Accuracy of endobronchial ultrasound (EBUS) in the staging of lung cancer - A comparison of staging EBUS with postoperative pathological nodal staging

BACKGROUND

Endobronchial ultrasound-guided transbronchial fine-needle aspiration (EBUS-TBNA) has replaced mediastinoscopy as the preferred investigation for evaluating mediastinum in staging lung cancer. There is little evidence of mediastinal staging by EBUS-TBNA from India.

OBJECTIVES

To study endobronchial ultrasound's diagnostic accuracy in staging lung cancer.

METHODOLOGY

We retrospectively analysed patients operated on for lung cancer where EBUS was performed preoperatively for mediastinal staging. We compared the histological findings obtained from different mediastinal lymph nodes (LNs) by EBUS-TBNA with the pathology of the same LNs obtained after surgical dissection as the reference standard.

RESULTS

Seventy-six patients underwent curative surgery for lung cancer. The diagnostic accuracy, sensitivity, specificity, positive predictive value and negative predictive value of EBUS-TBNA in predicting mediastinal metastasis were 93.9%, 40%, 99%, 80% and 94.6%, respectively. Of the 115 LNs sampled, EBUS-TBNA was false negative in six nodes, resulting in an up-staging of six patients.

CONCLUSIONS

EBUS-TBNA has a high diagnostic accuracy for lung cancer staging.

Clinical and pathologic staging accuracy in patients with synchronous multiple primary lung cancers

Background

The incidence of synchronous multiple primary lung cancer (SMPLC) is increasing, occurring in up to 20% of lung cancer patients. Accurately identifying SMPLC can be challenging, and failure to recognize SMPLC results in poor outcomes. We sought to assess the staging accuracy of patients with SMPLC at our tertiary institution.

Methods

We retrospectively reviewed all patients who were evaluated for lung cancer resection between January 2018 to September 2019. Patients with SMPLC were identified using the modified Martini-Melamed criteria. Preoperative imaging, clinical assessment, and pathologic interpretation were reviewed and compared to the final staging assigned by a multidisciplinary lung cancer tumor board to determine accuracy.

Results

Out of 227 patients presenting for lung cancer resection, 47 patients with 119 SMPLC were identified, of which 38 (80.9%) were incorrectly staged by at least one report. Incorrect staging was most common by computed tomography (CT) reports (n=33/47, 70.2%), followed by positron emission tomography-CT (PET-CT) reports (n=28/45, 62.2%), surgeons' clinical assessment (n=10/47, 21.3%), and histopathology reports (n=8/47, 17.0%). CT reports, when incorrect, under-staged 97.0% (n=32) of patients. PET-CT reports, when incorrect, over-staged 25.0% (n=7) of patients by reporting the second primary nodule to be "consistent with metastasis". Histopathology reports, when incorrect, over-staged 87.5% (n=7) of patients despite lack of lymph node involvement.

Conclusions

Patients with SMPLC are at risk of receiving incorrect treatment based on radiographic and histopathologic staging reports alone. The observed staging inaccuracies are concerning, necessitating increased awareness among physicians caring for lung cancer patients.

False Positive Positron Emission Tomography/Computed Tomography (PET/CT) Requiring Biopsy for Proper Staging of Lung Cancer

Lung cancer is the leading cause of cancer death in women in developed countries. Staging is crucial in determining the treatment modality. Different treatment modalities for lung cancer include surgery, radiation therapy, and chemotherapy. PET/CT is the most sensitive and accurate modality for detecting hilar, mediastinal, and metastatic disease except in the brain. PET/CT scan often upstages the disease. PET/CT has also been shown to have false positive results. We present the case of a 72-year-old female who had a false positive finding on PET/CT, which would have changed the management process and outcome of her disease.

Efficient procedure planning for comprehensive lymph node staging bronchoscopy

Purpose: For a patient at risk of having lung cancer, accurate disease staging is vital as it dictates disease prognosis and treatment. Accurate staging requires a comprehensive sampling of lymph nodes within the chest via bronchoscopy. Unfortunately, physicians are generally unable to plan and perform sufficiently comprehensive procedures to ensure accurate disease staging. We propose a method for planning comprehensive lymph node staging procedures. Approach: Drawing on a patient's chest CT scan, the method derives a multi-destination tour for efficient navigation to a set of lymph nodes. We formulate the planning task as a traveling salesman problem. To solve the problem, we apply the concept of ant colony optimization (ACO) to derive an efficient airway tour connecting the target nodes. The method has three main steps: (1) CT preprocessing, to define important chest anatomy; (2) graph and staging zone construction, to set up the necessary data structures and clinical constraints; and (3) tour computation, to derive the staging plan. The plan conforms to the world standard International Association for the Study of Lung Cancer (IASLC) lymph node map and recommended clinical staging guidelines. Results: Tests with a patient database indicate that the method derives optimal or near-optimal tours in under a few seconds, regardless of the number of target lymph nodes (mean tour length = 1.4% longer than the optimum). A brute force optimal search, on the other hand, generally cannot reach a solution in under 10 min. for patients exhibiting > 16 nodes, and other methods provide poor solutions. We also demonstrate the method's utility in an image-guided bronchoscopy system. Conclusions: The method provides an efficient computational approach for planning a comprehensive lymph node staging bronchoscopy. In addition, the method shows promise for driving an image-guided bronchoscopy system or robotics-assisted bronchoscopy system tailored to lymph node staging.

