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Linear EBUS in staging non-small cell lung cancer and diagnosing benign diseases. J Bronchology Interv Pulmonol 2013; 20:66-76. [PMID: 23328148 DOI: 10.1097/lbr.0b013e31827d1514] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
As an evolving technique, linear endobronchial ultrasound is becoming the first choice and standard of care not only to diagnose the malignant and benign mediastinal lesions but also to stage non-small cell lung cancer. Lung cancer is the leading cause of cancer-related mortality in both men and women. The disease causes more death compared with colorectal, breast, and prostate cancers combined in the United States. Staging of lung cancer determines the prognosis. The type of lung cancer has changed in the past few decades. The frequency of adenocarcinoma has increased, whereas squamous cell carcinoma now is less frequent. Determining the cell type and its molecular characteristics allow targeted treatments in adenocarcinoma. The diagnosis of indeterminate mediastinal lymph nodes or masses and staging lung cancer might be challenging. This article will review the principles and clinical utility of endobronchial ultrasound in mediastinal lesions.
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203
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Silvestri GA, Gonzalez AV, Jantz MA, Margolis ML, Gould MK, Tanoue LT, Harris LJ, Detterbeck FC. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e211S-e250S. [PMID: 23649440 DOI: 10.1378/chest.12-2355] [Citation(s) in RCA: 1009] [Impact Index Per Article: 84.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Correctly staging lung cancer is important because the treatment options and prognosis differ significantly by stage. Several noninvasive imaging studies and invasive tests are available. Understanding the accuracy, advantages, and disadvantages of the available methods for staging non-small cell lung cancer is critical to decision-making. METHODS Test accuracies for the available staging studies were updated from the second iteration of the American College of Chest Physicians Lung Cancer Guidelines. Systematic searches of the MEDLINE database were performed up to June 2012 with the inclusion of selected meta-analyses, practice guidelines, and reviews. Study designs and results are summarized in evidence tables. RESULTS The sensitivity and specificity of CT scanning for identifying mediastinal lymph node metastasis were approximately 55% and 81%, respectively, confirming that CT scanning has limited ability either to rule in or exclude mediastinal metastasis. For PET scanning, estimates of sensitivity and specificity for identifying mediastinal metastasis were approximately 77% and 86%, respectively. These findings demonstrate that PET scanning is more accurate than CT scanning, but tissue biopsy is still required to confirm PET scan findings. The needle techniques endobronchial ultrasound-needle aspiration, endoscopic ultrasound-needle aspiration, and combined endobronchial ultrasound/endoscopic ultrasound-needle aspiration have sensitivities of approximately 89%, 89%, and 91%, respectively. In direct comparison with surgical staging, needle techniques have emerged as the best first diagnostic tools to obtain tissue. Based on randomized controlled trials, PET or PET-CT scanning is recommended for staging and to detect unsuspected metastatic disease and avoid noncurative resections. CONCLUSIONS Since the last iteration of the staging guidelines, PET scanning has assumed a more prominent role both in its use prior to surgery and when evaluating for metastatic disease. Minimally invasive needle techniques to stage the mediastinum have become increasingly accepted and are the tests of first choice to confirm mediastinal disease in accessible lymph node stations. If negative, these needle techniques should be followed by surgical biopsy. All abnormal scans should be confirmed by tissue biopsy (by whatever method is available) to ensure accurate staging. Evidence suggests that more complete staging improves patient outcomes.
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Affiliation(s)
| | - Anne V Gonzalez
- Montreal Chest Institute, McGill University Health Centre, Montreal, QC, Canada
| | - Michael A Jantz
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, Gainesville, FL
| | | | - Michael K Gould
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Lynn T Tanoue
- Section of Pulmonary and Critical Care Medicine, New Haven, CT
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204
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Darling GE. Current status of mediastinal lymph node dissection versus sampling in non-small cell lung cancer. Thorac Surg Clin 2013; 23:349-56. [PMID: 23931018 DOI: 10.1016/j.thorsurg.2013.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article addresses the appropriate use of lymph node sampling versus dissection, recommendations for minimum sampling for staging, and the role of lymph node dissection in improving survival.
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Affiliation(s)
- Gail E Darling
- Thoracic Surgery, Kress Family Chair in Esophageal Cancer, University of Toronto, Toronto General Hospital, University Health Network, 200 Elizabeth Street, Room 9N-955, Toronto, Ontario M5G 2C4, Canada.
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Folch E, Majid A. Point: are >50 supervised procedures required to develop competency in performing endobronchial ultrasound-guided transbronchial needle aspiration for mediastinal staging? Yes. Chest 2013; 143:888-891. [PMID: 23546478 DOI: 10.1378/chest.12-2462] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Erik Folch
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA.
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA
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206
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Gilmore DM, Khullar OV, Jaklitsch MT, Chirieac LR, Frangioni JV, Colson YL. Identification of metastatic nodal disease in a phase 1 dose-escalation trial of intraoperative sentinel lymph node mapping in non-small cell lung cancer using near-infrared imaging. J Thorac Cardiovasc Surg 2013; 146:562-70; discussion 569-70. [PMID: 23790404 DOI: 10.1016/j.jtcvs.2013.04.010] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 04/01/2013] [Accepted: 04/18/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Early-stage non-small cell lung cancer (NSCLC) has a high recurrence rate and poor 5-year survival, particularly if lymph nodes are involved. Our objective was to perform a dose-escalation study to assess safety and feasibility of intraoperative near-infrared (NIR) fluorescence imaging to identify the first tumor-draining lymph nodes (ie, sentinel lymph nodes [SLNs] in patients with NSCLC). METHODS A-dose escalation phase 1 clinical trial assessing real-time NIR imaging after peritumoral injection of 3.8 to 2500 μg indocyanine green (ICG) was initiated in patients with suspected stage I/II NSCLC. Visualization of lymphatic migration, SLN identification, and adverse events were recorded. RESULTS Thirty-eight patients underwent ICG injection and NIR imaging via thoracotomy (n = 18) or thoracoscopic imaging (n = 20). SLN identification increased with ICG dose, with fewer than 25% SLNs detected in dose cohorts of 600 μg or less versus 89% success at 1000 μg or greater. Twenty-six NIR(+) SLNs were identified in 15 patients, with 7 NIR(+) SLNs (6 patients) harboring metastatic disease on histologic analysis. Metastatic nodal disease was never identified in patients with a histologically negative NIR(+) SLN. No adverse reactions were noted. CONCLUSIONS NIR-guided SLN identification with ICG was safe and feasible in this initial dose-escalation trial. ICG doses greater than 1000 μg yielded nearly 90% intrathoracic SLN visualization, with the presence or absence of metastatic disease in the SLN directly correlating with final nodal status of the lymphadenectomy specimen. Further studies are needed to optimize imaging parameters and confirm sensitivity and specificity of SLN mapping in NSCLC using this promising imaging technique.
