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Interactive Cardiovascular and Thoracic... Dec 2016A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether there is a specific subgroup of patients... (Review)
Review
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether there is a specific subgroup of patients that would benefit from pulmonary metastasectomy for colorectal carcinoma (CRC). A total of 524 papers were identified using the reported search, of which 1 meta-analysis, 1 systematic review and 17 retrospective studies represented the best evidence to answer the clinical question. The authors, date, journal, country, study type, population, outcomes and key results are tabulated. Single pulmonary metastasis (PM) was identified as an independent prognostic favourable factor of survival in 5 of the studies (P = 0.059-0.001), whereas in 2 of the retrospective studies there was linear inverse correlation between the number of PMs and survival (P = 0.005-0.001). The presence of involved hilar and/or mediastinal lymph nodes was reported as a significant negative prognostic factor on multivariate analysis in 7 of the studies (P = 0.042 to <0.001), whereas the level and number of lymph node stations affected were not statistically significant. Seven studies showed an elevated pre-thoracotomy carcinoembrionic antigen (CEA) level (>5 ng/ml) to be a significant predictor of poor survival (P = 0.047-0.0008). In one of the studies, sublobar resection (wedge or segmentectomy) was associated with better survival compared with anatomic resection (P = 0.04). The size of the tumour (maximum diameter >3.75 cm) was associated with worse survival in 1 of the studies (P = 0.04), while another one reported size as a continuous variable to be a prognostic factor of poor survival. Synchronous chemotherapy (P = 0.027) on one study and neo-adjuvant chemotherapy prior to pulmonary metastasectomy (P = 0.0001) on another were found to be favourable prognostic factors, while disease progression during chemotherapy was associated with poor outcome in another paper (P < 0.0001). Patients older than 70 years were shown to have a worse prognosis in one of the studies. Rectal position of the tumour was associated with worse survival in one of the studies and worse disease-free interval in another one. Finally, one report showed no significant difference in terms of overall survival between thoracotomy and video-assisted thoracoscopic surgery groups. In conclusion, the prognostic factors for patients undergoing pulmonary metastasectomy for CRC include the size and number of metastases, intra-thoracic lymph node involvement, pre-thoracotomy CEA levels and the response to induction chemotherapy.
Topics: Colorectal Neoplasms; Female; Humans; Lung Neoplasms; Metastasectomy; Middle Aged; Pneumonectomy; Prognosis; Thoracic Surgery, Video-Assisted
PubMed: 27572615
DOI: 10.1093/icvts/ivw273 -
European Journal of Cardio-thoracic... Jun 2017To re-examine the evidence for recommendations for complete dissection versus sampling of ipsilateral mediastinal lymph nodes during lobectomy for cancer. (Meta-Analysis)
Meta-Analysis
Systematic lymphadenectomy versus sampling of ipsilateral mediastinal lymph-nodes during lobectomy for non-small-cell lung cancer: a systematic review of randomized trials and a meta-analysis.
OBJECTIVES
To re-examine the evidence for recommendations for complete dissection versus sampling of ipsilateral mediastinal lymph nodes during lobectomy for cancer.
METHODS
We searched for randomized trials of systematic mediastinal lymphadenectomy versus mediastinal sampling. We performed a textual analysis of the authors' own starting assumptions and conclusion. We analysed the trial designs and risk of bias. We extracted data on early mortality, perioperative complications, overall survival, local recurrence and distant recurrence for meta-analysis.
RESULTS
We found five randomized controlled trials recruiting 1980 patients spanning 1989-2007. The expressed starting position in 3/5 studies was a conviction that systematic dissection was effective. Long-term survival was better with lymphadenectomy compared with sampling (Hazard Ratio 0.78; 95% CI 0.69-0.89) as was perioperative survival (Odds Ratio 0.59; 95% CI 0.25-1.36, non-significant). But there was an overall high risk of bias and a lack of intention to treat analysis. There were higher rates (non-significant) of perioperative complications including bleeding, chylothorax and recurrent nerve palsy with lymphadenectomy.
CONCLUSIONS
The high risk of bias in these trials makes the overall conclusion insecure. The finding of clinically important surgically related morbidities but lower perioperative mortality with lymphadenectomy seems inconsistent. The multiple variables in patients, cancers and available treatments suggest that large pragmatic multicentre trials, testing currently available strategies, are the best way to find out which are more effective. The number of patients affected with lung cancer makes trials feasible.
