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Respiratory Medicine Nov 2023New tools such as cryobiopsy of mediastinal lymph nodes (cryoEBUS) have been described to improve the diagnostic usefulness of endobronchial ultrasound-guided... (Meta-Analysis)
Meta-Analysis Review
Is the diagnostic yield of mediastinal lymph node cryobiopsy (cryoEBUS) better for diagnosing mediastinal node involvement compared to endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)? A systematic review.
INTRODUCTION
New tools such as cryobiopsy of mediastinal lymph nodes (cryoEBUS) have been described to improve the diagnostic usefulness of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). The literature suggests that this novel procedure could be associated with greater diagnostic usefulness than conventional EBUS-TBNA.
METHODS
To develop a systematic analysis and meta-analysis on the diagnostic diagnostic yield and safety of cryobiopsy of hilar and mediastinal adenopathies compared to EBUS-TBNA.
RESULTS
Seven studies that had included a total of 555 patients were considered in this review, with 365 (65.7%) of these patients having an etiology of malignant lymph node involvement. The overall diagnostic usefulness of cryoEBUS was higher compared to EBUS-TBNA (92% vs. 80%). However, when the results were analysed according to the specific aetiologies of the adenopathies, cryoEBUS was especially useful in cases of lymphomas or non-pulmonary carcinomas (83% vs. 42%) and in cases that were benign (87% vs. 60.1%), with no significant differences being found in specific cases of lung cancer. For lymphoma, cryoEBUS was diagnostic in 87% of cases compared to 12% for EBUS-TBNA and in addition, also allowed the characterisation of every lymphoma subtype. Genetic studies and immunohistochemical determination of PD-L1 was possible in almost all (97%) of the samples obtained by cryoEBUS, while this was only possible in 79% of those obtained by EBUS-TBNA. The most frequent complication was light bleeding, which was described in up to 85% of cases in some series.
CONCLUSION
CryoEBUS could represent a promising technique in the diagnostic algorithm used for mediastinal and hilar involvement. Although cryoEBUS did not significantly improve the diagnosis of lung cancer compared to EBUS-TBNA, the results were significantly better in patients with benign pathologies and other tumour types, including lymphomas. In addition, it seems that the samples obtained by cryoEBUS better defined the histological subtypes of lymphoma and allowed complete molecular characterisation in cases of lung cancer. The technique has proven to be safe and no serious complications were described after the procedure.
Topics: Humans; Bronchoscopy; Mediastinum; Lymph Nodes; Lung Neoplasms; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Lymphadenopathy; Lymphoma; Retrospective Studies
PubMed: 37579981
DOI: 10.1016/j.rmed.2023.107389 -
Chest Mar 2016Endobronchial ultrasound (EBUS) was introduced in the last decade, enabling real-time guidance of transbronchial needle aspiration (TBNA) of mediastinal and hilar... (Review)
Review
BACKGROUND
Endobronchial ultrasound (EBUS) was introduced in the last decade, enabling real-time guidance of transbronchial needle aspiration (TBNA) of mediastinal and hilar structures and parabronchial lung masses. The many publications produced about EBUS-TBNA have led to a better understanding of the performance characteristics of this procedure. The goal of this document was to examine the current literature on the technical aspects of EBUS-TBNA as they relate to patient, technology, and proceduralist factors to provide evidence-based and expert guidance to clinicians.
METHODS
Rigorous methodology has been applied to provide a trustworthy evidence-based guideline and expert panel report. A group of approved panelists developed key clinical questions by using the PICO (population, intervention, comparator, and outcome) format that addressed specific topics on the technical aspects of EBUS-TBNA. MEDLINE (via PubMed) and the Cochrane Library were systematically searched for relevant literature, which was supplemented by manual searches. References were screened for inclusion, and well-recognized document evaluation tools were used to assess the quality of included studies, to extract meaningful data, and to grade the level of evidence to support each recommendation or suggestion.
RESULTS
Our systematic review and critical analysis of the literature on 15 PICO questions related to the technical aspects of EBUS-TBNA resulted in 12 statements: 7 evidence-based graded recommendations and 5 ungraded consensus-based statements. Three questions did not have sufficient evidence to generate a statement.
