniques still have to be analyzed in detail. Other issues to be discussed are the optimal combination of staging approaches and the influence of factors as the prevalence of nodal disease on the cost-effectiveness of the different methods. Future issues of invasive staging concern the possibility of extending the definition of nodal status to N1 intrapulmonary nodes, in the light of the development of new oncological and surgical therapeutic approaches.
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Affiliation(s)
- Angelo Carretta
- Department of Thoracic Surgery, San Raffaele Hospital, School of Medicine, Vita-salute San Raffaele University, Milan, Italy
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16
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Boada M, Sánchez-Lorente D, Libreros A, Lucena CM, Marrades R, Sánchez M, Paredes P, Serrano M, Guirao A, Guzmán R, Viñolas N, Casas F, Agustí C, Molins L. Is invasive mediastinal staging necessary in intermediate risk patients with negative PET/CT? J Thorac Dis 2020; 12:3976-3986. [PMID: 32944309 PMCID: PMC7475585 DOI: 10.21037/jtd-20-1248] [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] [Indexed: 11/14/2022]
Abstract
Background Tumor involvement of mediastinal lymph nodes is of high importance in non-small cell lung cancer (NSCLC). Invasive mediastinal staging is recommended in selected patients without evidence of mediastinal involvement on staging by imaging. In the present study we aimed to evaluate the effectiveness of invasive mediastinal staging in reducing pN2, its impact on survival and the risk factors for occult pN2. Methods Patients with NSCLC tumors larger than 3 cm, central tumors or cN1 cases treated in our institution between 2013 and 2018 were prospectively included in the study. Incidence of pN2 and overall survival was compared among invasively staged (IS) and non-invasively staged groups (NIS). Multivariate analysis was performed to identify risk factors of pN2. Results A total of 201 patients were included in the study, 79 (39.3%) of whom were not invasively staged (NIS group) and 122 (60.7%) were invasively staged (IS group). Incidence of cN1 and mean PET/CT uptake was different among both groups. Prevalence of pN2 was similar in both groups (7.6% in NIS vs. 12.6% in IS; P>0.05). Median survival in IS-pN2 patients was 11 months longer than in NIS-pN2 group (33.6 vs. 22.5 months; P=0.245). cN1 emerged as the only a risk factor for pN2. Conclusions Invasive staging does not reduce the incidence of pN2. However, this finding could be biased because in our series cN1 patients were more often staged and cN1 has been detected as a risk factor for pN2. In addition patient better selection after invasive staging might have an impact on overall survival. To conclude, invasive mediastinal staging in intermediate risk patients for positive mediastinal nodes is justified.
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Affiliation(s)
- Marc Boada
- Thoracic Surgery Department, Respiratory Institute, Hospital Clínic de Barcelona, Barcelona, Spain.,Thoracic Oncology Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - David Sánchez-Lorente
- Thoracic Surgery Department, Respiratory Institute, Hospital Clínic de Barcelona, Barcelona, Spain.,Thoracic Oncology Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Alejandra Libreros
- Thoracic Surgery Department, Respiratory Institute, Hospital Clínic de Barcelona, Barcelona, Spain.,Thoracic Oncology Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Carmen M Lucena
- Thoracic Oncology Unit, Hospital Clínic de Barcelona, Barcelona, Spain.,Pulmonology Department, Respiratory Institute, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Ramón Marrades
- Thoracic Oncology Unit, Hospital Clínic de Barcelona, Barcelona, Spain.,Pulmonology Department, Respiratory Institute, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Marcelo Sánchez
- Thoracic Oncology Unit, Hospital Clínic de Barcelona, Barcelona, Spain.,Radiology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Pilar Paredes
- Thoracic Oncology Unit, Hospital Clínic de Barcelona, Barcelona, Spain.,Nuclear Medicine Department, Hospital Clínic de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Mario Serrano
- Pulmonology Department, Hospital de Mollet, Barcelona, Spain
| | - Angela Guirao
- Thoracic Surgery Department, Respiratory Institute, Hospital Clínic de Barcelona, Barcelona, Spain.,Thoracic Oncology Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Rudith Guzmán
- Thoracic Surgery Department, Respiratory Institute, Hospital Clínic de Barcelona, Barcelona, Spain.,Thoracic Oncology Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Núria Viñolas
- Thoracic Oncology Unit, Hospital Clínic de Barcelona, Barcelona, Spain.,Medical Oncology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Francesc Casas
- Thoracic Oncology Unit, Hospital Clínic de Barcelona, Barcelona, Spain.,Radiotherapy Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Carles Agustí
- Thoracic Oncology Unit, Hospital Clínic de Barcelona, Barcelona, Spain.,Pulmonology Department, Respiratory Institute, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Laureano Molins
- Thoracic Surgery Department, Respiratory Institute, Hospital Clínic de Barcelona, Barcelona, Spain.,Thoracic Oncology Unit, Hospital Clínic de Barcelona, Barcelona, Spain.,Nuclear Medicine Department, Hospital Clínic de Barcelona, Barcelona, Spain
