Endosonography for mediastinal nodal staging of clinical N1 non-small cell lung cancer: a prospective multicenter study

Accuracy of endobronchial ultrasound-guided transbronchial needle aspiration for staging of non-small cell lung cancer

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is routinely performed to confirm a lung cancer diagnosis and/or to clinically stage disease. EBUS-TBNA findings may be used to determine whether patients can be offered potentially curative surgery. In this study, we evaluated the reporting in our service of EBUS-TBNA cytology for early-stage (operable) non-small cell lung cancer (NSCLC), focusing on diagnostic accuracy and analyzing cases with discordant cytologic and post-surgical histopathologic conclusions.

METHODS

Cytology slides and cytopathology reports of 120 NSCLC patients who had undergone EBUS-TBNA and lobectomy in our hospital system between 2015 and 2021 were retrospectively reviewed.

RESULTS

Of 290 lymph nodes (110 cases) able to be reviewed, interpretation of 48 lymph nodes was discordant with the original cytopathology report. This included 31 lymph nodes originally reported as adequate, which were found to be non-diagnostic on review. The diagnostic accuracy (benign/malignant) of lymph nodes that were sampled at EBUS-TBNA and excised at surgery was 89%. Specific examination of cases where EBUS-TBNA cytology did not reflect post-surgical findings illustrated important features and limitations of the procedure. These included potential misclassification of lymph node stations, the presence of multiple, variably involved nodes at lymph node stations, and the failure to detect small volume disease.

CONCLUSIONS

Continuous evaluation of EBUS-TBNA performance identifies technical limitations and areas of improvement for cytopathology reporting. This is increasingly important in an era where lung cancer screening is expected to increase diagnosis of early-stage disease and with the advent of novel treatments, including non-surgical management options.

Clinical Effect of Endosonography on Overall Survival in Patients with Radiological N1 Non-Small Cell Lung Cancer

PURPOSE

It is unclear whether performing endosonography first in non-small cell lung cancer (NSCLC) patients with radiological N1 (rN1) has any advantages over surgery without nodal staging. We aimed to compare surgery without endosonography to performing endosonography first in rN1 on the overall survival (OS) of patients with NSCLC.

MATERIALS AND METHODS

This is a retrospective analysis of patients with rN1 NSCLC between 2013 and 2019. Patients were divided into 'no endosonography' and 'endosonography first' groups. We investigated the effect of nodal staging through endosonography on OS using propensity score matching (PSM) and multivariable Cox proportional hazard regression analysis.

RESULTS

In the no endosonography group, pathologic N2 occurred in 23.0% of patients. In the endosonography first group, endosonographic N2 and N3 occurred in 8.6% and 1.6% of patients, respectively. Additionally, 51 patients were pathologic N2 among 249 patients who underwent surgery and mediastinal lymph node dissection (MLND) in endosonography first group. After PSM, the 5-year OSs were 68.1% and 70.6% in the no endosonography and endosonography first groups, respectively. However, the 5-year OS was 80.2% in the subgroup who underwent surgery and MLND of the endosonography first group. Moreover, in patients receiving surgical resection with MLND, the endosonography first group tended to have a better OS than the no endosonography group in adjusted analysis using various models.

CONCLUSION

In rN1 NSCLC, preoperative endosonography shows better OS than surgery without endosonography. For patients with rN1 NSCLC who are candidates for surgery, preoperative endosonography may help improve survival through patient selection.

Video-assisted mediastinoscopic lymphadenectomy (VAMLA): Mature results for staging non-small cell lung cancer with normal mediastinum

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.

Systematic mediastinal staging in non-small cell lung cancer: Filling in the guideline evidence gap

See related article

EBUS-TBNA for mediastinal staging of centrally located T1N0M0 non-small cell lung cancer clinically staged with PET/CT

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.

Endobronchial Ultrasound/Transbronchial Needle Aspiration-Biopsy for Systematic Mediastinal lymph Node Staging of Non-Small Cell Lung Cancer in Patients Eligible for Surgery: A Prospective Multicenter Study

BACKGROUND

The treatment of lung cancer depends on histological and/or cytological evaluation of the mediastinal lymph nodes. Endobronchial ultrasound/transbronchial needle aspiration-biopsy (EBUS/TBNA-TBNB) is the only minimally invasive technique for a diagnostic exploration of the mediastinum. The aim of this study is to analyze the reliability of EBUS in the preoperative staging of non-small cell lung cancer (NSCLC).