CONCLUSIONS
Evidence on the technical aspects of EBUS-TBNA varies in strength but is satisfactory in certain areas to guide clinicians on the best conditions to perform EBUS-guided tissue sampling. Additional research is needed to enhance our knowledge regarding the optimal performance of this effective procedure.
Topics: Bronchoscopy; Carcinoma, Non-Small-Cell Lung; Clinical Competence; Conscious Sedation; Deep Sedation; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Evidence-Based Medicine; Humans; Lung Neoplasms; Lymphatic Diseases; Lymphoma; Mediastinal Neoplasms; Needles; Pulmonary Medicine; Sarcoidosis; Simulation Training; Societies, Medical
PubMed: 26402427
DOI: 10.1378/chest.15-1216 -
Radiotherapy and Oncology : Journal of... Dec 2022To systematically review all dosimetric studies investigating the impact of deep inspiration breath hold (DIBH) compared with free breathing (FB) in mediastinal lymphoma... (Review)
Review
PURPOSE
To systematically review all dosimetric studies investigating the impact of deep inspiration breath hold (DIBH) compared with free breathing (FB) in mediastinal lymphoma patients treated with proton therapy as compared to IMRT (intensity-modulated radiation therapy)-DIBH.
MATERIALS AND METHODS
We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline using the PubMed database to identify studies of mediastinal lymphoma patients with dosimetric comparisons of proton-FB and/or proton-DIBH with IMRT-DIBH. Parameters included mean heart (MHD), lung (MLD), and breast (MBD) doses, among other parameters. Case reports were excluded. Absolute differences in mean doses > 1 Gy between comparators were considered to be clinically meaningful.
RESULTS
As of April 2021, eight studies fit these criteria (n = 8), with the following comparisons: proton-FB vs IMRT-DIBH (n = 5), proton-DIBH vs proton-FB (n = 5), and proton-DIBH vs IMRT-DIBH (n = 8). When comparing proton-FB with IMRT-DIBH in 5 studies, MHD was reduced with proton-FB in 2 studies, was similar (<1 Gy difference) in 2 studies, and increased in 1 study. On the other hand, MLD and MBD were reduced with proton-FB in 3 and 4 studies, respectively. When comparing proton-DIBH with proton-FB, MHD and MLD were reduced with proton DIBH in 4 and 3 studies, respectively, while MBD remained similar. Compared with IMRT-DIBH in 8 studies, proton-DIBH reduced the MHD in 7 studies and was similar in 1 study. Furthermore, MLD and MBD were reduced with proton-DIBH in 8 and 6 studies respectively. Integral dose was similar between proton-FB and proton-DIBH, and both were substantially lower than IMRT-DIBH.
CONCLUSION
Accounting for heart, lung, breast, and integral dose, proton therapy (FB or DIBH) was superior to IMRT-DIBH. Proton-DIBH can lower dose to the lungs and heart even further compared with proton-FB, depending on disease location in the mediastinum, and organ-sparing and target coverage priorities.
Topics: Humans; Proton Therapy; Breath Holding; Organs at Risk; Radiotherapy Planning, Computer-Assisted; Protons; Mediastinal Neoplasms; Lymphoma; Heart; Radiotherapy Dosage; Unilateral Breast Neoplasms
PubMed: 36252635
DOI: 10.1016/j.radonc.2022.10.003 -
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 -
The Lancet. Respiratory Medicine Dec 2016Guidelines recommend endosonography with fine-needle aspiration for mediastinal nodal staging in non-small-cell lung cancer, but most do not specify whether this should... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Guidelines recommend endosonography with fine-needle aspiration for mediastinal nodal staging in non-small-cell lung cancer, but most do not specify whether this should be through endobronchial endoscopy (EBUS), oesophageal endoscopy (EUS), or both. We assessed the added value and diagnostic accuracy of the combined use of EBUS and EUS.