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17
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Hoeijmakers F, Heineman DJ, Daniels JM, Beck N, Tollenaar RAEM, Wouters MWJM, Marang-van de Mheen PJ, Schreurs WH. Variation Between Multidisciplinary Tumor Boards in Clinical Staging and Treatment Recommendations for Patients With Locally Advanced Non-small Cell Lung Cancer. Chest 2020; 158:2675-2687. [PMID: 32738254 PMCID: PMC7768935 DOI: 10.1016/j.chest.2020.07.054] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/15/2020] [Accepted: 07/05/2020] [Indexed: 12/25/2022] Open
Abstract
Background Accurate diagnosis and staging are crucial to ensure uniform allocation to the optimal treatment methods for non-small cell lung cancer (NSCLC) patients, but may differ among multidisciplinary tumor boards (MDTs). Discordance between clinical and pathologic TNM stage is particularly important for patients with locally advanced NSCLC (stage IIIA) because it may influence their chance of allocation to curative-intent treatment. We therefore aimed to study agreement on staging and treatment to gain insight into MDT decision-making. Research Question What is the level of agreement on clinical staging and treatment recommendations among MDTs in stage IIIA NSCLC patients? Study Design and Methods Eleven MDTs each evaluated the same 10 pathologic stage IIIA NSCLC patients in their weekly meeting (n = 110). Patients were selected purposively for their challenging nature. All MDTs received exactly the same clinical information and images per patient. We tested agreement in cT stage, cN stage, cM stage (TNM 8th edition), and treatment proposal among MDTs using Randolph’s free-marginal multirater kappa. Results Considerable variation among the MDTs was seen in T staging (κ, 0.55 [95% CI, 0.34-0.75]), N staging (κ, 0.59 [95% CI, 0.35-0.83]), overall TNM staging (κ, 0.53 [95% CI, 0.35-0.72]), and treatment recommendations (κ, 0.44 [95% CI, 0.32-0.56]). Most variation in T stage was seen in patients with suspicion of invasion of surrounding structures, which influenced such treatment recommendations as induction therapy and type. For N stage, distinction between N1 and N2 disease was an important source of discordance among MDTs. Variation occurred between 2 patients even regarding M stage. A wide range of additional diagnostics was proposed by the MDTs. Interpretation This study demonstrated high variation in staging and treatment of patients with stage IIIA NSCLC among MDTs in different hospitals. Although some variation may be unavoidable in these challenging patients, we should strive for more uniformity.
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Affiliation(s)
- Fieke Hoeijmakers
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands.
| | - David J Heineman
- Department of Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands; Department of Cardiothoracic Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Johannes M Daniels
- Department of Pulmonary Diseases, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Naomi Beck
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Rob A E M Tollenaar
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Michel W J M Wouters
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Perla J Marang-van de Mheen
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands; Department of Surgical Oncology, The Netherlands Cancer Institute / Antoni van Leeuwenhoek, Amsterdam, The Netherlands
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18
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Sanz-Santos J, Call S. Preoperative staging of the mediastinum is an essential and multidisciplinary task. Respirology 2020; 25 Suppl 2:37-48. [PMID: 32656946 DOI: 10.1111/resp.13901] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/26/2020] [Accepted: 06/03/2020] [Indexed: 12/20/2022]
Abstract
Mediastinal staging is a crucial step in the management of patients with NSCLC. With the recent development of novel techniques, mediastinal staging has evolved from an activity of interest mainly for thoracic surgeons to a joint effort carried out by many specialists. In this regard, the debate of cases in MDT sessions is crucial for optimal management of patients. Current evidence-based clinical guidelines for preoperative NSCLC staging recommend that mediastinal staging should be performed with increasing invasiveness. Image-based techniques are the first approach, although they have limited accuracy and findings must be confirmed by pathology in almost all cases. In this setting, the advent of radiomics is promising. Invasive staging depends on procedural factors rather than diagnostic performance. The choice between endoscopy-based or surgical procedures should depend on the local expertise of each centre. As the extension of mediastinal disease in terms of number of involved lymph nodes and nodal stations affects prognosis and the choice of treatment, systematic samplings are preferred over random targeted samplings. Following this approach, a diagnosis of single mediastinal nodal involvement can be unreliable if all reachable mediastinal nodal stations have not been assessed. The performance of confirmatory mediastinoscopy after a negative endoscopy-based procedure is controversial but currently recommended. Current indications of invasive staging in patients with radiologically normal mediastinum have to be re-evaluated, especially for central tumour location.
