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Journal of Thoracic Oncology : Official... Mar 2010Many clinicians use restaging after induction therapy as a way to select patients for surgery. (Review)
Review
BACKGROUND
Many clinicians use restaging after induction therapy as a way to select patients for surgery.
METHODS
A systematic review was conducted to define the reliability of restaging tests after induction therapy for stage III(N2) lung cancer, when compared with pathologic findings at surgery.
RESULTS
A complete response at all sites carries a false-negative (FN) rate of 50% for computed tomography and 30% for positron emission tomography. Mediastinal node involvement has FN and false-positive rates of 33% and 33% by computed tomography, and 25% and 33% by positron emission tomography. The FN rate of invasive restaging is 22% by repeat mediastinoscopy, 14% by esophageal ultrasound and needle aspiration in expert hands (reliable results are not yet available for endobronchial ultrasound), and 9% by primary mediastinoscopy done with optimal thoroughness. These results are not significantly affected by the type of induction therapy or the timing of restaging.
CONCLUSION
The ability to identify patients who have achieved mediastinal downstaging other than by a careful primary mediastinoscopy is poor.
Topics: Carcinoma, Non-Small-Cell Lung; Clinical Trials as Topic; Humans; Lung Neoplasms; Mediastinoscopy; Neoplasm Staging; Positron-Emission Tomography; Prognosis; Remission Induction; Survival Rate; Tomography, X-Ray Computed
PubMed: 20186025
DOI: 10.1097/JTO.0b013e3181ce3e5e -
The European Respiratory Journal May 2009The aim of the present systematic review was to assess the effectiveness and safety of real time endobronchial ultrasound-guided transbronchial needle aspiration... (Review)
Review
The aim of the present systematic review was to assess the effectiveness and safety of real time endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in patients with suspected or known bronchopulmonary carcinoma, as well as in other clinical indications presented by lymphatic adenopathies. A systematic review was carried out in November 2007 and updated in April 2008 using the main databases. Inclusion and exclusion criteria were applied to the papers retrieved. A total of 20 publications were included. Of these, 14 were original studies that investigated the clinical usefulness of the technique in visualising and staging lymph nodes in patients with suspected or established lung cancer. Sensitivity ranged 85-100% and negative predictive value ranged 11-97.4%. Three studies assessed the clinical usefulness of the technique in the diagnosis of sarcoidosis. EBUS-TBNA was diagnostic in 88-93% of patients. One retrospective study evaluated the use of EBUS-TBNA in the diagnosis of lymphoma. None of the studies included in the present review reported important complications. Endobronchial ultrasound-guided transbronchial needle aspiration is a safe and highly accurate procedure for the examination and staging of mediastinal and hilar lymph nodes in patients with known or suspected lung malignancy. The evidence is promising for sarcoidosis but is not sufficient for lymphoma.
Topics: Adenocarcinoma; Biopsy, Fine-Needle; Carcinoma, Small Cell; Carcinoma, Squamous Cell; Endosonography; Humans; Lung; Lung Neoplasms; Lymph Nodes; Lymphatic Metastasis; Neoplasm Staging; Predictive Value of Tests; Safety; Sensitivity and Specificity
PubMed: 19407050
DOI: 10.1183/09031936.00097908 -
Thorax Jul 2006Surgery is considered the treatment of choice for patients with resectable stage I and II (and some patients with stage IIIA) non-small cell lung cancer (NSCLC), but... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Surgery is considered the treatment of choice for patients with resectable stage I and II (and some patients with stage IIIA) non-small cell lung cancer (NSCLC), but there have been no previously published systematic reviews.
METHODS
A systematic review and meta-analysis of randomised controlled trials was conducted to determine whether surgical resection improves disease specific mortality in patients with stages I-IIIA NSCLC compared with non-surgical treatment, and to compare the efficacy of different surgical approaches.
RESULTS
Eleven trials were included. No studies had untreated control groups. In a pooled analysis of three trials, 4 year survival was superior in patients undergoing resection with stage I-IIIA NSCLC who had complete mediastinal lymph node dissection compared with lymph node sampling (hazard ratio estimated at 0.78 (95% CI 0.65 to 0.93)). Another trial reported an increased rate of local recurrence in patients with stage I NSCLC treated with limited resection compared with lobectomy. One small study reported a survival advantage among patients with stage IIIA NSCLC treated with chemotherapy followed by surgery compared with chemotherapy followed by radiotherapy. No other trials reported significant improvements in survival after surgery compared with non-surgical treatment.
CONCLUSION
It is difficult to draw conclusions about the efficacy of surgery for locoregional NSCLC because of the small number of participants studied and methodological weaknesses of the trials. However, current evidence suggests that complete mediastinal lymph node dissection is associated with improved survival compared with node sampling in patients with stage I-IIIA NSCLC undergoing resection.
Topics: Carcinoma, Non-Small-Cell Lung; Humans; Lung; Lung Neoplasms; Randomized Controlled Trials as Topic; Risk Factors; Survival Analysis
PubMed: 16449262
DOI: 10.1136/thx.2005.051995 -
The Cochrane Database of Systematic... Jan 2005Surgical resection (usually lobectomy) is considered the treatment of choice for individuals with stage I and II non-small cell lung cancer (NSCLC) and for some patients... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Surgical resection (usually lobectomy) is considered the treatment of choice for individuals with stage I and II non-small cell lung cancer (NSCLC) and for some patients with resectable stage IIIA NSCLC. However much of the evidence supporting surgery is observational.