Five years of thoracic endoscopy unit activity on lung cancer staging: how teamwork can improve the outcomes

Background

Regarding the staging of mediastinal lymph nodes before lung cancer surgery, Endobronchial Ultrasound Transbronchial Needle Aspirations (EBUS-TBNA) have proven to be highly sensitive and specific as well as safe. Endoscopic Ultrasound Fine Needle Aspirations (EUS-FNA) plays an important role in the diagnosis and staging of thoracic diseases, including lung cancer. In this study we analysed all patients underwent endoscopic procedures in our endoscopic mediastinal ultrasound unit.

Methods

Between January 2013 and February 2018, we performed a total of 929 endoscopic procedures, 432 EBUS-TBNA and 497 EUS-FNA. Biopsy was performed at the following mediastinal sites: station 7 in 642 cases, at stations 8 and 9 in 211 cases; at station 3P and 4L in 27 and 114 cases respectively; with EUS we were able to perform biopsy at station 5 in 52 cases.

Results

A total of 841 patients showed a diagnosis of cancer: non-small cell lung cancer (NSCLC) in 645 patients, SCLC in 190 patients, neuroendocrine tumour in 5 patients and one patient with mesothelioma. 88 patients were negative for cancer. In terms of sensitivity, specificity and accuracy, the association between EUS-FNAb and EBUS-TBNAb showed a better quality on diagnosis compared to single procedures. EUS-FNA and EBUS-TBNA are safe, feasible, and highly sensitive techniques.

Conclusions

An endoscopic mediastinal ultrasound unit allows to perform a higher number of endoscopic procedures and improved the sensitivity and the accuracy of the minimally invasive hilar-mediastinal staging.

Optimizing Diagnostic and Staging Pathways for Suspected Lung Cancer: A Decision Analysis

BACKGROUND

The optimal diagnostic and staging strategy for patients with suspected lung cancer is not known.

RESEARCH QUESTION

What diagnostic and staging strategies are most cost-effective for lung cancer?

STUDY DESIGN AND METHODS

A decision model was developed by using a hypothetical patient with a high probability of lung cancer. Sixteen unique permutations of bronchoscopy with fluoroscopy, radial endobronchial ultrasound, electromagnetic navigation, convex endobronchial ultrasound with or without rapid-onsite evaluation (ROSE), CT-guided biopsy (CTBx), and surgery were evaluated. Outcomes included cost, complications, mortality, time to complete the evaluation, rate of undetected N2-3 disease at surgery, incremental cost-complication ratio, and willingness-to-pay thresholds. Sensitivity analyses were performed on primary outcomes.

RESULTS

For a peripheral lung lesion and radiographic N0 disease, the best bronchoscopy strategy costs $1,694 more than the best CTBx strategy but resulted in fewer complications (risk difference, 14%). The additional cost of bronchoscopy to avoid one complication from a CTBx strategy was $12,037. The cost and cumulative complications of bronchoscopy strategies increased compared with CTBx strategies for small lesions. The cost and cumulative complications of bronchoscopy strategies decreased compared with CTBx strategies when a bronchus sign was present, but bronchoscopy remained more costly overall. For a central lesion and/or radiographic N1-3 disease, convex endobronchial ultrasound with ROSE followed by lung biopsy with incremental cost-effectiveness ratio, if required, was more cost-effective than any CTBx strategy across all outcomes. Strategies with ROSE were always more cost-effective than those without, irrespective of scenario. Trade-offs also exist between different bronchoscopy strategies, and optimal choices depend on the value placed on individual outcomes and willingness-to-pay.

INTERPRETATION

The most cost-effective strategies depend on nodal stage, lesion location, type of peripheral bronchoscopic biopsy, and the use of ROSE. For most clinical scenarios, many strategies can be eliminated, and trade-offs between the remaining competitive strategies can be quantified.

The Evolving Concept of Complete Resection in Lung Cancer Surgery

Simple Summary

In the surgical treatment of lung cancer, the complete removal of the portion of the lung where the cancer is and of the involved adjacent structures is of paramount importance to achieve long-term survival. The International Association for the Study of Lung Cancer (IASLC) proposed a definition of complete resection that included a well-defined type of removal of the regional lymph nodes as a fundamental step. The lymph nodes may contain cancer cells and, if left behind, cancer will soon progress. The IASLC also defined incomplete resection when there is any evidence of persistent cancer after the operation. It also defined an intermediate condition, uncertain resection, when no evidence of residual disease can be proved, but all the conditions of complete resection are not fulfilled. Four validations of the definitions have proved their prognostic value and, therefore, the definitions should be followed when a surgical resection of lung cancer is planned.

Abstract

Different definitions of complete resection were formulated to complement the residual tumor (R) descriptor proposed by the American Joint Committee on Cancer in 1977. The definitions went beyond resection margins to include the status of the visceral pleura, the most distant nodes and the nodal capsule and the performance of a complete mediastinal lymphadenectomy. In 2005, the International Association for the Study of Lung Cancer (IASLC) proposed definitions for complete, incomplete and uncertain resections for international implementation. Central to the IASLC definition of complete resection is an adequate nodal evaluation either by systematic nodal dissection or lobe-specific systematic nodal dissection, as well as the integrity of the highest mediastinal node, the nodal capsule and the resection margins. When there is evidence of cancer remaining after treatment, the resection is incomplete, and when all margins are free of tumor, but the conditions for complete resection are not fulfilled, the resection is defined as uncertain. The prognostic relevance of the definitions has been validated by four studies. The definitions can be improved in the future by considering the cells spread through air spaces, the residual tumor cells, DNA or RNA in the blood, and the determination of the adequate margins and lymphadenectomy in sublobar resections.