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Affiliation(s)
- José Sanz-Santos
- Department of Pulmonology, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Spain.,Department of Medicine, Medical School, University of Barcelona, Barcelona, Spain.,Network of Centres for Biomedical Research in Respiratory Diseases (CIBERES) Lung Cancer Group, Terrassa, Spain
| | - Sergi Call
- Department of Thoracic Surgery, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Spain.,Department of Morphological Sciences, Medical School, Autonomous University of Barcelona, Cerdanyola, Spain
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19
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Obiols C, Call S, Rami-Porta R. The importance of the false-negative rate to validate a staging protocol for non-small cell lung cancer. Transl Lung Cancer Res 2020; 8:S400-S402. [PMID: 32038924 DOI: 10.21037/tlcr.2019.07.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Carme Obiols
- Department of Thoracic Surgery, Hospital Universitari MútuaTerrassa, University of Barcelona, Terrassa, Spain
| | - Sergi Call
- Department of Thoracic Surgery, Hospital Universitari MútuaTerrassa, University of Barcelona, Terrassa, Spain.,Department of Morphological Sciences, School of Medicine, Autonomous University of Barcelona, Bellaterra, Spain
| | - Ramon Rami-Porta
- Department of Thoracic Surgery, Hospital Universitari MútuaTerrassa, University of Barcelona, Terrassa, Spain.,Network of Centers for Biomedical Research in Respiratory Diseases (CIBERES) Lung Cancer Group, Terrassa, Spain
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20
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Dezube AR, Jaklitsch MT. Minimizing residual occult nodal metastasis in NSCLC: recent advances, current status and controversies. Expert Rev Anticancer Ther 2020; 20:117-130. [PMID: 32003589 DOI: 10.1080/14737140.2020.1723418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Introduction: Nodal involvement in lung cancer is a significant determinant of prognosis and treatment management. New evidence exists regarding the management of occult lymph node metastasis and residual disease in the fields of imaging, mediastinal staging, and operative management.Areas covered: This review summarizes the latest body of knowledge on the identification and management of occult lymph node metastasis in NSCLC. We focus on tumor-specific characteristics; imaging modalities; invasive mediastinal staging; and operative management including, technique, degree of resection, and lymph node examination.Expert opinion: Newly identified risk-factors associated with nodal metastasis including tumor histology, location, radiologic features, and metabolic activity are not included in professional societal guidelines due to the heterogeneity of their reporting and uncertainty on how to adopt them into practice. Imaging as a sole diagnostic method is limited. We recommend confirmation with invasive mediastinal staging. EBUS-FNA is the best initial method, but adoption has not been uniform. The diagnostic algorithm is less certain for re-staging of mediastinal nodes after neoadjuvant therapy. Mediastinal node sampling during lobectomy remains the gold-standard, but evidence supports the use of minimally invasive techniques. More study is warranted regarding sublobar resection. No consensus exists regarding lymph node examination, but new evidence supports reexamination of current quality metrics.
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Affiliation(s)
- Aaron R Dezube
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
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21
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Serra P, Centeno C, Sanz-Santos J, Torky M, Baeza S, Mendiluce L, Martínez-Barenys C, López de Castro P, Abad J, Rosell A, Andreo F. Is it necessary to sample the contralateral nodal stations by EBUS-TBNA in patients with lung cancer and clinical N0 / N1 on PET-CT? Lung Cancer 2020; 142:9-12. [PMID: 32062200 DOI: 10.1016/j.lungcan.2020.01.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 01/07/2020] [Accepted: 01/11/2020] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Pere Serra
- Pulmonology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Departament de Medicina, Universitat Autónoma de Barcelona (UAB), Spain.
