The role of mediastinal and multi-organ CT scans in staging presumable surgical candidates with non-small-cell lung cancer

In order to evaluate the role of CT scan and bone scan in staging patients with non-small-cell lung cancer presumably indicated for surgery, 70 consecutive patients who underwent thoracotomy were reviewed. Most of them received mediastinal and multi-organ (brain, liver and adrenal) CT scans and a bone scan. In the most recent 40 of the 70 patients, CT findings of the mediastinal lymph nodes were compared to the pathology following complete sampling. The overall accuracy of the mediastinal CT was 60.0 per cent (12 true positive and 12 true negative), but the negative predictable value was 12/(12+3) or 80.0 per cent, whereas 3 were false negatives though they showed an acceptable postoperative course. Sixteen out of 21 patients with one, or at the most, three enlarged nodes detected on CT also did well postoperatively and retrospectively, were considered not to have required mediastinoscopy. A group of patients showing no, or at the most, three enlarged mediastinal lymph nodes on CT may be considered as candidates for surgery even without mediastinoscopy. Multi-organ survey by means of CT was believed cost-ineffective and omittable. Bone scan however, retrospectively detected three true positives among 20 patients with a positive uptake, so that it cannot be omitted out of hand, though further examination of this point is required.     

Evaluation of mediastinoscopy in mediastinal lymph node staging for non-small-cell lung cancer

Open in a separate window OBJECTIVESThe purpose of this study was to assess the quality of video-assisted cervical mediastinoscopy (VACM) in the staging of non-small-cell lung cancer (NSCLC) at the Antwerp University Hospital with a focus on test effectiveness indicators, morbidity and unforeseen pN2 results.METHODSAll consecutive VACM workups of cases of NSCLC performed between January 2010 and December 2015 were included to assess overall test quality and effectiveness. Quality assurance was performed in accordance with the recommendations of the European Society of Gastrointestinal Endoscopy and European Society of Thoracic Surgeons (ESTS) where appropriate.RESULTSA total of 168 video-assisted cervical mediastinoscopies were included. A total of 91.7% of the procedures were performed in accordance with the ESTS guideline. An unforeseen pN2 staging was identified in 10 anatomical lung resections (8.6%). Statistical analysis showed no significant association between VACM performed in accordance with the ESTS guideline and the presence of pN2 positive lymph nodes [χ² (1) = 0.61; P = 0.57] and no association between VACM performed in accordance with the ESTS guideline and overall futile thoracotomy [χ² (1) = 0.76; P = 0.50]. Calculations revealed a sensitivity of 81.8 [95% confidence interval (CI) 69.1–90.9], specificity of 100%, positive predictive value of 100%, negative predictive value of 91.9% (95% CI 86.6–95.2) and diagnostic accuracy of 94.1% (95% CI 89.33–97.11).CONCLUSIONSOverall, 91.7% of the VACM were performed in accordance with the ESTS guideline. This process resulted in a sensitivity of 81.8%, a negative predictive value of 91.9% and an unforeseen pN2 rate of 8.6%.     

Preoperative intrathoracic lymph node staging in patients with non-small-cell lung cancer: accuracy of integrated positron emission tomography and computed tomography

Objective: To evaluate the accuracy of integrated positron emission tomography with ¹⁸F-fluoro-2-deoxy-d-glucose (FDG) and computed tomography (PET/CT) in preoperative intrathoracic lymph node staging in patients with non-small-cell lung cancer (NSCLC) and to ascertain the role of invasive staging in verifying positron emission tomography (PET)/computed tomography (CT) results. Methods: Retrospective, single institution study of consecutive patients with suspected or pathologically proven, potentially resectable NSCLC undergoing integrated PET/CT scanning in the same PET centre. Lymph node staging was pathologically confirmed on tissue specimens obtained at mediastinoscopy and/or thoracotomy. Statistical evaluation of PET/CT results was performed on a per-patient and per-nodal-station bases. Results: A total of 1001 nodal stations (723 mediastinal, 148 hilar and 130 intrapulmonary) were evaluated in 159 patients. Nodes were positive for malignancy in 48 (30.2%) out of 159 patients (N1 = 17; N2 = 30; N3 = 1) and 71 (7.1%) out of 1001 nodal stations (N1 = 24; N2 = 46; N3 = 1). At univariate analysis, lymph node involvement was significantly associated (p < 0.05) with the following primary tumour characteristics: increasing diameter, maximum standardised uptake value >9, central location and presence of vascular invasion. PET/CT staged the disease correctly in 128 out of 159 patients (80.5%), overstaging occurred in nine patients (5.7%) and understaging in 22 patients (13.8%). The overall sensitivity, specificity, positive and negative predictive values, and accuracy of PET/CT for detecting metastatic lymph nodes were 54.2%, 91.9%, 74.3%, 82.3% and 80.5% on a per-patient basis, and 57.7%, 98.5%, 74.5%, 96.8% and 95.6% on per-nodal-station basis. With regard to N2/N3 disease, PET/CT accuracy was 84.9% and 95.3% on a per-patient basis and on per-nodal-station basis, respectively. Referring to nodal size, PET/CT sensitivity to detect malignant involvement was 32.4% (12/37) in nodes <10 mm, and 85.3% (29/34) in nodes ≥10 mm. Conclusion: Our data show that integrated PET/CT provides high specificity but low sensitivity and accuracy in intrathoracic nodal staging of NSCLC patients and underscore the continued need for surgical staging.     

