1
|
Taylor O, Boardman G, Bentel J, Laycock A. Discordance between clinical and pathologic staging and the timeliness of care of non-small cell lung cancer patients diagnosed with operable tumors. Asia Pac J Clin Oncol 2023; 19:706-714. [PMID: 36707405 DOI: 10.1111/ajco.13934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 12/02/2022] [Accepted: 01/07/2023] [Indexed: 01/29/2023]
Abstract
AIM This study was performed to evaluate concordance between clinical and pathologic staging of non-small cell lung cancer (NSCLC) in our hospital network. METHODS We retrospectively reviewed records of 417 patients with NSCLC who received curative surgery and whose pathology was evaluated in our hospital between 2016 and 2021. Cytology, tissue pathology, and associated clinical, surgical, and imaging information were retrieved from hospital digital records. RESULTS The cohort included 214 female and 203 male patients aged 20.6-85.8 years. Median times among staging computed tomography and surgery (105 days [interquartile range (IQR) 77.0-143.0]), positron emission tomography and surgery (78.5 days [IQR 56.0-109.0]), and endobronchial ultrasound-guided transbronchial needle aspiration and surgery (59 days [IQR 42-94]) indicated that Australian guidelines of <42 days between original referral and commencement of treatment were not being met in the majority of cases. Discordance between clinical TNM (cTNM) and pathologic TNM staging was 25.9%, including 18.4% cases that were clinically understaged and two patients with undetected stage IVA disease. cTNM understaging was significantly associated with time between the final staging investigation and surgery (p = .023), pleural (p < .05) and vessel (p < .05) invasion, and diagnosis of high-grade adenocarcinoma (p = .001). CONCLUSION Discordance between clinical and pathologic staging of NSCLC is associated with tumor histopathologic characteristics and treatment delays. Although tumor factors that lead to discordant staging cannot be controlled, reduced time to surgery may have resulted in better outcomes for some patients in this potentially curable lung cancer cohort.
Collapse
Affiliation(s)
- Oliver Taylor
- PathWest Anatomical Pathology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- School of Medicine, The University of Notre Dame, Fremantle, Western Australia, Australia
| | - Glenn Boardman
- Clinical Service Planning & Population Health, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Jacqueline Bentel
- PathWest Anatomical Pathology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Andrew Laycock
- PathWest Anatomical Pathology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- School of Medicine, The University of Notre Dame, Fremantle, Western Australia, Australia
| |
Collapse
|
2
|
Chawla A, Wo J, Castillo CFD, Ferrone CR, Ryan DP, Hong TS, Blaszkowsky LS, Lillemoe KD, Qadan M. Clinical staging in pancreatic adenocarcinoma underestimates extent of disease. Pancreatology 2020; 20:691-697. [PMID: 32222341 DOI: 10.1016/j.pan.2020.03.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/10/2020] [Accepted: 03/16/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND/OBJECTIVES We sought to identify the reliability of AJCC clinical staging was in comparison to pathologic staging in surgically resected patients with pancreatic cancer. METHODS We used the National Cancer Database Pancreas from 2004 to 2016 and evaluated patients who underwent resection for PDAC with all documented components of clinical and pathologic stage. We first evaluated the distribution of overall clinical stage and pathologic stage and then evaluated for stage migration by assessing the number of patients who shifted from a clinical stage group to a respective pathologic stage group. To further characterize the migratory pattern, we assessed the distribution of clinical and pathologic T-stage and N-stage. RESULTS In our cohort of 28,338 patients who underwent resection for PDAC, AJCC clinical staging did not reliably predict pathologic stage. Stage migration after resection was responsible for discrepancies between the distribution of overall clinical stage and pathologic stage. The predominant migration was from patients with clinical stage I disease to pathologic stage II disease. Most patients with clinical T1 and T2 disease were upstaged to pathologic T3 disease and over half of patients with clinical N0 disease were upstaged to pathologic N1 disease after resection. DISCUSSION Clinical staging appears to overrepresent early T1, T2, and N0 disease, and underrepresent T3 and N1 disease.
Collapse
Affiliation(s)
- Akhil Chawla
- Division of Surgical Oncology, Department of Surgery, Northwestern Medicine Regional Medical Group, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jennifer Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David P Ryan
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Vernon Cancer Center, Newton-Wellesley Hospital, 2014 Washington Street, Newton, MA, 02462, USA
| | - Lawrence S Blaszkowsky
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Vernon Cancer Center, Newton-Wellesley Hospital, 2014 Washington Street, Newton, MA, 02462, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Vernon Cancer Center, Newton-Wellesley Hospital, 2014 Washington Street, Newton, MA, 02462, USA.