METHODS
For this systematic review and random effects meta-analysis, we searched MEDLINE, Embase, BIOSIS Previews, and Web of Science, without language restrictions, for studies published between Jan 1, 2000, and Feb 25, 2016. We included studies that assessed the accuracy of the combined use of EBUS and EUS in detecting mediastinal nodal metastases (N2/N3 disease) in patients with lung cancer. For each included study, we extracted data on the age and sex of participants, inclusion criteria regarding tumour stage on imaging, details of the endoscopic testing protocol, duration of each endoscopic procedure, number of lymph nodes sampled, serious adverse events occurring during the endoscopic procedures, the reference standard, and 2 × 2 tables for EBUS, EUS, and the combined approach. We evaluated the added value (absolute increase in sensitivity and in detection rate) of the combined use of EBUS and EUS in detecting mediastinal nodal metastases over either test alone, and the diagnostic accuracy (sensitivity and negative predictive value) of the combined approach. This study is registered with PROSPERO, number CRD42015019249.
FINDINGS
We identified 2567 unique manuscripts by database search, of which 13 studies (including 2395 patients) were included in the analysis. Median prevalence of N2/N3 disease was 34% (range 23-71). On average, addition of EUS to EBUS increased sensitivity by 0·12 (95% CI 0·08-0·18) and addition of EBUS to EUS increased sensitivity by 0·22 (0·16-0·29). Mean sensitivity of the combined approach was 0·86 (0·81-0·90), and the mean negative predictive value was 0·92 (0·89-0·93). The mean negative predictive value was significantly higher in studies with a prevalence of 34% or less (0·93 [95% CI 0·91-0·95]) compared with studies with a prevalence of more than 34% (0·89 [0·85-0·91]; p=0·013). We found no significant differences in mean sensitivity and negative predictive value between studies that did EBUS first or EUS first, or between studies that used an EBUS-scope or a regular echoendoscope to do EUS.
INTERPRETATION
The combined use of EBUS and EUS significantly improves sensitivity in detecting mediastinal nodal metastases, reducing the need for surgical staging procedures.
FUNDING
No external funding.
Topics: Adult; Aged; Aged, 80 and over; Bronchoscopy; Carcinoma, Non-Small-Cell Lung; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Endosonography; Esophagus; Female; Humans; Lung Neoplasms; Lymph Nodes; Male; Mediastinum; Middle Aged; Neoplasm Staging; Predictive Value of Tests; Sensitivity and Specificity
PubMed: 27773666
DOI: 10.1016/S2213-2600(16)30317-4 -
PloS One 2014This systematic review and meta-analysis aimed to evaluate the overall survival, local recurrence, distant metastasis, and complications of mediastinal lymph node... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
This systematic review and meta-analysis aimed to evaluate the overall survival, local recurrence, distant metastasis, and complications of mediastinal lymph node dissection (MLND) versus mediastinal lymph node sampling (MLNS) in stage I-IIIA non-small cell lung cancer (NSCLC) patients.
METHODS
A systematic search of published literature was conducted using the main databases (MEDLINE, PubMed, EMBASE, and Cochrane databases) to identify relevant randomized controlled trials that compared MLND vs. MLNS in NSCLC patients. Methodological quality of included randomized controlled trials was assessed according to the criteria from the Cochrane Handbook for Systematic Review of Interventions (Version 5.1.0). Meta-analysis was performed using The Cochrane Collaboration's Review Manager 5.3. The results of the meta-analysis were expressed as hazard ratio (HR) or risk ratio (RR), with their corresponding 95% confidence interval (CI).
RESULTS
We included results reported from six randomized controlled trials, with a total of 1,791 patients included in the primary meta-analysis. Compared to MLNS in NSCLC patients, there was no statistically significant difference in MLND on overall survival (HR = 0.77, 95% CI 0.55 to 1.08; P = 0.13). In addition, the results indicated that local recurrence rate (RR = 0.93, 95% CI 0.68 to 1.28; P = 0.67), distant metastasis rate (RR = 0.88, 95% CI 0.74 to 1.04; P = 0.15), and total complications rate (RR = 1.10, 95% CI 0.67 to 1.79; P = 0.72) were similar, no significant difference found between the two groups.
