Initial evaluation of the nonsmall cell lung cancer patient: diagnosis and staging

Self Cite

In patients with lung masses and evidence of mediastinal adenopathy without evidence of distant metastatic disease, a common clinical question is whether to perform biopsy of the peripheral lung lesions or the lymph nodes fi rst. When there are discrete enlarged lymph nodes on CT scan or PET scan without direct A ccurate staging is critical to the effective treatment of lung cancer. For patients without evidence of distant metastatic disease, assessment of the mediastinal lymph nodes is important, since the status of these nodes will determine treatment. 1,2 Clinical assessment of the mediastinal lymph nodes is guided by noninvasive imaging modalities, such as CT scan and PET scan. The median sensitivity and specifi city of CT scanning for identifying malignant involvement of mediastinal nodes is 61% and 79%, respectively. 3 The sensitivity of PET scanning is conditional upon whether the nodes are enlarged on CT scan. If the lymph nodes are enlarged on CT scan, the median sensitivity and specifi city of PET scan is 100% and 78%, respectively. If the lymph nodes are not enlarged on CT scan, the median sensitivity and specifi city of PET scan is 82% and 93%, respectively. 3 Because of the limited predictive value of both CT scanning and PET scanning, current guidelines recommend that patients with mediastinal adenopathy by CT scan or PET scan undergo lymph node sampling to ensure accurate staging.

Section: Methodssupporting

confidence: 70%

Quality Gaps and Comparative Effectiveness in Lung Cancer Staging

Almeida

Casal

Jiménez

et al. 2013

Self Cite

“…CT and PET imaging, although useful, do not always have suffi cient positive and negative predictive value to guide treatment decisions in these cases. 2,4,11 The result of relying solely on imaging to stage the mediastinum is that some patients will be falsely up-staged, leading to missed opportunities for surgery and possibly cure. Conversely, other patients will be falsely under-staged, leading to unnecessary thoracotomies and complications.…”

mentioning

confidence: 99%

Determinants of Practice Patterns and Quality Gaps in Lung Cancer Staging and Diagnosis

Ost

Niu

Elting

et al. 2014

Background: Guidelines recommend mediastinal lymph node sampling as the fi rst invasive diagnostic procedure in patients with suspected lung cancer with mediastinal lymphadenopathy without distant metastases. Methods: Patients were a retrospective cohort of 15,316 patients with lung cancer with regional spread without metastatic disease in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) or Texas Cancer Registry Medicare-linked databases. Patients were categorized based on the sequencing of invasive diagnostic tests performed: (1) evaluation consistent with guidelines, mediastinal sampling done fi rst; (2) evaluation inconsistent with guidelines, non-small cell lung cancer (NSCLC) present, mediastinal sampling performed but not as part of the fi rst invasive test; (3) evaluation inconsistent with guidelines, NSCLC present, mediastinal sampling never done; and (4) evaluation inconsistent with guidelines, small cell lung cancer. The primary outcome was whether guideline-consistent care was delivered. Secondary outcomes included whether patients with NSCLC ever had mediastinal sampling and use of transbronchial needle aspiration (TBNA) among pulmonologists. Results: Only 21% of patients had a diagnostic evaluation consistent with guidelines. Only 56% of patients with NSCLC had mediastinal sampling prior to treatment. There was signifi cant regional variability in guideline-consistent care (range, 12%-29%). Guideline-consistent care was associated with lower patient age, metropolitan areas, and if the physician ordering or performing the test was male, trained in the United States, had seen more patients with lung cancer, and was a pulmonologist or thoracic surgeon who had graduated more recently. More recent pulmonary graduates were also more likely to perform TBNA ( P , .001). Conclusions: Guideline-consistent care varied regionally and was associated with physician-level factors, suggesting that a lack of effective physician training may be contributing to the quality gaps observed. CHEST 2014; 145(5):1097-1113Abbreviations: EBUS 5 endobronchial ultrasound; NSCLC 5 non-small cell lung cancer; SEER 5 Surveillance, Epidemiology, and End Results; TBNA 5 transbronchial needle aspiration; TCR 5 Texas Cancer Registry

