Quality Gaps and Comparative Effectiveness in Lung Cancer Staging

Abstract

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.

Quality Gaps and Comparative Effectiveness in Lung Cancer Staging and Diagnosis

“…9,10,[23][24][25] This is in the context of randomized strategy of sampling peripheral lung masses fi rst. 17 The present study adds to the existing body of knowledge in this area. It confi rms that sampling the mediastinum fi rst is more effective, resulting in fewer tests and complications.…”

“…[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. We hypothesized that peripheral lung mass biopsy often occurs prior to sampling of the mediastinal lymph nodes, contrary to guidelines.…”

Molecular alterations in non‐small‐cell lung cancer: Perspective for targeted therapy and specimen management for the bronchoscopist

“…In patients with biopsy-proven or suspected primary lung cancer and either mediastinal lymphadenopathy by size criteria or PET-positive mediastinal LNs, use of needle-based technique for mediastinal staging as the first invasive test has been shown to result in fewer invasive tests than approach following a different staging protocol (1.3 + 0.5 vs 2.3 + 0.5 tests/ patient respectively, P < 0.0001) and have fewer complications (0 of 30, 0% vs 18 of 108, 17%; P = 0.01). 48 EBUS-TBNA was sufficient to guide treatment decisions without any other invasive tests in 88 (64%) patients. Simply changing the test sequence (use of EBUS-TBNA before a CT-guided biopsy) can eliminate up to two thirds of the complications and reduce costs related to CT-guided biopsies.…”

“…48,49 Historically, samples used for histopathological diagnosis in lung cancer patients came either from core needle biopsy specimens or from surgical specimens. However, a vast amount of literature has accumulated over the recent decade proving that cytology specimens are not only sufficient for histological assessment of lung tumours but also for molecular testing.…”

“…Simply changing the test sequence (use of EBUS-TBNA before a CT-guided biopsy) can eliminate up to two thirds of the complications and reduce costs related to CT-guided biopsies. 48 Other cytology specimens-bronchial brushing in cases of endobronchial lesions, conventional TBNA or pleural fluid cytology-may provide sufficient material for molecular testing. 59 However, close collaboration with the cytopathologist must take place at the time of sample collection or shortly after to ensure that sample cellularity is adequate.…”