Predicting Lymph Node Metastasis in Non-small Cell Lung Cancer: Prospective External and Temporal Validation of the HAL and HOMER Models

BACKGROUND

Two models, the Help with the Assessment of Adenopathy in Lung cancer (HAL) and Help with Oncologic Mediastinal Evaluation for Radiation (HOMER), were recently developed to estimate the probability of nodal disease in patients with non-small cell lung cancer (NSCLC) as determined by endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA). The objective of this study was to prospectively externally validate both models at multiple centers.

RESEARCH QUESTION

Are the HAL and HOMER models valid across multiple centers?

STUDY DESIGN AND METHODS

This multicenter prospective observational cohort study enrolled consecutive patients with PET-CT clinical-radiographic stages T1-3, N0-3, M0 NSCLC undergoing EBUS-TBNA staging. HOMER was used to predict the probability of N0 vs N1 vs N2 or N3 (N2|3) disease, and HAL was used to predict the probability of N2|3 (vs N0 or N1) disease. Model discrimination was assessed using the area under the receiver operating characteristics curve (ROC-AUC), and calibration was assessed using the Brier score, calibration plots, and the Hosmer-Lemeshow test.

RESULTS

Thirteen centers enrolled 1,799 patients. HAL and HOMER demonstrated good discrimination: HAL ROC-AUC = 0.873 (95%CI, 0.856-0.891) and HOMER ROC-AUC = 0.837 (95%CI, 0.814-0.859) for predicting N1 disease or higher (N1|2|3) and 0.876 (95%CI, 0.855-0.897) for predicting N2|3 disease. Brier scores were 0.117 and 0.349, respectively. Calibration plots demonstrated good calibration for both models. For HAL, the difference between forecast and observed probability of N2|3 disease was +0.012; for HOMER, the difference for N1|2|3 was -0.018 and for N2|3 was +0.002. The Hosmer-Lemeshow test was significant for both models (P = .034 and .002), indicating a small but statistically significant calibration error.

INTERPRETATION

HAL and HOMER demonstrated good discrimination and calibration in multiple centers. Although calibration error was present, the magnitude of the error is small, such that the models are informative.

Future Perspectives on the TNM Staging for Lung Cancer

Since its conception by Pierre Denoix in the mid-20th century, the tumor, node, and metastasis (TNM) classification has undergone seven revisions. The North American database managed by Clifton Mountain was used to inform the 2nd to the 6th editions, and an international database collected by the International Association for the Study of Lung Cancer, promoted by Peter Goldstraw, was used to inform the 7th and the 8th editions. In these two latest editions, it was evident that the impact of tumor size was much greater than it was suggested in previous editions; that the amount of nodal disease had prognostic relevance; and that the number and location of the distant metastases had prognostic implications. However, the TNM classification is not the only prognostic factor. Data are being collected now to inform the 9th edition of the TNM classification, scheduled for publication in 2024. Patient-, environment-, and tumor-related factors, including biomarkers (genetic biomarkers, copy number alterations, and protein alterations) are being collected to combine them in prognostic groups to enhance the prognosis provided by the mere anatomic extent of the tumor, and to offer a more personalized prognosis to an individual patient. International collaboration is essential to build a large and detailed database to achieve these objectives.

Optimising rapid on-site evaluation-assisted endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal lymph nodes: The real-time cytopathology intervention process

INTRODUCTION

Lymph node sampling by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the state of art procedure for staging the mediastinum and hilar regions in lung cancer patients. Our experience of implementing the real-time cytopathology intervention (RTCI) process for intraoperative EBUS-TBNAs is presented. This study is aimed to describe in detail the RTCI process for EBUS-TBNAs, and assess its utility and diagnostic yield before and after its implementation in parallel to conventional rapid on-site evaluation (c-ROSE).

METHODS

A retrospective review of all EBUS-TBNAs between July 2016 and July 2017 at the University of Rochester Medical Center was performed. Final diagnoses, patient clinical data, and number of non-diagnostic samples (NDS) were reviewed. The numbers of NDS obtained from EBUS-TBNAs with no cytology assistance (NCA), with RTCI and with c-ROSE were analysed.

RESULTS

Non-diagnostic lymph node samples were found in 20 out of 116 (17%), three out of 114 (2.6%) and 33 out of 286 (11.5%) cases with NCA, RTCI and c-ROSE, respectively. Application of statistical analysis revealed significant difference in the NDS between the groups of cases in the operating room with NCA and RTCI (P = .005). The different settings and variables between the cases performed using RTCI in the operating room and those assisted with c-ROSE in the bronchoscopy suite preclude legitimate comparison.

CONCLUSION

Our results indicate that the use of RTCI could yield a significantly low proportion of NDS when assisting EBUS-TBNA of mediastinal and hilar lymph node for lung cancer patients enhancing the diagnostic efficiency of the procedure.