METHODS

A prospective study was conducted from December 2019 to December 2022 on 217 NSCLC patients, who underwent preoperative mediastinal staging using EBUS/TBNA-TBNB according to the ACCP and ESTS guidelines. The following variables were analyzed in order to define the performance of the endoscopic technique-comparing the final staging of lung cancer after pulmonary resection with the operative histological findings: clinical characteristics, lymph nodes examined, number of samples, and likelihood ratio for positive and negative outcomes.

RESULTS

No morbidity or mortality was noted. All patients were discharged from hospital on day one. In 201 patients (92.6%), the preoperative staging using EBUS and the definitive staging deriving from the evaluation of the operative specimen after lung resection were the same; the same number of patients were detected in downstaging and upstaging (8 and 8, 7.4%). The sensitivity, specificity, positive and negative predictive value, and diagnostic accuracy were 90%, 90%, 82%, 94%, and 90%, respectively. The likelihood ratio for positive and negative results was 9 and 0.9, respectively, confirming cancer when present and excluding it when absent.

CONCLUSIONS

EBUS is the only low-invasive and easy procedure for mediastinal staging. The possibility to check the method in each of its phases-through direct visualization of the vessels regardless of their location in relation to the lymph nodes-makes it safe both for the endoscopist and for the patient. Certainly, the cytologist/histologist and/or operator must have adequate expertise in order not to negatively affect the outcome of the method, although three procedures appear to reduce the impact of the individual professional involved on performance.

Endosonography With or Without Confirmatory Mediastinoscopy for Resectable Lung Cancer: A Randomized Clinical Trial

PURPOSE

Resectable non-small-cell lung cancer (NSCLC) with a high probability of mediastinal nodal involvement requires mediastinal staging by endosonography and, in the absence of nodal metastases, confirmatory mediastinoscopy according to current guidelines. However, randomized data regarding immediate lung tumor resection after systematic endosonography versus additional confirmatory mediastinoscopy before resection are lacking.

METHODS

Patients with (suspected) resectable NSCLC and an indication for mediastinal staging after negative systematic endosonography were randomly assigned to immediate lung tumor resection or confirmatory mediastinoscopy followed by tumor resection. The primary outcome in this noninferiority trial (noninferiority margin of 8% that previously showed to not compromise survival, Pnoninferior < .0250) was the presence of unforeseen N2 disease after tumor resection with lymph node dissection. Secondary outcomes were 30-day major morbidity and mortality.

RESULTS

Between July 17, 2017, and October 5, 2020, 360 patients were randomly assigned, 178 to immediate lung tumor resection (seven dropouts) and 182 to confirmatory mediastinoscopy first (seven dropouts before and six after mediastinoscopy). Mediastinoscopy detected metastases in 8.0% (14/175; 95% CI, 4.8 to 13.0) of patients. Unforeseen N2 rate after immediate resection (8.8%) was noninferior compared with mediastinoscopy first (7.7%) in both intention-to-treat (Δ, 1.03%; UL 95% CIΔ, 7.2%; Pnoninferior = .0144) and per-protocol analyses (Δ, 0.83%; UL 95% CIΔ, 7.3%; Pnoninferior = .0157). Major morbidity and 30-day mortality was 12.9% after immediate resection versus 15.4% after mediastinoscopy first (P = .4940).

CONCLUSION

On the basis of our chosen noninferiority margin in the rate of unforeseen N2, confirmatory mediastinoscopy after negative systematic endosonography can be omitted in patients with resectable NSCLC and an indication for mediastinal staging.

Integral mediastinal staging in patients with NON-SMALL cell lung cancer and risk factors for occult N2 disease

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.

Historical eye: from traditional to endobronchial ultrasound-guided needle aspiration and beyond

PURPOSE OF REVIEW

In the history of bronchoscopy, the advent of flexible transbronchial needle aspiration (TBNA) before and, subsequently, of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), have represented fundamental events, as they have significantly and definitively changed interventional pulmonology's role in diagnostic and therapeutic work-up of most of thoracic diseases.Purpose of this historical review is to retrace the main stages that have contributed to the development of these two techniques.

