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Respiration; International Review of... 2023Advances in bronchoscopy have impacted the practice patterns in the sampling of thoracic lymph nodes and lung lesions.
BACKGROUND
Advances in bronchoscopy have impacted the practice patterns in the sampling of thoracic lymph nodes and lung lesions.
OBJECTIVES
The aim of the study was to study the trends in utilization of mediastinoscopy, transthoracic needle aspiration (TTNA), and bronchoscopic transbronchial sampling.
METHODS
We conducted an analysis of patient claims for sampling of thoracic lymph nodes and lung lesions in the Medicare population and a sample of the commercial population between 2016 and 2020. We used Current Procedural Terminology codes to identify mediastinoscopy, TTNA, and bronchoscopic transbronchial sampling. Post-procedural pneumothorax rates were assessed by procedure type including subset analyses for patients with chronic obstructive pulmonary disease (COPD).
RESULTS
Between 2016 and 2020, utilization of mediastinoscopy has decreased in both the Medicare and commercial populations (-47.3% and -65.4%, respectively), while linear endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) has increased only in the Medicare population (+28.2%). Percutaneous lung biopsy claims dropped by -17.0% in the Medicare and -41.22% in the commercial population. The use of bronchoscopic TBNA and forceps biopsy declined in both populations, but the reliance on a combination of guided technology (radial EBUS-guided and navigation) grew in the Medicare and commercial populations (+76.3% and +25%). Rates of post-procedural pneumothorax were significantly higher following percutaneous biopsy compared to bronchoscopic transbronchial biopsy.
CONCLUSIONS
Linear EBUS-guided sampling has surpassed mediastinoscopy as the technique for sampling thoracic lymph nodes. Transbronchial lung sampling is increasingly being performed with guidance technology. This trend is aligned with favorable rates of post-procedure pneumothorax for transbronchial biopsy.
Topics: United States; Humans; Aged; Lung Neoplasms; Pneumothorax; Medicare; Lung; Lymph Nodes; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Bronchoscopy; Neoplasm Staging; Sensitivity and Specificity
PubMed: 37290401
DOI: 10.1159/000530741 -
Acta Cytologica 2022In patients with a history of malignancy, follow-up surveillance of lymph nodes (LNs) is required to evaluate for potential malignancy or infection. In some cases, the...
INTRODUCTION
In patients with a history of malignancy, follow-up surveillance of lymph nodes (LNs) is required to evaluate for potential malignancy or infection. In some cases, the lymphadenopathy may be secondary to an intraprocedural hemostatic agent and/or related granulomatous reaction.
CASE PRESENTATION
We present the case of an 80-year-old female with a remote past medical history of breast cancer status post-lumpectomy and chemoradiation. Twenty years later, a 2.4 cm pulmonary right middle lobe nodule was noted on imaging studies. She underwent bronchoscopy, cervical mediastinoscopy, and right middle lobe wedge resection. The final pathologic diagnosis was a pulmonary carcinoid tumor, and the excised mediastinal LN was negative for malignancy. A 10-month surveillance positron emission tomography scan showed new mildly avid mediastinal and right hilar LNs. The following endobronchial ultrasound-guided transbronchial needle aspiration showed unremarkable lymphoid elements in the enlarged 4R LN, while the station 7 LN demonstrated ample dense hyaline-like foreign material. Subsequent review of the cell block/biopsy and communication with the thoracic surgeon revealed that Surgicel® (or oxidized regenerated cellulose) was placed during surgery at the station 7 site.
DISCUSSION/CONCLUSION
Assessment of the findings and based on the similar histologic appearance reported in previous cases associated with Surgicel® [Ann Thorac Med. 2017;12(1):55-6, Cancer Cytopathol. 2019;127(12):765-70, and Arch Bronconeumol. 2020;56(7):459-71], the station 7 acellular, amorphous, and hyaline-like exogenous material found in our case was interpreted as hemostatic agent compatible with Surgicel® (or oxidized regenerated cellulose). This case highlights the importance of cytologic/histologic recognition of hemostatic agents, specifically oxidized cellulose mesh.
Topics: Female; Humans; Aged, 80 and over; Cellulose, Oxidized; Mediastinum; Bronchoscopy; Lymph Nodes; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Lung Neoplasms; Hemostatics
PubMed: 35896064
DOI: 10.1159/000525857 -
The Annals of Thoracic Surgery Oct 2018Thymoma is a common neoplasm in the anterior mediastinum but rarely arises from the middle mediastinum. We report 3 patients with thymoma that arose from the middle...
Thymoma is a common neoplasm in the anterior mediastinum but rarely arises from the middle mediastinum. We report 3 patients with thymoma that arose from the middle mediastinum. Surgical resections were performed with dissection of the azygos vein, which led to safe separation of the tumors from mediastinal structures. Although rare, thymoma should be included in the differential diagnosis for middle mediastinal tumors.