Is Biopsy of Contralateral Hilar N3 Lymph Nodes With Negative PET-CT Scan Findings Necessary When Performing Endobronchial Ultrasound Staging?

BACKGROUND

Systematic endobronchial ultrasound (EBUS)-guided lung cancer staging starts with hilar N3 nodes, proceeding sequentially to mediastinal N3, N2, and N1 nodes, with sampling of all enlarged nodes (size, ≥ 5 mm) by EBUS. However, procedure time is limited by patient comfort when moderate sedation is used. It is unclear if EBUS staging should start with hilar N3 nodes or whether starting with mediastinal N3 nodes suffices. Knowing the probability of hilar N3 nodes with PET-CT scan negative findings harboring occult metastasis can inform this decision.

RESEARCH QUESTION

What proportion of patients with hilar N3 nodes showing negative PET-CT scan findings have malignancy by EBUS?

STUDY DESIGN AND METHODS

This retrospective observational, single-center cohort study included consecutive patients with clinical-radiographic T1-3, N0-3, M0 non-small cell lung cancer undergoing systematic EBUS staging with biopsy of hilar N3 nodes with negative PET-CT scan findings. The primary outcome was the proportion of patients with malignant hilar N3 nodes showing negative PET-CT scan findings. Based on expert opinion, a threshold probability of malignancy of less than 5% was considered sufficient to skip hilar N3 nodes. We used the binomial exact test to compare the observed proportion vs threshold probability of 5%.

RESULTS

Of 1,737 consecutive patients undergoing EBUS staging, 1,567 showed negative PET-CT scan findings of the hilar N3 nodes. These nodes were enlarged by EBUS and were sampled in 739 patients. Malignancy was found in the hilar N3 nodes of 5 of 739 patients (0.68%; 95% CI, 0.22%-1.57%). The proportion was significantly less than the threshold probability (P < .001). Patients with positive PET scan results of the mediastinal N3 nodes were at higher risk of having occult hilar N3 nodal metastasis (P = .003), found in 3 of 46 patients (6.5%; 95% CI, 1.4%-17.9%) with positive PET scan results of the mediastinal N3 nodes.

INTERPRETATION

When using moderate sedation, because time is limited, it is reasonable to start with the mediastinal N3 nodes if the hilar and mediastinal N3 nodes show negative PET scan results. Patients with positive PET scan findings of the mediastinal N3 nodes probably should undergo hilar N3 node sampling.

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

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

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

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

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

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

Molecular profiling of key driver genes improves staging accuracy in multifocal non-small cell lung cancer

OBJECTIVE

Multifocal non-small cell lung cancer has historically been separated into synchronous primary lung cancers or intrapulmonary metastases with the use of histopathology. We hypothesize that using targeted next-generation sequencing of key driver mutations in multifocal non-small cell lung cancer will improve our ability to differentiate intrapulmonary metastases from synchronous primary lung cancers.

METHODS

We identified patients who underwent surgery for non-small cell lung cancer between 2013 and 2018 with multifocal tumors. Archived specimens were reviewed with a 4-gene next-generation sequencing panel identifying mutations of EGFR, KRAS, BRAF, and NRAS. Synchronous primary lung cancers were classified as lesions with different histopathologic subtypes or driver mutations. Tests of hypotheses were performed with the Fisher exact test. Calculations were performed in Stata (v13.0; StataCorp LLC, College Station, Tex).

RESULTS

A total of 18 patients had non-small cell lung cancer tumor specimens (n = 41) available from 2 or more sites. The pathologic diagnosis was predominantly adenocarcinoma (39/41 specimens). We detected a driver mutation in 68.3% (28/41) of all tumors. The most common mutations observed were in KRAS (n = 17/41) and EGFR (n = 7/41). Eleven patients had synchronous primary lung cancers, and 4 patients had intrapulmonary metastases based on combined histopathologic and molecular profiling results. Three lacked driver mutations in either lesion. Eight synchronous primary lung cancers (8/18, 44%) were downstaged when compared with their original diagnosis (P = .08). Of these, 4 patients received adjuvant chemotherapy unnecessarily in hindsight.

CONCLUSIONS

Molecular non-small cell lung cancer profiling using a 4-gene next-generation sequencing panel allows for better distinction between synchronous primary lung cancers and intrapulmonary metastases than histopathology alone. Routine use of next-generation sequencing for multifocal lesions prevents unnecessary adjuvant treatment for patients with histologically similar synchronous primary lung cancers.

Validation of the 8th edition of the TNM staging system in 3,950 patients with surgically resected non-small cell lung cancer

Background

The International Association for the Study of Lung Cancer introduced the 8th edition of the tumor, node, and metastasis (TNM) staging system for lung cancer. In this study, we validated the 8th edition of the TNM staging system and compared its discrimination power with that of the previous 7th edition.

Methods

A retrospective analysis was carried out on patients who underwent complete resection with systematic lymph node dissection for non-small cell lung cancer (NSCLC) between 2006 and 2015 at a tertiary referral center in Seoul, South Korea. Cox regression model was used to identify significant differences between adjacent TNM stage groupings. The Concordance index (C-index), Akaike Information Criterion (AIC), and R2 measure were utilized to evaluate the discrimination ability of the staging systems.