CONCLUSIONS
Results for overall survival, local recurrence rate, and distant metastasis rate were similar between MLND and MLNS in early stage NSCLC patients. There was no evidence that MLND increased complications compared with MLNS. Whether or not MLND is superior to MLNS for stage II-IIIA remains to be determined.
Topics: Carcinoma, Non-Small-Cell Lung; Humans; Lung Neoplasms; Lymph Node Excision; Mediastinum; Neoplasm Staging
PubMed: 25296033
DOI: 10.1371/journal.pone.0109979 -
European Journal of Radiology May 2020To analyze the imaging manifestations of mediastinal hemangioma (MH) by CT and MRI to aid in its successful diagnosis and preoperative evaluation.
PURPOSE
To analyze the imaging manifestations of mediastinal hemangioma (MH) by CT and MRI to aid in its successful diagnosis and preoperative evaluation.
METHODS
Seventeen cases of MH diagnosed by histopathology combined with CT and MRI were retrospectively collected; and their CT and MRI features, including the lesions' site and range, shape, size, margin, density or signal, enhancement pattern, mass-cardiovascular interface, mass-pulmonary interface, and other characteristics were evaluated.
RESULTS
The anterior, middle, and posterior mediastinum were involved in 13, 13, and 8 cases, respectively. The masses size varied from 20 to 233 mm. Irregular, dumbbell-like, and oval masses were found in 13, 2, and 2 cases, respectively, while with pampiniform growth in 16 cases and expansive growth in 1 case. Mixed density, homogeneous density solid masses, and heterogeneous density masses with dominant fat were found in 9, 5, and 3 cases, respectively, showing mild or significant enhancement in aortic phase while no or mild enhancement in pulmonary artery phase. Draining veins were found in 16 cases and feeding arteries in 10 cases. Phleboliths were detected in 10 cases, splenic hemangiomas in 6 cases, and left lateral-chest-wall hemangioma in 1 case. In MRI sequences, mixed signal was found on TWI and heterogeneous hypersignal with nodular or linear hyposignal on TWI in 5 cases, mild or significant enhancement in 4 cases, draining veins in 2 cases, and no feeding arteries or phleboliths were seen.
CONCLUSION
Presence of phleboliths, pampiniform growth pattern, and aberrant draining veins are relatively specific characteristics in diagnosing MH.
Topics: Adolescent; Adult; Aged; Child; Female; Hemangioma; Humans; Magnetic Resonance Imaging; Male; Mediastinal Neoplasms; Mediastinum; Middle Aged; Retrospective Studies; Tomography, X-Ray Computed; Young Adult
PubMed: 32145596
DOI: 10.1016/j.ejrad.2020.108905 -
General Thoracic and Cardiovascular... Aug 2021The aim of this systematic review and meta-analysis was to define clinical indicator that predicts mediastinal lymph nodes metastasis (MLNM) in patients with... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
The aim of this systematic review and meta-analysis was to define clinical indicator that predicts mediastinal lymph nodes metastasis (MLNM) in patients with Esophagogastric junction cancer (EGJC) to select patient population requiring esophagectomy.
METHODS
A systematic and electronic search of several electronic databases was performed up to August 2020. Studies containing information on risk factors for MLNM in patients diagnosed with EJGC and who underwent curative surgery were included.
RESULTS
Two predictors, including undifferentiated type (OR = 1.82, 95% CI = 1.07-3.10, p = 0.03) and esophageal invasion length (EIL) (OR = 10.95, 95% CI = 6.37-18.82, p < 0.00001) were identified as significant predictors for the risk of MLNM.
CONCLUSION
Knowledge of the associations of these clinicopathological features with MLNM can be useful in determining operative strategy for EGJC.
Topics: Adenocarcinoma; Esophageal Neoplasms; Esophagectomy; Esophagogastric Junction; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Retrospective Studies; Stomach Neoplasms
PubMed: 34109538
DOI: 10.1007/s11748-021-01665-7 -
European Radiology Jan 2020This systematic review and meta-analysis aimed to evaluate the diagnostic outcomes and complication rates and to identify potential covariates that could influence these... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
This systematic review and meta-analysis aimed to evaluate the diagnostic outcomes and complication rates and to identify potential covariates that could influence these results for computed tomography (CT)-guided core needle biopsy (CNB) of mediastinal masses.