| | - Carmen Centeno
- Pulmonology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Departament de Medicina, Universitat Autónoma de Barcelona (UAB), Spain
| | - José Sanz-Santos
- Pulmonology Department, Hospital Universitari Mutua de Terrassa, Terrassa, Barcelona, Spain; Universitat de Barcelona, Facultad de Medicina, Spain
| | - Mohamed Torky
- Pulmonology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Sonia Baeza
- Pulmonology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Leire Mendiluce
- Pulmonology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Carlos Martínez-Barenys
- Thoracic Surgery Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Pedro López de Castro
- Thoracic Surgery Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Jorge Abad
- Pulmonology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Antoni Rosell
- Pulmonology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Departament de Medicina, Universitat Autónoma de Barcelona (UAB), Spain
| | - Felipe Andreo
- Pulmonology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Departament de Medicina, Universitat Autónoma de Barcelona (UAB), Spain
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Yang M, She Y, Deng J, Wang T, Ren Y, Su H, Wu J, Sun X, Jiang G, Fei K, Zhang L, Xie D, Chen C. CT-based radiomics signature for the stratification of N2 disease risk in clinical stage I lung adenocarcinoma. Transl Lung Cancer Res 2019; 8:876-885. [PMID: 32010566 DOI: 10.21037/tlcr.2019.11.18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Risk stratification of N2 disease is vital for selecting candidates to receive invasive mediastinal staging modalities. In this study, we aimed to stratify the risk of N2 metastasis in clinical stage I lung adenocarcinoma using radiomics analysis. Methods Two datasets of patients with clinical stage I lung adenocarcinoma who underwent lung resection were included (training dataset, 880; validation dataset, 322). Using PyRadiomics, 1,078 computed tomography (CT)-based radiomics features were extracted after semi-automated lung nodule segmentation. In order to predict N2 status, a radiomics signature was constructed after selecting the optimal radiomics feature subset by sequentially applying minimum-redundancy-maximum-relevance and least absolute shrinkage and selection operator (LASSO) techniques. Its performance was validated in the validation dataset. Results The incidences of N2 metastasis were 8.4% and 7.1% in the training and validation datasets, respectively. Unsupervised cluster analysis revealed that radiomics features significantly correlated with lymph node status and pathological subtypes. For N2 disease prediction, five radiomics features were selected to establish the radiomics signature, which showed a significantly better predictive performance than clinical factors (P<0.001). The area under the receiver operating characteristic curve was 0.81 (0.77-0.86) and 0.69 (0.63-0.75) for radiomics signature and clinical factors, respectively, in the training dataset, and 0.82 (0.71-0.92) and 0.64 (0.52-0.75), respectively, in the validation dataset. Conclusions The established CT-based radiomics signature could stratify the risk of N2 metastasis in clinical stage I lung adenocarcinoma, thus assisting clinicians in making patient-specific mediastinal staging strategy.
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Affiliation(s)
- Minglei Yang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China.,Department of Thoracic Surgery, Ningbo No.2 Hospital, Chinese Academy of Sciences, Ningbo 315010, China
| | - Yunlang She
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Jiajun Deng
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Tingting Wang
- Department of Radiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Yijiu Ren
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Hang Su
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Junqi Wu
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Xiwen Sun
- Department of Radiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Gening Jiang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Ke Fei
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Lei Zhang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Dong Xie
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Chang Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
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Bousema JE, van Dorp M, Hoeijmakers F, Huijbregts IA, Barlo NP, Bootsma GP, van Boven WP, Claessens NJ, Dingemans AMC, Hanselaar WE, Kortekaas RT, Lardenoije JWH, Maessen JG, Schreurs WH, Vissers Y, Youssef-El Soud M, Dijkgraaf MG, Annema J, van den Broek FJ. Guideline adherence of mediastinal staging of non-small cell lung cancer: A multicentre retrospective analysis. Lung Cancer 2019; 134:52-58. [DOI: 10.1016/j.lungcan.2019.05.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/19/2019] [Accepted: 05/29/2019] [Indexed: 12/26/2022]
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24
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Multidisciplinary consensus statement on the clinical management of patients with stage III non-small cell lung cancer. Clin Transl Oncol 2019; 22:21-36. [PMID: 31172444 DOI: 10.1007/s12094-019-02134-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/11/2019] [Indexed: 12/17/2022]
Abstract
Stage III non-small cell lung cancer (NSCLC) is a very heterogeneous disease that encompasses patients with resected, potentially resectable and unresectable tumours. To improve the prognostic capacity of the TNM classification, it has been agreed to divide stage III into sub-stages IIIA, IIIB and IIIC that have very different 5-year survival rates (36, 26 and 13%, respectively). Currently, it is considered that both staging and optimal treatment of stage III NSCLC requires the joint work of a multidisciplinary team of expert physicians within the tumour committee. To improve the care of patients with stage III NSCLC, different scientific societies involved in the diagnosis and treatment of this disease have agreed to issue a series of recommendations that can contribute to homogenise the management of this disease, and ultimately to improve patient care.
