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Bousema JE, Dijkgraaf MG, van der Heijden EH, Verhagen AF, Annema JT, van den Broek FJ. Endosonography With or Without Confirmatory Mediastinoscopy for Resectable Lung Cancer: A Randomized Clinical Trial. J Clin Oncol 2023; 41:3805-3815. [PMID: 37018653 PMCID: PMC10419618 DOI: 10.1200/jco.22.01728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 02/10/2023] [Accepted: 02/27/2023] [Indexed: 04/07/2023] Open
Abstract
PURPOSE Resectable non-small-cell lung cancer (NSCLC) with a high probability of mediastinal nodal involvement requires mediastinal staging by endosonography and, in the absence of nodal metastases, confirmatory mediastinoscopy according to current guidelines. However, randomized data regarding immediate lung tumor resection after systematic endosonography versus additional confirmatory mediastinoscopy before resection are lacking. METHODS Patients with (suspected) resectable NSCLC and an indication for mediastinal staging after negative systematic endosonography were randomly assigned to immediate lung tumor resection or confirmatory mediastinoscopy followed by tumor resection. The primary outcome in this noninferiority trial (noninferiority margin of 8% that previously showed to not compromise survival, Pnoninferior < .0250) was the presence of unforeseen N2 disease after tumor resection with lymph node dissection. Secondary outcomes were 30-day major morbidity and mortality. RESULTS Between July 17, 2017, and October 5, 2020, 360 patients were randomly assigned, 178 to immediate lung tumor resection (seven dropouts) and 182 to confirmatory mediastinoscopy first (seven dropouts before and six after mediastinoscopy). Mediastinoscopy detected metastases in 8.0% (14/175; 95% CI, 4.8 to 13.0) of patients. Unforeseen N2 rate after immediate resection (8.8%) was noninferior compared with mediastinoscopy first (7.7%) in both intention-to-treat (Δ, 1.03%; UL 95% CIΔ, 7.2%; Pnoninferior = .0144) and per-protocol analyses (Δ, 0.83%; UL 95% CIΔ, 7.3%; Pnoninferior = .0157). Major morbidity and 30-day mortality was 12.9% after immediate resection versus 15.4% after mediastinoscopy first (P = .4940). CONCLUSION On the basis of our chosen noninferiority margin in the rate of unforeseen N2, confirmatory mediastinoscopy after negative systematic endosonography can be omitted in patients with resectable NSCLC and an indication for mediastinal staging.
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Affiliation(s)
| | - Marcel G.W. Dijkgraaf
- Amsterdam UMC Location University of Amsterdam, Epidemiology and Data Science, Amsterdam Public Health, Methodology, Amsterdam, the Netherlands
| | | | - Ad F.T.M. Verhagen
- Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jouke T. Annema
- Amsterdam UMC Location University of Amsterdam, Respiratory Medicine, Amsterdam, the Netherlands
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Steinfort DP, Evison M, Witt A, Tsaknis G, Kheir F, Manners D, Madan K, Sidhu C, Fantin A, Korevaar DA, Van Der Heijden EHFM. Proposed quality indicators and recommended standard reporting items in performance of EBUS bronchoscopy: An official World Association for Bronchology and Interventional Pulmonology Expert Panel consensus statement. Respirology 2023; 28:722-743. [PMID: 37463832 DOI: 10.1111/resp.14549] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/28/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Since their introduction, both linear and radial endobronchial ultrasound (EBUS) have become an integral component of the practice of Pulmonology and Thoracic Oncology. The quality of health care can be measured by comparing the performance of an individual or a health service with an ideal threshold or benchmark. The taskforce sought to evaluate quality indicators in EBUS bronchoscopy based on clinical relevance/importance and on the basis that observed significant variation in outcomes indicates potential for improvement in health care outcomes. METHODS A comprehensive literature review informed the composition of a comprehensive list of candidate quality indicators in EBUS. A multiple-round modified Delphi consensus process was subsequently performed with the aim of reaching consensus over a final list of quality indicators and performance targets for these indicators. Standard reporting items were developed, with a strong preference for items where evidence demonstrates a relationship with quality indicator outcomes. RESULTS Twelve quality Indicators are proposed, with performance targets supported by evidence from the literature. Standardized reporting items for both radial and linear EBUS are recommended, with evidence supporting their utility in assessing procedural outcomes presented. CONCLUSION This statement is intended to provide a framework for individual proceduralists to assess the quality of EBUS they provide their patients through the identification of clinically relevant, feasible quality measures. Emphasis is placed on outcome measures, with a preference for consistent terminology to allow communication and benchmarking between centres.