Results

A total of 3,950 patients (2,440 male, median age: 63 years) were analyzed. Median follow-up was 59 months (interquartile ranges, 38-88 months). According to the 8th edition, survival curves of overall survival (OS) and recurrence-free survival (RFS) within adjacent stage groupings showed significant differences except for IIA vs. IIB. Compared with the 7th edition, the 8th edition showed higher C-index (0.753 vs. 0.751), lower AIC (17,517 vs. 17,543), and higher R2 (0.178 vs. 0.171) values, indicating better discrimination ability.

Conclusions

Stratification based on the 8th edition of the TNM staging system showed favorable prognostic validity compared with the 7th edition. The 8th edition also had superior discrimination ability in terms of OS and RFS.

Clinical implications of the innovations in the primary tumour and metastasis of the 8th edition of the TNM classification for lung cancer

The 8th edition of the tumour, node and metastasis (TNM) classification for lung cancer introduced two new categories to accommodate adenocarcinoma in situ (AIS)-Tis(AIS)-and minimally invasive adenocarcinoma-T1mi; subdivided T1 into T1a (≤1 cm), T1b (>1-2 cm) and T1c (>2-3 cm); and T2 into T2a (>3-4 cm) and T2b (>4-5 cm); reclassified tumours >5-7 cm as T3, and those >7 cm as T4; reclassified endobronchial location <2 cm from the carina and total atelectasis/pneumonitis as T2a; and reclassified invasion of the diaphragm as T4. Regarding metastasis, the 7^th edition M1a category remained the same, but M1b is now redefined to include single extrathoracic metastasis; and a new category, M1c, has been created for multiple extrathoracic metastases in one or in several organs. Tumours with worse prognosis than that assigned in previous editions, such as T3-4N2M0 and T3-4N3M0, were grouped in stages IIIB and IIIC, respectively. Stage IV was subdivided into IVA, for intrathoracic and single extrathoracic metastasis (M1a and M1b, respectively) and IVB, for multiple extrathoracic metastases (M1c). From the clinical point of view, these innovations will demand a more precise registration of tumour size, a thoughtful assessment of locally advanced tumours at multidisciplinary discussions, and a thorough search of extrathoracic metastases because the number of the metastatic sites has prognostic relevance and may influence therapy.

Variability in invasive mediastinal staging for lung cancer: A multicenter regional study

OBJECTIVE

Prior studies have reported underuse of-but not variability in-invasive mediastinal staging in the pretreatment evaluation of patients with lung cancer. We sought to compare rates of invasive mediastinal staging for lung cancer across hospitals participating in a regional quality improvement and research collaborative.

METHODS

We conducted a retrospective study (2011-2013) of patients undergoing resected lung cancer from the Surgical Clinical Outcomes and Assessment Program in Washington State. Invasive mediastinal staging included mediastinoscopy and/or endobronchial/esophageal ultrasound-guided nodal aspiration. We used a mixed-effects model to mitigate the influence of small sample sizes at any 1 hospital on rates of invasive staging and to adjust for hospital-level differences in the frequency of clinical stage IA disease.

RESULTS

A total of 406 patients (mean age, 68 years; 69% clinical stage IA; and 67% lobectomy) underwent resection at 5 hospitals (4 community and 1 academic). Invasive staging occurred in 66% of patients (95% confidence interval [CI], 61%-71%). CI inspection revealed that 2 hospitals performed invasive staging significantly more often than the overall average (94%, [95% CI, 89%-96%] and 84% [95% CI, 78%-88%]), whereas 2 hospitals performed invasive staging significantly less often than overall average (31% [95% CI, 21%-44%] and 17% [95% CI, 7%-36%]).

CONCLUSIONS

Rates of invasive mediastinal staging varied significantly across hospitals providing surgical care for patients with lung cancer. Future studies that aim to understand the reasons underlying variability in care may inform quality improvement initiatives or lead to the development of novel staging algorithms.

Quantitative computed tomography to predict postoperative FEV1 after lung cancer surgery

BACKGROUND

Predicted postoperative FEV1 (ppoFEV1) must be estimated preoperatively prior to surgery for non-small cell lung cancer (NSCLC). We evaluated a lung volumetry approach based on chest computed tomography (CT).

METHODS

A prospective study was conducted over a period of one year in eligible lung cancer patients to evaluate the difference between ppoFEV1 and the 3-month postoperative FEV1 (poFEV1). Patients in whom CT was performed in another hospital and those with factors influencing poFEV1, such as atelectasis, pleural effusion, pneumothorax, or pneumonia, were excluded. A total of 23 patients were included and ppoFEV1 was calculated according to 4 usual Methods: Nakahara formula, Juhl and Frost formula, ventilation scintigraphy, perfusion scintigraphy, and a fifth method based on quantitative CT. Lung volume was calculated twice and separately by 2 radiologists. Tumor volume, and emphysema defined by a -950 HU limit were subtracted from the total lung volume in order to estimate ppoFEV1.

RESULTS

We compared 5 methods of ppoFEV1 estimation and calculated the mean volume difference between ppoFEV1 and poFEV1. A better correlation was observed for quantitative CT than for Nakahara formula, Juhl and Frost formula, perfusion scintigraphy and ventilation scintigraphy with respectively: R²=0.79 vs. 0.75, 0.75, 0.67 and 0.64 with a mean volume difference of 266±229 mL (P<0.01) vs. 320±262 mL (P<0.01), 332±251 mL (P<0.01), 304±295 mL (P<0.01) and 312±303 mL (P<0.01).