RECENT FINDINGS

TBNA allowed the bronchoscopists to overcome the barrier of the tracheobronchial wall and to obtain samples from hilar-mediastinal lesions. With this additional method, bronchoscopy has become an essential procedure for staging of lung cancer.The advent of echo-bronchoscopes, allowing to perform TBNA under direct ultrasound guidance in real time, further increased the diagnostic yield of this technique. Furthermore, the insertion of the echo-bronchoscope through the oesophagus allowed to extend the landscape of targets to sample, including also para-esophageal lesions, liver metastases, celiac nodes and left adrenal glands.EBUS-TBNA has shown its usefulness not only in the approach to mediastinal lesions, but also in other clinical conditions, such as lung nodules or masses adjacent to the tracheobronchial tree.

SUMMARY

Despite the obvious advantages of EBUS-TBNA, this technology is not yet available in many centres and countries worldwide. For this reason, TBNA remains a basic technique that must complete the technical background of bronchoscopists and it should not be forgotten.

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

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

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

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.

The Value of a Systematic Protocol Using Endobronchial Ultrasound and Endoscopic Ultrasound in Staging of Lung Cancer for Patients with Imaging iN0–N1 Disease

<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.

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

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.

Central location and risk of imaging occult mediastinal lymph node involvement in cN0T2-4 non-small cell lung cancer

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.

Completeness of lymph node dissection in patients undergoing minimally invasive- or open surgery for non-small cell lung cancer: A nationwide study

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.

Preoperative mediastinal staging in patients with cT1-3NxM0 non-small cell lung cancer

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.

Cost-effectiveness of endoscopic mediastinal staging

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.

Variation Between Multidisciplinary Tumor Boards in Clinical Staging and Treatment Recommendations for Patients With Locally Advanced Non-small Cell Lung Cancer

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.

Preoperative staging of the mediastinum is an essential and multidisciplinary task

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.

An International Survey of Mediastinal Staging Practices amongst Interventional Bronchoscopists

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Rationale: When stereotactic ablative radiotherapy is an option for patients with non–small cell lung cancer (NSCLC), distinguishing between N0, N1, and N2 or N3 (N2|3) disease is important.

Objectives: To develop a prediction model for estimating the probability of N0, N1, and N2|3 disease.

Methods: Consecutive patients with clinical-radiographic stage T1 to T3, N0 to N3, and M0 NSCLC who underwent endobronchial ultrasound–guided staging from a single center were included. Multivariate ordinal logistic regression analysis was used to predict the presence of N0, N1, or N2|3 disease. Temporal validation used consecutive patients from 3 years later at the same center. External validation used three other hospitals.

Measurements and Main Results: In the model development cohort (n = 633), younger age, central location, adenocarcinoma, and higher positron emission tomography–computed tomography nodal stage were associated with a higher probability of having advanced nodal disease. Areas under the receiver operating characteristic curve (AUCs) were 0.84 and 0.86 for predicting N1 or higher (vs. N0) disease and N2|3 (vs. N0 or N1) disease, respectively. Model fit was acceptable (Hosmer-Lemeshow, P = 0.960; Brier score, 0.36). In the temporal validation cohort (n = 473), AUCs were 0.86 and 0.88. Model fit was acceptable (Hosmer-Lemeshow, P = 0.172; Brier score, 0.30). In the external validation cohort (n = 722), AUCs were 0.86 and 0.88 but required calibration (Hosmer-Lemeshow, P < 0.001; Brier score, 0.38). Calibration using the general calibration method resulted in acceptable model fit (Hosmer-Lemeshow, P = 0.094; Brier score, 0.34).

Conclusions: This prediction model can estimate the probability of N0, N1, and N2|3 disease in patients with NSCLC. The model has the potential to facilitate decision-making in patients with NSCLC when stereotactic ablative radiotherapy is an option.

Clinicopathologic Significance of False-Positive Lymph Node Status on FDG-PET in Lung Cancer

INTRODUCTION

2-[¹⁸F] Fluoro-d-deoxyglucose (FDG) positron emission tomography (PET) is a relevant diagnostic procedure for staging lung cancer. However, accurate evaluation of lymph node metastases by PET is controversial because of false-positive FDG uptake.