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Affiliation(s)
- Denis M Gilmore
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass 02115, USA
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Koulaxouzidis G, Karagkiouzis G, Konstantinou M, Gkiozos I, Syrigos K. Sampling versus systematic full lymphatic dissection in surgical treatment of non-small cell lung cancer. Oncol Rev 2013; 7:e2. [PMID: 25992223 PMCID: PMC4419616 DOI: 10.4081/oncol.2013.e2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 05/16/2013] [Indexed: 11/23/2022] Open
Abstract
The extent of mediastinal lymph node assessment during surgery for non-small cell cancer remains controversial. Different techniques are used, ranging from simple visual inspection of the unopened mediastinum to an extended bilateral lymph node dissection. Furthermore, different terms are used to define these techniques. Sampling is the removal of one or more lymph nodes under the guidance of pre-operative findings. Systematic (full) nodal dissection is the removal of all mediastinal tissue containing the lymph nodes systematically within anatomical landmarks. A Medline search was conducted to identify articles in the English language that addressed the role of mediastinal lymph node resection in the treatment of non-small cell lung cancer. Opinions as to the reasons for favoring full lymphatic dissection include complete resection, improved nodal staging and better local control due to resection of undetected micrometastasis. Arguments against routine full lymphatic dissection are increased morbidity, increase in operative time, and lack of evidence of improved survival. For complete resection of non-small cell lung cancer, many authors recommend a systematic nodal dissection as the standard approach during surgery, and suggest that this provides both adequate nodal staging and guarantees complete resection. Whether extending the lymph node dissection influences survival or recurrence rate is still not known. There are valid arguments in favor in terms not only of an improved local control but also of an improved long-term survival. However, the impact of lymph node dissection on long-term survival should be further assessed by large-scale multicenter randomized trials.
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Affiliation(s)
| | | | | | - Ioannis Gkiozos
- Oncology Unit GPP, Sotiria General Hospital , Athens, Greece
| | - Konstantinos Syrigos
- Oncology Unit GPP, Sotiria General Hospital , Athens, Greece ; Thoracic Oncology, Yale School of Medicine , New Haven, CT, USA
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208
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Mauguen A, Pignon JP, Burdett S, Domerg C, Fisher D, Paulus R, Mandrekar SJ, Belani CP, Shepherd FA, Eisen T, Pang H, Collette L, Sause WT, Dahlberg SE, Crawford J, O'Brien M, Schild SE, Parmar M, Tierney JF, Le Pechoux C, Michiels S. Surrogate endpoints for overall survival in chemotherapy and radiotherapy trials in operable and locally advanced lung cancer: a re-analysis of meta-analyses of individual patients' data. Lancet Oncol 2013; 14:619-26. [PMID: 23680111 PMCID: PMC3732017 DOI: 10.1016/s1470-2045(13)70158-x] [Citation(s) in RCA: 191] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background The gold standard endpoint in clinical trials of chemotherapy and radiotherapy for lung cancer is overall survival. Although reliable and simple to measure, this endpoint takes years to observe. Surrogate endpoints that would enable earlier assessments of treatment effects would be useful. We assessed the correlations between potential surrogate endpoints and overall survival at individual and trial levels. Methods We analysed individual patients' data from 15 071 patients involved in 60 randomised clinical trials that were assessed in six meta-analyses. Two meta-analyses were of adjuvant chemotherapy in non-small-cell lung cancer, three were of sequential or concurrent chemotherapy, and one was of modified radiotherapy in locally advanced lung cancer. We investigated disease-free survival (DFS) or progression-free survival (PFS), defined as the time from randomisation to local or distant relapse or death, and locoregional control, defined as the time to the first local event, as potential surrogate endpoints. At the individual level we calculated the squared correlations between distributions of these three endpoints and overall survival, and at the trial level we calculated the squared correlation between treatment effects for endpoints. Findings In trials of adjuvant chemotherapy, correlations between DFS and overall survival were very good at the individual level (ρ2=0·83, 95% CI 0·83–0·83 in trials without radiotherapy, and 0·87, 0·87–0·87 in trials with radiotherapy) and excellent at trial level (R2=0·92, 95% CI 0·88–0·95 in trials without radiotherapy and 0·99, 0·98–1·00 in trials with radiotherapy). In studies of locally advanced disease, correlations between PFS and overall survival were very good at the individual level (ρ2 range 0·77–0·85, dependent on the regimen being assessed) and trial level (R2 range 0·89–0·97). In studies with data on locoregional control, individual-level correlations were good (ρ2=0·71, 95% CI 0·71–0·71 for concurrent chemotherapy and ρ2=0·61, 0·61–0·61 for modified vs standard radiotherapy) and trial-level correlations very good (R2=0·85, 95% CI 0·77–0·92 for concurrent chemotherapy and R2=0·95, 0·91–0·98 for modified vs standard radiotherapy). Interpretation We found a high level of evidence that DFS is a valid surrogate endpoint for overall survival in studies of adjuvant chemotherapy involving patients with non-small-cell lung cancers, and PFS in those of chemotherapy and radiotherapy for patients with locally advanced lung cancers. Extrapolation to targeted agents, however, is not automatically warranted. Funding Programme Hospitalier de Recherche Clinique, Ligue Nationale Contre le Cancer, British Medical Research Council, Sanofi-Aventis.
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Affiliation(s)
- Audrey Mauguen
- Meta-analysis Unit, Department of Biostatistics and Epidemiology, Gustave Roussy Institute, Villejuif, France
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Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ. Physiologic Evaluation of the Patient With Lung Cancer Being Considered for Resectional Surgery. Chest 2013; 143:e166S-e190S. [DOI: 10.1378/chest.12-2395] [Citation(s) in RCA: 542] [Impact Index Per Article: 45.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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210
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Senthi S, Haasbeek CJA, Lagerwaard FJ, Verbakel WF, de Haan PF, Slotman BJ, Senan S. Radiotherapy for a second primary lung cancer arising post-pneumonectomy: planning considerations and clinical outcomes. J Thorac Dis 2013; 5:116-22. [PMID: 23585935 DOI: 10.3978/j.issn.2072-1439.2013.02.07] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 02/27/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Second primary non-small cell lung cancer (SPLC) is a significant cause of death amongst lung cancer survivors. As subsequent surgery is seldom feasible post-pneumonectomy, we studied the long-term clinical outcomes achieved with curative radiotherapy using modern delivery techniques. METHODS Retrospective review of an institutional database between 2003-2011 identified 27 patients who had received curative radiotherapy for SPLC arising post-pneumonectomy. Treatments included; stereotactic ablative radiotherapy (SABR, n=20, dose 54-60 Gy in 3-8 fractions), hypofractionated radiotherapy (HFR, n=6, dose 39-60 Gy in 12-23 fractions) and conventional radiotherapy (RT, n=1, 60 Gy in 30 fractions). Clinical follow-up with a CT scan at 3, 6 and 12 months, then yearly was performed. Toxicities were scored using the common toxicity criteria for adverse events (version 4.0). RESULTS The median overall survival was 39 months (95% CI, 33-44 months). After a median follow-up of 52 months (95% CI, 37-67 months), any recurrence was observed in four (15%) patients. Actuarial 3-year rates of local, regional and distant recurrences were 8% (95% CI, 0-21 months), 10% (95% CI, 0-23%) and 9% (95% CI, 0-20%), respectively. Patients receiving HFR or RT all had centrally located tumors. Of the patients treated with HFR delivered 12 fractions, 75% (3/4) developed grade 3 or higher radiation pneumonitis (RP), including one probable grade 5 toxicity. Of those receiving RT or HFR in 13 or more fractions no (0/3) grade 3 or worse RP was observed, despite such treatment being used for larger tumors and resulting in worse lung dose-volume histogram metrics. All the patients who developed RP had radiotherapy plans, which prioritized the sparing of central structures over lung sparing. No non-RP grade 3 or higher toxicities were observed. CONCLUSIONS Curative radiotherapy is an effective treatment for SPLC arising post-pneumonectomy. For larger central tumors, our data suggests that plans should prioritize reducing lung doses above the sparing of central structures.