METHODS
A computerized search of the PubMed and EMBASE databases was performed to identify original articles on the use of CT-guided CNB for mediastinal mass. The pooled proportions of the diagnostic yield and accuracy were assessed using random effects modeling. We assessed the pooled proportion of complication rates using random effects or fixed effects modeling. Multivariate meta-regression analyses were performed to evaluate the potential sources of heterogeneity.
RESULTS
Eighteen eligible studies (1310 patients with 1345 CT-guided CNBs) were included. The pooled proportions of the diagnostic yield and accuracy of CT-guided CNB for mediastinal masses were 92% (18 studies, 1345 procedures) and 94% (15 studies, 803 procedures), respectively. In the subgroup analysis, the pooled proportions of the total complication rate and major complication rate were 13% and 2%, respectively. In the meta-regression analyses, the number of tissue samplings (odds ratio [OR], 3.3; p = 0.03), real-time fluoroscopy-guided (OR, 2.1; p = 0.02), and percentage of lymphoma (OR, 2.2; p < 0.001) for diagnostic yield, number of tissue samplings (OR = 2.0, p = 0.02) for diagnostic accuracy, and biopsy needle diameter (OR, 2.5; p = 0.002) for total complication rate were all sources of heterogeneity.
CONCLUSIONS
CT-guided CNB for mediastinal mass demonstrates high diagnostic outcomes and low complication rates. The use of 20-gauge biopsy needles and obtaining ≥ 3 samples may be recommended to improve diagnostic outcomes and decrease complication rates.
KEY POINTS
• The pooled estimates of diagnostic yield and accuracy of computed tomography (CT)-guided core needle biopsy (CNB) for mediastinal masses are 92% and 94%, respectively. • The pooled estimates of the total complication rate and major complication rate were 13% and 2%, respectively. • The use of a 20-gauge needle and ≥ 3 tissue samplings are recommended for CT-guided mediastinal CNB to achieve high diagnostic outcomes and lower complication rates.
Topics: Adult; Aged; Biopsy, Large-Core Needle; Female; Humans; Image-Guided Biopsy; Male; Mediastinal Neoplasms; Mediastinum; Middle Aged; Odds Ratio; Radiography, Interventional; Retrospective Studies; Tomography, X-Ray Computed
PubMed: 31418086
DOI: 10.1007/s00330-019-06377-4 -
Critical Reviews in Oncology/hematology Nov 2021Secondary malignant neoplasms (SMNs) and cardiovascular diseases induced by chemotherapy and radiotherapy represent the main cause of excess mortality for early-stage... (Review)
Review
BACKGROUND
Secondary malignant neoplasms (SMNs) and cardiovascular diseases induced by chemotherapy and radiotherapy represent the main cause of excess mortality for early-stage Hodgkin lymphoma patients, especially when the mediastinum is involved. Conformal radiotherapy techniques such as Intensity-Modulated Radiation Therapy (IMRT) could allow a reduction of the dose to the organs-at-risk (OARs) and therefore limit long-term toxicity.
METHODS
We performed a systematic review of the current literature regarding comparisons between IMRT and conventional photon beam radiotherapy, or between different IMRT techniques, for the treatment of mediastinal lymphoma.
RESULTS AND CONCLUSIONS
IMRT allows a substantial reduction of the volumes of OARs exposed to high doses, reducing the risk of long-term toxicity. This benefit is conterbalanced by the increase of volumes receiving low doses, that could potentially increase the risk of SMNs. Treatment planning should be personalized on patient and disease characteristics. Dedicated techniques such as "butterfly" VMAT often provide the best trade-off.
Topics: Hodgkin Disease; Humans; Mediastinal Neoplasms; Radiotherapy Dosage; Radiotherapy Planning, Computer-Assisted; Radiotherapy, Conformal; Radiotherapy, Intensity-Modulated
PubMed: 34358649
DOI: 10.1016/j.critrevonc.2021.103437