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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 -
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 -
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 -
Journal of Cardiothoracic Surgery Oct 2020The standard for clinical staging of lung cancer is the use of CT and PET scans, however, these may underestimate the burden of the disease. The use of serum tumor... (Meta-Analysis)
Meta-Analysis
Elevated preoperative CEA is associated with subclinical nodal involvement and worse survival in stage I non-small cell lung cancer: a systematic review and meta-analysis.
BACKGROUND
The standard for clinical staging of lung cancer is the use of CT and PET scans, however, these may underestimate the burden of the disease. The use of serum tumor markers might aid in the detection of subclinical advanced disease. The aim of this study is to review the predictive value of tumor markers in patients with clinical stage I NSCLC.
METHODS
A comprehensive search was performed using the Medline, EMBASE, Scopus data bases. Abstracts included based on the following inclusion criteria: 1) adult ≥18 years old, 2) clinical stage I NSCLC, 3) Tumor markers (CEA, SCC, CYFRA 21-1), 4) further imaging or procedure, 5) > 5 patients, 6) articles in English language. The primary outcome of interest was utility of tumour markers for predicting nodal involvement and oncologic outcomes in patients with clinical stage I NSCLC. Secondary outcomes included sub-type of lung cancer, procedure performed, and follow-up duration.
RESULTS
Two hundred seventy articles were screened, 86 studies received full-text assessment for eligibility. Of those, 12 studies were included. Total of 4666 patients were involved. All studies had used CEA, while less than 50% used CYFRA 21-1 or SCC. The most common tumor sub-type was adenocarcinoma, and the most frequently performed procedure was lobectomy. Meta-analysis revealed that higher CEA level is associated with higher rates of lymph node involvement and higher mortality.
CONCLUSION
There is significant correlation between the CEA level and both nodal involvement and survival. Higher serum CEA is associated with advanced stage, and poor prognosis. Measuring preoperative CEA in patient with early stage NSCLC might help to identify patients with more advanced disease which is not detected by CT scans, and potentially identify candidates for invasive mediastinal lymph node staging, helping to select the most effective therapy for patients with potentially subclinical nodal disease. Further prospective studies are needed to standardize the use of CEA as an adjunct for NSCLC staging.
Topics: Biomarkers, Tumor; Carcinoembryonic Antigen; Carcinoma, Non-Small-Cell Lung; Humans; Lung Neoplasms; Neoplasm Staging; Predictive Value of Tests; Survival Analysis
PubMed: 33059696
DOI: 10.1186/s13019-020-01353-2 -
Interactive Cardiovascular and Thoracic... Mar 2022Our goal was to evaluate the effect of thymectomy on the progression of thymolipomatous myasthenia gravis.
OBJECTIVES
Our goal was to evaluate the effect of thymectomy on the progression of thymolipomatous myasthenia gravis.
METHODS
An electronic search performed across PubMed, MEDLINE and Web of Science databases included all article types. We included 15 series comprising 36 cases that met specific criteria, including case reports or case series related to thymolipoma with a myasthenia gravis association, where thymectomy was cited as the primary intervention with postoperative reporting of the prognosis and articles written in the English language.
RESULTS
Our study included 17 men (47.2%) and 19 women (52.8%). Tumour sizes varied between 34 × 18 × 7 cm and 2.8 × 2.3 × 1.9 cm; the weight of the tumours ranged between 38 and 1780 g (mean 190, standard deviation 341). The surgical approaches were a median sternotomy in 29 patients (80.6%), a thoracotomy in 1 patient (2.8%), video-assisted thoracoscopic surgery in 2 patients (5.6%) and unreported approaches in 4 (11.1%) patients. The disease was entirely resolved with complete, stable remission in 5 patients (13.9%); symptoms were improved in 19 (52.8%) and stable in 10 patients (27.7%). We identified 2 groups of patients according to their improvement post-thymectomy (improved group and group with no change).
CONCLUSIONS
Although the cases were uncontrolled and did not demonstrate strong associations, they do support some hypotheses. We found a significant statistical difference between the 2 groups in terms of age, because younger patients tended to improve to a greater degree post-thymectomy. Also, we found that female patients with thymoma visible on the imaging scans were significantly associated with post-thymectomy myasthenia gravis improvement.
REGISTRATION NUMBER IN PROSPERO
CRD42020173229.