CONCLUSIONS

Quantitative CT appears to be a satisfactory method to evaluate ppoFEV1 evaluation method, and appears to be more reliable than other approaches. Estimation of ppoFEV1, as part of the preoperative assessment, does not involve additional morphologic examinations, particularly scintigraphy. This method may become the reference method for ppoFEV1 evaluation.

A Prediction Model to Help with the Assessment of Adenopathy in Lung Cancer: HAL

RATIONALE

Estimating the probability of finding N2 or N3 (prN2/3) malignant nodal disease on endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in patients with non-small cell lung cancer (NSCLC) can facilitate the selection of subsequent management strategies.

OBJECTIVES

To develop a clinical prediction model for estimating the prN2/3.

METHODS

We used the AQuIRE (American College of Chest Physicians Quality Improvement Registry, Evaluation, and Education) registry to identify patients with NSCLC with clinical radiographic stage T1-3, N0-3, M0 disease that had EBUS-TBNA for staging. The dependent variable was the presence of N2 or N3 disease (vs. N0 or N1) as assessed by EBUS-TBNA. Univariate followed by multivariable logistic regression analysis was used to develop a parsimonious clinical prediction model to estimate prN2/3. External validation was performed using data from three other hospitals.

MEASUREMENTS AND MAIN RESULTS

The model derivation cohort (n = 633) had a 25% prevalence of malignant N2 or N3 disease. Younger age, central location, adenocarcinoma histology, and higher positron emission tomography-computed tomography N stage were associated with a higher prN2/3. Area under the receiver operating characteristic curve was 0.85 (95% confidence interval, 0.82-0.89), model fit was acceptable (Hosmer-Lemeshow, P = 0.62; Brier score, 0.125). We externally validated the model in 722 patients. Area under the receiver operating characteristic curve was 0.88 (95% confidence interval, 0.85-0.90). Calibration using the general calibration model method resulted in acceptable goodness of fit (Hosmer-Lemeshow test, P = 0.54; Brier score, 0.132).

CONCLUSIONS

Our prediction rule can be used to estimate prN2/3 in patients with NSCLC. The model has the potential to facilitate clinical decision making in the staging of NSCLC.

The critical role of EBUS-TBNA cytology in the staging of mediastinal lymph nodes in lung cancer patients: A correlation study with positron emission tomography findings

BACKGROUND

The sensitivity and specificity of positron emission tomography (PET) have been significantly improved for the identification of malignancies in recent years; however, it is still necessary to confirm PET findings in a lymph node (LN) by direct tissue sampling. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the most commonly used approach for diagnosing and staging mediastinal LNs, particularly in lung cancer patients with locally advanced disease. Despite this fact, evidence-based studies of EBUS-TBNA cytology and PET findings are still suboptimal.

METHODS

The electronic database at the Johns Hopkins Medical Institutions and the pathology archives were searched to identify patients with mediastinal lymphadenopathy who had both EBUS-TBNA mediastinal LN sampling and a PET scan over a 14-month period. Patients suspected of having lung cancer and patients with a history of lung cancer were included in this study. Cytological diagnoses and follow-up surgical LN diagnoses were reviewed and correlated with PET scan findings.

RESULTS

A total of 140 LNs from 79 patients, including 86 PET-positive LNs and 54 PET-negative LNs, were included. The most frequently sampled LNs were 4R and 7. The average size of PET-positive and PET-negative LNs was 1.2 and 1.6 cm, respectively. Among PET-positive LNs, 41.9% were malignant, 41.9% showed reactive changes or granulomatous inflammation, and 9.3% were nondiagnostic by EBUS-TBNA. However, among PET-negative LNs, 74.1% showed reactive changes or granulomatous inflammation, 7.4% were malignant, and 18.5% were nondiagnostic by EBUS-TBNA.

CONCLUSIONS

The data demonstrate that EBUS-TBNA cytology improves the diagnostic accuracy of mediastinal LNs and clinical staging. Furthermore, EBUS-TBNA may identify additional malignant LNs (7.4%), and this highlights the risk for false-negative findings with PET scanning in isolation. Cancer Cytopathol 2017;125:717-25. © 2017 American Cancer Society.

Multicentric study of endobronchial ultrasound-transbronchial needle aspiration for lung cancer staging in Italy

BACKGROUND

Multi-institutional studies of endobronchial-ultrasound transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging in lung cancer are scarce. It is unclear if the high diagnostic performance of EBUS-TBNA reported by experts' guidelines can be generally achieved.

METHODS

This is a retrospective study performed in five tertiary referral centers of thoracic surgery in Italy, to assess the EBUS-TBNA diagnostic performance in patients with non-small cell lung cancer (NSCLC). Patient inclusion criteria were: both genders; >18 years old; with suspect/confirmed NSCLC; undergoing EBUS-TBNA for mediastinal node enlargement at computed tomography (size >1 cm, ≤3 cm) and/or pathological uptake at positron emission tomography. Altogether we included 485 patients [male, 366; female, 119; median age, 68 years (IQR, 61-74 years)] undergoing mediastinal staging between January 2011 and July 2016. All EBUS-TBNAs were performed by experienced bronchoscopists, without pre-defined quality standards. Depending on usual practice in each center, EBUS-TBNA was done under conscious sedation, with 21- or 22-Gauge (G) needle, and specimen preparation was cell-block, or cytology slides, or core-tissue. Sampling was classified inadequate in absence of lymphocytes, or when sample was insufficient. We analyzed the EBUS-TBNA procedural steps likely to influence the rate of adequate samplings (diagnostic yield).