Lung cancer staging

The staging of lung cancer is a continuously progressing field, with advances in technology not only improving prognostic accuracy, but fundamentally changing pre-operative investigation algorithms. Noninvasive staging is currently undergoing revolutionary developments with the advent of Positron Emission Tomography, whereas Video-Assisted Thoracic Surgery has already been established as an essential, minimally invasive diagnostic tool for invasive histological staging. Molecular staging may transform future lung cancer staging, promising extremely accurate substaging, and potentially prompting a revision of our anatomically based conceptualization of lung cancer spread. This review presents an appraisal of current lung cancer staging modalities, and presents an overview of recent developments in molecular staging.     

Lung cancer: diagnosis,staging and treatment

Lung cancer is common and has a high mortality. Radical (curative intent) surgical resection is recommended for most early-stage non-small cell lung cancers and is also increasingly considered for higher stage tumours. Patients may have co-morbidities that restrict their suitability for surgery. All patients in the UK should be managed via a specialist lung cancer multidisciplinary team, including a thoracic surgeon, to ensure appropriate patient selection for surgery. Chemotherapy and radiotherapy may be used as sole treatment, with surgery, or as part of a palliative management pathway.     

Combined contrast-enhanced computed tomography and 18-fluoro-2-deoxy-D-glucose-positron emission tomography in the diagnosis and staging of non-small cell lung cancer

We present the current optimal uses and limitations of positron emission tomography/computed tomography (PET/CT) as it relates to the diagnosis and staging of non-small cell lung cancer (NSCLC). PET/CT demonstrates increased accuracy in the workup of solitary pulmonary nodules for malignancy compared with CT alone, and we discuss its benefits and limitations. We review pitfalls in measured standardized uptake values of lung lesions caused by respiratory artifacts, the lower sensitivity for detection of small lung nodules on non-breath-hold CT, and the benefits of obtaining an additional diagnostic CT for the maximum sensitivity of lung nodule detection. There are limitations of quantitatively comparing separate PET/CT examinations from different facilities with standardized uptake values. As for staging, we describe how PET/CT supplements clinical tumor-nodes-metastases (ie, TNM) staging, as well as mediastinoscopy, endobronchial ultrasound, and endoscopic ultrasound, which are the gold standard pathologic staging methods. We touch on the 7th edition TNM staging system based on the work by the International Association for the Study of Lung Cancer, an anatomically based staging method.     

全胸腔镜下肺叶切除治疗早期非小细胞肺癌

目的 探讨全胸腔镜下肺叶切除在早期非小细胞肺癌治疗中的安全性、有效性及适应证.方法 2006年11月至2007年11月共施行全胸腔镜下肺叶切除治疗早期非小细胞肺癌44例,其中男2,4例,女20例;平均年龄61.5岁.手术全部通过3个胸腔镜切口完成,肺叶解剖性切除和系统性淋巴结清扫的操作顺序与常规开胸手术基本相同.结果 全部手术顺利,未发生严重并发症及围手术期死亡,中转开胸1例.平均手术202.6 min,平均出血216.8 ml,无输血病例.术后平均带胸管7.4 d.术后病理:腺癌30例,鳞癌10例,肺泡细胞癌3例,肉瘤样癌1例.随访平均7.7个月,1例Ⅲa期腺癌病人术后3个月发生转移,其余无复发.结论 全胸腔镜下肺叶切除在有效性、彻底性方面可以达到开胸手术相同的效果,对于早期非小细胞肺癌是一种安全、有效的手术方式.     