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Affiliation(s)
- Sashendra Senthi
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
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211
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Donington J, Ferguson M, Mazzone P, Handy J, Schuchert M, Fernando H, Loo B, Lanuti M, de Hoyos A, Detterbeck F, Pennathur A, Howington J, Landreneau R, Silvestri G. American College of Chest Physicians and Society of Thoracic Surgeons consensus statement for evaluation and management for high-risk patients with stage I non-small cell lung cancer. Chest 2013. [PMID: 23208335 DOI: 10.1378/chest.12-0790] [Citation(s) in RCA: 175] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The standard treatment of stage I non-small cell lung cancer (NSCLC) is lobectomy with systematic mediastinal lymph node evaluation. Unfortunately, up to 25% of patients with stage I NSCLC are not candidates for lobectomy because of severe medical comorbidity. METHODS A panel of experts was convened through the Thoracic Oncology Network of the American College of Chest Physicians and the Workforce on Evidence-Based Surgery of the Society of Thoracic Surgeons. Following a literature review, the panel developed 13 suggestions for evaluation and treatment through iterative discussion and debate until unanimous agreement was achieved. RESULTS Pretreatment evaluation should focus primarily on measures of cardiopulmonary physiology, as respiratory failure represents the greatest interventional risk. Alternative treatment options to lobectomy for high-risk patients include sublobar resection with or without brachytherapy, stereotactic body radiation therapy, and radiofrequency ablation. Each is associated with decreased procedural morbidity and mortality but increased risk for involved lobe and regional recurrence compared with lobectomy, but direct comparisons between modalities are lacking. CONCLUSIONS Therapeutic options for the treatment of high-risk patients are evolving quickly. Improved radiographic staging and the diagnosis of smaller and more indolent tumors push the risk-benefit decision toward parenchymal-sparing or nonoperative therapies in high-risk patients. Unbiased assessment of treatment options requires uniform reporting of treatment populations and outcomes in clinical series, which has been lacking to date.
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Affiliation(s)
- Jessica Donington
- Department of Cardiothoracic Surgery, NYU School of Medicine, New York, NY.
| | - Mark Ferguson
- Department of Surgery, University of Chicago, Chicago, IL
| | - Peter Mazzone
- Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | | | - Matthew Schuchert
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Hiran Fernando
- Department of Cardiothoracic Surgery, Boston Medical Center, Boston, MA
| | - Billy Loo
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA
| | - Michael Lanuti
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA
| | - Alberto de Hoyos
- Department of Cardiothoracic Surgery, Northwestern Memorial Hospital, Chicago, IL
| | - Frank Detterbeck
- Department of Thoracic Surgery, Yale University School of Medicine, New Haven, CT
| | - Arjun Pennathur
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John Howington
- Department of Surgery, Northshore University Health System, Evanston, IL
| | - Rodney Landreneau
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Gerard Silvestri
- Division of Pulmonary Medicine and Critical Care, Medical University of South Carolina, Charleston, SC
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Kinsey CM, Channick CL. Counterpoint: Are >50 Supervised Procedures Required to Develop Competency in Performing Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Lung Cancer Staging? No. Chest 2013; 143:891-893. [DOI: 10.1378/chest.12-2464] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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213
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Dougherty B, Jersmann HPA, Robinson PC, Nguyen P. Staging the mediastinum: what is current best practice? Lung Cancer Manag 2013. [DOI: 10.2217/lmt.13.4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
SUMMARY Staging of the mediastinum has long been a part of essential best practice in lung cancer management. This review aims to provide an overview of important key issues, such as anatomical considerations from the 2009 International Association for the Study of Lung Cancer lymph node map, as well as noninvasive and invasive staging techniques for the mediastinum. A suggested sequence of staging the mediastinum is provided, which is by no means prescriptive, but will evolve over time as more evidence is gathered regarding this important step in the clinical work-up of lung cancer patients.
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Affiliation(s)
- Brendan Dougherty
- The Department of Thoracic Medicine, The Royal Adelaide Hospital, Adelaide, Australia
| | - Hubertus PA Jersmann
- The Department of Thoracic Medicine, The Royal Adelaide Hospital, Adelaide, Australia
| | - Peter C Robinson
- The Department of Thoracic Medicine, The Royal Adelaide Hospital, Adelaide, Australia
| | - Phan Nguyen
- The Department of Thoracic Medicine, The Royal Adelaide Hospital, Adelaide, Australia.
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214
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Osarogiagbon RU, Miller LE, Wang CG, Ramirez RA. Response to editorial titled 'Intrapulmonary lymph node retrieval: unclear benefit for aggressive pathologic dissection'. Transl Lung Cancer Res 2013; 2:E33-6. [PMID: 25806226 DOI: 10.3978/j.issn.2218-6751.2013.02.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 02/13/2013] [Indexed: 11/14/2022]
Affiliation(s)
| | - Laura E Miller
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, TN, USA
| | - Christopher G Wang
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, TN, USA
| | - Robert A Ramirez
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, TN, USA
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215
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Cardillo G, Spaggiari L, Galetta D, Carleo F, Carbone L, Morrone A, Ricci A, Facciolo F, Martelli M. Pneumonectomy with en bloc chest wall resection: is it worthwhile? Report on 34 patients from two institutions. Interact Cardiovasc Thorac Surg 2013; 17:54-8. [PMID: 23529751 DOI: 10.1093/icvts/ivt091] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Pneumonectomy with en bloc chest wall resection is often denied because of the procedure-related high risk. We evaluated the short- and long-term outcome of this procedure. METHODS From January 1995 to October 2011, 34 patients (30 males and 4 females; mean age: 61.8 years) underwent pneumonectomy with en bloc chest wall resection for 33 non-small-cell lung cancer and 1 metastatic osteosarcoma in two institutions. Data were retrospectively reviewed. RESULTS Operative (30-day) mortality was 2.9% (1 of 34), and morbidity was 38.2% (13 of 34). There were 14 (41.1%) right-side procedures and 20 (58.8%) left-side procedures. Three (8.8%) patients developed bronchopleural fistulas. The mean number of resected ribs per patient was 2.7 ± 1.1. In 13 (38.2%) patients, a prosthetic reconstruction of the chest wall was needed. In 3 (8.8%) cases, the bronchial step was buttressed. Preoperative pain was statistically significantly related to the depth of chest wall invasion (P = 0.026). The N status was N0 in 18 (52.9%) cases, N1 in 9 (26.4%), N2 in 6 (17.6%) and Nx in 1 (metastatic osteosarcoma). Patients were followed-up for a total of 979 months. The median survival was 40 months. The overall 5-year survival was 46.8% (± 95% confidence interval [CI]: 0.2-0.6): 45.2 (± 95% CI: 0.03-0.8) for right-side and 48.4% (± 95% CI: 0.2-0.7) for left-side procedures, respectively. According to the N status, the 5-year survival was 59.7 (± 95% CI: 0.3-0.8) in N0, 55.5 (± 95% CI: 0.06-1) in N1 and 16.6% (± 95% CI: 0-0.4) in N2. The subgroup N0 plus N1 (27 patients) showed a 58.08% (± 95% CI: 0.3-0.8) 5-year survival compared with 16.6% (± 95% CI: 0-0.4) in N2 (χ(2): 3.7; P = 0.053). CONCLUSIONS Pneumonectomy with en bloc chest wall reconstruction can be safely offered to selected patients. The addition of en bloc chest wall resection to pneumonectomy does not affect operative mortality and morbidity compared with standard pneumonectomy. The pivotal additional effect of the chest wall resection should not be considered a contraindication for such procedures. Survival showed a clinically relevant difference by comparing N0 plus N1 with N2 (58.1 vs 16.6%), not confirmed by the statistical analysis (P = 0.053).