Topics: Carcinoma, Non-Small-Cell Lung; Humans; Lung Neoplasms; Lymph Node Excision; Lymph Nodes; Mediastinum; Neoplasm Staging; Pneumonectomy; Randomized Controlled Trials as Topic
PubMed: 28158453
DOI: 10.1093/ejcts/ezw439 -
Chest Jul 2018The optimal modality for restaging the mediastinum following neoadjuvant therapy for lung cancer remains unclear. Surgical methods are currently considered the reference... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The optimal modality for restaging the mediastinum following neoadjuvant therapy for lung cancer remains unclear. Surgical methods are currently considered the reference standard. The present study evaluates the role of endosonographic techniques for mediastinal restaging in lung cancer.
METHODS
A systematic review of PubMed and Embase databases was performed to identify studies using endoscopic ultrasound, endobronchial ultrasound, or a combination of the two for mediastinal restaging following induction therapy for stage III lung cancer. The quality of the included studies was assessed by using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. The accuracy of endosonography was analyzed by calculating the sensitivity, specificity, likelihood ratio, and diagnostic OR for each study and pooling the results by using a bivariate model. Heterogeneity and publication bias were assessed. Potential causes of heterogeneity were explored by using sensitivity analysis and meta-regression.
RESULTS
Ten studies (N = 574) were included. The pooled sensitivity, specificity, diagnostic OR, and positive and negative likelihood ratios were 67% (95% CI, 56-77), 99% (95% CI, 89-100), 157, 52.0, and 0.33, respectively. No complications were reported. Significant heterogeneity was observed for the outcome of sensitivity. Sensitivity analysis identified several factors accounting for heterogeneity, including study design and risk of bias. The sensitivity of the endosonographic procedure was also linked to the prevalence of N2 disease on meta-regression. Funnel plot showed publication bias, but this finding was not evident on statistical tests.
CONCLUSIONS
Endosonographic procedures are safe and highly specific in mediastinal restaging of lung cancer.
Topics: Bronchoscopy; Endosonography; Humans; Lung Neoplasms; Mediastinoscopy; Mediastinum; Neoadjuvant Therapy; Neoplasm Staging
PubMed: 29684314
DOI: 10.1016/j.chest.2018.04.014 -
Journal of Bronchology & Interventional... Jul 2019Performance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for staging the radiologically normal mediastinum has been reported with... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Performance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for staging the radiologically normal mediastinum has been reported with inconsistent findings. We assessed the sensitivity of systematic staging using EBUS-TBNA for detection of radiologically occult mediastinal metastases in cN0/N1 lung cancer.
METHODS
Studies evaluating EBUS-TBNA for systematic mediastinal staging in cN0/N1 lung cancer were identified by systematic review. Data extracted included: participant age and sex; EBUS-TBNA protocol; stage determined by radiology, EBUS-TBNA and surgery; 2×2 tables. Primary outcome was diagnostic accuracy of EBUS-TBNA for detection of unsuspected N2/N3 disease.
RESULTS
We identified 1173 articles. In total, 13 were included in a qualitative review and 9 (1146 patients) in a quantitative meta-analysis. Mean prevalence of N2/N3 disease was 15% (6% to 24%). EBUS-TBNA had pooled sensitivity of 49% [95% confidence interval (CI), 41%-57%], pooled specificity of 100% (95% CI, 99%-100%), mean negative predictive value 91% (82% to 100%) for detection of unsuspected N2/N3 metastases. Number needed to test to detect occult N2/N3 disease was 14 (95% CI, 10.8-16.3), which halved with addition of per-esophageal endoscopic ultrasound.
CONCLUSION
Preoperative systematic staging by EBUS-TBNA of early lung cancer can reduce postoperative upstaging. Sensitivity for detection of radiologically occult mediastinal metastases seems lower than selective sampling of pathologic lymph nodes. Verification of negative results by mediastinoscopy in selected cases remains of value.
Topics: Bronchoscopy; Carcinoma, Non-Small-Cell Lung; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Humans; Lung Neoplasms; Lymph Nodes; Lymphatic Metastasis; Mediastinum; Neoplasm Staging; Predictive Value of Tests; Preoperative Period
PubMed: 30119069
DOI: 10.1097/LBR.0000000000000545 -
Journal of Gastrointestinal Surgery :... Jun 2018Colonic interposition is a second-line option after oesophagectomy when a gastric neo-oesophagus is not viable. There is no consensus on the optimum anatomical colonic... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Colonic interposition is a second-line option after oesophagectomy when a gastric neo-oesophagus is not viable. There is no consensus on the optimum anatomical colonic conduit (right or left), or route of placement (posterior mediastinal, retrosternal or subcutaneous). The aim of this review was to determine the optimum site and route of neo-oesophageal conduit after adult oesophagectomy.