The incidence of hoarseness after mediastinoscopy and outcome of video-assisted versus conventional mediastinoscopy in lung cancer staging*

Objectives Theoretically, video-assisted mediastinoscopy (VM) should provide a decrease in the incidence of hoarseness in comparison with conventional mediastinoscopy (CM). Methods An investigation of 448 patients with the NSCLC who underwent mediastinoscopy (n?=?261?VM, n?=?187?CM) between 2006 and 2010.

Results With VM, the mean number of sampled LNs and of stations per case were both significantly higher (n?=?7.91?±?1.97 and n?=?4.29?±?0.81) than they were for CM (n?=?6.65?±?1.79 and n?=?4.14?±?0.84) (p?p?=?0.06). Hoarseness was reported in 24 patients (5.4%) with VM procedures resulting in a higher incidence of hoarseness than did CM procedures (6.9% and 3.2%) (p?=?0.08). The incidence of hoarseness was observed to be more frequent in patients with left-lung carcinoma who had undergone a mediastinoscopy (p?=?0.03). Hoarseness developed in 6% of the patients sampled at station 4L, whereas this ratio was 0% in patients who were not sampled at 4L (p?=?0.07). A multivariate analysis showed that the presence of a tumor in the left lung is the only independent risk factor indicating hoarseness (p?=?0.09). The sensitivity, NPV, and accuracy of VM were calculated as to be 0.87, 0.95, and 0.96, respectively. The same staging values for CM were 0.83, 0.94, and 0.95, respectively.

Conclusion VM, the presence of a tumor in the left-lung, and 4L sampling via mediastinoscopy are risk factors for subsequent hoarseness. Probably due to a wider area of dissection, VM can lead to more frequent hoarseness.     

Lung cancer: diagnosis,staging and treatment

Lung cancer is the most common malignancy worldwide and carries a high mortality rate. The risk of developing lung cancer is strongly associated with smoking. The predominant subtypes of lung cancer are non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). NSCLC forms the majority of cases while SCLC makes up a smaller proportion. Patients with symptoms and signs suggestive of lung cancer are managed by a multi-disciplinary team approach in order to diagnose and stage the disease. The type and stage of lung cancer guides further management. Early stage lung cancer should be treated aggressively; with the most appropriate modality which may include surgery, chemotherapy and radiotherapy, or a combination of these various modalities.     

跨肺裂型非小细胞肺癌患者手术预后分析及分期探讨

目的 探讨肿瘤跨肺裂侵犯对非小细胞肺癌( NSCLC)患者术后生存率的影响及合适的TNM分期.方法 回顾性分析上海肺科医院1997年至2007年接受根治性非小细胞肺癌手术病例临床和随访资料.将术后病理证实的非小细胞肺癌患者,按原发肿瘤是否跨肺裂侵犯,分别统计性别、年龄、吸烟史、肺功能、肿瘤部位、肿瘤大小、手术方式、淋巴结转移情况、TNM分期、病理类型,运用KaplanMeier生存分析和Cox比例风险模型,对预后因素进行分析.结果 跨肺裂侵犯(CF组)入组163例,肿瘤局限单肺叶(SL组)入组326例.根据IASLC最新推荐的第7版TNM非小细胞肺癌的分期,其中Ⅰa期10例(6.1％)、Ⅰb期79例(48.5％)、Ⅱa期5例(3.1％)、Ⅱb期44例(27.0％)、Ⅲa期25例(15.3％).CF组与SL组各期5年生存率分别为:Ⅰ期51％对63％,P＜0.05;Ⅱ期38％对36％,P=0.472、Ⅲa期27％对25％,P=0.422.按照T分期比较5年生存率,T2期CF组与SL组比较:35％对50％ (P =0.022);CF组T2期与SL组T3期比较35％对28％ (P =0.111).结论 Ⅰ期非小细胞肺癌患者伴跨肺裂侵犯邻近肺叶者,术后5年生存率较Ⅰ期不跨肺裂者低,为50％对63％,差异有统计学意义(P＜0.05);T2大小的肿瘤伴跨肺裂侵犯邻近肺叶者低于T2不跨肺裂者(P＜0.05),5年生存率与T3不跨肺裂组相近.肿瘤跨肺裂侵犯的T分期定义在当前分期系统中未明确提及,应当在以后的TNM分期中进一步修改.     