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Affiliation(s)
- Giuseppe Cardillo
- Unit of Thoracic Surgery, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy.
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216
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Outcomes of stereotactic ablative radiotherapy for central lung tumours: a systematic review. Radiother Oncol 2013; 106:276-82. [PMID: 23462705 DOI: 10.1016/j.radonc.2013.01.004] [Citation(s) in RCA: 190] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 01/09/2013] [Accepted: 01/14/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Stereotactic ablative radiotherapy (SABR) has improved the survival for medically inoperable patients with peripheral early-stage non-small cell lung cancer (NSCLC). We performed a systematic review of outcomes for central lung tumours. MATERIAL AND METHODS The systematic review was performed following PRISMA guidelines. Survival outcomes were evaluated for central early-stage NSCLC. Local control and toxicity outcomes were evaluated for any centrally-located lung tumour. RESULTS Twenty publications met the inclusion criteria, reporting outcomes for 563 central lung tumours, including 315 patients with early-stage NSCLC. There was heterogeneity in the planning, prescribing and delivery of SABR and the common toxicity criteria used to define toxicities (versions 2.0-4.0). Tumour location (central versus peripheral) did not impact overall survival. Local control rates were ≥ 85% when the prescribed biologically equivalent tumour dose was ≥ 100 Gy. Treatment-related mortality was 2.7% overall, and 1.0% when the biologically equivalent normal tissue dose was ≤ 210 Gy. Grade 3 or 4 toxicities may be more common following SABR for central tumours, but occurred in less than 9% of patients. CONCLUSIONS Post-SABR survival for early-stage NSCLC is not affected by tumour location. SABR achieves high local control with limited toxicity when appropriate fractionation schedules are used for central tumours.
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217
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Morano MT, Araújo AS, Nascimento FB, da Silva GF, Mesquita R, Pinto JS, de Moraes Filho MO, Pereira ED. Preoperative Pulmonary Rehabilitation Versus Chest Physical Therapy in Patients Undergoing Lung Cancer Resection: A Pilot Randomized Controlled Trial. Arch Phys Med Rehabil 2013; 94:53-8. [DOI: 10.1016/j.apmr.2012.08.206] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Revised: 08/05/2012] [Accepted: 08/09/2012] [Indexed: 11/17/2022]
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218
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Dhillon SS, Dexter EU. Advances in bronchoscopy for lung cancer. J Carcinog 2012; 11:19. [PMID: 23346012 PMCID: PMC3548337 DOI: 10.4103/1477-3163.105337] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2012] [Accepted: 12/13/2012] [Indexed: 12/14/2022] Open
Abstract
Bronchoscopic techniques have seen significant advances in the last decade. The development and refinement of different types of endobronchial ultrasound and navigation systems have led to improved diagnostic yield and lung cancer staging capabilities. The complication rate of these minimally invasive procedures is extremely low as compared to traditional transthoracic needle biopsy and surgical sampling. These advances augment the safe array of methods utilized in the work up and management algorithms of lung cancer.
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Affiliation(s)
- Samjot Singh Dhillon
- Department of Medicine Pulmonary Medicine and Thoracic Oncology, Roswell Park Cancer Institute, New York, USA ; Department of Medicine, State University of New York at Buffalo, New York, USA
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Hanna WC, Yasufuku K. Mediastinoscopy in the era of endobronchial ultrasound: when should it be performed? ACTA ACUST UNITED AC 2012. [DOI: 10.1007/s13665-012-0032-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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220
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On lymph node trays in lung cancer surgery. J Thorac Oncol 2012; 8:e8. [PMID: 23242448 DOI: 10.1097/jto.0b013e31827915b1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Use of a surgical specimen-collection kit to improve mediastinal lymph-node examination of resectable lung cancer. J Thorac Oncol 2012; 7:1276-82. [PMID: 22653076 DOI: 10.1097/jto.0b013e318257fbe5] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Pathologic examination of mediastinal lymph nodes (MLNs) after resection of non-small-cell lung cancer is critical in the determination of prognosis and postoperative management. Although systematic nodal dissection is recommended, the quality of pathologic lymph-node staging often falls short of recommendations in practice. We tested the feasibility of improving pathologic lymph-node staging of resectable non-small-cell lung cancer by using a prelabeled specimen-collection kit. METHODS Case-control study with comparison of 51 resections, using a special lymph-node collection kit, with 51 controls matched for surgeon, extent of resection, pathologist, and T category. Appropriate statistical methods were used for all comparisons. RESULTS The median number of MLNs examined increased from one in the control group, to six in the case group (p < 0.001). The percentage of resections attaining the National Comprehensive Cancer Network-recommended quality of MLN examination, and the proportion that would have been eligible for recent landmark postresection adjuvant therapy trials increased significantly (p < 0.001). The duration of surgery and postoperative complication rates were similar between cases and controls. Eighteen percent of kit cases had positive MLN, compared with 8% of controls. CONCLUSIONS The use of a specialized specimen-collection kit for MLN examination was feasible, markedly improved MLN staging, and showed a trend toward increased detection of patients with MLN metastasis, with only a modest increase in duration of surgery, and no increase in perioperative morbidity, mortality, or hospital length of stay.