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25
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Unforeseen N2 Disease after Negative Endosonography Findings with or without Confirmatory Mediastinoscopy in Resectable Non–Small Cell Lung Cancer: A Systematic Review and Meta-Analysis. J Thorac Oncol 2019; 14:979-992. [DOI: 10.1016/j.jtho.2019.02.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 02/10/2019] [Accepted: 02/22/2019] [Indexed: 02/06/2023]
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26
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Bostantzoglou C, Iliopoulou M, Hardavella G. Mediastinal staging by videomediastinoscopy in clinical N1 non-small cell lung cancer. Breathe (Sheff) 2018; 14:342-344. [PMID: 30519305 PMCID: PMC6269169 DOI: 10.1183/20734735.027118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
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
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Affiliation(s)
| | - Marianthi Iliopoulou
- 7th Respiratory Medicine Dept, "Sotiria" Athens Chest Diseases Hospital, Athens, Greece
| | - Georgia Hardavella
- 10th Respiratory Medicine Dept, "Sotiria" Athens Chest Diseases Hospital, Athens, Greece
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27
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Call S, Obiols C, Rami-Porta R. Present indications of surgical exploration of the mediastinum. J Thorac Dis 2018; 10:S2601-S2610. [PMID: 30345097 DOI: 10.21037/jtd.2018.03.183] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Sergi Call
- Department of Thoracic Surgery, Hospital Universitari Mutua Terrassa, University of Barcelona, Terrassa, Spain.,Department of Morphological Sciences, School of Medicine, Autonomous University of Barcelona, Bellaterra, Spain
| | - Carme Obiols
- Department of Thoracic Surgery, Hospital Universitari Mutua Terrassa, University of Barcelona, Terrassa, Spain
| | - Ramon Rami-Porta
- Department of Thoracic Surgery, Hospital Universitari Mutua Terrassa, University of Barcelona, Terrassa, Spain.,Network of Centres for Biomedical Research in Respiratory Diseases (CIBERES) Lung Cancer Group, Terrassa, Spain
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28
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Rami-Porta R, Call S, Dooms C, Obiols C, Sánchez M, Travis WD, Vollmer I. Lung cancer staging: a concise update. Eur Respir J 2018; 51:13993003.00190-2018. [PMID: 29700105 DOI: 10.1183/13993003.00190-2018] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 04/04/2018] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Ramón Rami-Porta
- Dept of Thoracic Surgery, Hospital Universitari Mutua Terrassa, University of Barcelona, Barcelona, Spain.,Network of Centres for Biomedical Research in Respiratory Diseases (CIBERES) Lung Cancer Group, Barcelona, Spain
| | - Sergi Call
- Dept of Thoracic Surgery, Hospital Universitari Mutua Terrassa, University of Barcelona, Barcelona, Spain.,Dept of Morphological Sciences, School of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Christophe Dooms
- Dept of Respiratory Diseases, University Hospitals, KU Leuven, Leuven, Belgium
| | - Carme Obiols
- Dept of Thoracic Surgery, Hospital Universitari Mutua Terrassa, University of Barcelona, Barcelona, Spain
| | - Marcelo Sánchez
- Centre of Imaging Diagnosis, Radiology Dept, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - William D Travis
- Dept of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ivan Vollmer
- Centre of Imaging Diagnosis, Radiology Dept, Hospital Clínic, University of Barcelona, Barcelona, Spain
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Addeo A, Banna G. Adding an invasive procedure will not necessarily change treatment or outcome of NSCLC patients with preoperative clinical N1 disease. Eur Respir J 2018; 51:51/4/1800084. [PMID: 29618603 DOI: 10.1183/13993003.00084-2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 01/23/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Alfredo Addeo
- Oncology Dept, University Hospital Geneva, Geneva, Switzerland
| | - Giuseppe Banna
- Division of Medical Oncology, Cannizzaro Hospital, Catania, Italy
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30
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Decaluwé H, Dooms C, De Leyn P, Thomas P, Rami-Porta R. Adding an invasive procedure will not necessarily change treatment or outcome of NSCLC patients with preoperative clinical N1 disease. Eur Respir J 2018; 51:51/4/1800410. [PMID: 29618606 DOI: 10.1183/13993003.00410-2018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 02/27/2018] [Indexed: 12/25/2022]
Affiliation(s)
- Herbert Decaluwé
- Dept of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Christophe Dooms
- Dept of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Paul De Leyn
- Dept of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Pascal Thomas
- Dept of Thoracic Surgery, Lung Transplantation and Diseases of the Esophagus, North University Hospital, Marseille, France
| | - Ramon Rami-Porta
- Dept of Thoracic Surgery, Hospital Universitari Mutua Terrassa, Terrassa, Spain
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