Topics: Adult; Aged; Biopsy; Diagnosis, Differential; Female; Humans; Magnetic Resonance Imaging; Male; Mediastinoscopy; Mediastinum; Thymectomy; Thymoma; Thymus Neoplasms; Tomography, X-Ray Computed
PubMed: 29733825
DOI: 10.1016/j.athoracsur.2018.03.085 -
Translational Lung Cancer Research Aug 2021The current preferred approach for surgical mediastinal staging of non-small-cell lung carcinoma is video-assisted mediastinoscopy. An alternative technique in which...
BACKGROUND
The current preferred approach for surgical mediastinal staging of non-small-cell lung carcinoma is video-assisted mediastinoscopy. An alternative technique in which lymph nodes are resected instead of biopsied is video-assisted mediastinoscopic lymphadenectomy (VAMLA) that is suggested to be superior in detecting N2 disease. Yet, evidence is conflicting and furthermore limited by sample size. The objective was to compare mediastinal staging through VAMLA and video-assisted mediastinoscopy.
METHODS
A single-center cohort study was conducted. All consecutive patients that underwent surgical mediastinal staging of non-small-cell lung carcinoma by VAMLA (2011 to 2018) were compared to historic video-assisted mediastinoscopy controls (2007 to 2011). Patients with negative surgical mediastinal staging underwent subsequent anatomical resection with systematic regional lymphadenectomy. Primary outcome was the sensitivity and negative predictive value for detecting N2 disease.
RESULTS
Two-hundred-sixty-nine video-assisted mediastinoscopic lymphadenectomies and 118 video-assisted mediastinoscopies were performed. The prevalence of N2 disease was 20% and 26% respectively in the VAMLA and video-assisted mediastinoscopy group, while the rate of unforeseen pN2 resulting from lymph node dissection during anatomical resection was 4% and 11%, respectively. Invasive staging using VAMLA demonstrated superior sensitivity of 0.82 and a negative predictive value of 0.96 when compared to video-assisted mediastinoscopy (0.62 and 0.89, respectively), offering a 64% decrease in risk of unforeseen pN2 following anatomical resection. However, VAMLA is also associated with a 75% risk increase on complications (P=0.36).
CONCLUSIONS
We conclude that performing invasive mediastinal lymph node assessment for staging of non-small-cell lung carcinoma, VAMLA should be the preferred technique with superior sensitivity and negative predictive value in detecting N2 disease. Though, VAMLA is also associated with an increased risk of complications.
PubMed: 34584863
DOI: 10.21037/tlcr-21-364 -
Expert Review of Anticancer Therapy 2015Surgical staging by mediastinoscopy has been considered the gold standard for staging the mediastinum in non-small-cell lung cancer; however, it is an invasive procedure... (Comparative Study)
Comparative Study Review
Surgical staging by mediastinoscopy has been considered the gold standard for staging the mediastinum in non-small-cell lung cancer; however, it is an invasive procedure which requires general anesthesia and is associated with significant risk. Endosonographic biopsy techniques are a minimally invasive alternative to surgical staging and may be even better than standard mediastinoscopy. Combined endosonographic procedures (EBUS/EUS) are safe, cost-effective, and superior to surgical mediastinal staging. It allows for the biopsy of lymph nodes and metastases that are unattainable with standard mediastinoscopy techniques thereby preventing futile thoracotomies. Combined endosonographic procedures (EBUS/EUS) are the new gold standard in mediastinal staging of non-small-cell lung cancer when performed by an experienced operator.
Topics: Biopsy; Carcinoma, Non-Small-Cell Lung; Endosonography; Humans; Lung Neoplasms; Lymphatic Metastasis; Mediastinoscopy; Neoplasm Staging
PubMed: 26165589
DOI: 10.1586/14737140.2015.1067143 -
Zentralblatt Fur Chirurgie Jun 2018Pancoast or superior pulmonary sulcus tumour is a subset of lung carcinoma that invades the structures of the thoracic inlet - first ribs, distal roots of the brachial... (Review)
Review
Pancoast or superior pulmonary sulcus tumour is a subset of lung carcinoma that invades the structures of the thoracic inlet - first ribs, distal roots of the brachial plexus, stellate ganglion, vertebrae, and subclavian vessels. The first symptom is usually shoulder pain; consequently, most patients are initially treated for osteoarthritis. Late diagnosis is common. Success of therapy depends on an accurate staging: standard imaging with CT scan of the chest, PET-CT scan, brain MRI are needed to rule out distant metastases, endobronchial ultrasound-guided needle biopsy (EBUS-TBNA) or mediastinoscopy are mandatory for reliable nodal staging. An MRI of the thoracic inlet allows to clearly define the boundaries of local invasion. Modern management of Pancoast tumour includes induction concurrent chemoradiotherapy followed by surgical resection. As compared with historical series treated by preoperative radiation, a trimodally approach did enhance complete resection rates and perhaps long-term survival - from about 30% 5-year survival rate to 60% in R0-resected patients. In patients who have unresectable but non-metastatic Pancoast tumours and appropriate performance status, definitive concurrent chemoradiotherapy and radiotherapy are recommended options.