RESULTS

EBUS-TBNA sensitivity, negative predictive value (NPV) and accuracy respectively were 90%, 78% and 93% in the whole cohort. At multivariate analysis, use of 21-G needle was associated with better diagnostic yield (P<0.001). Center and specimen processing technique were not independent factors affecting EBUS-TBNA diagnostic yield.

CONCLUSIONS

In this multicentric study, EBUS-TBNA was a highly sensitive and accurate method for NSCLC mediastinal node staging. Results indicate better performance of EBUS-TBNA with 21-G needle, and suggest that specimen processing technique could be chosen according to the local practice preference.

Prognostic impact of M descriptors of the 8th edition of TNM classification of lung cancer

BACKGROUND

The 8th edition of the tumor, node and metastasis (TNM) classification of lung cancer will be enacted in January 2017. The aim of this study was to analyze the survival differences among the three new categories of metastatic disease: intrathoracic metastasis (M1a), single extrathoracic metastasis (M1b) and multiple extrathoracic metastases (M1c) in our cohort of patients with non-small cell lung cancer (NSCLC).

METHODS

This is a retrospective single-center study including NSCLC patients with metastatic disease at diagnosis. Patients were divided into three groups (M1a, M1b, M1c). Overall survival (OS) within and between these subgroups was calculated using the Kaplan-Meier method.

RESULTS

A total of 288 patients were included (112 M1a, 28 M1b and 148 M1c). Median OS of M1c was significantly worse than M1a or M1b tumors (P<0.001). No significant differences were found among the M1a descriptors (pleural/pericardial nodules/effusion, bilateral tumor nodules or both descriptors) (P=0.722) and between M1a and M1b tumors (P=0.517). OS of patients with one metastasis in a single organ was not significantly different from OS of patients with two metastases in a single organ (P=0.180). Among M1c tumors, OS was significantly better in patients with multiple metastases in a single organ than in patients with multiple metastases in multiple organs (P=0.001).

CONCLUSIONS

Our results support the proposal to keep the M1a category unchanged in the 8th edition as well as the proposed restructuring of the M1b in the new M1b and M1c categories. However, our results raise questions about the definition of oligometastatic disease and, consequently, the criteria of M1b and M1c category.

Lung cancer - major changes in the American Joint Committee on Cancer eighth edition cancer staging manual

Answer questions and earn CME/CNE The revision for the eighth edition of the tumor, node, and metastasis (TNM) classification of lung cancer was based on analyses of the International Association for the Study of Lung Cancer database, which included 77,156 evaluable patients diagnosed with lung cancer from 1999 to 2010. Among tumor (T) descriptors, the following new tumor-size groups were created: T1a, ≤1 cm; T1b, >1 to 2 cm; T1c, >2 to 3 cm; T2a, >3 to 4 cm; T2b, >4 to 5 cm; T3, >5 to 7 cm; and T4, >7 cm. Tis and T1mi were introduced for adenocarcinoma in situ and minimally invasive adenocarcinoma, respectively. Endobronchial tumors located <2 cm from the carina have better prognosis than those with any other T3 descriptor and were classified as T2. Total atelectasis/pneumonitis was classified as a T2 descriptor, because it has a T2 prognosis. Diaphragmatic invasion is now T4. Visceral pleural invasion remains unchanged, and mediastinal pleura invasion, which is seldom used, disappears as a T descriptor. The lymph node (N) component descriptors are unchanged, but the number of involved nodal stations has prognostic impact. For the metastasis (M) component, M1a (intrathoracic metastases) remains unchanged, but extrathoracic metastases are divided into a single extrathoracic metastasis (new M1b) and multiple extrathoracic metastases in a single organ or multiple organs (M1c). Stage IA is now divided into IA1, IA2, and IA3 to accommodate T1a, T1b, and T1cN0M0 tumors, respectively; all N1 disease is stage IIB except for T3-T4N1M0 tumors, which are stage IIIA; a new stage IIIC is created for T3-T4N3M0 tumors; and stage IV is divided into IVA (M1a and M1b) and IVB (M1c). This revision enhances our capacity for prognostication and will have an important impact in the management of patients with lung cancer and in future research. CA Cancer J Clin 2017;67:138-155. © 2017 American Cancer Society.

Role of FDG-PET scan in staging of pulmonary epithelioid hemangioendothelioma

In this report we describe a case of pulmonary epithelioid hemangioendothelioma (PEH) in a young woman. The neoplasm manifested with dry cough, chest pain, finger clubbing, and multiple bilateral pulmonary nodules on chest x-ray and computed tomographic (CT) scan. She underwent thoracoscopy, and the histological features of the lung biopsies were initially interpreted as consistent with a not-well-defined interstitial lung disease. Our patient was clinically and radiologically stable over a period of four years, after which the disease progressed to involve not only the lung but also mediastinal lymph nodes, liver and bone. Fiberoptic bronchoscopy showed subtotal occlusion of the right middle and lower lobe bronchi. The histologic examination of bronchial biopsies revealed a poorly differentiated neoplasm immunohistochemically positive for vimentin and vascular markers CD31, CD34 and Factor VIII. A diagnosis of malignant hemangioendothelioma was made. Positron emission tomography (PET) is more sensitive than CT scan and bone scintigraphy in detecting PEH metastases. Furthermore, 18-fluorodeoxyglucose (FDG) uptake seems to be related to the grade of malignancy of PEH lesions. Therefore, we suggest that FDG-PET should be included in the staging system and follow-up of PEH.