The significance of intrapulmonary metastasis in non-small cell lung cancer: upstaging or downstaging? A re-appraisal for the next TNM staging system

OBJECTIVE: The management of patients with non-small cell lung cancer (NSCLC) with intrapulmonary metastases (PM) is controversial. In TNM classification, PM are designed as T4 when in the same lobe of the primary tumour (PM1) and M1 when in a different lobe(s) (PM2). Some authors have questioned the negative prognostic impact of PM. The present study assessed prevalence, correlation with clinico-pathologic variables and impact on survival of PM, along with a review of the literature. METHODS: From January 1993 to December 2006, 2013 NSCLC patients underwent surgical resection at our institution. Of these, 74 presented with PM (39 PM1, 35 PM2). Patients with bronchioloalveolar carcinoma (BAC), carcinoid tumours, contralateral disease and preoperative chemo/radiotherapy were excluded from the analysis. A logistic regression analysis was undertaken to evaluate a relationship between the presence of PM and different clinico-pathologic variables. Survival analysis was undertaken to investigate the prognostic significance of PM. RESULTS: PM represent 3.6% of our patient population of operated NSCLC. Metastases were multiple in 36 cases and single in 38. Thirty-six patients had node-negative disease. Among all the variables for the logistic regression analysis only vascular invasion (OR: 0. 45; 95% CI 0.24-0.85, p=0.01) and N status (OR: 0. 6; 95% CI 0.43-0.82, p=0.001) were significantly correlated with the presence of PM. Median survival rates of PM1, PM2, other T4 and other M1 patients were 25, 23, 15 and 14 months, respectively. A survival advantage was observed in patients with PM as compared to other T4/M1 patients, although the difference was not significant either overall (p=0.21) or in the N0 disease group (p=0.12). CONCLUSIONS: The presence of PM in NSCLC patients is a rare occurrence. Risk factors for the development of PM are a microscopic vascular invasion and a high nodal status. A survival advantage over other T4/M1 patients is evident from our experience, although not significant. The results of the literature which have been accumulating in the most recent years including ours bend to the conclusion that there is sufficient validated information to consider a downstaging in the presence of intrapulmonary metastases from NSCLC for the seventh edition of the TNM classification.     

Midterm survival of imaging-assisted robotic lung segmentectomy for non-small-cell lung cancer

Open in a separate window OBJECTIVESOur goal was to report our midterm results using imaging-assisted modalities with robotic segmentectomies for non-small-cell lung cancer (NSCLC).METHODSThis was a retrospective study of all robotic segmentectomies, with confirmed NSCLC, performed at our general and thoracic surgery unit in the Rouen University Hospital (France), from January 2012 through December 2019. Benign and metastatic lesions were excluded. Data were extracted from the EPITHOR French nationwide database.RESULTSA total of 121 robotic segmentectomies were performed for 118 patients with a median age of 65 (interquartile range: 60, 69) years. The majority had clinical stage T1aN0M0 (71.9%) or T1bN0M0 (13.2%). The mean (standard deviation) number of resected segments was 1.93 (1.09) with 80.2% imaging-assisted segmentectomies. Oriented (according to tumour location) or systematic lymphadenectomy or sampling was performed for 72.7%, 23.1% and 4.1% of patients. The postoperative course was uneventful for 94 patients (77.7%), whereas 34 complications occurred for 27 patients (22.3%), including 2 patients (1.7%) with Clavien-Dindo ≥III complications. The mean thoracic drainage duration was 4.12 days, and the median hospital stay was 4 days (interquartile range: 3, 5) after the operation. The 2-year survival rate was 93.9% (95% confidence interval: 86.4–97.8%). Excluding stage IV (n = 3) and stage 0 tumours (n = 6), the 2-year survival rate was 95.7% (95% confidence interval: 88.4–98.8%) compared to an expected survival rate of 94.0% according to stage-specific survival rates found in a large external reference cohort.CONCLUSIONSImaging-guided robotic-assisted thoracic surgery segmentectomy seems to be useful and oncological with good midterm results, especially for patients with early-stage NSCLC.     

