-
Journal of Thoracic Oncology : Official... Jun 2019Confirmatory mediastinoscopy after negative endosonography findings is advised by the guidelines on patients with resectable NSCLC and suspected intrathoracic nodes on... (Meta-Analysis)
Meta-Analysis
Unforeseen N2 Disease after Negative Endosonography Findings with or without Confirmatory Mediastinoscopy in Resectable Non-Small Cell Lung Cancer: A Systematic Review and Meta-Analysis.
INTRODUCTION
Confirmatory mediastinoscopy after negative endosonography findings is advised by the guidelines on patients with resectable NSCLC and suspected intrathoracic nodes on fludeoxyglucose F 18 positron emission tomography-computed tomography. Its role however is under debate owing to its limited nodal metastasis detection rate, morbidity, associated treatment delay, and unknown impact on survival.
METHODS
Systematic review and meta-analysis of studies on invasive mediastinal staging in patients with (suspected) NSCLC. The Medline, Embase, and Cochrane databases were searched until September 19, 2018, without year or language restrictions. The Quality Assessment Tool for Diagnostic Accuracy Studies, version 2, was used to evaluate the risk of bias and applicability of the included studies. Rates of unforeseen N2 disease were assessed for endobronchial ultrasound and/or endoscopic ultrasound staging strategies with or without confirmatory mediastinoscopy. Additionally, the complication rates of cervical video mediastinoscopy for mediastinal staging of NSCLC were investigated.
RESULTS
A total of 5073 articles were found, of which 42 studies or subgroups (covering a total of 3248 patients undergoing the surgical reference standard of treatment) were considered in the analysis. Random effects meta-analysis of endosonography with or without confirmatory mediastinoscopy showed rates of unforeseen N2 disease of 9.6% (95% confidence interval [CI]: 7.8%-11.7%, I = 30%) versus 9.9% (95% CI: 6.3%-15.2%, I = 73%), respectively. Random effects meta-analysis of mediastinoscopy (eight studies [1245 patients in total]) showed a complication rate of 6.0% (95% CI: 4.8%-7.5%), with laryngeal recurrent nerve palsy accounting for 2.8% (95% CI: 2.0%-4.0%).
CONCLUSION
The rate of unforeseen N2 disease after negative endosonography findings was similar in patients undergoing immediate lung tumor resection to those undergoing confirmatory mediastinoscopy first, at the cost of 6.0% rate of complications by mediastinoscopy.
Topics: Carcinoma, Non-Small-Cell Lung; Clinical Trials as Topic; Endosonography; Humans; Lung Neoplasms; Lymph Nodes; Lymphatic Metastasis; Mediastinoscopy; Neoplasm Staging; Observational Studies as Topic
PubMed: 30905829
DOI: 10.1016/j.jtho.2019.02.032 -
Surgery Today Oct 2019The robotic surgical system was designed to overcome the drawbacks of conventional endoscopic surgery. Since national health insurance in Japan began covering...
The robotic surgical system was designed to overcome the drawbacks of conventional endoscopic surgery. Since national health insurance in Japan began covering robotic-assisted thoracoscopic surgery (RATS) for malignant lung and mediastinal tumors in 2018, the number of RATS procedures being performed domestically has increased rapidly. This review evaluates the advantages and disadvantages of RATS for patients with lung cancers, based on an electronic literature search of PubMed. The main advantages of RATS are its ability to achieve excellent lymph-node removal with low morbidity and mortality, and minimal postoperative pain. Conversely, its disadvantages include a long operation time and the need for specialized instruments. However, the learning curve for RATS is reported to be shorter than that for VATS: some studies recommend that a surgeon needs to perform 18-22 robotic operations to attain sufficient skill. RATS for lung cancer is more expensive than VATS and the cost of training is high. Although the main disadvantage of RATS is that it reduces operator's tactile senses, the endoscope, which is directly manipulated by the surgeon at the console, using various magnifications, and 3D HD images on the monitor, may compensate for this. Ultimately, RATS offers better maneuverability, accuracy, and stability over VATS.
Topics: Clinical Competence; Education, Medical; General Surgery; Humans; Learning Curve; Lung Neoplasms; Operative Time; Pain, Postoperative; Pneumonectomy; Robotic Surgical Procedures; Surgery, Computer-Assisted; Thoracic Surgery, Video-Assisted; Thoracoscopy
PubMed: 30859310
DOI: 10.1007/s00595-019-01793-x -
Lung Cancer (Amsterdam, Netherlands) Dec 2018The primary objective of this study is to systematically review all pertinent literature related to the use of ultrasonographic features to predict malignancy in...