| |
Collapse
|
3
|
Navani N, Fisher DJ, Tierney JF, Stephens RJ, Burdett S. The Accuracy of Clinical Staging of Stage I-IIIa Non-Small Cell Lung Cancer: An Analysis Based on Individual Participant Data. Chest 2019; 155:502-509. [PMID: 30391190 PMCID: PMC6435782 DOI: 10.1016/j.chest.2018.10.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 08/17/2018] [Accepted: 10/02/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Clinical staging of non-small cell lung cancer (NSCLC) helps determine the prognosis and treatment of patients; few data exist on the accuracy of clinical staging and the impact on treatment and survival of patients. We assessed whether participant or trial characteristics were associated with clinical staging accuracy as well as impact on survival. METHODS We used individual participant data from randomized controlled trials (RCTs), supplied for a meta-analysis of preoperative chemotherapy (± radiotherapy) vs surgery alone (± radiotherapy) in NSCLC. We assessed agreement between clinical TNM (cTNM) stage at randomization and pathologic TNM (pTNM) stage, for participants in the control group. RESULTS Results are based on 698 patients who received surgery alone (± radiotherapy) with data for cTNM and pTNM stage. Forty-six percent of cases were cTNM stage I, 23% were cTNM stage II, and 31% were cTNM stage IIIa. cTNM stage disagreed with pTNM stage in 48% of cases, with 34% clinically understaged and 14% clinically overstaged. Agreement was not associated with age (P = .12), sex (P = .62), histology (P = .82), staging method (P = .32), or year of randomization (P = .98). Poorer survival in understaged patients was explained by the underlying pTNM stage. Clinical staging failed to detect T4 disease in 10% of cases and misclassified nodal disease in 38%. CONCLUSIONS This study demonstrates suboptimal agreement between clinical and pathologic staging. Discrepancies between clinical and pathologic T and N staging could have led to different treatment decisions in 10% and 38% of cases, respectively. There is therefore a need for further research into improving staging accuracy for patients with stage I-IIIa NSCLC.
Collapse
Affiliation(s)
- Neal Navani
- Lungs for Living Research Centre, UCL Respiratory and Department of Thoracic Medicine, University College London Hospital, London, England.
| | | | | | | | | |
Collapse
|
4
|
Becerra AZ, Wexner SD, Dietz DW, Xu Z, Aquina CT, Justiniano CF, Swanger AA, Temple LK, Noyes K, Monson JR, Fleming FJ. Nationwide Heterogeneity in Hospital-Specific Probabilities of Rectal Cancer Understaging and Its Effects on Outcomes. Ann Surg Oncol 2018; 25:2332-2339. [DOI: 10.1245/s10434-018-6530-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Indexed: 01/09/2023]
|
5
|
Abstract
Optimal management of non-small cell lung cancer requires treatment approach to be tailored to both the particular disease stage and the overall health and functional status of the patient. Even though surgical resection by means of an anatomic lobectomy remains the treatment of choice with the goal of cure for early-stage lung cancer, it is an invasive procedure with associated morbidity and mortality. Although these risks continue to decrease in the modern era with improvements in surgical technique and perioperative management, the risks are elevated in patients with associated medical comorbidities. As a consequence, patients at potentially increased or high risk for surgical lobectomy need to be identified by a structured preoperative assessment. This has gained increasing importance, given the emergence of alternative treatment approaches such as minimally invasive surgery, less extensive pulmonary resection, and stereotactic body radiation therapy. We review the clinical approach to suspected early-stage lung cancer based on a tumor and patient-centered stratification of risk and benefit.
Collapse
|
6
|
Lupi Herrera E, Horwitz S, Quintana F, Testelli M, Bialostozky D, Baldwin DR, Stephens RJ, Parmar MK, Spiro SG, Morris S, Janes SM. [Radiology of Ebstein's anomaly. Report of new x-ray signs and review of the literature]. THE LANCET RESPIRATORY MEDICINE 1973; 3:282-9. [PMID: 25660225 PMCID: PMC4648022 DOI: 10.1016/s2213-2600(15)00029-6] [Citation(s) in RCA: 167] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 11/05/2014] [Indexed: 02/06/2023]
Abstract
Background The diagnosis and staging of lung cancer is an important process that identifies treatment options and guides disease prognosis. We aimed to assess endobronchial ultrasound-guided transbronchial needle aspiration as an initial investigation technique for patients with suspected lung cancer. Methods In this open-label, multicentre, pragmatic, randomised controlled trial, we recruited patients who had undergone a CT scan and had suspected stage I to IIIA lung cancer, from six UK centres and randomly assigned them to either endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) or conventional diagnosis and staging (CDS), for further investigation and staging. If a target node could not be accessed by EBUS-TBNA, then endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) was allowed as an alternative procedure. Randomisation was stratified according to the presence of mediastinal lymph nodes measuring 1 cm or more in the short axis and by recruiting centre. We used a telephone randomisation method with permuted blocks of four generated by a computer. Because of the nature of the intervention, masking of participants and consenting investigators was not possible. The primary endpoint was the time-to-treatment decision after completion of the diagnostic and staging investigations and analysis was by intention-to-diagnose. This trial is registered with ClinicalTrials.gov, number NCT00652769. Findings Between June 10, 2008, and July 4, 2011, we randomly allocated 133 patients to treatment: 66 to EBUS-TBNA and 67 to CDS (one later withdrew consent). Two patients from the EBUS-TBNA group underwent EUS-FNA. The median time to treatment decision was shorter with EBUS-TBNA (14 days; 95% CI 14–15) than with CDS (29 days; 23–35) resulting in a hazard ratio of 1·98, (1·39–2·82, p<0·0001). One patient in each group had a pneumothorax from a CT-guided biopsy sample; the patient from the CDS group needed intercostal drainage and was admitted to hospital. Interpretation Transbronchial needle aspiration guided by endobronchial ultrasound should be considered as the initial investigation for patients with suspected lung cancer, because it reduces the time to treatment decision compared with conventional diagnosis and staging techniques. Funding UK Medical Research Council.
Collapse
Affiliation(s)
| | | | | | | | | | - David R Baldwin
- Department of Respiratory Medicine, Nottingham University Hospital, Nottingham, UK
| | | | | | - Stephen G Spiro
- Department of Thoracic Medicine, University College London Hospital, London, UK; Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Sam M Janes
- Department of Thoracic Medicine, University College London Hospital, London, UK; Lungs for Living Research Centre, UCL Respiratory, University College London, London, UK.
| | | |
Collapse
|