Topics: Humans; Male; Middle Aged; Pancoast Syndrome; Prognosis; Shoulder Pain
PubMed: 29933484
DOI: 10.1055/s-0043-109931 -
Journal of Thoracic Disease Mar 2017This review provides an update on the current role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and mediastinoscopy (Med) in... (Review)
Review
This review provides an update on the current role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and mediastinoscopy (Med) in assessment of patients with non-small cell lung cancer (NSCLC). Invasive mediastinal lymph node (LN) staging is the major application for both of these techniques. Up until recently, Med was the gold standard for invasive mediastinal LN staging in NSCLC. However, EBUS-TBNA has shown to be equivalent, and in some studies better than Med for invasive staging of lung cancer. EBUS-TBNA offers access to N1 LNs and development of the thin convex probe EBUS (TCP-EBUS) will expand EBUS-TBNA access from the paratracheal region and central airways to more distal parabronchial regions allowing for more extensive N1 LN assessment and sampling more distal lung tumors. EBUS-TBNA is more cost-effective than Med and it is currently recommended as the test of first choice for invasive mediastinal LN staging in lung cancer. Confirmatory Med should be performed selectively in patients with high pretest probability of metastatic disease. Addition of esophageal ultrasound fine needle aspiration (EUS-FNA) may increase diagnostic yield of EBUS-TBNA mediastinal staging. Both Med and EBUS-TBNA can be used in primary lung cancer diagnosis, restaging of the mediastinum following neoadjuvant therapy and in diagnosis of lung cancer recurrence. In the future, a combination of EBUS-TBNA with or without EUS-FNA and Med is most likely going to provide the most optimal invasive assessment of the mediastinum in patients with lung cancer. The decision on test choice and sequence should be made on a case-by-case basis and factoring in local resources and expertise.
PubMed: 28446970
DOI: 10.21037/jtd.2017.03.102 -
The Annals of Thoracic Surgery Nov 2016Whether endosonography can replace mediastinoscopy as the initial procedure for mediastinal staging of non-small cell lung cancer remains controversial. Herein, we... (Meta-Analysis)
Meta-Analysis Review
Whether endosonography can replace mediastinoscopy as the initial procedure for mediastinal staging of non-small cell lung cancer remains controversial. Herein, we perform a systematic review of randomized controlled trials and observational studies (both procedures performed in same subjects) comparing the two procedures. Nine studies (960 subjects) were identified. The pooled risk-difference of the sensitivity of endosonography versus mediastinoscopy in observational studies and randomized controlled trials was 0.11 (95% confidence interval, -0.07 to 0.29) and 0.11 (95% confidence interval, -0.03 to 0.25), respectively suggesting equivalence of the two procedures. The complication rate was significantly lower with endosonographic procedures. Endoscopic ultrasound-guided fine needle aspiration/endobronchial ultrasound-guided transbronchial needle aspiration was found to have similar yield but lower complication rate compared to mediastinoscopy in the initial mediastinal staging of non-small cell lung cancer.
Topics: Endosonography; Humans; Lung Neoplasms; Lymph Nodes; Lymphatic Metastasis; Mediastinoscopy; Mediastinum; Neoplasm Staging; Reproducibility of Results
PubMed: 27637288
DOI: 10.1016/j.athoracsur.2016.05.110 -
Multimedia Manual of Cardiothoracic... Sep 2021Mediastinal staging in potentially resectable non-small cell lung cancer is of paramount importance since it impacts the survival of the patient. With increasing nodal...
Mediastinal staging in potentially resectable non-small cell lung cancer is of paramount importance since it impacts the survival of the patient. With increasing nodal stage, survival was noted to precipitously decline. Nodal status also determined the use of neoadjuvant/adjuvant therapy and other treatment modalities. Various methods of obtaining lymphatic tissue from the mediastinum for staging purposes have been described in the literature, although mediastinoscopic lymph node evaluation remains the gold standard. Endoscopic methods of mediastinal staging, like the endobronchial ultrasound guided and esophageal ultrasound guided fine-needle aspiration techniques, although minimally invasive, provide the highest levels of accuracy when used in conjunction with surgical mediastinal staging. Video-assisted mediastinoscopic lymphadenectomy (VAMLA) provides clear advantages, as far as ergonomics and training are concerned, over conventional mediastinoscopy. Access to stations 2R, 2L, 4R, 4L, and 7 is feasible with VAMLA. In this video vignette, we present the step-by-step technique of a standard VAMLA, with an overview of relevant anatomical relationships, for the effective and safe clearance of lymph node stations for the purposes of staging and defining appropriate therapy.
Topics: Carcinoma, Non-Small-Cell Lung; Humans; Lung Neoplasms; Lymph Node Excision; Lymph Nodes; Mediastinoscopy; Mediastinum; Neoplasm Staging
PubMed: 34672142
DOI: 10.1510/mmcts.2021.055