OBJECTIVES
The primary objective of this study is to systematically review all pertinent literature related to the use of ultrasonographic features to predict malignancy in mediastinal lymph nodes seen during endobronchial ultrasound (EBUS) procedures.
MATERIALS AND METHODS
Two independent reviewers completed the search and review (PubMed, EMBASE, Medline, and Cochrane databases) of the resulting titles and abstracts. Following full-text screening, thirteen articles met the inclusion criteria. Heterogeneity prevented any meta-analysis, instead a narrative review was completed. Results from each included article are categorized by the following ultrasonographic features: shape, echogenicity, margin status, central necrosis, short axis length, and central hilar structure. Diagnostic tools are also described in detail.
RESULTS
Absence of a central hilar structure and heterogeneous echogenicity were often associated with malignancy; however, consensus was not achieved amongst the included articles. The remaining ultrasonographic features were not consistently associated with malignancy or benign disease status, suggesting a need for prospective analysis. Four diagnostic tools were also assessed. These tools demonstrate that a combination of ultrasonographic features may accurately predict lymph node malignancy rather than a single feature.
CONCLUSION
Analysis of ultrasonographic features may prevent the need for repeat EBUS procedures when initial biopsy results are inconclusive. However, prospective external validation of these features is required to determine their true predictive capability. PROSPERO registration number: CRD42017068468.
Topics: Diagnosis, Differential; Endosonography; Humans; Lung Neoplasms; Lymph Nodes; Lymphatic Metastasis; Mediastinum; Reproducibility of Results; Sensitivity and Specificity; Ultrasonography
PubMed: 30527199
DOI: 10.1016/j.lungcan.2018.10.020 -
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 -
Annals of the American Thoracic Society Oct 2018Endobronchial ultrasound and transbronchial needle aspiration (EBUS-TBNA) are commonly used for the diagnosis and mediastinal staging of lung cancer. Molecular markers... (Meta-Analysis)
Meta-Analysis
Adequacy of Samples Obtained by Endobronchial Ultrasound with Transbronchial Needle Aspiration for Molecular Analysis in Patients with Non-Small Cell Lung Cancer. Systematic Review and Meta-Analysis.
RATIONALE
Endobronchial ultrasound and transbronchial needle aspiration (EBUS-TBNA) are commonly used for the diagnosis and mediastinal staging of lung cancer. Molecular markers are becoming increasingly important in patients with lung cancer to define targetable mutations suitable for personalized therapy, such as epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), reactive oxygen species proto-oncogene (ROS1), and programmed death-ligand 1 (PD-L1).
OBJECTIVES
To evaluate the adequacy of EBUS-TBNA-derived tissue for molecular analysis.
METHODS
We searched the MEDLINE, LILACS, www.clinicaltrials.gov , and Epistemonikos databases through January 2018.
DATA EXTRACTION
Two independent reviewers performed the data search, quality assessment, and data extraction. We included both prospective and retrospective studies; risk of bias was evaluated using the ROBINS-I tool. The primary outcome was the proportion of adequate samples obtained by EBUS-TBNA for molecular analysis. Data were pooled by using a binary random effects model. Finally, evidence was rated by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.
RESULTS
A total of 33 studies including 2,698 participants were analyzed. In 28 studies that evaluated EBUS-TBNA for the identification of EGFR mutations, the pooled probability of obtaining a sufficient sample was 94.5% (95% confidence interval CI], 93.2-96.4%). For identification of ALK mutations, the pooled probability was 94.9% (95% CI, 89.4-98.8%). Finally, the prevalence of EGFR mutation was 15.8% (95% CI, 12.1-19.4%), and the prevalence of ALK mutation was 2.77% (95% CI, 1.0-4.8%). Data for ROS1 and PD-L1 mutations were not suitable for meta-analysis.
CONCLUSIONS
EBUS-TBNA has a high yield for molecular analysis of both EGFR and ALK mutations. However, the suitability of TBNA samples for next-generation sequencing is uncertain and should be explored in further studies. Clinical trial registered with PROSPERO (CRD42017080008).