“…All with suspected lung cancer with mediastinal adenopathy without distant metastases because the procedure can be used for both diagnosis and staging. [2][3][4][11][12][13][14][15][16] However, to our knowledge, only one single-center comparative effectiveness study has evaluated how test sequencing affects outcomes. 17 The goal of the present study was to compare practice patterns and outcomes of diagnostic and staging strategies in patients with lung cancer with mediastinal lymph node involvement without distant metastasis.…”

Section: Discussionmentioning

confidence: 99%

“…Thus, multiple guidelines recommend biopsy of the mediastinal lymph nodes fi rst in patients with evidence of nodal disease rather than biopsy of the peripheral mass. [2][3][4][11][12][13][14][15][16] A previous single-center retrospective study suggested that a strategy of sampling the mediastinum fi rst resulted in fewer tests and complications than a as the fi rst test, those with stage II disease were more likely to have mediastinal sampling than those with stage IIIA or IIIB disease (67% vs 34% vs 16%, respectively; P , .001).…”

Section: Number Of Invasive Tests Performedmentioning

confidence: 99%

“…1 Because of the lim ited accuracy of both CT and PET scanning, current evidence-based guidelines recommend that patients with mediastinal adenopathy by CT or PET scan undergo lymph node sampling to ensure accurate staging. [1][2][3][4] However, signifi cant discordance may exist between what is recommended in evidence-based guidelines and what is actually done in practice. Previous studies of patients with non-small cell lung cancer (NSCLC) found that mediastinoscopy is infrequently performed, and even then, lymph nodes are biopsied in , 50% of cases.…”

mentioning

confidence: 99%

See 1 more Smart Citation

Quality Gaps and Comparative Effectiveness in Lung Cancer Staging and Diagnosis

Ost

Niu

Elting

et al. 2014

Background: Guidelines recommend mediastinal lymph node sampling as the fi rst invasive test in patients with suspected lung cancer with mediastinal lymphadenopathy without distant metastases, but there are no comparative effectiveness studies on how test sequencing affects outcomes. The objective was to compare practice patterns and outcomes of diagnostic strategies in patients with lung cancer. Methods: The study included a retrospective cohort of 15,316 patients with lung cancer with regional spread without distant metastases in the Surveillance, Epidemiology, and End Results or Texas Cancer Registry Medicare-linked databases. If the fi rst invasive test involved mediastinal sampling, patients were classifi ed as receiving guideline-consistent care; otherwise, they were classifi ed as receiving guideline-inconsistent care. We used propensity matching to compare the number of tests performed and multivariate logistic regression to compare the frequency of complications. Results: Twenty-one percent of patients had guideline-consistent diagnostic evaluations. Among patients with non-small cell lung cancer, 44% never had mediastinal sampling. Patients who had guideline-consistent care required fewer tests than those with guideline-inconsistent care ( P , .0001), including thoracotomies (49% vs 80%, P , .001) and CT image-guided biopsies (9% vs 63%, P , .001), although they had more transbronchial needle aspirations (37% vs 4%, P , .001). The consequence was that patients with guideline-consistent care had fewer pneumothoraxes (4.8% vs 25.6%, P , .0001), chest tubes (0.7% vs 4.9%, P , .001), hemorrhages (5.4% vs 10.6%, P , .001), and respiratory failure events (5.3% vs 10.5%, P , .001). Conclusions: Guideline-consistent care with mediastinal sampling fi rst resulted in fewer tests and complications. We found three quality gaps: failure to sample the mediastinum fi rst, failure to sample the mediastinum at all in patients with non-small cell lung cancer, and overuse of thoracotomy. CHEST 2014; 145(2):331-345Abbreviations: EBUS 5 endobronchial ultrasound; NSCLC 5 non-small cell lung cancer; SEER 5 Surveillance, Epidemiology, and End Results; TBNA 5 transbronchial needle aspiration; TCR 5 Texas Cancer Registry