PATIENTS AND METHODS

A total of 245 patients with lung cancer were retrospectively analyzed. Standardized maximum uptake values (SUV_max) of the primary tumor and lymph nodes were compared to pathologic lymph node metastases to correlate PET findings with clinicopathologic variables and patient outcomes.

RESULTS

The SUV_max values of metastatic lymph nodes were significantly higher than those of lymph nodes without metastases (P = .0036). When SUV_max ≥ 4 was defined as PET positive for metastasis, the sensitivity, specificity, and accuracy were 48.1%, 79.8%, and 73.1%, respectively. Multivariate logistic regression analysis showed that age > 75 years, bilateral hilar FDG uptake, and no lymph node swelling were significant factors related to false-positive lymph node metastases. Smoking status, FDG uptake in the primary tumor, and concurrent lung diseases were not significant factors.

CONCLUSION

Metastatic lymph nodes show higher FDG uptake than false-positive lymph nodes, and older patient age, bilateral hilar FDG uptake, and no swollen nodes are associated with no metastases. Patients with lymph node metastases have worse survival than those with false-positive FDG-PET findings. However, abnormal FDG uptake in the lymph node is an important prognostic factor.

Safe performance of diagnostic bronchoscopy/EBUS during the SARS-CoV-2 pandemic

The SARS‐CoV‐2 pandemic is unprecedented in our professional lives and much effort and resources will be devoted to care of patients (and HCW) affected by this illness. We must also continue to aim for the same standard of care for our non‐COVID respiratory patients, while minimizing risks of infection transmission to our colleagues. This commentary addresses the key paired issues of minimizing performance of diagnostic/staging bronchoscopy in patients with suspected/known lung cancer while maximizing the safety of the procedure with respect to HCW transmission of COVID‐19.

Adherence to the mediastinal staging guideline and unforeseen N2 disease in patients with resectable non-small cell lung cancer: Nationwide results from the Dutch Lung Cancer Audit - Surgery

OBJECTIVES

Invasive mediastinal staging is advised by guidelines in patients with resectable non-small cell lung cancer (NSCLC) and suspicious lymph nodes (cN1-3) or for central, FDG-non-avid or peripheral tumours >3 cm. Our objective was to assess current guideline adherence and consequent unforeseen N2 disease (uN2) in NSCLC patients having various indications for mediastinal staging.

MATERIALS AND METHODS

We analysed the Dutch Lung Cancer Audit - Surgery data of all patients who underwent a primary lung resection with lymph node dissection for NSCLC in 2017-2018. Based on the 2015 ESTS-ERS-ESGE guideline we assessed the use of initial endosonography and confirmatory mediastinoscopy as well as uN2 rates.

RESULTS

A total of 2238 patients were analysed. 43 % (95 %-CI: 41-45) underwent initial endosonography followed by a confirmatory mediastinoscopy in 44 % (95 %-CI:40-47) of them, resulting in a 19 % (95 %-CI: 17-20) rate of properly staged patient according to the guidelines. uN2 was demonstrated in 12.5 % (95 %-CI: 9.7-16.0) of correctly staged patients compared to 10.9 % (95 %-CI: 9.6-12.4) who were not (p = .36). The highest uN2 rate was found in cN1-3 patients who were not staged (23.0 %, 95 %-CI: 16.4-31.2) compared to 13.0 % (95 %-CI: 9.7-17.1) who were (p = .01).

CONCLUSION

Guideline adherence in Dutch NSCLC patients with an indication for invasive mediastinal staging is poor. The highest uN2 rate was found in unstaged cN1-3 patients, suggesting that this subgroup may benefit from an appropriate staging conform guidelines.

Minimizing residual occult nodal metastasis in NSCLC: recent advances, current status and controversies

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.

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

OBJECTIVES

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Prognosticating Outcomes in Interstitial Lung Disease by Mediastinal Lymph Node Assessment. An Observational Cohort Study with Independent Validation

RATIONALE

Mediastinal lymph node (MLN) enlargement on chest computed tomography (CT) is prevalent in patients with interstitial lung disease (ILD) and may reflect immunologic activation and subsequent cytokine-mediated immune cell trafficking.

OBJECTIVES

We aimed to determine whether MLN enlargement on chest CT predicts clinical outcomes and circulating cytokine levels in ILD.