METHODS
PubMed, MEDLINE, and the Cochrane Library (January 1985 to January 2017) were systematically searched for studies which reported outcomes following colonic interposition in adults. The outcome measures were overall morbidity and mortality.
RESULTS
Twenty-seven observational studies involving 1849 patients [1177 males; median age (range) 60.5 (18-84) years] undergoing colonic interposition for malignant (n = 697) and benign (n = 1152) pathology were analysed. Overall pooled morbidity of left vs. right colonic conduit was 15.7% [95% CI (11.93-19.46), p < 0.001] and 18.7% [95% CI (15.58-21.82), p < 0.001] respectively. Overall pooled mortality of left vs. right colonic conduit was 6.5% [95% CI (4.55-8.51), p < 0.001] and 10.1% [95% CI (7.35-12.82), p < 0.001] respectively. Retrosternal route placement was associated with the lowest overall pooled morbidity and mortality of 9.2% [95% CI (6.48-11.99), p < 0.001] and 4.8% [95% CI (3.74-5.89), p < 0.001] respectively.
CONCLUSION
Left colonic conduits placed retrosternally were safest.
Topics: Colon; Esophageal Neoplasms; Esophagectomy; Esophagus; Humans; Surgically-Created Structures; Transplantation, Autologous; Treatment Outcome
PubMed: 29520647
DOI: 10.1007/s11605-018-3735-8 -
Diseases of the Esophagus : Official... Aug 2019Gastric conduit used for reconstruction after esophagectomy for cancer has the potential to develop a metachronous neoplasm known as gastric tube cancer (GTC). The aim...
Gastric conduit used for reconstruction after esophagectomy for cancer has the potential to develop a metachronous neoplasm known as gastric tube cancer (GTC). The aim of this study was to review literature and evaluate outcomes and possible treatment strategies for GTC. A comprehensive systematic literature search was conducted using PubMed, EMBASE, Scopus, and the Cochrane Library Central Register of Controlled Trials. No restriction was set for the type of publication, number, age, or sex of the patients. The search was limited to articles in English. Characteristics of esophageal cancer (EC) and its treatment and GTC and its treatment were analyzed. A total of 28 studies were analyzed, 12 retrospective analyses and 16 case reports, involving 229 patients with 250 GTCs in total. The majority of ECs (88.2%) were squamous cell carcinomas. In 120 patients (52.4%) a posterior mediastinal reconstructive route was used when esophagectomy was performed. The mean interval between esophagectomy and diagnosis of GTC was 55.8 months, with a median interval of 56.8 months (4-236 months). One hundred and twenty-four GTCs (49.6%) were located in the lower part of the gastric tube. One hundred and forty patients were endoscopically treated. Eighty-five patients underwent surgery. Thirty-six total gastrectomies with lymphadenectomy with colon or jejunal interposition were performed. Forty-three subtotal gastrectomies and 6 wedge resections were performed. The main reported postoperative complications were anastomotic leak, vocal cord palsy, and respiratory failure. Twenty-five patients were treated with palliative chemotherapy. Three-year survival rates were 69.3% for endoscopically treated patients, 58.8% for surgically resected patients, and 4% for patients who underwent palliative treatment. The feasibility of endoscopic resections in patients diagnosed with superficial GTC has been reported. Surgical treatment represented the preferred treatment method in operable patients with locally invasive tumor. Patients treated with conservative therapy have a scarce prognosis. The development of GTC should be taken into consideration during the extended follow-up of patients undergoing esophagectomy for cancer. Total gastrectomy plus lymphadenectomy should be considered the preferred treatment modality in operable patients with locally invasive tumor, when endoscopy is contraindicated. Long-term yearly endoscopic follow-up is recommended.
Topics: Adult; Aged; Carcinoma, Squamous Cell; Esophageal Neoplasms; Esophagectomy; Female; Gastrectomy; Humans; Intubation, Gastrointestinal; Male; Middle Aged; Neoplasms, Second Primary; Postoperative Complications; Retrospective Studies; Stomach Neoplasms; Treatment Outcome
PubMed: 31111880
DOI: 10.1093/dote/doz049 -
Herz Feb 2018Malignant mesothelioma is a rare but aggressive tumor, with a high misdiagnosis rate and overall bleak prognosis. In 0.7% of all cases, the origin is the pericardium.