Topics: Carcinoma, Non-Small-Cell Lung; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Humans; Lung Neoplasms; Mediastinum; Molecular Diagnostic Techniques; Proto-Oncogene Mas
PubMed: 30011388
DOI: 10.1513/AnnalsATS.201801-045OC -
Archivos de Bronconeumologia Jan 2019The aim of this study is to assess the diagnostic value of the magnetic resonance imaging (MRI) in differentiating metastasic from non-metastatic lymph nodes in NSCLC... (Comparative Study)
Comparative Study
INTRODUCTION
The aim of this study is to assess the diagnostic value of the magnetic resonance imaging (MRI) in differentiating metastasic from non-metastatic lymph nodes in NSCLC patients compared with computed tomography (CT) and fluorodeoxyglucose (FDG) - positron emission tomography (PET) or both combined.
METHODS
Twenty-three studies (19 studies and 4 meta-analysis) with sample size ranging between 22 and 250 patients were included in this analysis. MRI, regardless of the sequence obtained, where used for the evaluation of N-staging of NSCLC. Histopathology results and clinical or imaging follow-up were used as the reference standard. Studies were excluded if the sample size was less than 20 cases, if less than 10 lymph nodes assessment were presented or studies where standard reference was not used. Papers not reporting sufficient data were also excluded.
RESULTS
As compared to CT and PET, MRI demonstrated a higher sensitivity, specificity and diagnostic accuracy in the diagnosis of metastatic or non-metastatic lymph nodes in N-staging in NSCLC patients. No study considered MRI inferior than conventional techniques (CT, PET or PET/CT). Other outstanding results of this review are fewer false positives with MRI in comparison with PET, their superiority over PET/CT to detect non-resectable lung cancer, to diagnosing infiltration of adjacent structures or brain metastasis and detecting small nodules.
CONCLUSION
MRI has shown at least similar or better results in diagnostic accuracy to differentiate metastatic from non-metastatic mediastinal lymph nodes. This suggests that MRI could play a significant role in mediastinal NSCLC staging.
Topics: Carcinoma, Non-Small-Cell Lung; Diagnosis, Differential; Humans; Lung Neoplasms; Lymph Nodes; Lymphatic Metastasis; Magnetic Resonance Imaging; Neoplasm Staging; Positron Emission Tomography Computed Tomography; Positron-Emission Tomography; Prospective Studies; Retrospective Studies; Sensitivity and Specificity; Tomography, X-Ray Computed
PubMed: 29803524
DOI: 10.1016/j.arbres.2018.03.007 -
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 -
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 -
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 -
Clinical Lung Cancer May 2018Stereotactic ablative body radiotherapy (SABR) is popular because of the high rates of local control with low toxicity seen in lung cancer patients. In this study we... (Comparative Study)
Comparative Study Meta-Analysis
Comparing the Outcomes of Stereotactic Ablative Radiotherapy and Non-Stereotactic Ablative Radiotherapy Definitive Radiotherapy Approaches to Thoracic Malignancy: A Systematic Review and Meta-Analysis.
Stereotactic ablative body radiotherapy (SABR) is popular because of the high rates of local control with low toxicity seen in lung cancer patients. In this study we compared clinically significant toxicity and overall survival for SABR and non-SABR definitive radiotherapy (conformal radiotherapy) patients. A PUBMED search of all human, English language articles on SABR and non-SABR radically treated early stage lung cancer patients was performed until June 2016. Results of these searches were filtered in accordance with a set of eligibility criteria and analyzed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eighty-seven SABR and 25 non-SABR articles were reviewed. There was no significant difference in pneumonitis rates between patients receiving SABR (11.4%; 95% confidence interval [CI], 9.7-13.3) and non-SABR treatment (14.4%; 95% CI, 10.6-18.8; P = .20). Esophagitis was the most common mediastinal toxicity reported with 15% of all non-SABR patients versus 1% of all SABR patients reporting developing Grade ≥2 toxicity. The proportion of patient surviving at 2 and 3 years was superior for SABR patients (P < .001). Treatment-related deaths were rare (approximately 1% for both treatments). Both radiotherapy approaches had low rates of pneumonitis, mediastinal toxicity, and treatment-related deaths. However, significant heterogeneity in the patient population and study regimens limit the power of direct comparison, showing that further high-quality studies are required to define the role of SABR in higher risk and operable patients.
Topics: Aged; Aged, 80 and over; Female; Humans; Lung Neoplasms; Male; Middle Aged; Radiosurgery; Radiotherapy, Conformal; Treatment Outcome
PubMed: 29370978
DOI: 10.1016/j.cllc.2017.11.006