METHODS

MLN measurements were obtained from chest CT scans of patients with ILD at baseline evaluation over a 10-year period. Patients with sarcoidosis and drug toxicity-related ILD were excluded. MLN diameter and location were assessed. Plasma cytokine levels were analyzed in a subset of patients. The primary outcome was transplant-free survival (TFS). Secondary outcomes included all-cause and respiratory hospitalizations, lung function, and plasma cytokine concentrations. Cox regression was used to assess mortality risk. Outcomes were assessed in three independent ILD cohorts.

MEASUREMENTS AND MAIN RESULTS

Chest CT scans were assessed in 1,094 patients (mean age, 64 yr; 52% male). MLN enlargement (≥10 mm) was present in 66% (n = 726) and strongly predicted TFS (hazard ratio [HR], 1.53; 95% confidence interval [CI], 1.12-2.10; P = 0.008) and risk of all-cause and respiratory hospitalizations (internal rate of return [IRR], 1.52; 95% CI, 1.17-1.98; P = 0.002; and IRR, 1.71; 95% CI, 1.15-2.53; P = 0.008, respectively) when compared with subjects with MLN <10 mm. Patients with MLN enlargement had lower lung function and decreased plasma concentrations of soluble CD40L (376 pg/ml vs. 505 pg/ml, P = 0.001) compared with those without MLN enlargement. Plasma IL-10 concentration >45 pg/ml predicted mortality (HR, 4.21; 95% CI, 1.21-14.68; P = 0.024). Independent analysis of external datasets confirmed these findings.

CONCLUSIONS

MLN enlargement predicts TFS and hospitalization risk in ILD and is associated with decreased levels of a key circulating cytokine, soluble CD40L. Incorporating MLN and cytokine findings into current prediction models might improve ILD prognostication.

Preoperative Staging by EBUS in cN0/N1 Lung Cancer: Systematic Review and Meta-Analysis

BACKGROUND

Performance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for staging the radiologically normal mediastinum has been reported with inconsistent findings. We assessed the sensitivity of systematic staging using EBUS-TBNA for detection of radiologically occult mediastinal metastases in cN0/N1 lung cancer.

METHODS

Studies evaluating EBUS-TBNA for systematic mediastinal staging in cN0/N1 lung cancer were identified by systematic review. Data extracted included: participant age and sex; EBUS-TBNA protocol; stage determined by radiology, EBUS-TBNA and surgery; 2×2 tables. Primary outcome was diagnostic accuracy of EBUS-TBNA for detection of unsuspected N2/N3 disease.

RESULTS

We identified 1173 articles. In total, 13 were included in a qualitative review and 9 (1146 patients) in a quantitative meta-analysis. Mean prevalence of N2/N3 disease was 15% (6% to 24%). EBUS-TBNA had pooled sensitivity of 49% [95% confidence interval (CI), 41%-57%], pooled specificity of 100% (95% CI, 99%-100%), mean negative predictive value 91% (82% to 100%) for detection of unsuspected N2/N3 metastases. Number needed to test to detect occult N2/N3 disease was 14 (95% CI, 10.8-16.3), which halved with addition of per-esophageal endoscopic ultrasound.

CONCLUSION

Preoperative systematic staging by EBUS-TBNA of early lung cancer can reduce postoperative upstaging. Sensitivity for detection of radiologically occult mediastinal metastases seems lower than selective sampling of pathologic lymph nodes. Verification of negative results by mediastinoscopy in selected cases remains of value.

CT-based radiomics signature for the stratification of N2 disease risk in clinical stage I lung adenocarcinoma

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.

A Randomized Controlled Trial Comparing a Mapleson Circuit with Nasal Trumpet to Standard Oxygen Supplementation during EBUS Bronchoscopy under Monitored Anesthesia Care

Background

Endobronchial ultrasound (EBUS) procedures tend to be longer than routine bronchoscopies. Increased duration and sedative dosing put patients at increased risk for ­hypoxic events.

Objective

To determine whether oxygen supplementation via a nasal trumpet connected to a Mapleson B circuit (NTM) was effective in decreasing hypoxic events when compared with the standard of care, oxygen supplementation with a nasal cannula (NC).