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Mediastinal Lymph Node Examination and Survival in Resected Early-Stage Non–Small-Cell Lung Cancer in the Surveillance, Epidemiology, and End Results Database. J Thorac Oncol 2012; 7:1798-1806. [DOI: 10.1097/jto.0b013e31827457db] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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223
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Caglayan B, Salepci B, Dogusoy I, Fidan A, Sener Comert S, Kiral N, Yavuzer D, Sarac G. The role of convex probe endobronchial ultrasound guided transbronchial needle aspiration in the diagnosis of malignant mediastinal and hilar lymph nodes. IRANIAN JOURNAL OF RADIOLOGY 2012; 9:183-9. [PMID: 23407664 PMCID: PMC3569549 DOI: 10.5812/iranjradiol.3882] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 09/04/2012] [Accepted: 09/08/2012] [Indexed: 11/22/2022]
Abstract
Background In the diagnosis of malignant lymph nodes (LNs) and staging of lung cancer, sampling of mediastinal and hilar LNs is essential. Mediastinoscopy is known as the gold standard. Convex probe (CP) endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) is a noninvasive and highly sensitive diagnostic method in mediastinal and hilar LN sampling. Objectives Evaluating the role of CP-EBUS-guided TBNA in the diagnosis of mediastinal and hilar LNs suspicious of malignancy. Patients and Methods One hundred twenty patients with a known lung malignancy or hilar/mediastinal LNs detected by thoracic computed tomography (CT) and/or positron emission tomography (PET)-CT suspicious for malignancy were included in this prospective study. The procedure was performed by Olympus 7.5 MHz CP endoscope and EU C2000 processor by the oral route under topical anesthesia and conscious sedation. After visualization of LNs, their dimensions were recorded. Aspiration was considered as “insufficient” if there were inadequate lymphocytes on the smears. Diagnosis of “malignancy” on cytologic examination was considered as the “final diagnosis”. If diagnosis was negative for malignancy, more invasive procedures were performed to confirm the diagnosis. Results Twenty four females and 96 male patients (mean age, 57.8 ± 9.1) were included. A total of 177 LN stations were aspirated in 120 patients. In 82 patients, the diagnosis was malignant by EBUS-guided TBNA and in the remaining 38; the diagnosis was established by further invasive procedures. Of the 38 EBUS-guided TBNA negative patients, 28 were diagnosed as non-malignant and 10 were malignant. The sensitivity, diagnostic accuracy and negative predictive value of CP EBUS-guided TBNA were 89.1%, 91.6% and 73.6%, respectively. No major complications were seen. Conclusion As an alternative method to mediastinoscopy, EBUS-guided TBNA is a safe and noninvasive procedure with high sensitivity in the diagnosis of malignant mediastinal LNs.
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Affiliation(s)
- Benan Caglayan
- Department of Pulmonary Diseases, Dr. Lütfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Banu Salepci
- Department of Pulmonary Diseases, Dr. Lütfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Ilgaz Dogusoy
- Department of Thoracic Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ali Fidan
- Department of Pulmonary Diseases, Dr. Lütfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Sevda Sener Comert
- Department of Pulmonary Diseases, Dr. Lütfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
- Corresponding author: Sevda Sener Comert, Pembekosksok, Emek apt. No: 16 D: 14 34732 Merdivenkoy Kadikoy, Istanbul, Turkey. Tel.: +90-2163505187, Fax: +90-2164421884, E-mail:
| | - Nesrin Kiral
- Department of Pulmonary Diseases, Dr. Lütfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Dilek Yavuzer
- Department of Pathology, Dr. Lütfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
| | - Gulsen Sarac
- Department of Pulmonary Diseases, Dr. Lütfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
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Resection rate and outcome of pulmonary resections for non-small-cell lung cancer: a nationwide study from Iceland. J Thorac Oncol 2012; 7:1164-9. [PMID: 22592213 DOI: 10.1097/jto.0b013e318252d022] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The proportion of patients with non-small-cell lung cancer (NSCLC) who undergo surgery with curative intent is one measure of effectiveness in treating lung cancer. To the best of our knowledge, surgical resection rate (SRR) for a whole nation has never been reported before. We studied the SRR and surgical outcome of NSCLC patients in Iceland during a recent 15-year period. METHODS This was a retrospective study of all pulmonary resections performed with curative intent for NSCLC in Iceland from 1994 to 2008. Information was retrieved from medical records and from the Icelandic Cancer Registry. Patient demographics, postoperative tumor, node, metastasis stage, overall survival, and complication rates were compared over three 5-year periods. RESULTS Of 1530 confirmed cases of NSCLC, 404 were resected, giving an SRR of 26.4%, which did not change significantly during the study period. Minor and major complication rates were 37.4% and 8.7%, respectively. Operative mortality rates were 0.7% for lobectomy, 3.3% for pneumonectomy, and 0% for lesser resection. Five-year survival after all procedures was 40.7% and improved from the first to the last 5-year period (34.8% versus 43.8%, p = 0.04). Five-year survival for stages I and II together was 46.8%, with no significant change in stage distribution between periods. Five-year survival after pneumonectomy was 22.0%, which was significantly lower than for lobectomy (44.6%) and lesser resection (40.7%) (p < 0.005). Unoperated patients had a 5-year survival of 4.8%, as compared to 12.4% for all the NSCLC patients together. CONCLUSION Compared with most other published studies, the SRR of NSCLC in Iceland is high. Short-term outcome is good, with a low rate of major complications and an operative mortality of only 1.0%. Five-year survival improved significantly over the study period.
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Icard P, Heyndrickx M, Guetti L, Galateau-Salle F, Rosat P, Le Rochais JP, Hanouz JL. Morbidity, mortality and survival after 110 consecutive bilobectomies over 12 years. Interact Cardiovasc Thorac Surg 2012; 16:179-85. [PMID: 23117235 DOI: 10.1093/icvts/ivs419] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To analyse statistical aspects of mortality, morbidity and survival after bilobectomy (BT), an operation rarely studied in the literature. METHODS One hundred and ten cases were studied, comprising 58 upper-middle bilobectomies and 52 lower-middle bilobectomies performed between 1999 and 2010. Indications were of 9 benign diseases, 12 carcinoid tumours, 5 metastases and 84 non-small cell lung cancers (2 stage 0; 34 stage I; 22 stage II; 25 stage III and 1 stage IV). RESULTS Mortality was nil. Twenty-six percent of patients experienced significant morbidity, influenced in multivariate analysis by the presence of three or more comorbidities (P = 0.03) and by a forced expiratory volume in 1 s of <60% (P = 0.01). Lower-middle BT was associated with more postoperative complications than upper-middle BT (P = 0.012). The 5-year survival rate of patients with non-small cell lung carcinoma was 82% in stage I, 59% in stage II and 20% in stage IIIA. Survival was significantly influenced by stage (P = 0.0018) and tobacco weaning (P = 0.0012). CONCLUSIONS BT can be achieved with low mortality, and survival results that are comparable with those unregistered after standard lobectomy. However, almost one quarter of patients experienced significant postoperative complications. Surgical techniques aiming to reduce residual pleural space should be especially considered after lower-middle BT, due to the highest morbidity being associated with this procedure.