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Affiliation(s)
- Daniel P Steinfort
- Department of Medicine, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Parkville, Victoria, Australia
- Department of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Matthew Evison
- Lung Cancer & Thoracic Surgery Directorate, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Ashleigh Witt
- Department of Medicine, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Parkville, Victoria, Australia
- Department of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Georgios Tsaknis
- Department of Respiratory Sciences, College of Life Sciences, University of Leicester, Leicester, UK
- Department of Respiratory Medicine, Kettering General Hospital, UK
| | - Fayez Kheir
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David Manners
- St John of God Midland Public and Private Hospitals, Midland, Western Australia, Australia
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
| | - Karan Madan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Calvin Sidhu
- School of Health Sciences, Edith Cowan University, Perth, Western Australia, Australia
| | - Alberto Fantin
- Department of Pulmonology, University Hospital of Udine (ASUFC), Udine, Italy
| | - Daniel A Korevaar
- Department of Respiratory Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- University of Amsterdam, Amsterdam, The Netherlands
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Messina G, Bove M, Noro A, Opromolla G, Natale G, Mirra R, Capasso F, Pica DG, Di Filippo V, Pirozzi M, Caterino M, Facchini S, Zotta A, Polito R, Vicidomini G, Santini M, Fiorelli A, Ciardiello F, Fasano M. Intraoperative ultrasound: "Alternative eye" in lymph nodal dissection in non-small cell lung cancer. Thorac Cancer 2022; 13:3250-3256. [PMID: 36267041 PMCID: PMC9715883 DOI: 10.1111/1759-7714.14623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Staging of the mediastinum lymph nodes involvement in patients with non-small cell lung cancer (NSCLC) is an important prognostic factor determining the most appropriate multimodality treatment plan. The objective of this study is to assess ultrasound characteristics of mediastinal lymph nodes metastasis and effectiveness of intraoperative ultrasound-guided mediastinal nodal dissection in patients with resected NSCLC. MATERIALS AND METHODS All patients undergoing video-assisted thoracoscopic surgery lobectomy and pulmonary lymphadenectomy from November 2020 to March 2022 at the thoracic surgery department of the Vanvitelli University of Naples underwent intraoperative ultrasound-guided mediastinal lymph nodal dissection. RESULTS This study evaluates whether individual B-mode features and a compounding thereof can be used to accurately and reproducibly predict lymph node malignancy. DISCUSSION Intraoperative ultrasound, during systematic mediastinal lymph node dissection, is helpful in preventing lesion to mediastinal structures. Pathological nodal sonographic characteristics are round shape, short-axis diameter, echogenicity, margin, the absence or presence of coagulation necrosis sign, and the absence or presence of central hilar structure, increased color Doppler flow, the absence or presence of calcification, and nodal conglomeration. Operating time was not substantially prolonged. The procedure is simple, safe and highly accurate. CONCLUSIONS Ultrasonic techniques allow surgeons to detect the relationship between lymph nodes and surrounding large blood vessels during biopsy, improving the safety and simplicity of the operation, increasing the number of harvested lymph nodes, and reducing the risk of intraoperative injury; it is a fast, easily reproducible, and inexpensive method.