Predicting the prognosis of lung cancer: the evolution of tumor, node and metastasis in the molecular age-challenges and opportunities

The tumor, node and metastasis (TNM) classification of malignant tumors was proposed by Pierre Denoit in the mid-20(th) century to code the anatomic extent of tumors. Soon after, it was accepted by the Union for International Cancer Control and by the American Joint Committee on Cancer, and published in their respective staging manuals. Till 2002, the revisions of the TNM classification were based on the analyses of a database that included over 5,000 patients, and that was managed by Clifton Mountain. These patients originated from North America and almost all of them had undergone surgical treatment. To overcome these limitations, the International Association for the Study of Lung Cancer proposed the creation of an international database of lung cancer patients treated with a wider range of therapeutic modalities. The changes introduced in the 7(th) edition of the TNM classification of lung cancer, published in 2009, derived from the analysis of an international retrospective database of 81,495 patients. The revisions for the 8(th) edition, to be published in 2016, will be based on a new retrospective and prospective international database of 77,156 patients, and will mainly concern tumor size, extrathoracic metastatic disease, and stage grouping. These revisions will improve our capacity to indicate prognosis and will make the TNM classification more robust. In the future the TNM classification will be combined with non-anatomic parameters to define prognostic groups to further refine personalized prognosis.

Paget's disease of pelvis mimicking metastasis in a patient with lung cancer evaluated using staging and follow-up imaging with fluorine-18 fluorodeoxyglucose-positron emission tomography/computed tomography

Paget's disease of bone is a benign disease, of uncertain etiology, characterized by an accelerated turnover, that is, bone resorption and formation. Paget's disease may be present in up to 5% of the population, and the majority of cases are asymptomatic. We report the imaging findings of Paget's disease of pelvis discovered incidentally in patient with lung cancer evaluated by fluorine-18-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) for staging. FDG PET-CT scan showed intense uptake in the right lung lower lobe primary and mediastinal lymph nodes. Furthermore, increased uptake noted in left hemipelvis suggestive of Paget's disease. He underwent follow-up FDG PET-CT after chemotherapy showed decrease in lung mass and mediastinal nodes. However, the uptake in left hemipelvis remains same confirming Paget's disease.

Outcome of patients with negative and unsatisfactory cytologic specimens obtained by endobronchial ultrasound-guided transbronchial fine-needle aspiration of mediastinal lymph nodes

BACKGROUND

Endobronchial ultrasound-guided transbronchial fine-needle aspiration (EBUS-FNA) has gained acceptance as the diagnostic procedure of choice with which to sample hilar and mediastinal lymph nodes (LNs) for diagnosing and staging patients with lung cancer. Studies have shown that EBUS has a high positive predictive value; however, its negative predictive value (NPV) varies significantly. The aim of the current study was to evaluate the clinical outcome surrounding negative and nondiagnostic EBUS-FNA of mediastinal LNs.

METHODS

A retrospective chart review of cases of EBUS-FNA performed between 2008 and the middle of 2011 was conducted. Mediastinal LNs with cytologic diagnoses of negative for malignant cells and unsatisfactory were selected for the study. Each LN was followed for up to 1 year with imaging or biopsy/surgical resection. A true-negative result was defined as a LN that did not enlarge on repeat imaging or was negative for malignancy on repeat biopsy or surgery during the follow-up period.

RESULTS

Among 1418 LNs sampled, 479 from 228 patients met the search criteria, including 394 LN (82.3%) with the cytologic diagnosis of negative for malignant cells and 85 (17.8%) with a diagnosis of unsatisfactory. A total of 104 patients (45.6%) were followed with imaging, and 124 patients (54.3%) underwent repeat biopsy/surgery. A total of 445 LNs met the definition of a true-negative finding, resulting in an overall NPV of 92.9% (95% confidence interval [95% CI], 90.6%-95.2%). The NPVs of a negative and unsatisfactory diagnosis were 93.9% (95% CI, 91.6%-96.3%) and 88.2% (95% CI, 81.4%-95.1%), respectively.

CONCLUSIONS

The vast majority of LNs with a cytologic diagnosis of negative and unsatisfactory were likely to be true-negative findings. In these patients, a more conservative approach to follow-up may be appropriate.

Endobronchial ultrasound: what is it and when should it be used?

Endobronchial ultrasound has become increasingly used in the UK as a lung cancer staging and diagnostic tool. It has many applications especially in the mediastinal lymph nodes but also the vascular structures as well as the airway wall itself. It is superior to conventional transbronchial needle aspiration in lung cancer staging and diagnosis of mediastinal lymphadenopathy. With time it may well replace mediastinoscopy completely for staging lung cancer. There are, however, training issues and revenue-based tariff systems have been slow to reflect this innovation. Future developments may include routine use in the assessment of central pulmonary vasculature and assessment of airway wall remodelling.