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Affiliation(s)
- Philippe Icard
- Department of Thoracic Surgery, University of Caen Basse-NormandSie and University Hospital of Caen, Caen, France
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Ahmad U, Detterbeck FC. Current status of lung cancer screening. Semin Thorac Cardiovasc Surg 2012; 24:27-36. [PMID: 22643659 DOI: 10.1053/j.semtcvs.2012.01.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2012] [Indexed: 11/11/2022]
Abstract
Recent results have demonstrated a major reduction in lung cancer mortality through computed tomography screening and no benefit from chest radiograph (CXR) screening. This presents a huge potential for benefit but also poses challenges regarding management of details to minimize harm. Many unresolved questions remain that must be addressed to implement computed tomography screening for lung cancer in a thoughtful and responsible way.
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Affiliation(s)
- Usman Ahmad
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut 06520-8062, USA
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Osarogiagbon RU. Predicting survival of patients with resectable non-small cell lung cancer: Beyond TNM. J Thorac Dis 2012; 4:214-6. [PMID: 22833830 DOI: 10.3978/j.issn.2072-1439.2012.03.06] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 03/09/2012] [Indexed: 01/19/2023]
Affiliation(s)
- Raymond U Osarogiagbon
- Multidisciplinary Thoracic Oncology Program, Baptist Centers for Cancer Care, Memphis, TN, USA
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229
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Ramirez RA, Wang CG, Miller LE, Adair CA, Berry A, Yu X, O'Brien TF, Osarogiagbon RU. Incomplete Intrapulmonary Lymph Node Retrieval After Routine Pathologic Examination of Resected Lung Cancer. J Clin Oncol 2012; 30:2823-8. [DOI: 10.1200/jco.2011.39.2589] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Pathologic nodal stage affects prognosis in patients with surgically resected non–small-cell lung cancer (NSCLC). Unlike examination of mediastinal lymph nodes (LNs), which depends on surgical practice, accurate examination of intrapulmonary (N1) nodes depends primarily on pathology practice. We investigated the completeness of N1 LN examination in NSCLC resection specimens and its potential impact on stage. Patients and Methods We performed a case-control study of a special pathologic examination (SPE) protocol using thin gross dissection with retrieval and microscopic examination of all LN-like material on remnant NSCLC resection specimens after routine pathologic examination (RPE). We compared LNs retrieved by the SPE protocol with nodes examined after RPE of the same lung specimens and with those of an external control cohort. Results We retrieved additional LNs in 66 (90%) of 73 patient cases and discovered metastasis in 56 (11%) of 514 retrieved LNs from 27% of all patients. We found unexpected LN metastasis in six (12%) of 50 node-negative patients. Three other patients had undetected satellite metastatic nodules. Pathologic stage was upgraded in eight (11%) of 73 patients. The time required for the SPE protocol decreased significantly with experience, with no change in the number of LNs found. Conclusion Standard pathology practice frequently leaves large numbers of N1 LNs unexamined, a clinically significant proportion of which harbor metastasis. By improving N1 LN examination, SPE can have an impact on prognosis and adjuvant management. We suggest adoption of the SPE to improve pathologic staging of resected NSCLC.
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Affiliation(s)
- Robert A. Ramirez
- Robert A. Ramirez, Christopher G. Wang, Laura E. Miller, and Raymond U. Osarogiagbon, University of Tennessee; Courtney A. Adair and Thomas F. O'Brien, Duckworth Pathology Group; Allen Berry, St Francis Hospital; and Xinhua Yu, University of Memphis, Memphis, TN
| | - Christopher G. Wang
- Robert A. Ramirez, Christopher G. Wang, Laura E. Miller, and Raymond U. Osarogiagbon, University of Tennessee; Courtney A. Adair and Thomas F. O'Brien, Duckworth Pathology Group; Allen Berry, St Francis Hospital; and Xinhua Yu, University of Memphis, Memphis, TN
| | - Laura E. Miller
- Robert A. Ramirez, Christopher G. Wang, Laura E. Miller, and Raymond U. Osarogiagbon, University of Tennessee; Courtney A. Adair and Thomas F. O'Brien, Duckworth Pathology Group; Allen Berry, St Francis Hospital; and Xinhua Yu, University of Memphis, Memphis, TN
| | - Courtney A. Adair
- Robert A. Ramirez, Christopher G. Wang, Laura E. Miller, and Raymond U. Osarogiagbon, University of Tennessee; Courtney A. Adair and Thomas F. O'Brien, Duckworth Pathology Group; Allen Berry, St Francis Hospital; and Xinhua Yu, University of Memphis, Memphis, TN
| | - Allen Berry
- Robert A. Ramirez, Christopher G. Wang, Laura E. Miller, and Raymond U. Osarogiagbon, University of Tennessee; Courtney A. Adair and Thomas F. O'Brien, Duckworth Pathology Group; Allen Berry, St Francis Hospital; and Xinhua Yu, University of Memphis, Memphis, TN
| | - Xinhua Yu
- Robert A. Ramirez, Christopher G. Wang, Laura E. Miller, and Raymond U. Osarogiagbon, University of Tennessee; Courtney A. Adair and Thomas F. O'Brien, Duckworth Pathology Group; Allen Berry, St Francis Hospital; and Xinhua Yu, University of Memphis, Memphis, TN
| | - Thomas F. O'Brien
- Robert A. Ramirez, Christopher G. Wang, Laura E. Miller, and Raymond U. Osarogiagbon, University of Tennessee; Courtney A. Adair and Thomas F. O'Brien, Duckworth Pathology Group; Allen Berry, St Francis Hospital; and Xinhua Yu, University of Memphis, Memphis, TN
| | - Raymond U. Osarogiagbon
- Robert A. Ramirez, Christopher G. Wang, Laura E. Miller, and Raymond U. Osarogiagbon, University of Tennessee; Courtney A. Adair and Thomas F. O'Brien, Duckworth Pathology Group; Allen Berry, St Francis Hospital; and Xinhua Yu, University of Memphis, Memphis, TN
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Kernstine K. A lobectomy by any other name. J Clin Oncol 2012; 30:2803-4. [PMID: 22778316 DOI: 10.1200/jco.2012.42.1222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Mediastinal lymph nodes: ignore? sample? dissect? The role of mediastinal node dissection in the surgical management of primary lung cancer. Gen Thorac Cardiovasc Surg 2012; 60:724-34. [PMID: 22875714 DOI: 10.1007/s11748-012-0086-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Indexed: 10/28/2022]
Abstract
The role of mediastinal lymph node dissection (MLND) during the resection of non-small-cell lung cancer is still unclear although most surgeons agree that a minimum of hilar and mediastinal nodes must be examined for appropriate pathological staging. Current surgical practices vary from visual inspection of the mediastinum with biopsy of only abnormal looking nodes to systematic mediastinal node sampling which is to the biopsy of lymph nodes from multiple levels whether they appear abnormal or not to MLND which involves the systematic removal of all lymph node bearing tissue from multiple sites unilaterally or bilaterally within the mediastinum. This review article looks at the evidence and arguments in favour of lymphadenectomy, including improved pathological staging, better locoregional control, and ultimately longer disease-free survival and those against which are longer operating time, increased operative morbidity, and lack of evidence for survival benefit.