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Affiliation(s)
- Gaetana Messina
- Thoracic Surgery UnitUniversità degli Studi della Campania “Luigi Vanvitelli”NapoliItaly
| | - Mary Bove
- Thoracic Surgery UnitUniversità degli Studi della Campania “Luigi Vanvitelli”NapoliItaly
| | - Antonio Noro
- Thoracic Surgery UnitUniversità degli Studi della Campania “Luigi Vanvitelli”NapoliItaly
| | - Giorgia Opromolla
- Thoracic Surgery UnitUniversità degli Studi della Campania “Luigi Vanvitelli”NapoliItaly
| | - Giovanni Natale
- Thoracic Surgery UnitUniversità degli Studi della Campania “Luigi Vanvitelli”NapoliItaly
| | - Rosa Mirra
- Thoracic Surgery UnitUniversità degli Studi della Campania “Luigi Vanvitelli”NapoliItaly
| | - Francesca Capasso
- Thoracic Surgery UnitUniversità degli Studi della Campania “Luigi Vanvitelli”NapoliItaly
| | - Davide Gerardo Pica
- Thoracic Surgery UnitUniversità degli Studi della Campania “Luigi Vanvitelli”NapoliItaly
| | - Vincenzo Di Filippo
- Thoracic Surgery UnitUniversità degli Studi della Campania “Luigi Vanvitelli”NapoliItaly
| | - Mario Pirozzi
- Oncology, Department of Precision MedicineUniversità della Campania “L. Vanvitelli”NaplesItaly
| | - Marianna Caterino
- Oncology, Department of Precision MedicineUniversità della Campania “L. Vanvitelli”NaplesItaly
| | - Sergio Facchini
- Oncology, Department of Precision MedicineUniversità della Campania “L. Vanvitelli”NaplesItaly
| | - Alessia Zotta
- Oncology, Department of Precision MedicineUniversità della Campania “L. Vanvitelli”NaplesItaly
| | - Rita Polito
- Nutrition ScienceUniversity of FoggiaFoggiaItaly
| | - Giovanni Vicidomini
- Thoracic Surgery UnitUniversità degli Studi della Campania “Luigi Vanvitelli”NapoliItaly
| | - Mario Santini
- Thoracic Surgery UnitUniversità degli Studi della Campania “Luigi Vanvitelli”NapoliItaly
| | - Alfonso Fiorelli
- Oncology, Department of Precision MedicineUniversità della Campania “L. Vanvitelli”NaplesItaly
| | - Fortunato Ciardiello
- Oncology, Department of Precision MedicineUniversità della Campania “L. Vanvitelli”NaplesItaly
| | - Morena Fasano
- Oncology, Department of Precision MedicineUniversità della Campania “L. Vanvitelli”NaplesItaly
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Morishita M, Uchimura K, Furuse H, Imabayashi T, Tsuchida T, Matsumoto Y. Predicting Malignant Lymph Nodes Using a Novel Scoring System Based on Multi-Endobronchial Ultrasound Features. Cancers (Basel) 2022; 14:cancers14215355. [PMID: 36358774 PMCID: PMC9658474 DOI: 10.3390/cancers14215355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 10/26/2022] [Accepted: 10/28/2022] [Indexed: 11/16/2022] Open
Abstract
Endobronchial ultrasound (EBUS) features with B-, power/color Doppler, and elastography modes help differentiate between benign and malignant lymph nodes (MLNs) during transbronchial needle aspiration (TBNA); however, only few studies have assessed them simultaneously. We evaluated the diagnostic accuracy of each EBUS feature and aimed to establish a scoring system to predict MLNs. EBUS features of consecutive patients and final diagnosis per lymph node (LN) were examined retrospectively. In total, 594 LNs from 301 patients were analyzed. Univariable analyses revealed that EBUS features, except for round shape, could differentiate MLNs from benign LNs. Multivariable analysis revealed that short axis (>1 cm), heterogeneous echogenicity, absence of central hilar structure, presence of coagulation necrosis sign, and blue-dominant elastographic images were independent predictors of MLNs. At three or more EBUS features predicting MLNs, our scoring system had high sensitivity (77.9%) and specificity (91.8%). The area under the receiver operating curve (AUC) was 0.894 (95% confidence interval (CI): 0.868−0.920), which was higher than that of B-mode features alone (AUC: 0.840 (95% CI: 0.807−0.873)). The novel scoring system could predict MLNs more accurately than B-mode features alone. Multi-EBUS features may increase EBUS-TBNA efficiency for LN evaluation.
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Affiliation(s)
- Momoko Morishita
- Department of Endoscopy, Respiratory Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
- Department of Thoracic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
- Department of Respiratory Medicine, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan
| | - Keigo Uchimura
- Department of Endoscopy, Respiratory Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
- Correspondence: ; Tel.: +81-3-3542-2511
| | - Hideaki Furuse
- Department of Endoscopy, Respiratory Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Tatsuya Imabayashi
- Department of Endoscopy, Respiratory Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Takaaki Tsuchida
- Department of Endoscopy, Respiratory Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Yuji Matsumoto
- Department of Endoscopy, Respiratory Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
- Department of Thoracic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
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