BACKGROUND
Malignant mesothelioma is a rare but aggressive tumor, with a high misdiagnosis rate and overall bleak prognosis. In 0.7% of all cases, the origin is the pericardium.
METHODS
The present study is a review of the literature published in recent decades focusing on the advances in clinical manifestations, radiological findings, diagnosis, differential diagnosis, and treatment of malignant pericardial mesothelioma (MPM).
RESULTS
No clear relationship has been established between the etiologies and the development of MPM. Clinical symptoms and signs are nonspecific when present. The main presentations are chest pain and dyspnea. Imaging plays an important role in the detection, characterization, staging, and posttreatment follow-up. The definitive diagnosis is made on the basis of pathological findings. Chest radiography and echocardiography are common techniques used initially, but their roles are limited. Computed tomography and magnetic resonance imaging have an advantage in depicting the thickened pericardium, mediastinal lymph node, tumor, and the extension of adjacent structures. Surgery is the most important treatment modality and remains palliative in most cases, while the roles of chemo- and radiotherapy are unsatisfactory.
CONCLUSION
Clinical trials of malignant pleural and peritoneal mesothelioma remain important for MPM management. Multimodality treatment of surgery, chemotherapy, radiotherapy, and immunotherapy is expected to have a role in the treatment of MPM.
Topics: Clinical Trials as Topic; Combined Modality Therapy; Diagnosis, Differential; Heart Neoplasms; Humans; Lung Neoplasms; Mesothelioma; Mesothelioma, Malignant; Palliative Care; Pericardium; Prognosis
PubMed: 28130567
DOI: 10.1007/s00059-016-4522-5 -
Annals of Surgical Oncology Feb 2022The role of upper mediastinal lymphadenectomy for distal esophageal or gastroesophageal junction (GEJ) adenocarcinomas remains a matter of debate. This systematic review...
BACKGROUND
The role of upper mediastinal lymphadenectomy for distal esophageal or gastroesophageal junction (GEJ) adenocarcinomas remains a matter of debate. This systematic review aims to provide a comprehensive overview of evidence on the incidence of nodal metastases in the upper mediastinum following transthoracic esophagectomy for distal esophageal or GEJ adenocarcinoma.
METHODS
A literature search was performed using Medline, Embase and Cochrane databases up to November 2020 to include studies on patients who underwent transthoracic esophagectomy with upper mediastinal lymphadenectomy for distal esophageal and/or GEJ adenocarcinoma. The primary endpoint was the incidence of metastatic nodes in the upper mediastinum based on pathological examination. Secondary endpoints were the definition of upper mediastinal lymphadenectomy, recurrent laryngeal nerve (RLN) palsy rate and survival.
RESULTS
A total of 17 studies were included and the sample sizes ranged from 10-634 patients. Overall, the median incidence of upper mediastinal lymph node metastases was 10.0% (IQR 4.7-16.7). The incidences of upper mediastinal lymph node metastases were 8.3% in the 7 studies that included patients undergoing primary resection (IQR 2.0-16.6), 4,4% in the 1 study that provided neoadjuvant therapy to the full cohort, and 10.6% in the 9 studies that included patients undergoing esophagectomy either with or without neoadjuvant therapy (IQR 8.9-15.8%). Data on survival and RLN palsy rates were scarce and inconclusive.
CONCLUSIONS
The incidence of upper mediastinal lymph node metastases in distal esophageal adenocarcinoma is up to 10%. Morbidity should be weighed against potential impact on survival.
Topics: Adenocarcinoma; Esophageal Neoplasms; Esophagectomy; Esophagogastric Junction; Humans; Lymph Node Excision; Retrospective Studies
PubMed: 34845567
DOI: 10.1245/s10434-021-10810-8 -
Annals of the American Thoracic Society Jul 2018An accurate assessment of the mediastinal lymph node status is essential in the staging and treatment planning of potentially resectable non-small-cell lung cancer. (Meta-Analysis)
Meta-Analysis
RATIONALE
An accurate assessment of the mediastinal lymph node status is essential in the staging and treatment planning of potentially resectable non-small-cell lung cancer.
OBJECTIVES
We performed this meta-analysis to evaluate the role of endobronchial ultrasound-guided transbronchial needle aspiration in detecting occult mediastinal disease in non-small-cell lung cancer with no radiologic mediastinal involvement.