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Kim AW, Detterbeck FC, Boffa DJ, Decker RH, Soulos PR, Cramer LD, Gross CP. Characteristics associated with the use of nonanatomic resections among Medicare patients undergoing resections of early-stage lung cancer. Ann Thorac Surg 2012; 94:895-901. [PMID: 22835558 DOI: 10.1016/j.athoracsur.2012.04.091] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 04/23/2012] [Accepted: 04/26/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND Racial disparities in access to surgical resection for treatment of early-stage non-small-cell lung cancer (NSCLC) are well documented. However it is unclear how race, clinical, and hospital characteristics affect the surgical approach among patients undergoing resection. METHODS Using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)/Medicare linked database, we identified patients 67 years of age or older diagnosed with stage I NSCLC who underwent surgical resection from 2000 to 2007. Surgical approach was categorized as lobectomy or segmentectomy (anatomic) versus wedge resection (nonanatomic). We used logistic regression to identify the association between demographic, clinical, and hospital factors and the use of nonanatomic resections. RESULTS There were 8,986 patients in the sample (mean age, 75 years; 53% women); 12.8% underwent nonanatomic resection. The use of nonanatomic resection increased significantly, from 11.0% in 2000 to 15.9% in 2007 (p=0.008). In multivariable analysis, race was not associated with the receipt of nonanatomic resection. Factors associated with the use of nonanatomic resections included age greater than 80 years (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.15-1.98), T1a primary tumor status, chronic obstructive pulmonary disease (COPD) (OR, 1.81; 95% CI, 1.55-2.12), and volume of hospital lung resections performed (highest versus lowest hospital volume, OR, 1.58; 95% CI, 1.23-2.04). More nonanatomic resections were performed in 2007 than in 2000 (OR, 1.73; 95% CI, 1.27-2.37). After stratifying by tumor size, the temporal trend in the use of nonanatomic resection remained significant only among patients with tumors greater than 3 cm. CONCLUSIONS Since 2000, the use of nonanatomic resections in stage I NSCLC has increased, most significantly among patients with larger tumors. After adjusting for clinical factors, there was no relation between race and type of surgical resection.
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Affiliation(s)
- Anthony W Kim
- Section of Thoracic Surgery, Department of Therapeutic Radiology and Radiation Oncology, Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Comprehensive Cancer Center, Yale School of Medicine, Yale University, New Haven, Connecticut 06520, USA.
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233
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Gilmore DM, Khullar OV, Colson YL. Developing intrathoracic sentinel lymph node mapping with near-infrared fluorescent imaging in non-small cell lung cancer. J Thorac Cardiovasc Surg 2012; 144:S80-4. [PMID: 22726707 DOI: 10.1016/j.jtcvs.2012.05.072] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 04/06/2012] [Accepted: 05/18/2012] [Indexed: 11/16/2022]
Abstract
With poor survival and high recurrence rates, early-stage lung cancer currently appears to be understaged or undertreated, or both. Although sentinel lymph node biopsy is standard for patients with breast cancer and melanoma, its success has been unreliable in non-small cell lung cancer. Sentinel lymph node biopsy might aid in the identification of lymph nodes at the greatest risk of metastasis and allow for more detailed analysis to select for patients who might benefit from adjuvant therapy. The early results in our recent clinical trial of patients with early-stage lung cancer have suggested that near-infrared imaging might offer a platform for reliable sentinel lymph node identification in these patients.
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Affiliation(s)
- Denis M Gilmore
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
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234
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Khullar OV, Gangadharan SP. Video-assisted thoracoscopic mediastinal lymph node dissection. J Thorac Cardiovasc Surg 2012; 144:S32-4. [PMID: 22676976 DOI: 10.1016/j.jtcvs.2012.05.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 05/10/2012] [Accepted: 05/15/2012] [Indexed: 11/15/2022]
Affiliation(s)
- Onkar V Khullar
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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A prospective study of quality of life including fatigue and pulmonary function after stereotactic body radiotherapy for medically inoperable early-stage lung cancer. Support Care Cancer 2012; 21:211-8. [DOI: 10.1007/s00520-012-1513-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 05/21/2012] [Indexed: 12/26/2022]
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Medford-Davis L, Decamp M, Recht A, Flickinger J, Belani CP, Varlotto J. Surgical management of early-stage non-small cell lung carcinoma and the present and future roles of adjuvant therapy: a review for the radiation oncologist. Int J Radiat Oncol Biol Phys 2012; 84:1048-57. [PMID: 22632771 DOI: 10.1016/j.ijrobp.2012.03.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 01/28/2012] [Accepted: 03/16/2012] [Indexed: 12/30/2022]
Abstract
We review the evidence for optimal surgical management and adjuvant therapy for patients with stages I and II non-small cell lung cancer (NSCLC) along with factors associated with increased risks of recurrence. Based on the current evidence, we recommend optimal use of mediastinal lymph node dissection, adjuvant chemotherapy, and post-operative radiation therapy, and make suggestions for areas to explore in future prospective randomized clinical trials.
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Affiliation(s)
- Laura Medford-Davis
- Department of Emergency Medicine, Ben Taub General Hospital, Houston, TX, USA
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Abstract
INTRODUCTION Guidelines recommend that patients with clinical stage IIIA non-small cell lung cancer (NSCLC) undergo histologic confirmation of pathologic lymph nodes. Studies have suggested that invasive mediastinal staging is underutilized, although practice patterns have not been rigorously evaluated. METHODS We used the Surveillance, Epidemiology, and End Results-Medicare database to identify patients with stage IIIA NSCLC diagnosed from 1998 through 2005. Invasive staging and use of positron emission tomography (PET) scanning were assessed using Medicare claims. Multivariable logistic regression was used to identify patient characteristics associated with use of invasive staging. RESULTS Of 7583 stage IIIA NSCLC patients, 1678 (22%) underwent invasive staging. Patients who received curative intent cancer treatment were more likely to undergo invasive staging than patients who did not receive cancer-specific therapy (30% versus 9.8%, adjusted odds ratio, 3.31; 95% confidence interval, 2.78-3.95). The oldest patients (age, 85-94 years) were less likely to receive invasive staging than the youngest (age, 67-69 years; 27.6% versus 11.9%; odds ratio, 0.46; 95% confidence interval, 0.34-0.61). Sex, marital status, income, and race were not associated with the use of the invasive staging. The use of invasive staging was stable throughout the study period, despite an increase in the use of PET scanning from less than 10% of patients before 2000 to almost 70% in 2005. CONCLUSION Nearly 80% of Medicare beneficiaries with stage IIIA NSCLC do not receive guideline adherent mediastinal staging; this failure cannot be entirely explained by patient factors or a reliance on PET imaging. Incentives to encourage use of invasive staging may improve care.
