Clinical efficacy and cost-effectiveness of endobronchial ultrasound-guided transbronchial needle aspiration for preoperative staging of non-small-cell lung cancer: Results of a French prospective multicenter trial (EVIEPEB)

Mediastinal staging lymph node probability map in non-small cell lung cancer

BACKGROUND

Mediastinal lymph node (LN) staging is routinely performed using PET/CT and EBUS-TBNA. Promising predictive algorithms for lymph nodes have been reported for each technique, both individually and in combination. This study aims to develop a predictive algorithm that combines EBUS, PET/CT and clinical data to provide a probability of malignancy.

METHODS

A retrospective study was conducted on consecutive patients with non-small cell lung carcinoma staged using PET/CT and EBUS-TBNA. Lymph nodes were identified by level (N1, N2, and N3) and anatomical region (AR) (subcarinal, paratracheal, and hilar). A Standardized Uptake Value (SUV) was determined for each sampled LN. The ultrasound features collected included diameter in the short axis (DSA), morphology, border, echogenicity and the presence of the vascular hilum. A robust logistic regression model was used to construct an algorithm to estimate the probability of malignancy of the lymph node.

RESULTS

A total of 116 patients with a mean age of 66, 93% of whom were men, were included. 358 lymph nodes were evaluated, 51% of which exhibited adenocarcinoma and 35% were squamous, while 14% were classified as non-small-cell lung carcinoma. The model estimated the probability of malignancy for each lymph node using age, DSA, SUVmax, and AR. The Area Under the ROC curve, was 0.89. A user-friendly application was also developed ( https://ubidi.shinyapps.io/lymma/ .) CONCLUSIONS: The integration of patient clinical characteristics, EBUS features, and PET/CT findings may generate a pre-sampling malignancy probability map for each lymph node. The model requires prospective and external validation.

Impact of Pulmonary and Critical Care Fellow Participation during Advanced Diagnostic Bronchoscopy

Background: Pulmonary and critical care medicine (PCCM) fellows frequently participate in advanced diagnostic bronchoscopy (ADB) procedures. Objective: To investigate the impact of PCCM fellow involvement during ADB on various procedural outcomes in a real-world setting. Methods: This was a retrospective observational cohort study analyzing prospectively collected registry data of consecutive ADB procedures performed between February 2018 and December 2021. Procedure duration, safety, breadth, and diagnostic performance of ADBs performed by PCCM fellows supervised by interventional pulmonologists (IPs) were compared with those completed solely by IP faculty. Results: Among 628 ADBs, fellows participated in 379 (60.3%). With unadjusted analysis, fellow-involved cases were a median 11.5 minutes longer for convex-probe endobronchial ultrasound bronchoscopy (95% confidence interval [CI], 6.0-14.0; P < 0.001) and 10.5 minutes longer for peripheral bronchoscopy (95% CI, 2.0-18.0; P = 0.016). Compared with ADBs performed by IP faculty alone, procedures with second-year (post-graduate year 5) fellows had the largest duration differences. These included convex-probe endobronchial ultrasound bronchoscopy (+14.5 min; 95% CI, 7.0-18.0 min; P < 0.001), cases not using rapid on-site evaluation (+14.0 min; 95% CI, 8.0-21.0 min; P < 0.001) and those performed with moderate sedation (+12.0 min; 95% CI, 7.0-18.0 min; P < 0.001). After multivariate adjustment, fellow-involved procedures overall were 7.2 minutes longer in duration (95% CI, 3.8-10.5; P < 0.001), and 8.8 minutes longer when performed by post-graduate year 5 fellows-an approximate 16% decrease in efficiency. Bronchoscopies performed with fellows were also more likely to experience complications (38.7% compared with 25.8% with faculty procedures; adjusted odds ratio [OR], 2.0; 95% CI, 1.3-3.0; P < 0.001) and be prematurely terminated (adjusted OR, 4.95; 95% CI, 1.44-17.02; P = 0.011). Diagnostic performance and occurrence of major complications were similar between fellow and no-fellow bronchoscopies. Conclusion: Participation of PCCM fellows during ADB increases procedure duration and the risk for minor complications compared with cases completed solely by IPs. Procedures performed with fellows on the steepest portion of the ADB learning curve are the least efficient. Fellowship directors and faculty bronchoscopists should acknowledge these potential impacts on ABD practice while optimizing the approach to bronchoscopy training.

Analysis of variation of serum CEA, SCC, CYFRA21-1 in patients with lung cancer and their diagnostic value with EBUS-TBNA

Background

To explore the variation of serum carcinoembryonic antigen (CEA), cytokeratin 19 fragment (CYFRA21-1), and squamous cell carcinoma (SCC) antigen in patients with lung cancer (LC) and their diagnostic value with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA).

Methods

This study examined the diagnostic value of serum tumor marker testing and EBUS-TBNA joint detection for LC in 150 patients with suspected LC.