METHODS
The PubMed, Embase, and Cochrane libraries were searched for studies describing the role of endobronchial ultrasound-guided transbronchial needle aspiration in patients with lung cancer with radiologically negative mediastinum. The individual and pooled sensitivity, prevalence, negative predictive value, and diagnostic odds ratio were calculated using the random effects model. Meta-regression analysis, heterogeneity, and publication bias were also assessed.
RESULTS
A total of 13 studies that met the inclusion criteria were included in the meta-analysis. The pooled effect sizes of the different diagnostic parameters were estimated as follows: prevalence, 12.8% (95% confidence interval, 10.4-15.7%); sensitivity, 49.5% (95% confidence interval, 36.4-62.6%); negative predictive value, 93.0% (95% confidence interval, 90.3-95.0%); and log diagnostic odds ratio, 5.069 (95% confidence interval, 4.212-5.925). Significant heterogeneity was noticeable for the sensitivity, disease prevalence, and negative predictive value, but not observed for log diagnostic odds ratio. Publication bias was detected for sensitivity, negative predictive value, and log diagnostic odds ratio but not for prevalence. Bivariate meta-regression analysis showed no significant association between the pooled calculated parameters and the type of anesthesia, imaging used to define negative mediastinum, rapid on-site test usage, and presence of bias by Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool. Interestingly, we observed a greater sensitivity, negative predictive value, and log diagnostic odds ratio for studies published before 2010 and for prospective multicenter studies.
CONCLUSIONS
Among patients with non-small-cell lung cancer with a radiologically normal mediastinum, the prevalence of mediastinal disease is 12.8% and the sensitivity of endobronchial ultrasound-guided transbronchial needle aspiration is 49.5%. Despite the low sensitivity, the resulting negative predictive value of 93.0% for endobronchial ultrasound-guided transbronchial needle aspiration suggests that mediastinal metastasis is uncommon in such patients.
Topics: Bronchoscopy; Carcinoma, Non-Small-Cell Lung; Endosonography; Humans; Lung Neoplasms; Lymph Nodes; Lymphatic Metastasis; Mediastinum; Neoplasm Staging; Radiography, Thoracic
PubMed: 29684288
DOI: 10.1513/AnnalsATS.201711-863OC -
Respirology (Carlton, Vic.) Aug 2014Intrathoracic lymph node metastases in patients with extrathoracic malignancies are a common clinical manifestation. Several studies evaluating intrathoracic lymph node... (Meta-Analysis)
Meta-Analysis Review
Endobronchial ultrasound-guided transbronchial needle biopsy for the diagnosis of intrathoracic lymph node metastases from extrathoracic malignancies: a meta-analysis and systematic review.
Intrathoracic lymph node metastases in patients with extrathoracic malignancies are a common clinical manifestation. Several studies evaluating intrathoracic lymph node metastases in patients with extrathoracic malignancy by using the endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) have been reported. The objective of this meta-analysis is to investigate the diagnostic value of EBUS-TBNA for diagnosing intrathoracic lymph node metastases in patients with extrathoracic malignancies. We systematically searched Cochrane Library, Medline and Embase for relevant studies published prior to May 2013. Studies specifically designed to evaluate the diagnostic accuracy of EBUS-TBNA for intrathoracic lymph node metastases in patients with an extrathoracic malignancy were selected. Diagnostic accuracy meta-analysis was conducted by pooling estimates of sensitivity, specificity, negative likelihood ratio (NLR), positive likelihood ratio (PLR) and diagnostic odds ratios (DOR) derived from a summary receiver operating characteristic (SROC) analysis of the original studies. Six studies were included, which provided a dataset of 533 patients. EBUS-TBNA pooled estimates had 0.85 sensitivity (95% confidence interval (CI): 0.80-0.89), 0.99 specificity (95% CI: 0.95-1.00), PLR 28.63 (95% CI: 11.51-71.22) and NLR 0.16 (95% CI: 0.12-0.21). The overall DOR was 179.77 (95% CI: 66.29-487.50). The area under the SROC curve and the diagnostic accuracy were 0.9247 and 0.8588, respectively. Evidence gathered from studies of moderate quality reveals a high degree of diagnostic accuracy of EBUS-TBNA for diagnosing intrathoracic lymph node metastases in patients with extrathoracic malignancies.
Topics: Adult; Aged; Aged, 80 and over; Biopsy, Needle; Bronchoscopy; Endosonography; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; ROC Curve; Reproducibility of Results; Sensitivity and Specificity; Thoracic Neoplasms
PubMed: 24935652
DOI: 10.1111/resp.12335