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Lagerwaard FJ, Verstegen NE, Haasbeek CJ, Slotman BJ, Paul MA, Smit EF, Senan S. Outcomes of Stereotactic Ablative Radiotherapy in Patients With Potentially Operable Stage I Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2012; 83:348-53. [PMID: 22104360 DOI: 10.1016/j.ijrobp.2011.06.2003] [Citation(s) in RCA: 247] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 05/18/2011] [Accepted: 06/25/2011] [Indexed: 12/25/2022]
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Date H. The impact of complete lymph node dissection for lung cancer on the postoperative course. Thorac Surg Clin 2012; 22:239-42. [PMID: 22520291 DOI: 10.1016/j.thorsurg.2011.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
The role of lymph node dissection (LND) for non-small cell lung cancers (NSCLCs) remains controversial. LND adds little morbidity to a pulmonary resection for NSCLC, although it requires an additional 15 to 20 minutes of operative time. Four prospective randomized trials have been performed to compare lymph node sampling and LND; 3 trials showed no difference in survival and 1 showed survival benefit of LND. It is recommended that all patients with resectable NSCLC undergo LND because the procedure provides patients with the most accurate staging and the opportunity for effective adjuvant therapy.
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Affiliation(s)
- Hiroshi Date
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan.
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241
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Ferraris VA, Saha SP, Davenport DL, Zwischenberger JB. Thoracic Surgery in the Real World: Does Surgical Specialty Affect Outcomes in Patients Having General Thoracic Operations? Ann Thorac Surg 2012; 93:1041-7; discussion 1047-8. [DOI: 10.1016/j.athoracsur.2011.12.061] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Revised: 12/08/2011] [Accepted: 12/12/2011] [Indexed: 10/28/2022]
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Lankarani A, Wallace MB. Endoscopic ultrasonography/fine-needle aspiration and endobronchial ultrasonography/fine-needle aspiration for lung cancer staging. Gastrointest Endosc Clin N Am 2012; 22:207-19, viii. [PMID: 22632944 DOI: 10.1016/j.giec.2012.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This article reviews different techniques available for diagnosis and staging of patients with non-small cell lung cancer (NSCLC). The advantages and disadvantages of each staging method are highlighted. The role of the gastroenterologist in NSCLC staging is explored. A new algorithm is proposed for the staging of NSCLC that incorporates endoscopic and endobronchial ultrasonography for mediastinal staging in patients with intrathoracic disease.
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Affiliation(s)
- Ali Lankarani
- Department of Gastroenterology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224, USA
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Nwogu CE, Groman A, Fahey D, Yendamuri S, Dexter E, Demmy TL, Miller A, Reid M. Number of lymph nodes and metastatic lymph node ratio are associated with survival in lung cancer. Ann Thorac Surg 2012; 93:1614-9; discussion 1619-20. [PMID: 22440365 DOI: 10.1016/j.athoracsur.2012.01.065] [Citation(s) in RCA: 120] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Revised: 01/19/2012] [Accepted: 01/23/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND The non-small cell lung cancer TNM classification system uses only the anatomic extent of lymph node (LN) metastases to define the N category. The number of LNs resected and the ratio of positive LNs to total examined LNs are prognostic in other solid tumors. We used the Surveillance, Epidemiology and End Results database to investigate the effect of these factors on the overall survival of non-small cell lung cancer. METHODS All patients with non-small cell lung cancer in the Surveillance, Epidemiology and End Results database from 1988 through 2007 who had curative resections and had at least one LN examined were included. The prognostic value of age, race, sex, tumor size, histologic grade, number of examined LNs, and ratio of positive LNs to total examined LNs was assessed using a multivariate Cox proportional hazards model for overall survival. The number of LNs examined was categorized into four levels. The percentage of positive LNs was stratified into three levels. RESULTS Among patients with localized disease, fewer LNs examined corresponded with a worse prognosis. Prognosis improved as more LNs were examined. For patients with regional disease, the differences were significant only at the extremes. Older patients, males, and those with higher grade or larger tumors did worse. Patients with low or moderate ratios of positive to total LNs had better prognoses than those with high ratios. CONCLUSIONS More LNs resected and lower ratios of positive LNs to total examined LNs are associated with better patient survival after non-small cell lung cancer resection independent of age, sex, grade, tumor size, and stage of disease.
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Affiliation(s)
- Chukwumere E Nwogu
- Department of Surgery, State University of New York (SUNY) at Buffalo, Buffalo, New York 14263, USA.
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Objective Review of Mediastinal Lymph Node Examination in a Lung Cancer Resection Cohort. J Thorac Oncol 2012; 7:390-6. [DOI: 10.1097/jto.0b013e31823e5e2d] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Verhagen AF, Schoenmakers MCJ, Barendregt W, Smit H, van Boven WJ, Looijen M, van der Heijden EHFM, van Swieten HA. Completeness of lung cancer surgery: is mediastinal dissection common practice? Eur J Cardiothorac Surg 2012; 41:834-8. [DOI: 10.1093/ejcts/ezr059] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Bhatt JM, Young JN, Cooke DT. Comparison of Patient Survival after Resection for Pulmonary Carcinoid Tumors Compared to Other Neuroendocrine Tumors: A United States Population Study. ACTA ACUST UNITED AC 2012. [DOI: 10.4236/ojts.2012.24020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Katlic MR, Facktor MA, Berry SA, McKinley KE, Bothe A, Steele GD. ProvenCare lung cancer: a multi-institutional improvement collaborative. CA Cancer J Clin 2011; 61:382-96. [PMID: 21748730 DOI: 10.3322/caac.20119] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Geisinger's ProvenCare™ Program (for elective coronary artery bypass surgery, total hip replacement, and others) has shown that the principles of reliability science, facilitated by a robust electronic health record and institutional commitment, allow the re-engineering of complicated clinical processes. This eliminates unwarranted variation and promotes the completion of evidence-based elements of care. It has not been established that ProvenCare can be generalized to other institutions. Now, under the auspices of the American College of Surgeons Commission on Cancer, ProvenCare has been adapted to a multi-institutional collaborative for the care of the patient with resectable lung cancer.
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Affiliation(s)
- Mark R Katlic
- Department of Thoracic Surgery, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA, USA.
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Puchalski J, Feller-Kopman D. The pulmonologist's diagnostic and therapeutic interventions in lung cancer. Clin Chest Med 2011; 32:763-71. [PMID: 22054884 DOI: 10.1016/j.ccm.2011.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Diagnostic and therapeutic strategies for lung cancer have improved with advancing technology and the acquisition of the necessary skills by bronchoscopists to fully use these advanced techniques. The diagnostic yield for lung cancer has significantly increased with the advent of technologies such as endobronchial ultrasound, navigational systems, and improved imaging modalities. Similarly, the therapeutic benefit of bronchoscopy in advanced lung cancer has begun to be understood for its impact on quality and quantity of life. This article highlights the pulmonologists' diagnostic advances and therapeutic options, with an emphasis on outcomes.
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Affiliation(s)
- Jonathan Puchalski
- Division of Pulmonary and Critical Care Medicine, Yale University School of Medicine, Boardman Building 205, 330 Cedar Street, New Haven, CT 06510, USA.
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