Results

Compared to benign patients, the serum levels of CYFRA21-1, SCC, and CEA in LC were higher (P<0.05). In patients with squamous cell carcinoma (LSCC), small cell lung cancer (SCLC), and lung adenocarcinoma, lung adenocarcinoma had higher serum CEA levels (P<0.05). In comparison, LSCC patients had higher serum SCC and CYFRA21-1 levels (P<0.05). As compared to each index detected alone, the AUC of combined detection of each index to diagnose LC and identify pathological types of LC was elevated.

Conclusions

The clinical significance of serum CYFRA21-1, SCC, and CEA conjugated with EBUS-TBNA is demonstrated for diagnostic purposes and identification of LC pathological types.

[The role of endoscopy in exploration of the mediastinum, indications and results]

Since 2005, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as a standard pulmonological tool. The procedure is safe and well tolerated by patients, with minimal morbidity and almost no mortality. A previous review on the technique was published in 2012. However, over the last ten years, a number of new studies have been published on "benign" (sarcoidosis, tuberculosis…) as well as "malignant" diseases (lung cancer, metastases of extra-thoracic cancers, search for mutations and specific oncogenic markers…). These developments have led to expanded indications for EBUS-TBNA, with which it is indispensable to be familiar, in terms of "staging" as well as "diagnosis". In view of optimizing lymph node sampling, several publications have described and discussed EBUS exploration by means of newly available tools (biopsy forceps, larger needles…), and proposed interpretation of the images thereby produced. Given the ongoing evolution of linear EBUS, it seemed indispensable that information on this marvelous tool be updated. This review is aimed at summarizing the novel elements we have found the most important.

Perspective and practice patterns of mediastinal staging among thoracic surgeons

Background

Accurate mediastinal staging of lung cancer patients is critical for determining appropriate treatment. Mediastinoscopy and endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration are the most commonly utilized techniques. Limited data exist on training and practice trends among thoracic surgeons. We aimed to determine training and practice patterns and find whether there is a paradigm shift in mediastinal staging after the introduction of EBUS into practice among thoracic surgeons in the United States.

Methods

28-question survey was constructed querying demographic, training, and practice patterns with mediastinoscopy and EBUS and was sent to practicing thoracic surgeons in the United States. Descriptive statistics were used to summarize quantitative data.

Results

Ninety-eight responded with a 93% completion rate. Eighty-seven percent of respondents received training in EBUS and 70% perform EBUS routinely. All respondents believe EBUS should be incorporated into thoracic surgery training curriculums. Majority of those who prefer EBUS feel EBUS is safer than mediastinoscopy, allows access to lymph nodes stations or lesions inaccessible by mediastinoscopy and prefer EBUS to avoid re-do mediastinoscopy and in irradiated mediastinum. Majority of those who prefer mediastinoscopy reported they perform more accurate staging compared to EBUS, that mediastinoscopy is more accurate in diagnosing lymphoma or sarcoidosis and that frozen section can be done at the same interval as resection. Among surgeons who prefer EBUS, 94% biopsy 3 or more lymph node stations, 86% routinely biopsy hilar (N1) nodes while 8% never biopsy N1 nodes. Of surgeons who prefer mediastinoscopy. Ninety-seven percent biopsy 3 or more lymph node stations, only 27% routinely biopsy N1 nodes and 70% never biopsy N1 nodes.

Conclusions

EBUS is used frequently by thoracic surgeons in their practice for mediastinal staging. Methods of obtaining proficiency in EBUS widely varied among surgeons. In addition to mediastinoscopy, dedicated EBUS training should be incorporated into thoracic surgery training curriculums.

Confirmatory Mediastinoscopy after Negative EBUS-TBNA for Mediastinal Staging of Lung Cancer: Systematic Review and Meta-analysis

RATIONALE

Current guidelines of non-small cell lung cancer (NSCLC) mediastinal staging recommend starting invasive staging with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). However, the indication to confirm a negative result of EBUS-TBNA by means of video-assisted mediastinoscopy (VAM) prior to resection differs in every guideline.

OBJECTIVE

Our aim was to evaluate the current evidence regarding the added value of confirmatory VAM after a negative EBUS-TBNA for mediastinal staging in patients with NSCLC.

METHODS

Systematic searches of studies on EBUS-TBNA for NSCLC mediastinal staging with or without confirmatory VAM but with surgical confirmation of negative results were conducted in accordance with PRISMA statement in PubMed, SCOPUS, Cochrane and Guidelines from 2005 through November 2021. In the meta-analysis the sensitivity of confirmatory VAM after a negative EBUS-TBNA, the sensitivity and negative predictive value (NPV) of the combination EBUS-TBNA plus confirmatory VAM, alongside the number of confirmatory VAM required to detect additional N2/3 disease (number needed to treat [NNT]), in patients with a previous negative EBUS-TBNA were estimated.