OBJECTIVES
To determine whether, in patients with early stage non-small cell lung cancer, surgical resection of cancer improves disease-specific and all-cause mortality compared with no treatment, radiotherapy or chemotherapy. To compare the effectiveness of different surgical approaches (e.g. lobectomy versus limited resection) in improving disease-specific or all-cause mortality in patients with early stage lung cancer.
SEARCH STRATEGY
Electronic databases (the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE (1966 to December 2003)), bibliographies, handsearching of a journal and discussion with experts were used to identify published and unpublished trials.
SELECTION CRITERIA
Randomised controlled trials comparing surgery alone (or in combination with other therapy) with non-surgical therapy and randomised trials comparing different surgical approaches.
DATA COLLECTION AND ANALYSIS
A pooled hazard ratio was calculated where possible. Tests for statistical heterogeneity were performed.
MAIN RESULTS
Eleven trials were included with a total of 1910 subjects. There were no studies with an untreated control group. In a pooled analysis of three trials, four-year survival was superior in patients with resectable stage I to IIIA NSCLC who underwent resection and complete mediastinal lymph node dissection compared with those undergoing resection and lymph node sampling, the hazard ratio was estimated to be 0.78 (95% CI 0.65-0.93, P = 0.005). A further trial found an increased rate of local recurrence in patients with stage I NSCLC treated with limited resection compared with lobectomy. One small trial found a survival advantage in favour of chemotherapy followed by surgery compared to chemotherapy followed by radiotherapy in patients with stage IIIA NSCLC. However none of the other trials included in the review demonstrated a significant improvement in survival in patients treated with surgery compared with non surgical therapy. Several of the included trials had potential methodological weaknesses.
AUTHORS' CONCLUSIONS
Conclusions about the efficacy of surgery for local and loco-regional NSCLC are limited by the small number of participants studied to date and potential methodological weaknesses of trials. Current evidence suggests that lung cancer resection combined with complete mediastinal lymph node dissection is associated with a small to modest improvement in survival compared with lung cancer resection combined with systematic sampling of mediastinal nodes in patients with stage I to IIIA NSCLC.
Topics: Carcinoma, Non-Small-Cell Lung; Combined Modality Therapy; Humans; Lung Neoplasms; Neoplasm Staging; Pneumonectomy; Randomized Controlled Trials as Topic
PubMed: 15674959
DOI: 10.1002/14651858.CD004699.pub2 -
Thorax Aug 2001To determine the effectiveness of radical radiotherapy in medically inoperable stage I/II non-small cell lung cancer (NSCLC) and the extent of treatment related... (Review)
Review
OBJECTIVES
To determine the effectiveness of radical radiotherapy in medically inoperable stage I/II non-small cell lung cancer (NSCLC) and the extent of treatment related morbidity.
METHODS
Randomised trials were sought by electronically searching the Cochrane Clinical Trials Register, and both randomised and non-randomised trials were sought by searching Medline and Excerpta Medica (Embase). Further studies were identified from references cited in those papers already identified by electronic searching. The studies included were those of patients of any age with stage I/II NSCLC receiving radiotherapy at a dose of >40 Gy in 20 fractions over 4 weeks or its radiobiological equivalent.
RESULTS
Two randomised and 35 non-randomised studies were identified. One randomised and nine non-randomised studies did not meet the selection criteria, leaving one randomised and 26 non-randomised studies for analysis. In the randomised trial 2 year survival was higher following continuous hyperfractionated accelerated radiotherapy (CHART; 37%) than following 60 Gy in 30 fractions over 6 weeks (24%). An estimated 2003 patients were included in the 26 non-randomised studies; overall survival was 22-72% at 2 years, 17-55% at 3 years, and 0-42% at 5 years. Following treatment, 11-43% of patients died from causes other than cancer. Cancer specific survival was 54-93% at 2 years, 22-56% at 3 years, and 13-39% at 5 years. Complete response rates were 33-61% and local failure rates were 6-70%. Distant metastases developed in approximately 25% of patients. Better response rates and survival were seen in those with smaller tumours and in those receiving higher doses although the reasons for prescribing higher doses were not clearly stated. The outcome was worse in those with prior weight loss or poor performance status. Assessment of treatment related morbidity and effects on quality of life and symptom control were inconclusive because of the lack of prospective evaluation and paucity of data.
CONCLUSIONS
No randomised trials compared a policy of immediate radical radiotherapy with palliative radiotherapy given when patients develop symptoms. In the absence of such trials, radical radiotherapy appears to result in a better survival than might be expected had treatment not been given. A substantial, though variable, proportion of patients died during follow up from causes other than cancer. The optimal radiation dose and treatment technique (particularly with respect to mediastinal irradiation) remain uncertain.
Topics: Adult; Aged; Aged, 80 and over; Carcinoma, Non-Small-Cell Lung; Dose-Response Relationship, Radiation; Humans; Lung Neoplasms; Middle Aged; Neoplasm Staging; Randomized Controlled Trials as Topic; Survival Analysis; Treatment Outcome
PubMed: 11462066
DOI: 10.1136/thorax.56.8.628