Topics: Female; Humans; Male; Myasthenia Gravis; Thymectomy; Thymoma; Thymus Neoplasms; Treatment Outcome
PubMed: 35362060
DOI: 10.1093/icvts/ivab295 -
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 -
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 -
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 -
The Journal of Thoracic and... Mar 2020Mediastinal restaging after induction treatment is still a difficult and controversial issue. We aimed to investigate the diagnostic accuracy of endobronchial... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Mediastinal restaging after induction treatment is still a difficult and controversial issue. We aimed to investigate the diagnostic accuracy of endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound-guided fine-needle aspiration for restaging the mediastinum after induction treatment in patients with lung cancer.
METHODS
Embase and PubMed databases were searched from conception to March 2019. Data from relevant studies were analyzed to assess sensitivity and specificity of endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound-guided fine-needle aspiration, and to fit the hierarchical summary receiver operating characteristic curves.
RESULTS
A total of 10 studies consisting of 558 patients fulfilled the inclusion criteria. All patients were restaged by endobronchial ultrasound-guided transbronchial needle aspiration, endoscopic ultrasound-guided fine-needle aspiration, or both. Negative results were confirmed by subsequent surgical approaches. There were no complications reported during any endosonography approaches reviewed. The pooled sensitivities of endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound-guided fine-needle aspiration were 65% (95% confidence interval [CI], 52-76) and 73% (95% CI, 52-87), respectively, and specificities were 99% (95% CI, 78-100) and 99% (95% CI, 90-100), respectively. The area under the hierarchical summary receiver operating characteristic curves were 0.85 (95% CI, 0.81-0.88) for endobronchial ultrasound-guided transbronchial needle aspiration and 0.99 (95% CI, 0.98-1) for endoscopic ultrasound-guided fine-needle aspiration. Moreover, for patients who received chemotherapy alone, the pooled sensitivity of endosonography with lymph node sampling for restaging was 66% (95% CI, 56-75), and specificity was 100% (95% CI, 34-100); for patients who received chemoradiotherapy, the results seemed similar with a sensitivity of 77% (95% CI, 47-92) and specificity of 99% (95% CI, 48-100).
CONCLUSIONS
Endosonography with lymph node sampling is an accurate and safe technique for mediastinal restaging of lung cancer.
Topics: Adult; Aged; Aged, 80 and over; Bronchoscopy; Chemotherapy, Adjuvant; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Female; Humans; Lung Neoplasms; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Male; Middle Aged; Neoadjuvant Therapy; Neoplasm Staging; Pneumonectomy; Predictive Value of Tests; Reproducibility of Results; Young Adult
PubMed: 31590952
DOI: 10.1016/j.jtcvs.2019.07.095 -
Journal of Thoracic Oncology : Official... Dec 2019Synchronous oligometastatic (sOM) disease is an oncological concept characterized by a limited cancer burden. Patients with oligometastasis could potentially benefit...
INTRODUCTION
Synchronous oligometastatic (sOM) disease is an oncological concept characterized by a limited cancer burden. Patients with oligometastasis could potentially benefit from local radical treatments. Despite the fact that the sOM condition is well recognized, a universal definition, including a specific definition for NSCLC, is not yet available. The aim of this systematic review was to summarize the definitions of and staging requirements for use of the term synchronous oligometastatic in the context of NSCLC.
METHODS
The key issue was formulated in one research question according to the population, intervention, comparator, and outcomes strategy. The question was introduced in MEDLINE (OvidSP). All articles dealing with sOM NSCLC and providing a definition of synchronous oligometastasis in NSCLC were selected and analyzed.
RESULTS
A total of 21 eligible articles focusing on sOM NSCLC were retrieved and analyzed. In 17 studies (81%), patients had to be staged with magnetic resonance imaging or computed tomography of the brain, thoracic and abdominal computed tomography, and positron emission tomography. The total number of metastases allowed in the definitions ranged from one to eight, but in 38.1% of studies the maximum number was 5. Most of the publications did not define the number of involved organs or the maximum number of metastases per organ. For mediastinal lymph node involvement, only five articles (27.8%) counted this as a metastatic site.
CONCLUSIONS
No uniform definition of sOM NSCLC could be retrieved by this systematic review. However, extended staging was mandated in most of the studies. An accepted oncological definition of synchronous oligometastasis is essential for patient selection to define prospective clinical trials.
Topics: Carcinoma, Non-Small-Cell Lung; Female; Humans; Lung Neoplasms; Male; Neoplasm Metastasis; Treatment Outcome
PubMed: 31195177
DOI: 10.1016/j.jtho.2019.05.037