Comparison of clinical and surgical-pathologic staging of the patients with non-small cell lung carcinoma

Objective: Clinical staging of non-small cell lung cancer helps to determine the extent of disease and separate patients with potentially resectable disease from those that are unresectable. Since, clinical staging is based on radiologic and bronchoscopic findings, overstaging or understaging may occur comparing to the final surgical-pathologic evaluation. We aimed to analyze preoperative and postoperative stagings in order to evaluate stage migrations and our surgical strategy for marginally resectable patients. Methods: We did a retrospective analysis of 180 patients with non-small cell lung cancer who underwent resectional surgery between 1994 and 2000. In all patients, a thoracic computerized tomography and bronchoscopy were performed to define clinical staging (cTNM). Results: In 86 patients (47.7%) clinical and surgical-pathologic staging concurred. When comparing T subsets alone, correct staging, overstaging and understaging occurred in 133 (73.9%), 28 (15.5%), 47 (26.1%) patients, respectively. Only 13 of 21 patients (61.9%) who were thought to have T4 tumor preoperatively were found to have pT4. Also six patients with cT2 and five patients with cT3 were subsequently found to have T4 disease according to pathology. Clinical staging overestimated the nodal staging in 35 patients (19.4%), while underestimated the lymph node involvement in 45 patients (25%). Conclusion: Construction of cTNM stage remains a crude evaluation, preoperative mediastinoscopy in every patient must be performed. Preoperative limited T4 disease is not to deny surgery to patients since a considerable number of patients with cT4 are to be understaged following surgery.     

Postoperative complications after induction chemoradiotherapy in patients with non-small-cell lung cancer

Objective: This study evaluates the risks of postoperative complications in 124 patients with non-small-cell lung cancer who received pre-operative induction chemoradiotherapy and surgery. Methods: All patients with non-small-cell lung cancer who underwent surgery after induction therapy between January 1990 and December 2003 were reviewed. We adopted univariate and multiple logistic regression models to identify predictors that increased the incidence of postoperative complications. Results: Of 124 patients, 59 received carboplatin and docetaxel, 53 received cisplatin and etoposide, and 12 received other platinum-based combinations. Pre-operative thoracic radiotherapy was performed concurrently with chemotherapy. The median dose to the primary tumor was 40 Gy, and 29 patients (23.4%) received radiotherapy of more than 45 Gy before surgery. There were 25 pneumonectomies (20.2%). The overall postoperative mortality was 9 of 124 patients (7.3%), and complications developed in 54 patients (43.5%). Multivariate analysis demonstrated that only thoracic radiotherapy of more than 45 Gy predicted postoperative complications (P = 0.021; odds ratio, 3.620; 95% confidence interval, 1.214–10.797). Conclusions: Thoracic radiotherapy of more than 45 Gy, in combination with chemotherapy, was a significant risk factor for postoperative complications.     

Transrectal ultrasound in the diagnosis of prostate cancer: location, echogenicity, histopathology, and staging

Adenocarcinoma of the prostate produces specific ultrasonic findings that can be used in diagnosis. We have examined 211 patients using transrectal ultrasound in both the sagittal and axial planes. Thirty-three carcinomas were detected, and 31 histologically confirmed; 24 by needle biopsy, six by transurethral resection, one by total prostatectomy, and two by the demonstration of distant metastases. On ultrasound, all of the carcinomas were less echogenic than normal prostate. All appeared to originate in the peripheral zone of the prostate and produced asymmetry of the gland. The majority of carcinomas in this series showed capsular involvement and ten penetrated and extended beyond the prostatic capsule. The results of this series indicate that transrectal ultrasound can be used to detect cancer of the prostate gland. Ultrasound demonstrated the extent of tumor involvement and enabled accurate staging of these cancers.     

中期因子mRNA在非小细胞肺癌患者外周血中的表达及其临床意义

目的 探讨非小细胞肺癌( NSCLC)患者外周血中中期因子(MK)mRNA的表达及其临床意义.方法 采用定量聚合酶链反应(PCR)法检测87例NSCLC患者、35例肺良性疾病患者及30例健康志愿者外周血中MK mRNA的表达.结果 NSCLC患者外周血中MK mRNA的相对表达(6.749±1.117)与良性疾病患者(7.988 ±0.633)和健康志愿者(8.156±0.525)比较,差异有统计学意义(P＜0.05),而后两者比较差异无统计学意义(P ＞0.05)NSCLC患者外周血中MK mRNA表达水平与其临床TNM分期,细胞分化程度及淋巴结转移密切相关(P＜0.05),而与年龄、性别、吸烟与否和病理类型无明显相关(P＞0.05).结论 外周血MK mRNA有望成为NSCLC微转移检测的有效标志物.