RESULTS

5412 articles were found, of which 29 studies were included. Random effects meta-analysis showed a sensitivity of 66.9% (95% CI: 55.8%-77.1%) for confirmatory VAM, and 96.7% (95% CI: 95.1%- 98%) for the combination EBUS-TBNA plus confirmatory VAM. NPV in studies with confirmatory VAM increased of 79.2% (95% CI: 71.4%-86.1%) for EBUS-TBNA alone to 91.8% (95% CI: 87.1%-95.5%) for EBUS-TBNA plus confirmatory VAM. The NNT of confirmatory VAM in patients with a previous negative EBUS-TBNA was 23.8 (95% CI: 19.3-31.2) CONCLUSIONS: Confirmatory VAM after negative EBUS-TBNA reduces the rate of unforeseen N2/3 disease, but with a high NNT, and should be recommended only to certain cases yet to be defined.

Impact of EBUS-TBNA in addition to [18F]FDG-PET/CT imaging on target volume definition for radiochemotherapy in stage III NSCLC

Purpose/introduction

[¹⁸F]FDG-PET/CT is the standard imaging-technique for radiation treatment (RT) planning in locally advanced non-small cell lung cancer (NSCLC). The purpose of this study was to examine the additional value of endobronchial-ultrasound transbronchial needle aspiration (EBUS-TBNA) to standard PET/CT for mediastinal lymph-node (LN) staging and its impact on clinical target volume (CTV).

Materials and methods

All consecutive patients with primary stage III NSCLC who underwent [¹⁸F]FDG-PET/CT and EBUS-TBNA prior to RT were analyzed from 12/2011 to 06/2018. LN-stations were assessed by an expert-radiologist and a nuclear medicine-physician. CTV was evaluated by two independent radiation oncologists. LNs were grouped with increasing distance along the lymphatic chains from primary tumor into echelon-1 (ipsilateral hilum), echelon-2 (LN-station 7 and ipsilateral 4), and echelon-3 (remaining mediastinum and contralateral hilum).

Results

A total of 675 LN-stations of which 291 were positive for tumor-cells, were sampled by EBUS-TBNA in 180 patients. The rate of EBUS-positive LNs was 43% among all sampled LNs. EBUS-positivity in EBUS-probed LNs decreased from 85.8% in echelon-1 LNs to 42.4%/ 9.6% in echelon-2/ -3 LNs, respectively (p < 0.0001, Fisher’s exact test). The false discovery rate of PET in comparison with EBUS results rose from 5.3% in echelon-1 to 32.9%/ 69.1% in echelon-2/ -3 LNs, respectively (p < 0.0001, Fisher’s exact test). Sensitivity and specificity of FDG-PET/CT ranged from 85 to 99% and 67 to 80% for the different echelons. In 22.2% patients, EBUS-TBNA finding triggered changes of the treated CTV, compared with contouring algorithms based on FDG-avidity as the sole criterion for inclusion. CTV was enlarged in 6.7% patients due to EBUS-positivity in PET-negative LN-station and reduced in 15.5% by exclusion of an EBUS-negative but PET-positive LN-station.

Conclusion

The false discovery rate of [¹⁸F]FDG-PET/CT increased markedly with distance from the primary tumor. Inclusion of systematic mediastinal LN mapping by EBUS-TBNA in addition to PET/CT has the potential to increase accuracy of target volume definition, particularly in echelon-3 LNs. EBUS-TBNA is recommended as integral part of staging for radiochemotherapy in stage III NSCLC.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00259-021-05204-7.

Is Routine Chest Radiography Necessary After Endobronchial Ultrasound-guided Fine Needle Aspiration?

BACKGROUND

Chest radiography is routinely performed after endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA) to detect clinically occult pneumothorax. Because the established rate of postprocedure pneumothorax is low, this study sought to determine whether routine chest radiography can be safely eliminated and to ascertain the potential cost reduction with its omission.

METHODS

Patients who underwent EBUS-FNA between January 1, 2017 and December 31, 2018 at Memorial Sloan Kettering Cancer Center (New York, NY) were retrospectively identified. Patient-related factors were summarized using descriptive statistics. Outcomes were compared using the χ², Fisher exact, and analysis of variance tests. Univariate regression analysis was used to identify factors predictive of postprocedure pneumothorax.

RESULTS

A total of 757 patients were included in the study: 72.4% (548 of 757) underwent routine chest radiography in the postanesthesia care unit. Clinically relevant or radiographically evident pneumothorax developed in 1.5% of patients (11 of 757). Of the patients who underwent chest radiography, 0.5% (3 of 548) required unplanned admission for postprocedure pneumothorax, and 0.2% (1 of 548) required tube thoracostomy. Of the 209 patients who did not undergo chest radiography, none experienced a clinically evident pneumothorax. In total, only 1 patient (0.1%) had symptomatic pneumothorax. The pneumothorax event rate was so low that no association with demographic or clinical factors and no predictive factors could be identified. The number of patients needed to be screened by chest radiography to identify 1 patient requiring deviation from routine management is 183. The potential total cost reduction if routine chest radiography had been eliminated was $33,950.

CONCLUSIONS

The extremely low rate of postprocedure pneumothorax precluded informative statistical analysis. Routine chest radiography after EBUS-FNA may not be necessary, and its omission may confer a cost savings.

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.