Methods

Patients referred for EBUS-guided transbronchial needle aspiration with monitored anesthesia care (MAC) were randomized 1:1 to NTM or to NC. Hypoxia-related procedural interruptions, the primary endpoint of the study, were documented for all patients. Patients in the NC group who had refractory desaturations were allowed to cross over to the NTM group. Secondary endpoints included: number of crossovers from NC to NTM, sedative dosing, total procedure times, whether procedure goals were achieved, complications apart from hypoxia, patient discharge status.

Results

Fifty-two patients were randomized to NC and 48 to NTM. Baseline characteristics were comparable. The NC group had significantly more interruptions than did the NTM group (p < 0.001). Procedure duration was also significantly (p < 0.03) shorter for the NTM group. Fourteen patients were crossed over from NC to NTM because of hypoxia. Thirteen out of the 14 completed the procedure with no interruptions. All procedures were successfully completed, and all goals were achieved. All patients returned to baseline status prior to discharge. Three minor complications of epistaxis occurred.

Conclusion

For patients undergoing EBUS with MAC, oxygen supplementation with NTM significantly decreased the incidence of hypoxic events when compared with NC. NTM may also be of value for other subsets of patients who are at increased risk for desaturation when undergoing bronchoscopy.

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

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

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

Present indications of surgical exploration of the mediastinum

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

Lung cancer staging: a concise update

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

Endobronchial ultrasound-transbronchial needle aspiration (EBUS/TBNA): a diagnostic challenge for mediastinal lesions

Lung cancer is one of the most frequent neoplastic diseases. To date, most lung cancer is diagnosed at an advanced stage, making it difficult to choose the diagnostic and therapeutic strategy. Surgical resection represents the best therapeutic solution. However, the best results are obtained only in the early stages of the disease. Lymph node involvement conditions the treatment (surgical or non-surgical approach). Mediastinoscopy is an effective and widely used method for mediastinal staging but does not allow us to reach many mediastinal lymph nodes. Endobronchial ultrasound/transbronchial needle aspiration (EBUS-TBNA) allows us to reach more lymph nodes and is referred to as a first-choice exam for mediastinal staging.

Mediastinal staging by videomediastinoscopy in clinical N1 non-small cell lung cancer: a prospective multicentre study

A quarter of patients with clinical N1 (cN1) non-small cell lung cancer (NSCLC) based on positron emission tomography-computed tomography (PET-CT) imaging have occult mediastinal nodal involvement (N2 disease). In a prospective study, endosonography alone had an unsatisfactory sensitivity (38%) in detecting N2 disease. The current prospective multicentre trial investigated the sensitivity of preoperative mediastinal staging by video-assisted mediastinoscopy (VAM) or VAM-lymphadenectomy (VAMLA).Consecutive patients with operable and resectable (suspected) NSCLC and cN1 after PET-CT imaging underwent VAM(LA). The primary study outcome was sensitivity to detect N2 disease. Secondary endpoints were the prevalence of N2 disease, negative predictive value (NPV) and accuracy of VAM(LA).Out of 105 patients with cN1 on imaging, 26% eventually developed N2 disease. Invasive mediastinal staging with VAM(LA) had a sensitivity of 73% to detect N2 disease. The NPV was 92% and accuracy 93%. Median number of assessed lymph node stations during VAM(LA) was 4 (IQR 3-5), and in 96%, at least three stations were assessed.VAM(LA) has a satisfactory sensitivity of 73% to detect mediastinal nodal disease in cN1 lung cancer, and could be the technique of choice for pre-resection mediastinal lymph node assessment in this patient group with a one in four chance of occult-positive mediastinal nodes after negative PET-CT.

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

BACKGROUND AND OBJECTIVE

Standard nodal staging of lung cancer consists of positron emission tomography/computed tomography (PET/CT), followed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) if PET/CT shows mediastinal lymphadenopathy. Sensitivity of EBUS-TBNA in patients with N0/N1 disease by PET/CT is unclear and largely based on retrospective studies. We assessed the sensitivity of EBUS-TBNA in this setting.

METHODS

We enrolled patients with proven or suspected lung cancer staged as N0/N1 by PET/CT and without metastatic disease (M0), who underwent staging EBUS-TBNA. Primary outcome was sensitivity of EBUS-TBNA compared with a composite reference standard of surgical stage or EBUS-TBNA stage if EBUS demonstrated N2/N3 disease.

RESULTS

Seventy-five patients were included in the analysis. Mean tumour size was 3.52 cm (±1.63). Fifteen of 75 patients (20%) had N2 disease. EBUS-TBNA identified six while nine were only identified at surgery. Sensitivity of EBUS-TBNA for N2 disease was 40% (95% CI: 16.3-67.7%).

CONCLUSION

A significant proportion of patients with N0/N1 disease by PET/CT had N2 disease (20%) and EBUS-TBNA identified a substantial fraction of these patients, thus improving diagnostic accuracy compared with PET/CT alone. Sensitivity of EBUS-TBNA however appears lower compared with historical data from patients with larger volume mediastinal disease. Therefore, strategies to improve EBUS-TBNA accuracy in this population should be further explored.

European Organization for Research and Treatment of Cancer (EORTC) recommendations for planning and delivery of high-dose, high precision radiotherapy for lung cancer

PURPOSE

To update literature-based recommendations for techniques used in high-precision thoracic radiotherapy for lung cancer, in both routine practice and clinical trials.

METHODS

A literature search was performed to identify published articles that were considered clinically relevant and practical to use. Recommendations were categorised under the following headings: patient positioning and immobilisation, Tumour and nodal changes, CT and FDG-PET imaging, target volumes definition, radiotherapy treatment planning and treatment delivery. An adapted grading of evidence from the Infectious Disease Society of America, and for models the TRIPOD criteria, were used.

RESULTS

Recommendations were identified for each of the above categories.

CONCLUSION

Recommendations for the clinical implementation of high-precision conformal radiotherapy and stereotactic body radiotherapy for lung tumours were identified from the literature. Techniques that were considered investigational at present are highlighted.

Added value of combined endobronchial and oesophageal endosonography for mediastinal nodal staging in lung cancer: a systematic review and meta-analysis

BACKGROUND

Guidelines recommend endosonography with fine-needle aspiration for mediastinal nodal staging in non-small-cell lung cancer, but most do not specify whether this should be through endobronchial endoscopy (EBUS), oesophageal endoscopy (EUS), or both. We assessed the added value and diagnostic accuracy of the combined use of EBUS and EUS.

METHODS

For this systematic review and random effects meta-analysis, we searched MEDLINE, Embase, BIOSIS Previews, and Web of Science, without language restrictions, for studies published between Jan 1, 2000, and Feb 25, 2016. We included studies that assessed the accuracy of the combined use of EBUS and EUS in detecting mediastinal nodal metastases (N2/N3 disease) in patients with lung cancer. For each included study, we extracted data on the age and sex of participants, inclusion criteria regarding tumour stage on imaging, details of the endoscopic testing protocol, duration of each endoscopic procedure, number of lymph nodes sampled, serious adverse events occurring during the endoscopic procedures, the reference standard, and 2 × 2 tables for EBUS, EUS, and the combined approach. We evaluated the added value (absolute increase in sensitivity and in detection rate) of the combined use of EBUS and EUS in detecting mediastinal nodal metastases over either test alone, and the diagnostic accuracy (sensitivity and negative predictive value) of the combined approach. This study is registered with PROSPERO, number CRD42015019249.

FINDINGS

We identified 2567 unique manuscripts by database search, of which 13 studies (including 2395 patients) were included in the analysis. Median prevalence of N2/N3 disease was 34% (range 23-71). On average, addition of EUS to EBUS increased sensitivity by 0·12 (95% CI 0·08-0·18) and addition of EBUS to EUS increased sensitivity by 0·22 (0·16-0·29). Mean sensitivity of the combined approach was 0·86 (0·81-0·90), and the mean negative predictive value was 0·92 (0·89-0·93). The mean negative predictive value was significantly higher in studies with a prevalence of 34% or less (0·93 [95% CI 0·91-0·95]) compared with studies with a prevalence of more than 34% (0·89 [0·85-0·91]; p=0·013). We found no significant differences in mean sensitivity and negative predictive value between studies that did EBUS first or EUS first, or between studies that used an EBUS-scope or a regular echoendoscope to do EUS.

INTERPRETATION

The combined use of EBUS and EUS significantly improves sensitivity in detecting mediastinal nodal metastases, reducing the need for surgical staging procedures.

FUNDING

No external funding.